VHA INNOVATION PROGRAM Innovation #263 Parking A Prescription (PARK) VHA ISB Business Case September...

VHA INNOVATION PROGRAMInnovation #263 Parking A Prescription (PARK)VHA ISB Business Case

September 25, 2013

VETERANS HEALTH ADMINISTRATION

Project Background

• Problem Statement – The VA pharmacy computer system does not allow for the updating or changing of a prescription without a fill generated. This has created the following problems:• Tremendous amount of waste in expensive drugs

– Once the prescription is dispensed to Veteran, pharmacies cannot take it back

• Medication reconciliation is almost impossible with the current system• Patient confusion due to receiving multiple bottles of the same medication• Veterans being charged copay for medication they did not request• Potential for erroneous claims with regard to insurance billing

• Description of Proposed Solution – Provides a method for providers to be able to “PARK” a prescription placing it in a status of “hold until requested by patient or provider.” The provider would be able to write for the medication order or edit current medication orders and then choose whether the medication should be sent immediately (current functionality) or to wait for the patient to request the medication (parking). Additionally:• The pharmacy would be able to prepare the order electronically in the patient record, but not fill the

medication until the patient requests it• The Veteran can request using the AudioCare telephone refill request system, the MyHealtheVet (MHV)

internet refill system, or mail in their request• Any member of the medical team can request the medication be sent using CPRS

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Execution Status

• Fully developed PARK prototype in the Innovation Sandbox– Includes: the necessary software enhancements/modifications to VistA Pharmacy, CPRS, and

AudioCare telephone refill request system – Does not include: MHV components (not available in the Sandbox)

• Final code and documentation is being submitted to OSEHRA

• Full support of Pharmacy Benefits Management (PBM) leadership for enterprise-wide release

• PARK supports fulfillment of the Medication Reconciliation NSR (20100914) submitted by PBM

• High level, project specific, tasks required for enterprise deployment:– CPRS portions that have been developed and need to be migrated to v29 of CPRS (was developed on

v28 in Sandbox)– AudioCare telephone refill request system development needs to be changed from API to Cache and

a plan for release needs to be negotiated with AudioCare– MHV portion of development needs to be completed– Six (6) month pilot at approximately six (6) sites and Class III to Class I verification performed prior to

national release

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ISB Selection Criteria

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Criteria See… Self-Assigned Score

Compliance Slide 4 1

Five-Year Net Operational Cost Change Slide 5 5

Implementation Cost Slide 6 -6

Clinical Impact (Broadness) Slide 7 10

Clinical Impact (Degree) Slide 7 10

Business Impact (Broadness) Slide 8 10

Business Impact (Degree) Slide 8 10

Patient Safety Slide 9 5

Patient Value Slide 10 10

Healthcare Disparity Slide 11 1

Summary Value = 1 * (19+36) = 55

Business Value = 5 + (-6) + 10 + 10 = 19

Clinical Value = 10 + 10 + 10 + 1 + 5 = 36


Business Case – Compliance

• PARK is compliant with regulations, including patient safety

- VistA Pharmacy, CPRS, and Audiocare portion of solution do not require 508 compliance

- Future MHV development portion may require 508 compliance

- Addresses medication reconciliation with regard to Meaningful Use, Affordable Care Act, and Joint Commission

- PARK complies with patient safety requirements

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Self Assigned Score: 1


Business Case – 5 Year Net Operational Cost Change

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• In CY2010, 1.8% of the prescriptions filled at the pharmacy window were returned to stock because they were never picked up by the patient (unneeded)

Assumption: A similar fraction of new and renewal prescriptions filled through mail (CMOP and local) are unneeded

• Unlike the pharmacy window, unneeded prescriptions filled through the mail (CMOP and local) cannot be returned to stock

• The cost of filling these prescriptions, including the cost of the medication, labor, and shipping/overhead, are all wasted

• PARK would eliminate this waste and save VA approximately $107,838,460 over 5 years or $21,567,692 annually (see slide 13)



Business Case - Implementation Costs

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Year 1 Year 2 Year 3 Year 4 Year 5

Pilot Phase $1,140,000 $0 $0 $0 $0

Deployment Phase $0 $3,140,000 $0 $0 $0

Annual Total $1,140,000 $3,140,000 $0 $0 $0

Cumulative Costs $1,140,000 $4,280,000 $4,280,000 $4,280,000 $4,280,000

Self Assigned Score: -6


Business Case – Clinical Impact

• Broadness: PARK positively impacts three (3) clinical performance metrics

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Self Assigned Score, Broadness: 10Self Assigned Score, Degree: 10

Clinical Performance Metric Degree of Impact

Communication about medications (NDPP) 30% improvement

Discharge information (NDPP) 10% improvement

Provider wait time 20 minutes or less (NDPP/OMB/PAR) 5% improvement

• Degree: PARK positively impacts these metrics in the following ways

- Improves communication on medications among PACT team members- Improves quality of care by preventing medication errors- Improves accuracy of medication profiles (medication reconciliation) for clinical decision making- Eliminates Veteran confusion associated with receiving multiple bottles of the same medication - Limits adverse drug events and decreases patient misuse and abuse- Improves hospital admission/discharge communication on medications- Improves provider wait times by standardizing and streamlining medication reconciliation process


