VA Pharmacy Reengineering Project Plagued by Ongoing Problems

By Annette M. Boyle

WASHINGTON — Originally launched in March 2003 and restarted in October 2009, the Pharmacy Reengineering (PRE) software development project continues to miss deadlines, stumble in deployment and suffer from project management failures.

That’s according to a recent audit by the VA’s Office of the Inspector General which notes that these problems put delivery of critical patient safety functionality at risk of missing a 2019 deadline.

PRE isn’t just another software project that’s running a little behind schedule, according to Linda A. Halliday, assistant inspector general for audits and evaluations. “PRE is critically needed to help address patient safety issues associated with adverse drug events,” she pointed out.

Technological innovations are improving patient safety at VA pharmacies. The facility at the Long Beach, CA, VAMC is shown in this photo.

Technological innovations are improving patient safety at VA pharmacies. The facility at the Long Beach, CA, VAMC is shown in this photo.

At inception, the goals for PRE were lofty.

“Initially the plan was to modernize the entire pharmacy module used in VistA [Veterans Health Information Systems and Technology Architecture] — the national drug file, bar codes, consolidated mail order pharmacy — everything,” said Alan Constantian, advocate for health, Office of Information Technology (OIT), Department of Veterans Affairs.

The bulk of the VA’s legacy pharmacy applications, created in the 1980s, had become obsolete and too expensive to continue modifying to meet current and future demands. The original scope of the project included improving pharmacy operations, enhancing workflow efficiency and increasing patient safety.

Failure to deliver on those goals led to a project reboot in 2009 that placed PRE under the newly created Project Management Accountability System (PMAS).

“PMAS had not evolved to provide the oversight needed to ensure project success,” Halliday wrote in her summary of the OIG report. “Consequently, OIT is at an increased risk of not completing PRE on time and within budget.”

Recognizing some of the challenges, OIT scaled down the project two years ago.

“About 2012, there was a shift to focus almost exclusively on patient safety aspects,” Constantian told U.S. Medicine.

The three modules that already have rolled out nationwide, however, are focused on patient safety improvements:

  • The pharmacy enterprise customization system (PECS) enables Pharmacy Benefits Management staff to tailor the drug information maintained by the provider of the off-the-shelf database to better reflect issues common to veterans, such as raising the level of alert for drug interactions that pose greater risks for the elderly.
  • The medication order check healthcare application (MOCHA) alerts clinicians and pharmacists to potential drug interactions and duplicate medications at the point of order.
  • The pharmacy product system that maintains the national formulary and enhances MOCHA to make clinicians aware of drug-drug interactions also has begun to be deployed by OIT.

The Inspector General’s report acknowledged that these modules have increased patient safety at the VA but criticized the length of time before they were available systemwide. For example, from start to national deployment, PECS took 19 months. The initial components of MOCHA took 29 months and the upgrade that includes the pharmacy product system will take more than four years.

At the same time, the PMAS dashboard that OIT and senior VA leadership used to monitor PRE showed that the each component was on schedule because the management system only tracked time to functionality at the first site, not total time to national deployment, according to the OIG report.

The nature of health information systems has made quick rollouts difficult, Constantian said.

“The greatest challenge in meeting the schedule has been the impact that any change to the pharmacy system has on every aspect of medical practice as well other IT systems,” he explained. “The changes can’t be isolated because of the complexity of dependencies on other systems. It requires meticulous checking to ensure we don’t get anything wrong that would affect patient safety or introduce problems. It’s like the Hippocratic Oath for IT people. We don’t want to do any harm.”

The time and funding needed to complete these parts of PRE jeopardize the ability of the organization to meet the rest of its objectives — on time or at all. As of May 31, 2013, OIT had completed less than 30% of the total number of PRE increments, 20 out of 66. Yet, the Inspector General’s report noted that, based on estimates provided by the PRE program manager, the project spent 100% of the funding available for development by the end of 2013.

The VA ‘s Exhibit 300 submission with the fiscal 2014 budget proposal showed one way out of the budget quandary: a plan to cut project costs to $53 million by transferring further PRE development to the Integrated Electronic Health Record (iEHR) project starting this year.

That’s really no plan at all, according to the OIG report, which states, “the decision to transfer funding and development of all remaining Pharmacy Reengineering functionality to iEHR raises concerns, especially in light of the uncertainty surrounding the interagency project.”

Last April, the DoD acknowledged that it was substantially behind the VA in development of an iEHR and halted progress to reevaluate the best path forward. The VA has continued to modernize VistA, its core system for the iEHR effort.

In a response to the audit report, Stephen Warren, executive in charge and chief information officer, OIT, wrote that “current plans do not call for Pharmacy Reengineering to be absorbed into iEHR in FY14. Instead, under current plans, Pharmacy Reengineering will move forward as an independent project.”

While his summary letter said the VA’s “prioritization process will ensure adequate plans for resources and funding based on the transformation priorities of the Department,” the accompanying detailed response noted that PRE may or may not be funded in FY14 depending on its priority among other OIT projects and the impact of budget cuts expected in the FY14 continuing resolution.

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