Centralized Non-Formulary Processing: Implementation of a CPRS “Reminder Dialog Template” Note
to Request Restricted Drugs and Utilization of VISN 17 PBM Clinical Pharmacy Specialists
Jennifer T. Gunter, PharmD, BCPS, Jimmie D. Gillum, PharmD, CGP, CDE, Peter G. Kwan, PharmD (VISN 17 PBM),
Sandra J. Trask, PharmD, Michelle D. Shank, RPh (VISN 17 PBM), and Julia A. Long, IT Specialist (CAC)
VHA North Texas Health Care System and VISN 17 Pharmacy Benefits Management
Results
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Objectives
Introduce concept of an RDR note to request restricted drugs
Explain unique qualities and benefits to utilization of an RDR note
Discuss benefits of centralized PBM Clinical Pharmacy Specialist’s review of requests
Demonstrate safety benefits and cost savings of a centralized review process
Methods
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Reminder Dialog Note template (aka RDR)
created with assistance of the Clinical Applications Coordinator (CAC)
functions as a progress note with medication/laboratory and consult quick order sets
ability to incorporate health factors
VISN PBM Clinical Pharmacy Specialists
VISN 17 approved hire of 5 FTE VISN PBM Clinical Pharmacy Specialist in Q3 FY07
Specialists provide consistent review of requests for the 3 facilities
RDRs Completed by PharmD
Q1FY10
# of Uniques, Drug X
700
600
Dr. P
500
STX
Dr. G
NTX
CTX
Dr. C
400
300
200
100
0
Dr. S
0
50
100
150
200
VISN 17
250
Improved Safety Outcomes:
Review of epoetin prescriptions at VA North Texas demonstrated significant reduction in high
risk prescribing patterns such as rapid correction, insufficient follow-up monitoring, and overly
aggressive hemoglobin (Hgb) goals. In addition to utilization of the RDR and the VISN PBM
Clinical Pharmacy Specialists, prescribing has also been delegated to services treating
appropriate patient populations for epoetin therapy via protocol based treatment algorithms.
Epoetin statistics PRIOR to RDR
Time Period of Review
Total number on
epoetin/darbepoetin
Number of charts reviewed
(based on most recent Hgb >12g/dl)
12/1/06 – 3/1/07
N= 304
N= 99
(Hgb >12 g/dl)
Epoetin statistics AFTER RDR
Time Period of Review
Total number on epoetin
Number of charts reviewed
(random sample of all)
10/1/08 to 1/13/10
N = 131
N=65
% with most recent Hgb >12 g/dl
32.6% (of total 304)
% with any Hgb >12 g/dl
32.3%
% with most recent Hgb >13 g/dl
49%
% with any Hgb >13 g/dl
4.6%
% with most recent Hgb >14 g/dl
24%
% with any Hgb >14 g/dl
none
Action to most recent Hgb >12g/dl
N=99
Action to any Hgb >12g/dl
N=21
• suspend therapy or decrease dose
36%
• suspend therapy or decrease dose
76.2%
• no action
64%
• no action
23.8%
Mean # days to initial follow-up
38 days
3,300
3,200
3,100
3,000
2,900
2,800
2,700
2,600
2,500
Dec'08
Jan'09
Feb'09
Mar'09
Apr'09
May'09
Jun'09
Jul'09
Aug'09
Sep'09
Oct'09
Nov'09
VISN PBM Clinical Pharmacy Specialists:
Four of five VISN PBM Clinical Pharmacy
Specialists were hired by Q3 FY08 to work
Monday thru Friday. These pharmacists
have advanced training such as residency
or national certifications and provide
consistency within the review process via
adherence to National Criteria for Use, as
well as 1:1 provider education. Requests
are reviewed with a goal of 72 hours with
an average of 173 RDR reviews/pharmacist
in Q1 FY10.
Mean # of days to initial follow-up
22 days
% with >12 weeks between
monitoring
46% (n=46)
% with >12 weeks between
monitoring
10.8% (n=7)
% with rapid Hgb correction
(>1g/dl in 2 wks)
27% (n=27)
% with rapid Hgb correction
(>1g/dl in 2 wks)
6.2% (n=4)
Action to rapid correction
N = 27
Action to rapid correction
N=4
• suspend therapy or decrease dose
22.5%
• suspend therapy or decrease dose
75%
• no action
77.5%
• no action
25%
OtherVISNs
Improved Drug Utilization and Cost
Containment:
Since implementation of this new review
process utilizing an RDR Note with
centralized review by VISN PBM Clinical
Pharmacy Specialists, VISN 17 has
successful reduced its outpatient
prescription cost per unique from a
quarterly high of $273.69 to it most recent
value of $194.60 and is now ranked as one
of the top 3 lowest VISNs for outpatient
pharmacy drug cost per unique.
Quarterly Outpatient Prescription Cost per Unique by VISN
$275.00
$265.00
$255.00
Cost per Unique
In 2004 VISN 17, which is comprised of 3 facilities (North, Central, and South, TX) with 17
pharmacies, was the highest cost VISN in the VA based on outpatient pharmacy cost per
unique. Variations among the three facilities in their non-formulary drug request approval
process led to inconsistencies across the VISN. These inconsistencies were a direct result of
differences in pharmacist education/experience, knowledge of or adherence to national
criteria, time constraints, staffing, and often influences and pressures from local providers.
In an effort to encourage evidence-based medicine, rational use of pharmacy dollars, and
standardization across the VISN, VISN 17 implemented a Reminder Dialog Template note
(aka Restricted Drug Request or RDR) and funded five VISN 17 PBM Clinical Pharmacy
Specialist positions to more uniformly review the requests for twelve drugs identified as
VISN monitors or potential safety concerns.
Uniques
Introduction
$245.00
$235.00
$225.00
$215.00
$205.00
$195.00
$185.00
$175.00
VISN 22
VISN 3
VISN 15
VISN 20
VISN 6
VISN 1
VISN 8
VISN 10
VISN 2
VISN 5
VISN 9
VISN 16
VISN 11
VISN 21
VISN 23
VISN 19
VISN 7
VISN 18
VISN 4
VISN 17
VISN 12
Discussion / Conclusion
Centralization of these reviews has resulted in better adherence to the national
criteria and VISN PBM policies and removed local provider influences and pressure,
thus increasing evidence-based practice. The PBM Clinical Pharmacy Specialist
positions require advanced training or certification as well as knowledge in formulary
management. Unlike the local facility pharmacists who may review non-formulary
requests, evidence-based adjudication is a primary duty rather than an added task for
the PBM Clinical Pharmacy Specialists. Streamlining the review of medications with
associated safety or VISN monitor goals to a centralized group of Clinical Pharmacy
Specialists via an RDR note has resulted in consistency in reviews across VISN 17. This
centralized and more consistent review process has significantly improved adherence
to VA PBM National Criteria, minimized safety related concerns, improved provider
education of national criteria, and reduced pharmacy drug costs by encouraging
formulary alternatives.
Special Thanks to Amy B. Martin, PharmD, BCPS, Kevin C. Kelly, PharmD, BCPS, and
Rick A. Weideman, PharmD, BCPS for their contributions and assistance.