Dell Perot Systems is an information technology services provider based in Plano, Texas, USA.

Peter Altabef has served as president and chief executive officer since 2004. On September 21, 2009, Perot Systems agreed to be acquired by Dell for $3.9 billion. Dell Services maintains offices in more than 25 countries around the world, including the United States, Europe, India, China and Mexico. As a top-five finisher for the third consecutive year, it was named to the Fortune magazine Most Admired Companies in America list for IT Services in 2008. The expanded Dell is better positioned for immediate and long-term growth and efficiency driven by:-Providing a broader range of IT services and solutions and optimizing how they re delivered

Introductiony Veterans health information systems and technology

architecture (VistA).y VistA software is in the public domain and has been available to non- VA

users under the freedom of information act (FOIA) for several decades now. Like open source software, the application code is made available to anyone requesting a copy of the system.

y VistA Pharmacyy VA pharmacy databases are comprehensive, recording all aspects of

prescription drug therapy across inpatient and outpatient settings. y The pharmacy package provides a method of management, dispensing of out-patient and inpatients drugs within the hospital. Hospital medications also interacts with the computerized patient record system (CPRS) and the bar code medication administration (BCMA) packages to provide more comprehensive patient care.

Objectivey The objective of this project is to study the perceived

changes that will be brought due to VistA Pharmacy implementation in hospital & also to measure the parameters that will be affected such as TAT, efficiency, economic losses etc.

Workflow of Pharmacy (outpatient department)HISORDERING

DEO

VERIFICATION

RPh 1 RPh 3 CHECKING

PRINTER

LABELLING

RPh 2

PULLING

RPH- Pharmacist DEO- Data Entry Operator GDA- General Duty Attendant

Workflow of Pharmacy (Inpatient department)HISDEOORDERING THROUGH CPRS

CHECKING

RPh 3

VERIFICATION BY VistA PHARMACY

RPh 1

PRINTER

LABELLING

RPh 2RPH- Pharmacist DEO- Data Entry Operator GDA- General Duty Attendant

C A R T F I L LGDA

PULLING

Study Designy The study is divided in following stages: y Study of the VistA Pharmacy process at the Dell

Services. y Survey To study the impact of IT implementation (VistA Pharmacy) in efficiency and work flow of Pharmacy department . y Compilation of the data and data analysis. y Finding the perceptual benefits of it implementation of VistA Pharmacy module.

Methodologyy SampleTotal 60 pharmacists were taken for the study. Both executive pharmacists and junior pharmacist feedback were taken.

y Tools Questionnaire was used. To study the impact of IT implementation (VistA Pharmacy) in

efficiency and work flow of Pharmacy department Study was basically an exploratory study using a mixed approach (quantitative and qualitative).

y Procedure The data collection was chiefly done using the primary sources. The data collection was carried out through the help of questionnaire

in the field. To collect data using primary sources one can go for several methods such as observation, interview and questionnaire. The method undertaken in this study was questionnaire as it was apt for the project. SPSS version 16 was used to analyze the data collected.

AnalysisBasic computer skills are

mandatory to work on vista pharmacy.

Interpretation As calculated value is 49.9 is greater than tabular value 5.99 at 5% level of significance so null hypothesis is rejected and alternative hypothesis is accepted. Hence basic computer skills are mandatory to work on vista pharmacy and 75% pharmacists agreed on this.

Q:- What do you think about the losses in pharmacy after the concept of unit dose? (Losses in terms of economic aspects caused due to unidentified returned medicines from IP)Interpretation:-

As calculated value 54.93

is greater than the tabular value7.82 at 5% level of significance ,so null hypothesis is rejected and alternative hypothesis is accepted. Hence concept of unit dose affect the losses in inpatient pharmacy and 65 % pharmacists said that losses (economic losses due to unidentified returned medicines from wards) will decrease.

Q:- Will there be an effect on turnaround time (tat) in dispensing the drugs from inpatient pharmacy to the nursing station?Interpretation:

As calculated value85.6 is greater than the tabular value7.82 at 5% level of significance so null hypothesis is rejected and alternative hypothesis is accepted. Hence turnaround time is affected from inpatient pharmacy to nursing station and 77% pharmacists said that it will decrease.

Q :- Refill system is convenient to the patient.

Interpretation:

As calculated value 92.1 is greater than the tabular value 5.99 at 5% level of significance so null hypothesis is rejected and alternative hypothesis is accepted . Hence refill system is convenient to outpatients and 92% pharmacists said so.

Q: - Cart fill and pick list will increase the efficiency of the inpatient pharmacy department.

