117 Pharmacy Reengineering FY07 Update

1
117 Pharmacy Reengineering FY07 Update

• A Perfect World

2
Faculty

• Mike Mims, Program Manager Pharmacy
  Reengineering (PRE)
• Cathryn Herren Analyst, PRE
• Lina Bertuzis Analyst, PRE

3
PRE Background

• Many VHA technology problem areas and weaknesses
  identified
• Prior to 2001 First Consulting study
• Included patient safety issues
• SwRI awarded multi-year, fixed-price contract
• FY04 to develop new pharmacy system
• Period of performance ends September 2008

4
PRE Proof of Concept Demo

• December 14, 2006
• Purpose Demonstrate viability of Pharmacy
  Enterprise Product System (PEPS)
• Successfully interoperated VistA pharmacy with
  COTS database (First DataBank-FDB)

5
POC Summary

• Proof of Concept
• Demonstrated key functionality
• Identified major risks for production system
• Tested VistA - PRE info flow
• Validated refined PEPS system requirements
• Provided environment to evaluate VistA
  integration strategy
• Allowed Level of Effort (LOE) estimate adjustment
  for production build

6
POC Lessons Learned

• Proof of Concept showed
• Level of effort gt originally thought
• Testing Activities require significant time/
  resources
• HealtheVet (HeV) architecture not maturing as
  quickly as hoped
• Dramatic funding reductions significant project
  delays
• Cost estimates to continue current pace w/ SwRI
  greatly exceed original expectations

7
POC Testing Activities

• 2006 Testing
• Usability
• Functional Acceptance Test
• Code Evaluation
• 508 Compliance

8
FY07 - Changing Environment

• Entire VA Environment changed
• New Organizational Structure
• Continuing Resolution
• No Approved Budget (80 of FY06 Budget)
• Unable to move forward with New Contract with
  SwRI
• Generated Re-planning effort

9
PRE Versions

• PRE v0.5, v1.0 and Remaining Work
• V. 0.5 pre-release
• V. 0.5 Enhanced Order Checks
• V. 1.0 Pharmacy Enterprise Product System (PEPS)
• Beyond PRE V. 1.0

10
Risks

• Production environment
• Support staff
• Legacy system enhancements
• Performance
• COTS drug database licenses
• COTS drug database

11
Dependencies

• Standards Terminology Services (STS)
• SwRI
• CPRS
• COTS Drug Database
• Clinical Data Services (CDS)
• Cross-Application Integration Protocol (CAIP)

12
Beyond PRE v1.0

• Working with Business Owners
• Organize
• Prioritize
• Sequencing must consider
• Patient safety issues
• Funding requirements
• Availability of common services
• Ability of other applications to implement

13
PRE V. 0.5 Pre-Release

• Cathryn Herren

14
Background Information

• Current Order Checks to be enhanced
• Using First Data Bank (FDB)
• New Dosing Order Checks
• Using FDB
• National Drug File Connection to FDB
• GCNSEQNo in VA Product File

15
Why A Pre-Release

• Data required for FDB dosing checks
• Not currently in VistA
• FDB medication route for dosing
• FDB drug unit for dosing
• Numeric dose and corresponding unit for Local
  Possible Dosages
• Needs checking in VistA
• Administration Schedule Frequency

16
Medication Route Mapping

17
STANDARD MEDICATION ROUTE file (51.23)

• Standard Routes
• Created by Standards and Terminology Service
  (STS)
• Approved by Pharmacy Benefits Management (PBM)
• Mapped to FDB dose route table by STS
• To be exported as a Pharmacy Data Management
  (PDM) file

18
STANDARD MEDICATION ROUTE file (51.23)

• No local editing allowed
• Future updates by STS
• via New Term Rapid Turnaround (NTRT)

19
Mapping Local to Standard Medication Routes

• New field in MEDICATION ROUTES file (51.2)
• Pointer to STANDARD MEDICATION ROUTES file
  (51.23)
• Required only for Medication Routes marked for
  ALL PACKAGES
• In PACKAGE USE field (3)

20
Mapping Local to Standard Medication Routes

• Auto-population of new field
• Exact matches to Standard Medication Route
• Exact match to FDB route
• Mapped to Standard Medication Route for that
  entry

21
Mapping Local to Standard Medication Routes

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

22
Medication Route File Enter/Edit

• Modified for mapping to standard medication route
• User to get warning if route not mapped when
  required

23
Map Local Medication Route to Standard

• Option only for mapping to Standard Medication
  Route
• User selects route to map
• FDB route is displayed when mapping to Standard
• Displays mapping for a route already mapped
• Redisplays the mapping and FDB route after mapped
  to standard

