117 Pharmacy ReEngineering PRE Update

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117 Pharmacy Re-Engineering (PRE) Update

• Eric Williamson (Project Manager)
• Lina Bertuzis (Lead Functional Analyst)

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Project Update

• Eric Williamson

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Project Update - Releases

• PRE V.0.5 pre-release
• Pharmacy Data Management patch allowing
  preparation time for overall v.0.5 implementation
• PRE V.0.5
• Enhanced order checks using COTS drug database

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Project Update - Schedule

• Pre-release (completion dates)
• Stage III/Site testing (mid August 2008)
• National release (early September 2008)
• V.0.5 on track (completion dates)
• Coding (September 2008)
• Stage I testing (January 2009)
• Stage II testing (late March 2009)
• Stage III/Site testing (late May 2009)
• Complete to EPS (mid June 2009)
• National release (July 2009)

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Project Update - Testing

• Testing Process (4 Stages)
• Stage I Internal (Team) Testing
• Stage II Testing Services
• Stage III Production Site Testing
• Stage IV Final Review and Approval

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Project Update - Issues

• Major Issues and Risks
• Equipment Acquisition and Deployment
• Testing Preparation and Execution
• Technical and Business Process Documentation

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PRE V.0.5 Pre-Release

• Lina Bertuzis

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Background Information

• Preparation Work Needed for PRE V. 0.5
• To implement Enhanced Order Checking
• Improve existing order checks
• Drug-Drug Interactions
• Duplicate Therapy (Class)
• Add Dosing Checks
• Interfacing with First DataBank (FDB) database
  and APIs
• Mapping required between VistA and FDB
• File review and setup activities

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Why A Pre-Release

• Mapping Activities (VistA to FDB)
• Drug Connection
• GCNSEQNo in VA Product File
• Local Medication Routes
• Dose Units
• File Review and Setup
• Local Possible Dosages
• Administration Schedule and Medication
  Instruction frequency
• Identify PreMix Solutions

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Pre-Release Patch Installation

• New Files
• Standard Medication Routes (51.23)
• Dose Unit (51.24)
• New Fields
• Drug File (50) Local Possible Dosage multiple
  (904)
• Numeric Dose (5)
• Dose Unit (4)
• Dosage Form File (50.606)
• Exclude From Dosage Checks (11)

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Pre-Release Patch Installation (cont.)

• New Fields (continued)
• Medication Routes file (51.2)
• Standard Medication Route (10)
• Standard Med Route Change Log (7)
• Activity Date and Time (.01)
• Person making change (1)
• Old Value (2)
• New Value (3)
• IV Solution file (52.7)
• PreMix (18)

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Pre-Release Patch Installation (cont.)

• Menu Changes
• Enhanced Order Checks Setup Menu (New)
• Pharmacy Data Management Menu (Restructuring)

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Enhanced Order Checks Setup Menu
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Pre-Release Patch Installation (cont.)

• Post Init
• Initiate NTRT population of VUIDs for Standard
  Medication Route file
• Auto mapping of local Medication Routes file to
  Standard
• Auto population of numeric dose and dose unit for
  Local Possible Dosages
• MailMan message upon completion

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Medication Route Mapping
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Standard Medication Route

• Standard Medication Route file (51.23)
• Created by Standards and Terminology Service
  (STS)
• Mapped to FDB dose route table by STS
• Approved by Pharmacy Benefits Management (PBM)
• Facilitate mapping of local medication route to
  FDB

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Standard Medication Route (contd)

• Initially exported as a Pharmacy Data Management
  (PDM) file
• No local editing allowed
• Updates via New Term Rapid
• Turnaround (NTRT)
• Change Requests
• Via VistA option (temporary)
• NTRT Website (permanent)
• Available with PRE V. 0.5 release

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Change Requests

• Request Change to Standard Medication
• Routes File option
• Request additions and/or modifications to
  standard medication route
• Request Information submitted
• Medication route to be added/modified
• Example of medication administered by route
• References/reason for request
• Sent to VHA OI SDD HDS NTRT Outlook mail group
  and requestor on VistA account
• To be reviewed by established committee

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Request Change To Standard Med Route
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Request Change To Standard Med Route
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Req Change To Standard Med Route
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Mapping Local to Standard