Interpretation:As calculated value 87.1 is greater than the tabular value5.99 at 5% level of significance so null hypothesis is rejected and alternative hypothesis is accepted. Hence concepts of cart fill and pick list affect the efficiency of inpatient pharmacy and 90% pharmacists said that efficiency will increase.

Q: - Work flow of inpatient pharmacy department will be more planned through the VistA Pharmacy.

Interpretation: As calculated value 77.2 is greater than the tabular value5.99 at 5% level of significance so null hypothesis is rejected and alternative hypothesis is accepted. Hence work flow of pharmacy will be more planned and 87% pharmacists agreed on this.

Q:- VistA Pharmacy will also help the nursing department to do their job better than earlier.

Interpretation: As calculated value 44.80 is greater than the tabular value7.82 at 5% level of significance so null hypothesis is rejected and alternative hypothesis is accepted. Hence vista pharmacy helps the nurses to do their job better than the earlier and 73% pharmacists said that vista pharmacy will help the nurses in their job.

Q:- Dispensing errors caused due to misinterpretation of the prescription (about the name of the drug, dosage, schedule etc.) will be reduced after vista implementation. Interpretation: As calculated value 45.7 is greater than the tabular value5.99 at 5% level of significance so null hypothesis is rejected and alternative hypothesis is accepted. Hence vista pharmacy will help in reduction in dispensing errors and 73% pharmacists said that the dispensing errors will decrease.

Q:- Will there be an effect on turnaround time (tat) in dispensing the drugs from the outpatient pharmacy to the patients?

Interpretation: As calculated value 15.73 is greater than the tabular value 7.82 at 5% level of significance so null hypothesis is rejected and alternative hypothesis is accepted. Hence turnaround time in outpatient pharmacy will be affected ,33% and 20% pharmacists said that tat decrease and increase respectively.

Q:- VistA pharmacy will help the pharmacist to tackle the problems faced during counseling of the patient about medication in outpatient pharmacy department.

Interpretation:-As calculated value 63.7 is greater than the tabular value 5.99 at 5% level of significance so null hypothesis is rejected and alternative hypothesis is accepted. Hence VistA Pharmacy helps in counseling by the pharmacists in outpatient pharmacy and 82% pharmacists agreed on this.

Q:- Through VistA Pharmacy the records can be safely and securely maintained for a long duration.

Interpretation: As calculated value 82.3 is greater than the tabular value 5.99 at 5% level of significance so null hypothesis is rejected and alternative hypothesis is accepted. Hence vista pharmacy stores the records safely and securely and 88% pharmacists said that vista pharmacy does so.

Q:- It is easy to learn and work on VistA Pharmacy.

Interpretation: As calculated value 53.2 is greater than the tabular value 5.99at 5% level of significance so null hypothesis is rejected and alternative hypothesis is accepted. Hence VistA Pharmacy is easy to learn and 77% pharmacists agreed on this.

Q:RELATIONSHIP BETWEEN PHARMACISTS EXPERIENCE AND THEIR PERCEPTION REGARDING COMPUTER SKILLS COMPULSION Interpretation: It was found that 85% pharmacists who have experience more than 5 years agreed that computer skills are compulsory to work on VistA ,80% pharmacists who have experience more than 3 but less than 5 years agreed for computer skills compulsion,60% pharmacists who have the experience more than 1 but less than 3 years agreed for computer skills compulsion and 83% pharmacists who have the experience less than 1 year agreed that computer skills are compulsory to work on VistA.

Q:RELATIONSHIP BETWEEN PHARMACISTS EXPERIENCE AND THEIR PERCETION REGARDING VistA THAT IT IS GOING TO HELP IN COUNSELING Interpretation: After analyzing data it was found that 81% pharmacists who have the experience more than 5 years ,80% pharmacists who have the experience more than 3 but less than 5 years,83% pharmacists who have the experience more than 1 but less than 3 years and 83% pharmacists who have the experience less than 1 year agreed that pharmacy VistA will help the pharmacists in counseling.

Q:RELATIONSHIP BETWEEN PHARMACISTS EXPERIENCE AND THEIR PERCEPTION REGARDING INPATIENT PHARMACY EFFICIENCY THROUGH CARTFILL AND PICKLIST Interpretation: After analyzing the data it was found that 92% pharmacists who have experience more than 5 years ,80% pharmacists who have experience more than 3 years but less than 5 years ,86% pharmacists who have experience more than 1 year but less than 3 years and 100% pharmacists who have experience less than 1 year agreed that inpatient pharmacy efficiency will be positively affected through Cartfill and Picklist.