24
Map Local Medication Route to Standard
Select Enhanced Order Checks Setup Menu Option 
Map Local Medication Route to Standard   Select
MEDICATION ROUTES NAME   OPHTHALMIC     
OPH OPHTHALMIC   Select STANDARD MEDICATION
ROUTES NAME O     1   OPTHALMIC    FDB Route
OPTHALMIC     2   ORAL    FDB Route
ORAL     3   OTIC     FDB Route OTICCHOOSE
1-3 1  OPTHALMIC  FDB Route OPTHALMIC  Local
Route 'OPHTHALMIC' has been mapped to
OPTHALMIC'  FDB Route OPTHALMIC'   Select
MEDICATION ROUTES NAME  SWISH AND SWALLOW     
SAS  SWISH AND SWALLOW   Already mapped to
OTIC'  FDB Route 'OTIC'   Select
STANDARD MEDICATION ROUTES NAME ORAL    FDB
Route ORAL   Local Route SWISH AND SWALLOW'
has been mapped to ORAL'   FDB
Route ORAL'    Select MEDICATION ROUTES NAME
ltEntergt  Select Enhanced Order Checks Setup Menu
Option
25
Find Unmapped Local Medication Routes

• Loops through unmapped medication routes for
  mapping to Standard Medication Route
• System displays routes to user for mapping
• FDB route is displayed when mapping to Standard

26
Find Unmapped Local Medication Routes

• Redisplays the mapping and FDB route after mapped
  to the standard
• If route not mapped, user is presented with next
  route requiring mapping
• User can enter to exit the loop

27
Find Unmapped Local Medication Routes
Select Enhanced Order Checks Setup Menu Option
Find Unmapped Local Medication Routes   This
option will find local Medication Routes marked
for 'ALL PACKAGES' not mapped to a Standard
Medication Route, and prompt you to map the local
route.This mapping is necessary to perform
Dosage checks.   Searching for unmapped Med
Routes  Mapping local Med Route of
'INHALATION'               Select STANDARD
MEDICATION ROUTES NAME ?    Answer with
STANDARD MEDICATION ROUTES NAME   Choose
from   INHALATION FDB Route
INHALATION   INTRA-ARTERIAL FDB Route
INTRA-ARTERIAL   INTRA-ARTICULAR FDB
Route INTRA-ARTICULAR '' TO STOP     Select
STANDARD MEDICATION ROUTES NAME INHALATION   
FDB Route INHALATION  Local Route 'INHALATION'
has been mapped to      INHALATION'   FDB
Route INHALATION'   Mapping local Med Route of
INTRA-ARTERIAL'      ltThe next local Med Route
that needs mapping is displayedgt   Select
STANDARD MEDICATION ROUTES NAME ltEntergt ltIf user
just enters ltretgt, the next unmapped local med
route is displayedgt   (Continued...)
28
Find Unmapped Local Medication Routes
 Mapping local Med Route of 'INTRA-ARTICULAR'    
      Select STANDARD MEDICATION ROUTES NAME
          Do you want to continue mapping Med
Routes? Y// NO       ltUser prompted if they want
to continue, since user entered ""
previouslygt   Checking for any remaining
unmapped Local Med Routes...  ltOn exit system
checks if all local med routes are
mappedgt   There are still local Med Routes marked
for 'ALL PACKAGES' not yet mapped. See
'Medication Route Mapping Report' option for more
details.                     lt System will
display this message if all not
mappedgt OR All local Med Routes marked for
ALL PACKAGES have been mapped. ltSystem will
display this message if all are mappedgt   Select
Enhanced Order Checks Setup Menu Option
29
Dosage Form File Enter/Edit

• Modified to not allow entry of a new Medication
  Route

30
Medication Routes Mapping Local to Standard

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

31
Medication Route Mapping Report

• Displays all medication routes requiring mapping
  or just unmapped medication routes
• Displays medication routes alphabetically
• Displays Standard Medication route when mapped

32
Medication Route Mapping Report

• Displays FDB route when mapped
• Displays Outpatient Expansion for the medication
  route

33
Medication Route Mapping Report
34
Medication Route Mapping Report
35
Medication Route Mapping History Report

• Report of mapping changes between local
  medication routes and standard medication routes
• Display all medication routes or a single
  medication route
• User selects time range

36
Medication Route Mapping History Report
37
Medication Route Mapping History Report
(User selects all medication routes )
This option provides a report that displays
changes made to mapping of Medication Routes in
the MEDICATION ROUTES file (51.2) to Medication
Routes in the STANDARD MEDICATION ROUTES file
(51.23). Print report for a Single Med Route,
or All Med Routes (S/A) Single // A All This
report will be sorted by Medication Route, and
within Medication Route will be sorted by
Date/time. A beginning and ending date must now
be entered for the search. Beginning Date
4-20-07 (ARP 20, 2007) Ending Date T (JUN 22,
2007) DEVICE HOME// P-35 Right Margin
80// ltEntergt Medication Route mapping changes
for ALL Medication Routes PAGE
1 made between APR 20, 2007 and JUN 22,
2007 ---------------------------------------------
------------------------------- Medication Route
BOTH EYES Date/time APR 25,
2007_at_083619 Edited by PHARMACY,RPH20
Old Value ltno previous valuegt
New Value INTRAOCULAR Date/time APR
25, 2007_at_083619 Edited by
PHARMACY,RPH20 Old Value INTRAOCULAR
New Value OPTHALMIC End of Report
38
Drug Units Mapping

39
Drug Units Mapping

• New field to associate possible dosages to FDB
  drug unit for dosing

40
Local Possible Dosages

• Two new fields added to DRUG file (50) within
  the LOCAL POSSIBLE DOSAGES multiple (904)
• UNITS FDB drug units for dosing
• NUMERIC DOSE a numeric representation of the
  dosage based on the unit defined