Business Case – Business Impact

• Broadness: PARK positively impacts six (6) business performance metrics

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Self Assigned Score, Broadness: 10Self Assigned Score, Degree: 10

• Degree: PARK positively impacts these metrics in the following ways- Improves accuracy of medication profiles (medication reconciliation) for clinical decision making- Standardizes and streamlines medication reconciliation process among providers- Improves data access and integrity with regard to medication profiles- Reduces eClaim fraud and medication errors- Reduces medication, labor, shipping, and overhead cost associated with unnecessary/unneeded prescription fills- Patient confusion due to receiving multiple bottles of the same medication- Decreases Veterans co-pay charges- Improves pharmacy wait times due to better prioritization of prescription fills- Improves provider wait times by standardizing and streamlining medication reconciliation process - Improves accessibility to prescription refills and increases availability of medication for on-demand ordering

Business Performance Metric Degree of Impact

Improved accuracy of decision making (quality of work) 20% improvement

Standardization of best practices (quality of work) 10% improvement

Enhanced data access, integrity, or aggregation (quality of work) 5% improvement

Reduces program or organizational risk (quality of work) 35% improvement

Reduces costs (VA staff efficiency or workflow) 15% improvement

Improves the environment of care (Veteran/beneficiary’s experience) 5% improvement


Business Case - Patient Safety

• PARK demonstratively improves patient safety

- Improves accuracy of medication profiles (medication reconciliation) for clinical decision making

- Improves quality of care by preventing medication errors

- Limits adverse drug events and decreases patient misuse and abuse

- Eliminates Veteran confusion due to receiving multiple bottles of the same medication

Evaluation CriteriaScored -10 to 10 where -10 is severe decrease in patient safety, 0 is no change in patient safety and +10 is very strong impact in patient safety

1. Demonstratively reduces preventative harm in this population: 62. Reduces mortality and morbidity in this population: 23. Improves patient safety by demonstratively reducing the chance of human error: 7

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Business Case – Patient Value

• PARK significantly increases patient satisfaction

- Decreases Veterans co-pay charges by $2.7 million annually (see slide 15)

- Improves pharmacy wait times by 20%

- Improves provider wait times by 10%

- Improves accessibility to prescription refills

- Increases availability of medication for on-demand ordering

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Business Case – Healthcare Disparity

• PARK does not address a healthcare disparity

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Back Up Slides

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Other Considerations - Calculating the Annual Cost Savings for PARK

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Data Element AmountTotal number of new and renewal Rx filled by mail annually1 (FY10) 49,776,000

Percentage of Rx that are unnecessary/unused by patient2 1.8%

Number of unnecessary Rx filled through mail annually 895,968

Average cost of filling an Rx through mailMedication3 (FY12)Labor4(FY10)Shipping/Overhead4 (FY10)

$24.63$21.39

$0.99$2.25

Annual cost savings that can be realized by not filled unwanted/unneeded Rx through mail

MedicationLaborShipping/Overhead

$22,067,692$19,164,756

$887,008$2,015,928

Annual cost savings less operational expenses for sustainment and increased capability ($500k)

$21,567,692

Net operational cost savings over5 year period $107,838,460


Other Considerations – Environmental Impact

• PARK will:

- Reduce hazardous waste reaching landfills and major water sources

- Decrease availability of unused medication for accidental ingestion or poisoning and drug diversion

• Over the past 2 ½ years, the DEA has held five Prescription Drug Take-Back Days which provide the public with a way to dispose of unwanted, unused, and expired prescription medications

• Through these events, the DEA has collected more than 2.8 million pounds (1,409 tons) of prescription medications

• The prescription medication collected through the Drug Take-Back Initiative likely represents a small fraction of the unwanted, unused, or expired medication

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Other Considerations – Avoided Co-Pay Cost to Veteran

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Veterans cannot be reimbursed for co-pays they are charged for unwanted/unused prescriptions. PARK will save Veterans $2,723,744 annually in unnecessary co-pays.

Assumption: As with the previous cost savings estimate, we are assuming that the percentage of unnecessary prescriptions issued through mail (CMOP and local) are similar to the rate observed at the pharmacy window (1.8%).

Unlike the pharmacy window, unneeded prescriptions filled through the mail (CMOP and local) cannot be returned to stock.

The co-pay associated with filling these prescriptions are unnecessary. PARK would allow Veterans to avoid these co-pays.

*Veteran responsibility for co-pay is based on their service-connected disability rating and/or the condition being treated by the Rx.

Data Element Amount

Number of new or renewal Rx filled by mail annually that require a Veteran co-pay1 (FY10) 18,914,880

Percentage of Rx that are unnecessary/unused by patient2 1.8%

Number of Rx filled annually through mail that require a co-pay but are non needed 340,468

Average Rx co-pay $8

Veteran co-pay costs for unneeded Rx that can be avoided with Park a Prescription* $2,723,744


Other Considerations - CPRS New Orders Screenshot

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Other Considerations - CPRS Meds Tab (New Status) Screenshot

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VHA INNOVATION PROGRAM Innovation #263 Parking A Prescription (PARK) VHA ISB Business Case September...

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