Findingsy 65% pharmacists agreed that the economic losses in inpatient pharmacy due to y y y y y y y y y y y

unidentified returned medicines from ward will be reduced. 77% and 33%pharmacists found that the turn around time in inpatient and outpatient pharmacy will be decreased respectively. 73% pharmacists said that VistA Pharmacy will help the nurses in doing their job done better than the earlier . Dispensing errors will reduce upto 73%. 88% pharmacists agreed that vista pharmacy stores the record safely and securely . 75% pharmacists found that there is compulsion to have basic computer skills. 77% pharmacists found it easy to learn. 82% pharmacists agreed that vista pharmacy will help the pharmacists to tackle the problems faced during counseling those were faced earlier. 87% pharmacists found that vista pharmacy will make the entire pharmacy more planned as it was earlier. It was found that the pharmacists who has experience more than 5 years felt that computer skills are compulsory to work on VistA. 100% pharmacists who have experience less than 1 year agreed that cartfill and picklist will positively affect the efficiency of the inpatient pharmacy. 85% pharmacists who have experience more that 5 years agreed that TAT will decrease but only 67% pharmacists who have experience less than 1 year said that TAT will decrease.

Conclusiony It was found experience in pharmacy has the positive impact on the y

y

y

y

perception of pharmacists about the computer skills compulsion to work on VistA pharmacy. 100% pharmacists who are new in this profession found that the efficiency of the inpatient pharmacy will be increased because dispensing of drugs to the wards will be more planned and error free. In case of inpatient pharmacy it was found that experience has the positive effect on the perception of pharmacists that the TAT will decrease but in case of outpatient pharmacy, pharmacists are in dilemma about TAT that whether it will decrease or increase. Hence VistA Pharmacy is supposed to be boon for the hospital pharmacy and it will resolve the various problems faced by the pharmacists with the earlier pharmacy system. Also, it was noted that a well designed training plan was a stepping stone towards successful deployment of any information system in a hospital. Because at the end success and failure depends on not only the design of the software but also on how well people are able to use a system.

Recommendationsy Further advancement can be incorporated by using vista inventory as a part of y y y y y y

y y y y

pharmacy package. Computer proficiency should be one of the main criteria for selection of the pharmacist along with pharmacy knowledge which is the foremost requirement. Proper and well planned training of vista pharmacy module should be organized for the pharmacist. Separate meeting and discussion should be held with the pharmacist and executive pharmacist to plan for further tailoring of the system as per their requirement. Special care need to be taken care of in terms of providing role base access for the pharmacist as it s a big responsibility in terms of pharmacy management. Access code and verify code must be kept as secret and should not be shared with any of the colleague. The work force of the pharmacist or the duty rooster should be designed in such a way that there should be bare minimum of three (3) pharmacist along with one (1) GDA (general duty attendant) & a DEO (data entry operator) present for optimum services. Special attention and care should be taken in case of stat, now and routine order & pre- exchange dose. Manuals for end users should be there for guidance and troubleshooting purpose which contains FAQ s. Repeated training should be provided to the end users. Yearly or quarterly re-training must be organized to keep the users up to date .

Referencesy US department of veterans affairs. vista monograph y

y y

y

[internet]. Jha ak, perlin jb, kizer kw, dudley ra. effect of the transformation of the veterans affairs health care system on the quality of care. Health information technology : a new world for pharmacy. lisa webster and rachelle f. spiro Bizovi ke, beckley be, mcdade mc, adams, al, lowe ra, zechnich ad, hedges jr.the effect of computer-assisted prescription writing on emergency department prescription errors. American society of hospital pharmacists. ashp technical assistance bulletin on hospital drug distribution and control.

STANDARD OPERATING PROCEDURE (SOP s) FOR DOWNTIME OF ELECTRONIC HEALTH RECORD (EHR).

Introduction:y Downtime of an Electronic Health Record (EHR) means the time when the system is not working within the network of hospital and the network is down which effects the business of the organization. y Types: Planned Downtime. Unplanned Downtime. Unexpected events can make downtime unavoidable. Thats why its important to plan ahead.

y Downtime that can even be split into levels of significance. y Level 1 downtime: Level 1 downtime might mean that part of the system is down, but the majority of the content is still accessible. y Level 2 downtime: Level 2 might be that the majority of the content is unavailable. y Level 3 downtime: Level 3 could mean that you have absolutely no access to the system. Once we define these levels, its important to create response plan to each.