41
Local Possible Dosages

• Population of two new fields
• Not required for supply items
• Not required for FDB topical dosage forms
• Software to auto populate, if possible

42
Options for Population

• Enter/Edit Dosages
• Drug Enter/Edit
• Edit Local Possible Dosages
• Edit All Local Possible Dosages

43
Enter/Edit Dosages

• Modified to allow editing of the two new fields
• User to get a warning if the DRUG file (50)
  strength does not match the VA Product strength
• Redisplays data once entered

44
Drug Enter/Edit

• Modified to allow editing of the two new fields
• User to get a warning if the DRUG file (50)
  strength does not match the VA Product strength
• Redisplays data once entered

45
Edit Local Possible Dosages

• To allow editing of the two new fields
• User selects drug
• System prompts for entry of two new fields
• Redisplays data once entered

46
Edit All Local Possible Dosages

• Loops through local possible dosages eligible for
  dosage checks that do not have either the Numeric
  Dosage or Units entered
• System displays drug and local possible dosage
  requiring the needed fields
• System prompts for entry of two new fields

47
Edit All Local Possible Dosages

• Redisplays data once entered
• If no data is entered, user is asked if they want
  to continue
• User can enter to exit the loop

48
Reports

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

49
Strength Mismatch Report

• Displays dosage information
• For entries in the DRUG file (50) with local
  possible dosages whose strength is different
  than the strength of the VA Product match
• Displays strength of DRUG file (50) entry and
  strength of VA Product match entry
• Displays VA Product match entry

50
Strength Mismatch Report

• Select Pharmacy Data Management Option ENhanced
  Order Checks Setup Menu
•  
• Select Enhanced Order Checks Setup Menu Option
  STrength Mismatch Report
•  
• This report will print Dosage information for all
  entries in the DRUG (50)File that have a
  different Strength than what is in the VA Product
  (50.68)match. If these drugs have Local
  Possible Dosages, you need to be careful
  whensetting the new Units and Dosage field to be
  used for Dosage checks. This report can only
  identify Strength mismatches if the Drug has
  Possible Dosages, and the Strength has
  beenedited. This report cannot identify Strength
  mismatches where no Possible Dosageshave been
  created.
•  
•    This report is designed for 132 column format!
•  
• DEVICE HOME// ltEntergt
• Mismatched Strength Report
  Outpatient Expansion PAGE
  1------------------------------------------------
  -----------------------------------------
• (156) GUAIFENSESIN 100MG/5ML SYRUP
  Inactive Date
• Strength 50 Units
  Application Package OX
• Possible Dosages
• Dispense Units Per Dose 1 Dose
  50MG/2.5ML Package I
• Dispense Units Per Dose 2 Dose
  100MG/5ML Package I
• Local Possible Dosages
• 1 TEASPOONFUL Numeric Dose 100
  Units MG Package O
• 2 TEASPOONFUL(S) Numeric Dose 200
  Units MG Package O

51
Review Dosages Report

• Modified to display two new fields defined for
  Local Possible Dosages

Select Pharmacy Data Management Option ENhanced
Order Checks Setup Menu   Select Enhanced Order
Checks Setup Menu Option Review Dosages
Report   Select one of the following
A ALL S SELECT A
RANGE Print Report for (A)ll or (S)elect a Range
S// ALL This report will be for all drugs. Is
this correct? Y// ES     This report is designed
for 132 column format!   DEVICE HOME// ltEntergt
52
Review Dosages Report

• Dosage report for all drugs
  Outpatient Expansion
• --------------------------------------------------
  ---------------------------------------
• (699) GUAIFENESIN 100MG/5ML SYRUP
  Inactive Date
• Strength 100 Units
  Application Package OX
• Possible Dosages
• Dispense Units Per Dose 1 Dose
  100MG/5ML Package I
• Dispense Units Per Dose 2 Dose
  200MG/10ML Package I
• Local Possible Dosages
• 1 TEASPOONFUL Numeric Dose 100
  Units MG Package O
• 2 TEASPOONSUL(S) Numeric Dose 200
  Units MG Package O
• (2280) IBUPROFEN 300MG TAB N/F
  Inactive Date
• Strength 300 Units
  MG Application Package OX
• Possible Dosages (None)
• Local Possible Dosages
• 900MG Numeric Dose 900
  Units MG Package IO
• 1200MG Numeric Dose 1200
  Units MG Package IO

53
Local Possible Dosages Report

• Displays drugs in the DRUG file (50) with local
  possible dosages that have missing data in the
  numeric dose and units fields
• Excludes supplies and FDB topical dosage forms
• User can print all drugs or a specific alphabetic
  range of drugs

54
Local Possible Dosages Report

• Displays local possible dosage information
• Displays strength of NDF match (if strength does
  not match DRUG file (50) entry)
• Prints VA Product match when strength mismatch

55
Local Possible Dosages Report

•  Local Possible Dosages Report for Drugs G
  through G PAGE
  1------------------------------------------------
  -----------------------------------
• (30) GELUSIL TABLES
  Inactive Date
• Strength Units
  