• Mapping Local to Standard Med Routes
• New STANDARD MEDICATION ROUTE field (10) in
  MEDICATION ROUTES file (51.2)
• Only required for local Medication Routes marked
  for ALL PACKAGES
• Map to ACTIVE Standard Medication Route
• No changes to Order Entry selection lists

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Mapping Local to Standard (contd)

• Options for mapping
• Find Unmapped Local Medication Routes
• Map Local Medication Route to Standard
• Medication Route File Enter/Edit

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Mapping Local to Standard (contd)

• All three options
• Allow for mapping of a local medication route
  marked for All Packages to an active standard
  route
• FDB route is displayed when selecting an active
  standard medication route
• User can bypass route without mapping

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Find Unmapped Local Med Routes

• Find Unmapped Local Medication Routes
• Loops through every unmapped local medication
  route and presents each route to user for mapping
  
• Redisplays the mapping after mapping
• At completion or if the user to exit loop,
  the software rechecks status of mapping
• Displays status of mapping to user

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Find Unmapped Local Med Routes
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Find Unmapped Local Med Routes
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Find Unmapped Local Med Routes
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Mapping Local to Standard (contd)

• Next two options also
• Display mapping for a route already mapped
• Allow remapping
• Redisplay the mapping after remapping
• If no mapping occurs, warning message displayed

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Map Local Medication Route

• Map Local Medication Route to Standard
• Allows individual selection of a local medication
  route marked for ALL PACKAGES
• Only used for mapping to a standard route

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Map Local Med Route to Standard
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Medication Route File Enter/Edit

• If a local medication route is not marked for ALL
  PACKAGES user will not be asked to map to
  standard
• Allows deletion of mapping

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Dosage Form File Enter/Edit

• Modified to not allow entry of a new Medication
  Route
• Will still be able to associate existing local
  medication route with a Dosage Form

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Mapping Local to Standard

• Mapping Reports
• Medication Route Mapping Report
• Medication Route Mapping History Report

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Medication Route Mapping Report

• Allows printing of all local medication routes or
  unmapped local medication routes
• Only displays local medication routes marked for
  ALL PACKAGES
• Report Display Information
• Local Medication Route
• Outpatient Expansion for Local Medication Route

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Medication Route Mapping Report

• Report Display Information (cont)
• Standard Medication Route
• FDB Route
• Totals for local medication routes and/or
  unmapped local medication routes
• Alphabetical display
• 132 column format
• Output to screen or printer

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Medication Route Mapping Report
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Medication Route Mapping Report
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Medication Route Mapping Report
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Medication Route Mapping Report
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Medication Route Mapping Report
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Med Route Mapping History Report

• Medication Route Mapping History Report
• Tracks mapping changes between local medication
  routes and standard medication routes
• Allows printing for all local medication routes
  with mapping changes or a single local medication
  route
• Can specify timeframe

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Med Route Mapping History Report

• Output to screen or printer
• Report Display Information
• Local Medication Route
• Date/Time change occurred
• User who made mapping change
• Old Value
• New Value

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Med Route Mapping History Report
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Med Route Mapping History Report
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Med Route Mapping History Report
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Med Route Mapping History Report
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Dose Unit Mapping
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New VistA Dose Unit File

• Dose Unit File (51.24)
• New VistA file
• Mapped to FDB dose unit table
• Facilitate mapping of local possible dosage unit
  to FDB
• Being analyzed by STS for standardization (for
  PRE V. 1.0)
• No local editing allowed
• Exported as PDM file
• Updates via PDM patch
• Change Requests
• Via VistA option

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Change Requests

• Request Change to Dose Unit Option
• Request additions and/or modifications to dose
  unit
• Request Information submitted
• Dose Unit to be added/modified
• References/reason for request
• Sent to VA OIT VHIT PS DOSE UNIT REQ Outlook mail
  group and requestor on VistA account
• To be reviewed by established committee

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Request Change to Dose Unit Option
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Request Change to Dose Unit Option
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Dosage Form File (50.606)

• New field added to exclude dosage form from
  dosage checks
• Initial data population with Pre-Release patch
• To be managed by NDF manager nationally
• Future data updates via NDF data update patches

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Local Possible Dosages

• Two new fields added to DRUG file (50) within
  LOCAL POSSIBLE DOSAGES multiple (904)
• UNITS - points to New Dose Unit File
• NUMERIC DOSE - numeric representation of dosage
  based on unit defined