Methodology:y The method used in the case study is interview method. The information collected in the case study is primarily gathered by interview conducted with Clinical Transformation Team. Secondary data was also reviewed through healthcare IT journals. y Major points of discussion were: Policy designing for downtime of electronic health record. Ways to tackle and designing the workflow in downtime. Predicting the challenges faced during downtime scenario. Understanding the consequences and seriousness of the downtime in case of electronic health record.

Observations:y Workflow designing is must and necessary for understanding the steps to be followed during downtime. y A policy for unscheduled downtime should feature complete documentation of the recovery strategy and the resources available during the outage. y The downtime policy involves reverting to the use of paper records. y So, the workflow should be designed very carefully keeping in mind all the conditions and rational approach should be used.

DOWNTIME PROCEDUREAll team will have a Downtime Pack. These will include paper versions of specific forms . These paper forms must be completed once the business continuity procedure has been implemented. These paper records must be filed in the patients secondary record. All information captured on these forms must be retrospectively entered into the EHR. Each service will locally agree who will be responsible for this retrospective entry of data.

Contact helpdesk and register the problem.

Additional business continuity forms are available on the HIS intranet site

OR

Manual forms should be made available to each and every department in case intranet is down.

Ensure all the fields on the data validation front sheet are complete and signed.

Helpdesk confirm EHR is unavailable

Complete paper forms as appropriate and file in the secondary records

EHR on line?

YES

Locally agreed person responsible Retrospectively enters all information from the paper form into EHR.

NOConfirmation of EHR not being available must be confirmed by helpdesk before downtime process is implemented.

Once information has been validated by the originator the paper form should be destroyed as confidential waste or shredded.

Progress notes is entered identifying business continuity forms have been entered onto EHR. Mark the progress note as a significant event.

STANDARD OPERATING PROCEDURE1.SCOPE & APPLICATION:

y This procedure applies to all the modules of the VistA EHR in the

hospital.

2.RESPONSIBILITY:

y It is the responsibility of each head of department to. To assign someone to take responsibility for continuity of business of

the department in downtime of EHR. He/she should also design department specific downtime form to help facilitate the process in downtime. Task should be assigned to the person who should retrospectively enter the data captured in downtime back onto the system when system goes online again.

3.PROCEDURE:y All team will have a Downtime Pack. These will include paper versions of

specific forms . These paper forms must be completed once the business continuity procedure has been implemented. These paper records must be filed in the patients secondary record. All information captured on these forms must be retrospectively entered into the EHR. Each service will locally agree who will be responsible for this retrospective entry of data.

y STEPS:A. B.

C. D. E.

Contact helpdesk and register the problem. Once helpdesk confirm EHR is unavailable, additional business continuity forms should be made available on the HIS intranet site or manual forms should be made available to each and every department in case intranet is down. Once EHR goes online, locally agreed person responsible retrospectively enters all information from the paper form into EHR. Progress notes is entered identifying business continuity forms have been entered onto EHR. Mark the progress note as a significant event. Once information has been validated by the originator the paper form should be destroyed as confidential waste or shredded.

4.DOCUMENTATION:

y Maintain individual files of the department containing reports and

activity logs of downtime. y During downtime paper work carried out should be preserved until they have been retrospectively entered into the system. y Manuals must be provided and should be made available to each and every department to handle downtime.5.End of Document.

Disadvantages of downtime of electronic health record (EHR):y Leads to chaotic situation within the organization. y Can lead to loss of business continuity. y Unplanned downtime extending beyond expected time can lead to trouble in case of some legal suite is filed during downtime. y Paperless electronic record and seamless procedure of electronic transformation is hampered in a big way. y Frequent downtime can cause loss of faith of patient in healthcare system of the hospital. y Administering staff ,treating and non-treating staff will be pulled back to do work back on paper and when the system is up and running they have to retrospectively enter the data back onto the system that leads to double work to the staff which leads to dis-satisfaction among them.

Recommendations:y The policy design should be well planned and must be design with the y y y y y

inputs of the users and experts. Flawless workflow should be designed to keep the business continuity working. Downtime policy form should be made available on the intranet if in case they are required during downtime and even if the intranet is down manual forms should be made available to each and every department. Educating staff on how to handle EHR downtime will help ensure that operations run smoothly. Any department that is affected by downtime needs to have a representative on a downtime committee so that clear communication and coordination plans can be made. A parallel off-line system should be installed along with the online electronic health record (EHR) so that the data could be captured and transferred to the off-line system via online one in uptime so that the information can be utilized in downtime of the electronic health record (EHR).