• Local Possible Dosages
• 1 TABLET Numeric Dose Units
  Package I
• 2 TABLET(S) Numeric Dose Units
  Package I
• (156) GUAIFENSESIN 100MG/5ML SYRUP
  Inactive Date
• Strength 50 Units MG
  Application Package OUX
• Local Possible Dosages
• 1 TEASPOONFUL Numeric Dose Units
  Package IO
• 2 TEASPOONFUL(S) Numeric Dose Units
  Package IO
• Note Strength 50 does not match NDF strength of
  100.
• VA PRODUCT MATCH GUAIFENESIN 100MG/5ML SYRUP

56
Administration Schedule Frequency

• Administration Schedule File Report
• Displays
• Administration schedules (all or just those with
  no frequency defined)
• Standard administration times (ward specific
  administration times if defined)
• Outpatient Expansion
• Other Language Expansion
• Schedule Type
• Frequency (in Minutes)

57
Administration Schedule Frequency
ADMINISTRATION SCHEDULE FILE REPORT
Page 1 -----------------------------------
----------------------------------------- BID
STANDARD ADMINISTRATION TIMES 09-17 (rest of
administration times, if needed)
OUTPATIENT EXPANSION TWICE A DAY OTHER
LANGUAGE EXPANSION WARD 5NM WARD
ADMINISTRATION TIMES 08-16 (rest of
administration times, if needed)
WARD 6AS WARD ADMINISTRATION TIMES
10-22 (rest of administration times, if needed)
SCHEDULE TYPE CONTINUOUS
FREQUENCY (IN MINUTES) 720 MO-WE-FR
STANDARD ADMINISTRATION TIMES 09 (rest of
administration times, if needed) OUTPATIENT
EXPANSION TWICE A DAY OTHER LANGUAGE
EXPANSION WARD 5NM WARD
ADMINISTRATION TIMES 08 (rest of administration
times, if needed) SCHEDULE TYPE DAY OF THE
WEEK FREQUENCY (IN MINUTES) QD STANDARD
ADMINISTRATION TIMES 09 (rest of administration
times, if needed) OUTPATIENT EXPANSION
EVERY DAY OTHER LANGUAGE EXPANSION
WARD 5NM WARD ADMINISTRATION TIMES 10
(rest of administration times, if needed)
WARD 6AS WARD ADMINISTRATION TIMES 08
(rest of administration times, if needed)
SCHEDULE TYPE CONTINUOUS FREQUENCY (IN
MINUTES) 1440
58
Administration Schedule Frequency
ADMINISTRATION SCHEDULE WITHOUT FREQUENCY REPORT
Page 1 -----------------------------
------------------------------------------------
MO-WE-FR STANDARD ADMINISTRATION TIMES 09
(rest of administration times, if needed)
OUTPATIENT EXPANSION TWICE A DAY OTHER
LANGUAGE EXPANSION WARD 5NM WARD
ADMINISTRATION TIMES 08 (rest of administration
times, if needed) SCHEDULE TYPE DAY OF THE
WEEK FREQUENCY (IN MINUTES) Q3H
STANDARD ADMINISTRATION TIMES 03-06-09-12-15-18-2
1-24 (rest of administration times, if
needed) OUTPATIENT EXPANSION EVERY 3 HOURS
OTHER LANGUAGE EXPANSION SCHEDULE TYPE
CONTINUOUS FREQUENCY (IN MINUTES) End of
Report
59
New Menu

• Enhanced Order Checks Setup Menu option

Select Enhanced Order Checks Setup Menu Option
? Find Unmapped Local Medication
Routes Map Local Medication Route to
Standard Medication Route Mapping
Report Medication Route File
Enter/Edit Medication Route Mapping
History Report Edit All Local Possible
Dosages Edit Local Possible Dosages
Local Possible Dosages Report
Strength Mismatch Report Enter/Edit
Dosages Administration Schedule File
Report
60
PRE V. 0.5 Enhanced Order Checks

• Lina Bertuzis

61
Enhanced Order Checks

• Use FDB Drug Information Framework (DIF) APIs and
  database
• Enhance Existing Order Checks
• Drug-Drug
• Duplicate Drug
• Duplicate Class
• Add New Dosing Order Checks
• Max single daily dose range
• General Dosing range information

62
Enhanced Order Checks

• Incorporate Dosing Checks in Verification Process
• CPRS Order Checks added
• Order Check History
• New - Check Drug Interaction Option
• New Hidden Action Order Check vs. Med Profile
• Consistent Pharmacy Order Check Display

63
Enhanced Order Checks Plus

• Hidden Action - Intervention Menu
• Identify Recently Discontinued/Expired Orders
• Identify D/C and Hold Action

64
Order Checks Data Flow
65
Drug-Drug Interaction - FDB

• FDB Drug-Drug Interaction Module (DDIM)
• Supports drug products marketable in US
• Reports only most clinically significant
  interactions
• Evaluated at ingredient and route levels
• Four Severity levels
• classify drug interactions based on degree of
  patient risk
• do not incorporate level of documentation for an
  interaction

66
Drug-Drug Interaction - FDB

• Severity Level 1 Contraindicated Drug
  Combination
• Severity Level 2 Severe Interaction
• Severity Level 3 Moderate Interaction
• Severity Level 9 Undetermined Severity-
  Alternative Therapy Interaction