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Local Possible Dosages

• Population of two new fields
• Will not be done for
• Supply items
• Drug associated with a dosage form excluded from
  dosing checks
• Auto population
• During post init based on established business
  rules

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Options for Population

• Find Unmapped Local Possible Dosages
• Map Local Possible Dosages
• Drug Enter/Edit
• Enter/Edit Dosages

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Options for Population (contd)

• All four options
• Allow for editing of the Numeric Dose and Dose
  Unit fields for a local possible dosage
• Exclude the following drugs
• Marked as a supply item
• Associated with a Dosage Form excluded from
  dosage checks
• Has no local possible dosages defined

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Options for Population (contd)

• System displays to user
• Drug name
• Strength and unit (if data exists)
• Local possible Dosage
• Numeric Dose and Dose Unit (if data exists)
• If strength of Drug does not match VA Product
  strength, a warning is displayed to the user and
  respective strengths displayed
• User can bypass prompts without entering data

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Options for Population (contd)

• New options also
• Redisplay entered/modified data
• If user will be asked if they want to continue

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Find Unmapped Dosages

• Find Unmapped Local Possible Dosages
• Loops through drugs that have local possible
  dosages eligible for dosage checks that do not
  have either Numeric Dose or Units entered
• Excludes the following additional drugs
• Inactive
• Not matched to NDF
• At completion or if the user to exit loop,
  the software rechecks status of data population

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Find Unmapped Dosages (contd)
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Find Unmapped Dosages (contd)
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Find Unmapped Dosages (contd)
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Map Local Possible Dosages

• Allows selection of an individual drug
• Displays warning message for excluded drugs
• No local possible dosages defined
• Supply item
• Associated with dosage form excluded from dosage
  checks
• Displays warning message and/or information, but
  allows population of fields for drugs that are
• Inactive
• Not matched to NDF

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Map Local Possible Dosages
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Map Local Possible Dosages
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Drug Enter/Edit

• Modified to allow editing of the Numeric Dose and
  Dose Unit fields when
• Entering/Editing a new drug
• Matching a drug to NDF
• Rematching a drug to NDF
• Fields not shown for editing if drug
• Supply Item
• Associated with Dosage Form excluded from dosage
  checks

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Enter/Edit Dosages

• Modified to allow editing of the Numeric Dose and
  Dose Unit fields
• Fields not shown for editing if drug
• Supply Item
• Associated with Dosage Form excluded from dosage
  checks

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Reports

• Strength Mismatch Report
• Review Dosages Report
• Local Possible Dosages Report

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Strength Mismatch Report

• Displays dosage information
• For DRUG file (50) entries that have a different
  strength than what the VA product match has
• Information Displayed
• Local drug IEN
• Drug Name
• Inactive Date
• Strength and Units
• Application Package Use
• Possible Dosage Fields (Dispense Units Per Dose,
  Dose, Package, Outpatient Expansion)
• Local Possible Dosage Fields (Local Possible
  Dosage, Package, Numeric Dose, Dose Unit)
• Strength mismatch warning and strength comparisons

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Strength Mismatch Report
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Strength Mismatch Report
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Review Dosages Report

• Modified to displayed Numeric Dose and Dose Unit
  fields for a Local Possible Dosage
• If strength of Drug does not match VA Product
  strength, a warning is displayed to the user and
  respective strengths displayed

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Local Possible Dosages Report

• Allows printing of all drugs with local possible
  dosages eligible for dosage checks or for drugs
  with just missing data in the Numeric Dose and
  Dose Unit fields
• Excludes drugs that are
• Supply Items
• Associated with Dosage Form excluded from dosage
  checks
• Inactivated
• Not matched to NDF

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Local Possible Dosages Report

• 132 column format
• Information displayed
• IEN of local drug
• Drug Name
• Strength and Units
• Application Package Use
• Local Possible Dosage data (Local possible
  dosage, Package, Numeric Dose, Dose Unit)
• Strength mismatch warning and information

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Local Possible Dosages Report
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Local Possible Dosages Report
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Frequency Review
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Administration Schedule Frequency

• Administration Schedule File Report
• Allows for printing of all Administration
  Schedules or those without a frequency
• Only those schedules that have a PSJ in the
  package prefix will be included
• 80 or 132 column format

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Administration Schedule Frequency

• Display Information
• Administration Schedule
• Standard administration times
• Outpatient Expansion
• Other Language Expansion
• Ward(s)
• Ward(s) Administration Times
• Schedule Type
• Frequency (in Minutes)