Conclusion:y Downtime policy designing is one of the most important work in the process of implementation of electronic health record (EHR). y Standard operating procedure (SOPs) should be we laid and planned well in advance to keep the business continuity. y Training and educating the staff about downtime ensures smooth running of the process even in downtime of electronic health record (EHR). y High level care should be taken care off to avoid unplanned downtime and ensure optimum services are provided to the patient with standard quality care.

References:y AHIMA (American Health Information Management

Association) Guidelines. y World Health Organization (WHO) South-East Asia Reports and Articles. y PubMed Central.

Introduction to the concept of cart-fill and pre-exchange dosage in InPatient Dept. based on VistA Pharmacy Module.

Introduction:y Cart-fill is the concept based on delivery of medication, well in advance to the concerned wards for patient administrations soon as they are ordered by the physician. y The cart-fill process applies to in-patient pharmacy department and is processed through a channels or sequence of events starting from drug ordering through computerized patient record system(CPRS) by physician to delivery of drug to the ward by pharmacy department. y Cart-fill is delivered within fix timing to the concerned ward which is fixed in terms with the ward administrators.

y Pre-exchange dose is the dose which is required before the next cart-fill runs. The dose which is to be delivered to the ward which is not in routine order i.e, stat order, now order and preexchange dose is delivered by the pharmacy department through GDA. y Stat order is the order which is to be delivered to the ward and administered within half an hour (30 min.). Now order is an order which is to be delivered and administered within an hour (60 min.).

Methodology:y The methodology used in the case study is interview and discussion method. y The information collected in the case study is primarily gathered by attending the training session of the executive pharmacist and junior pharmacist. y Points of focus of the discussion were: Understanding the workflow and the concept of cart-fill. Understanding the clear idea of pre-exchange dose and method to determine pre-exchange dose. Benefits of the cart-fill concept in the In-patient department. Effects of cart-fill on TAT (Turn Around Time) on the pharmacy.

Work Flow of Cart-fill process:HIS DEOORDERING THROUGH CPRS

CHECKING

RPH3

VERIFICATION BY vistA PHARMACY RPH 1

PRINTER

LABELLING RPH2RPH- Pharmacist DEO- Data Entry Operator GDA- General Duty Attendant

C A R T F I L L GDA

PULLING

Process:y Provider ordered through computerized patient record system (CPRS). y And then it is transferred to VistA pharmacy module, here first pharmacist verifies the order and from here two triggers are generated one is sent to HIS (Hospital Information System) and other is sent to printer where labels are printed. y Now the second pharmacist pulls and labels the drug. After this step data entry operator (DEO) bills in HIS. y And then third pharmacist checks the medication according to dosage and schedule. y Once all this steps are done general duty attendant (GDA) delivers the cart to specified ward within specific time which is pre- decided with the ward.

Discussion:y Clearly shows the benefits of the cart-fill process. y One more important point that was reveled in the discussion was the benefit of the process will also help in improved coordination among pharmacy department. y The process also improve the efficiency of workflow and reduces the workload of the pharmacist.

Disadvantages of Cart-fill concept:y The cart-fill depends largely on the coordination between nursing and pharmacy department. y Any modification in the process require lots of time as it involves redesigning of timings of the floor. y The delivery time of the cart to be delivered should be after doctors round and it could be difficult to fix the timing of cart delivery and could lead to hectic schedule.

Recommendations:y The work force of the pharmacist or the duty rooster should be designed in y y

y

y y

such a way that there should be bare minimum of three (3) pharmacist along with one(1) GDA (General Duty Attendant) present for optimum services. The time for cart-fill and delivery to the ward should be pre-decide and should be well planned in advance for effective and efficient service. Special attention and care should be taken in case of stat, now and routine order in case of pre-exchange dose as the stat order and now order should be delivered and administered to the patient within half an hour in case of stat order and one hour in now order. Pick list should be run two (2) hours prior to the delivery of cart-fill to the ward so that necessary arrangement should be done for timely delivery of cart to the ward. Proper and well planned training for the pharmacist and GDA(General Duty Attendant) should be done. The cart-fill process should be well in tuned with wards for achieving maximum efficiency.

Conclusion:y Cart-fill process is one of the most important process of the pharmacy in-patient department which they will be using in day to day activity as the part of their business practice. Its a beneficial concept both in terms of quality and quantitative part of business and helps in improving the efficiency and effectiveness of the services for the betterment of the healthcare service in the hospital. y The success of the concept and process will reflect in terms of improved TAT (Turn Around Time) for delivery of medication to the wards.