67
Drug-Drug Interaction - FDB

• Professional Interaction Monograph
• Monograph Title
• Severity Level
• Mechanism of action
• Clinical Effects
• Predisposing factors
• Patient Management
• Discussion
• References

68
Drug-Drug Interaction - FDB

• Consumer Interaction Monograph
• Monograph Title
• Medical Warning
• How the Interaction Occurs
• What Might Happen
• References

69
Drug-Drug Interaction - FDB

• Customization
• Severity level may be changed
• Clinical effect codes for the interaction may be
  changed
• Custom messages may be assigned to the
  interaction
• Custom interaction may be created

70
Enhanced Drug-Drug Interaction Order Check - VistA

• Continue to use VistA severity levels
• Critical
• Significant
• Customize FDB severity level and add custom
  interactions at National Level
• No change to current user actions in VistA

71
Enhanced Drug-Drug Interaction Order Check
VistA (continued)

• Provide new warning message
• Display VistA severity
• Short description of interactions clinical
  effects
• Provide optional display of detailed interaction
  monograph (professional)

72
Enhanced Drug-Drug Interaction Local Order Check
- Outpatient
73
Enhanced Drug-Drug Interaction Remote Order Check
- Outpatient
74
Enhanced Drug-Drug Interaction IV Order Check -
Inpatient
75
Enhanced Drug-Drug Interaction
76
Enhanced Drug-Drug Interaction (continued)
77
Professional Drug Monograph
78
Professional Drug Interaction Monograph
(continued)
79
Enhanced Drug-Drug Interaction Pharmacy Data
Management

• Modify Enter/Edit Local Drug Interaction option
• No changes to Drug Interaction file (56) locally
• Request severity change _at_ National
• Request add of drug interaction _at_ National
• Provide option to check if FDB link is up
• Notification when FDB link is down
• Provide report on order checks that could not be
  performed and that corrective action can be taken.

80
New Option Check Drug Interaction

• Allows user to check drug interactions between
  two or more drugs
• Provided on Outpatient Pharmacy Inpatient
  Medication (UD IV modules) menus
• Selection from DRUG file (50)

81
New Option Check Drug Interaction (continued)

• User will see the following information
• Numbered list of interacting drug pairs
• VistA severity
• Short description of drug interaction
• Detailed professional monograph (optional)
• Consumer interaction monograph (optional)

82
New Option Check Drug Interaction (continued)
83
New Option Check Drug Interaction (continued)
84
New Option Check Drug Interaction (continued)
85
New Option Check Drug Interaction (continued)
86
Duplicate Ingredient Duplicate Therapy Check -
FDB

• FDB Duplicate Therapy Module
• Duplicate Ingredient checking compares
  ingredients of the drugs
• Duplicate Therapy Class checking
• uses therapeutic drug classes developed
  specifically for duplicate therapy selection
• identifies drug groups involved and provides a
  duplicate therapy class name relative to the
  duplication

87
Duplicate Ingredient Duplicate Therapy Check
FDB (continued)

• Drugs assigned to one or more classes
• classification category MOA (e.g.
  Beta-Adrenergic Receptor Blockers, ACE
  inhibitors)
• classification category Therapeutic Indication
  (e.g. Anticonvulsants, Antimalarials)
• Each Duplicate Therapy Class is assigned a
  duplication allowance
• Customization
• Change duplication allowance for therapy class

88
Enhanced Duplicate Drug Duplicate Class Checks
- VistA

• VistA changes
• Use FDB Enhanced Therapeutic Classification
  instead of VA drug class (order checks only)
• Outpatient Pharmacy Application
• left current VistA duplicate drug check
• added FDB duplicate ingredient check
• replaced VistA class check with FDB duplicate
  therapy check
• combined duplicate ingredient therapy warnings
• no change in user actions to be taken

89
Local Duplicate Drug - Outpatient
90
Local Therapeutic Duplication - Outpatient
91
Local and Remote Therapeutic Duplication -
Outpatient
92
Local/Remote Therapeutic Ingredient Duplication
- Outpatient
93
Enhanced Duplicate Ingredient Duplicate Therapy
Checks - VistA

• VistA changes (continued)
• Inpatient Medications Application
• replaced duplicate drug with FDB duplicate
  ingredient
• replaced duplicate class with FDB duplicate
  therapy
• combined duplicate ingredient therapy warnings
• no change in user actions to be taken

94
Local Therapeutic Duplication Inpatient
95
Local/Remote Outpatient Orders Therapeutic
Duplication - Inpatient
96
Local Therapeutic and Ingredient Duplication -
Inpatient
97
Local Therapeutic and Ingredient Duplication
Inpatient (continued)
98
Therapeutic and/or Ingredient Duplication -
Inpatient
99
Dosage Checks - FDB

• Maximum Single Dose Check
• Daily Dosage Range Check
• General dosing range Common Indicator

100
Dosing Checks FDB (continued)

• Information required by FDB
• Patient parameters passed to API
• Age (in days) - required
• Weight (in Kg) only reqd for certain drug/age
  combos
• Body Surface Area (BSA in m2) using DuBois
  formula only reqd for certain drug/age combos

101
Dosing Checks FDB (continued)

• Order information passed to API
• Drug GCNSEQNO map to FDB
• Single Dose Amount Number or decimal value
• Dose Unit - FDB Dose Unit (from VistA Drug unit
  map)
• Dose Route FDB Dose Route (from VistA Med Route
  map)

102
Dosing Checks FDB (continued)

• Order information passed to API
• Dose Type Maintenance, Single Dose, etc
• Dose Rate DAY, HOUR, MINUTE
• Frequency - of Administrations per Day derived
  from VistA schedule
• Duration - of days dosing regimen administered
• Duration Rate DAY, HOUR, MINUTE
• Common dose indication when general dosing
  required.