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Administration Schedule File Report
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Administration Schedule File Report
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Medication Instruction Frequency

• Medication Instruction File Report
• Allows for printing of all Medication
  Instructions or those without a frequency
• 80 or 132 column format
• Information Displayed
• Name
• Synonym
• Expansion
• Other Language Expansion
• Plural
• Intended Use
• Frequency (In Minutes)

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Medication Instruction File Report
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Medication Instruction File Report
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Identify PreMixes

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Identify PreMix Solutions

• Flag IV solutions as PreMixes
• Identify for order check inclusion
• Option modifications/adds
• Added PreMix field for editing in
• Drug Enter/Edit
• Primary Solution file
• Mark PreMix solution (new)
• IV Solution Report (new)

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Mark PreMix Solution

• Allow marking of IV Solution as a Premix
• Fields presented for Editing
• Print Name
• Print Name 2
• Generic Drug
• Volume
• Inactivation Date
• Used in IV Fluid Order Entry
• PreMix

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Mark PreMix Solution
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IV Solution Report

• Option to print all IV Solutions or those only
  marked as PreMixes
• Display Information
• Print Name
• Print Name 2
• Volume
• Synonyms
• Generic Drug
• Pharmacy Orderable Item
• Inactivation Date
• Used in IV Fluid Order Entry
• Premix Flag

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IV Solution Report
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IV Solution Report
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PRE V.0.5 Enhanced Order Checks

• Whats coming

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Enhanced Order Checks

• Build a HeV component to utilize services
  provided by a commercial drug database to support
  Legacy VistA order check changes
• Create/Modify APIs in M environment to support
  order check enhancements

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Order Checks Data Flow
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Enhance Existing Order Checks

• Drug-Drug Interactions
• Short description of drug interaction clinical
  effects
• Detailed professional drug interaction monograph
  (optional)
• Display Changes
• Enter/Edit Local Drug Interaction Edit Drug
  Interaction Severity options no longer available
• Request Changes to Enhanced Order Checks Database
  option

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Enhance Existing Order Checks

• Duplicate Therapy (Class)
• Utilize FDBs Enhanced Therapeutic Classification
  (ETC) System
• Allows for multiple classes per drug
• Each therapeutic class assigned Duplication
  Allowance
• No longer processed in pairs
• Display changes

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Enhance Existing Order Checks

• Duplicate Drug
• Display changes
• Removed from Inpatient Medications
• Allergy/ADR
• Provide consistent displays between Outpatient
  Pharmacy Inpatient Medications
• Allow user to take action after display for
  Inpatient Medications application

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New Order Checks

• Dosing Order Checks
• Single Maximum Dosage Check
• Daily Dose Range Check
• General Dosing Information for a Drug
• Incorporate dosing checks in Outpatient Pharmacy
  verification options
• New intervention types to accommodate dosing
  checks

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New Order Checks

• CPRS Order Checks
• Incorporate in Pharmacy backdoor
• Aminoglycoside Ordered
• Glucophage Lab Results
• Dangerous Meds for Patient gt64

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Enhanced Order Checks Plus

• Allow user to take action after order check
  display for Inpatient Medications (PSI-07-080)
• Order Check Display Sequence Changes
• Consistency between Outpatient Pharmacy
  Inpatient Medication (PSI-07-080)
• Display changes between Remote and Local Order
  Checks for consistency
• Ability to perform order checks on PreMix
  solutions (PSI-06-012)

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Enhanced Order Checks Plus

• Error Handling
• Messages at system, drug and order level when
  order checks cannot be performed
• Priority message when FDB link is down
• Provide option to check connectivity to FDB
  database
• Placing Intervention Menu hidden action on
  additional ListMan order screens

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Enhanced Order Checks Plus

• Identify Recently Discontinued/Expired Orders
• Identify D/C and Hold Action on Profile
• User notifications for Standard Medication Route
  and Dose Unit file changes

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Customization

• GUI Application for Customization
• Ability to customize FDB standard reference
  tables used in enhanced order checks
• Provide facility users access to request custom
  changes and to view information
• Ability to accept/process custom requests
• Provide designated users ability to review and
  then to approve/reject customization requests
• Ability to manage queries and reports
• Provide method via FTP to update local/regional
  instances of FDB standard and custom tables

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Questions?