103
Dosing Checks FDB (continued)

• FDB Dosing Checks screen out
• Topicals
• Medical Supplies

104
Dosage Checks - VistA

• VistA Changes
• Outpatient Pharmacy application
• For simple orders
• Dosing checks performed after conjunction prompt
• For complex orders
• Business rules defined for type of check(s)
  performed per dosing sequence
• Dosing checks performed after conjunction prompt

105
Dosage Checks - VistA (continued)

• User must log intervention to continue
• Screened out supply items
• Dosing Check unable to be performed against
  vendor database
• User informed
• Reason for failure provided

106
Dosage Checks - VistA (continued)

• VistA changes
• Inpatient Medications application
• Dosing checks after administration times prompt
• Business rules defined for type of check(s)
  performed for order types

107
Dosage Checks - VistA (continued)

• User must log intervention to continue
• Screened out supply items
• Dosing Check unable to be performed against
  vendor database
• User informed
• Reason for failure provided

108
Dosage Checks - VistA (continued)
109
Dosing ChecksPharmacy Data Management

• Pharmacy Data Management
• Add entries in APSP Intervention Type file
  (9009032.3)
• Exceeds Max Single Dose
• Exceeds Daily Dose Range
• Exceeds Max Single Dose Daily Dose Range

110
Outpatient Pharmacy Verification Options Dosing
Checks

• Verification Options modified to incorporate
  dosing checks
• Same business rules as critical drug interaction
• Dosing warning displayed, no action required
• Non-verified status assigned to order
• Warning displayed on Rx label

111
Verification OptionsDosing Checks

• Update Options
• Pharmacy Prescription Processing
• Complete Orders from OERR
• Rx Verification by Clerk
• Process Drug/Drug Interactions (renamed Process
  Order Checks)
• List Non-Verified Scripts

112
Verification OptionsDosing Checks (continued)
113
Verification OptionsDosing Checks (continued)
114
Verification OptionsDosing Checks (continued)
115
Verification OptionsDosing Checks (continued)
116
Verification OptionsDosing Checks (continued)
117
CPRS Order Checks Added

• CPRS Checks included in Pharmacy Checks
  (backdoor)
• Aminoglycoside Ordered
• Dangerous Meds for Pt over 64
• Glucophage- Lab Results

118
Order Check History

• Order check details stored
• Types of order checks included
• Clozapine order checks
• CPRS order checks (front door generated)
• Pharmacy order checks (backdoor generated)
• Viewable through Activity log (OP IP)

119
Order Check History Details
Information stored (depending on type of order/
order check)

• Date/Time
• Order Check Name
• Severity (drug-drug interactions)
• Interacting Rx   (OP orders)
• Interacting Drug(s)
• Dosage (if complex order)

• Warning message (text)
• Override Reason
• Override Provider
• Pharmacy Intervention IEN
• Pharmacy Intervention Recommendation

120
Order Check History Details
121
Order Checks Against Patient Active Medication
Profile

• A new ListMan hidden action - Medication profile
  screen
• User can perform order checks for one or more
  drugs against a patients active medication
  profile (IP OP)
• Drug selection from DRUG file 50

122
Order Checks Against Patient Active Medication
Profile (continued)

• Order checks performed
• Drug-Drug
• Duplicate Ingredient
• Duplicate Therapy
• Allergy/Adverse drug reaction (ADR) - against
  VistA database
• Users can select order statuses to check against

123
Order Checks Against Patient Active Medication
Profile (continued)

• Optional detailed drug interaction monograph
  (consumer and professional)
• For Inpatient Profile output - A list of drugs
  (from the outpatient profile) common to both
  inpatient outpatient profiles

124
Order Checks Against Patient Active Medication
Profile (continued)
125
Order Checks Against Patient Active Medication
Profile (continued)
126
Order Checks Against Patient Active Medication
Profile (continued)
127
Order Checks Against Patient Active Medication
Profile (continued)
128
Order Checks Against Patient Active Medication
Profile (continued)
129
Pharmacy Order Check Display Order

• Make display order consistent between Outpatient
  and Inpatient
• When finishing pending orders
• Entering new orders via backdoor
• Allow user action after display - Inpatient
• Minimize performance issues
• Decrease Number of Warning Displays

130
Enhance Allergy/ADR Order Check Display

• Display the same order check information for
  Outpatient Pharmacy and Inpatient Medication
  applications
• Combine Local and Remote Allergy/ADR warnings

131
Enhance Allergy/ADR Order Check Display
(continued)
132
Pharmacy Order Check Display Order

• Outpatient Pharmacy
• Allergy/ADR (local and remote combined)
• CPRS order checks (new)
• Local Critical and Significant drug interactions
• Remote Drug Interactions
• Local Remote Duplicate Therapy/Duplicate
  Ingredient or Drug
• Dosing Checks

133
Pharmacy Order Check Display Order (continued)

• Inpatient Medications
• Allergy/ADR (local and remote combined)
• CPRS order checks (new)
• Local Critical and Significant drug interactions
• Outpatient Medication Orders (local and remote)
  Drug Interactions
• Duplicate Therapy - Local Inpatient, Outpatient
  Local Remote
• Duplicate Therapy/Duplicate Local Inpatient,
  Outpatient Local Remote
• Dosing Checks

134
Intervention Hidden Action

• Provide Intervention Menu Hidden Action to
• Delete an intervention
• Edit an intervention
• Enter an intervention
• Print an intervention
• View an intervention

135
Intervention Hidden Action (continued)

• Place on Outpatient and Inpatient ListMan screens
• Patient Information
• Medication Profile
• Detailed Order

136
Discontinued/Expired Medication Orders

• Identify Recently Discontinued/Expired Orders on
  Medication Profile
• Outpatient Pharmacy
• Displayed via reverse video
• Inpatient Medications
• Listed under New profile sub header

137
Discontinued/Expired Medication Orders (continued)

• Provide parameters to define recently
  discontinued/expired timeframe
• Outpatient Pharmacy
• Outpatient Site Parameter (7- 45 day range If
  no value assigned, system assumes 7 days)
• Use Site Parameter Enter/Edit option

138
Discontinued/Expired Medication Orders (continued)

• Inpatient Medications
• System Parameters (1-120 hour range, If no value
  assigned, system assumes 24 hours)
• Use Systems Parameter Edit option
• Ward Parameters (1-120 hour range no default
  takes precedence over system parameter value)
• Use Inpatient Ward Parameters Edit option

139
Discontinued/Held Medication Orders

• Quick identification of action by which orders
  were discontinued/held
• Display new code on medication profile
• No change in order status

140
Discontinued/Held Medication Orders (continued)

• Outpatient Discontinue Type Codes
• DF Discontinued due to edit by provider through
  CPRS
• DE Discontinued due to edit via backdoor
  Pharmacy
• DP Discontinued by provider through CPRS
• DC Discontinued via backdoor Pharmacy
• DD Discontinued due to death
• DA Auto discontinued due to admission

141
Discontinued/Held Medication Orders (continued)

• Inpatient Discontinue Type Codes
• DF Discontinued due to edit by a provider
  through CPRS
• DE Discontinued due to edit via backdoor
  Pharmacy
• DP Discontinued by provider through CPRS
• D Discontinued via backdoor Pharmacy
• DD Auto discontinued due to death
• DA Auto discontinued due to patient movements

142
Discontinued/Held Medication Orders Hold Action

• Hold Action Type Codes (Outpatient Inpatient)
• HP Placed on hold by provider through CPRS
• H Placed on hold via backdoor Pharmacy

143
Outpatient Medication Profile
144
Inpatient Medication Short Profile
145
Inpatient Medication Long Profile
146
PRE V. 1.0 Pharmacy Enterprise Product System
(PEPS)

• Cathryn Herren

147
PRE 1.0 Focus
148
General Information

• Replacement for National Drug File (NDF) and
  Pharmacy Data Management (PDM) applications
• Involves integration with COTS
• Involves integration with VistA

149
PEPS Roles

• PEPS National Manager
• Manages PEPS items at an enterprise level
• Reviews new item requests
• Reviews new COTS items
• Determines state of VA Data Fields
• PEPS Local Manager
• Manages PEPS items at a local level
• Requests new item additions
• Determines values of VA Data Fields for local use

150
PEPS Functionality

• Search Items
• Add Items
• Review Items
• Manage Items
• VistA File Synchronization

• Examine PEPS
• Order Checks
• VA Data Fields

151
Add New Item

• Search PEPS
• Local and National
• Enter using existing item as template
• Local and National
• Enter without using existing item as template
• Local and National

152
Add New Item (continued)

• Mark Item for local use (Local)
• Product entered into Local Drug file (50)
• Orderable Item Auto Created
• Vista Notification to requestor and locally
  created mail group
• Request sent to National PEPS Manager (Local)
• Ability to Lock down VA Data Fields (National)

153
Review Requests at National

• List of pending requests ready for review
• Makes data edits as needed
• Ability to lock down VA Data Fields
• Second Review prior to approval

154
Review Approved by National

• National and local NDF updated
• PDM files updated if marked for local use
• Auto Match to NDF
• Orderable Item Auto Created (if changed)
• VistA Notification of NDF and PDM update sent to
  local

155
Review Rejected by National

• National NDF Local NDFs NOT updated
• IF product had been marked for local use at
  requesting facility
• Unmarked for local use in PEPS
• Inactivated in Drug File 50
• VistA Notification of PDM update sent to local
• Includes orders containing the product

156
Manage Items at Local

• Mark for Local Use
• Edit VA Data Fields
• Product entered into Local Drug file (50)
• Orderable Item Auto Created
• Vista Notification to requestor and locally
  created mail group

157
Manage Item at Local (continued)

• Edit VA Data Fields
• For items previously marked for local use
• Unmark for Local Use
• Item inactivated in Local Drug File 50
• Vista Notification to requestor and locally
  created mail group

158
Manage Items at National

• Edit VA Data Fields
• Ability to Lock Down VA Data Fields
• Ability to have second review
• National NDF and Local NDFs updated once approved
  by second review
• PDM files updated locally if marked for local use
• VistA Notification of NDF and PDM update sent to
  local

159
National Review of COTS Update

• List of COTS Items Pending Review
• Makes VA specific data edits as needed
• Ability to lock down VA Data Fields
• Second Review prior to approval
• National NDF and Local NDFs updated once approved
  by second review
• VistA Notification of NDF update sent to local

160
VA Data Fields - PEPS

• Data fields stored in PEPS, but not in VistA
• Data pulled from PEPS for use in VistA Pharmacy
  applications
• Outpatient Pharmacy
• Inpatient Medications
• Automatic Replenishment/Ward Stock
• BCMA

161
Lab Results/Vital Measurements Display

• Define for a specific product in the EPL
• Lab test, specimen, functional area
• Vital measurement, functional area
• Information displayed in
• Outpatient Pharmacy
• Inpatient Medications
• BCMA

162
Lab Results/Vital Measurements Display (continued)

• An indicator ! in reverse video is shown on the
  medication profile and detailed order display
• No indicator if order status is expired or
  discontinued

163

Lab Results/Vital Measurements Display (continued)

• Where Lab results/vital measurements are
  displayed based on functional area defined
• Order Entry
• Finishing a Pending order
• Medication Administration (BCMA)
• Information displayed before order checks
  performed

164
Lab Results/Vital Measurements Display (continued)

• Three new hidden actions
• LAB Lab Results
• VIT Vital Measurements
• LV Latest Lab/Vital
• All hidden actions available from medication
  profile detailed order screens

165
Lab Results/Vital Measurements Display (continued)

• Parameters provided to set a default
• System/Ward level for Inpatient Medications
• System/Outpatient Site level for Outpatient
  Pharmacy
• Occurrence Limit (LAB VIT)
• Time limit (LAB VIT)

166
Do Not MailOutpatient Pharmacy

• Currently user can indicate that Patients meds
  cannot be mailed
• Added functionality
• Identify products in EPL that cannot be mailed
• Pharmacy Orderable Items for a patient that
  cannot be mailed (VistA)
• Patient for which Controlled Subs cannot be
  mailed (VistA)

167
Do Not MailOutpatient Pharmacy (continued)

• If patient/drug marked Do Not Mail
• Mail routing defaults to Window
• User cannot edit routing
• Patient or drug for patient is DO NOT MAIL
  displayed
• During various order entry process (finishing,
  editing, renewing, etc)
• On detailed display of order

168
Dispense Limit (Qty)Outpatient Pharmacy

• Maximum quantity to dispense (number) for a
  specific time period (days) defined in EPL for a
  product
• Used to calculate default quantity for an order
  if value defined in EPL lt result using schedule
  days supply values
• If user enters a quantity exceeding this value
• warning message is displayed
• Override reason required
• Override reason stored with each Rx fill

169
Dispense Limit (Days Supply) Outpatient Pharmacy

• Maximum days supply limit for product identified
  in the EPL
• Maximum upper limit for a drug 90 days
• Maximum upper limit for a supply 365 days
• Default upper limit for a CS 30 days

170
Dispense Limit (Days Supply) Outpatient Pharmacy

• Limit Days Supply (new field)
• Created in Rx Patient Status file 53
• Data type set of codes (Y/N)
• Export with value of Yes for
• AUTH ABS 96
• AUTH ABS -96
• EMPLOYEE
• Rx Patient Status Enter/Edit (new option)
• Created to maintain all fields in Rx Patient
  Status file 53

171
Dispense Limit (Days Supply) Outpatient Pharmacy

• During order entry, the days supply default will
  be
• Days supply defined for Rx Patient Status (order)
  if Limit Days Supply field is set to Yes
• Dispense limit (days supply) if defined in EPL
  for the product when Limit Days Supply field is
  set to No or null
• Days supply defined for Rx Patient Status (order)
  if dispense limit (days supply) IS NOT defined in
  the EPL for the product

172
Product Storage Requirements

• Product Identified in EPL
• Protect from light
• Inpatient Medications
• IV label
• Requiring refrigeration
• Inpatient Medications
• Unit Dose Pick List Updated Pick List
• Pre-exchange Unit Report
• Automatic Replenishment/Ward Stock (AR/WS)
• Pick List

173
Patient Specific Labels

• Product Identified in EPL
• Inpatient Medications
• Pre-exchange Unit Report
• Extra Units Dispensed
• BCMA
• Missing Dose e-mail and printed copy

174
New BCMA Functionality

• Provides a means to quickly identify
• Controlled Substances
• Drugs that require a witness (2nd signature) and
  capture the 2nd signature
• High-Risk drugs that require follow-up and
  document the follow-up action
• Display Lab and Vital information based on the
  drug being administered
• Create/modify BCMA reports to support this
  functionality

175
BCMA - Visual Queues

• Provide a means to quickly identify...
• Three new icons have been added to BCMA to
  quickly relay information related to a specific
  administration or order
• Controlled Substance
• Drug that requires a Witness (2nd signature)
• High-Risk drug requiring a Follow-Up

176
Questions?