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PRE-MOCHA

Pharmacy Reengineering Update August 2011 Amy K. Colón, R.Ph. Clinical Analyst, PBM Michael J. Martinko, R.Ph. Clinical Analyst, PBM. PRE-MOCHA. Medication Order Check Healthcare Application MOCHA is the first increment of Pharmacy Reengineering to be released to VAMCs

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PRE-MOCHA

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  1. Pharmacy Reengineering UpdateAugust 2011Amy K. Colón, R.Ph.Clinical Analyst, PBMMichael J. Martinko, R.Ph.Clinical Analyst, PBM

  2. PRE-MOCHA Medication Order Check Healthcare Application • MOCHA is the first increment of Pharmacy Reengineering to be released to VAMCs • Data comes from a commercial database, First DataBank (FDB), and from a VA Pharmacy Enterprise Customization System (PECS) • MOCHA 1 - Non-dosing, enhanced order checks • MOCHA 2 - Dosing checks

  3. Pharmacy Reengineering Overview Outpatient Pharmacy MOCHA v2.0

  4. Types of Dosage Information • Max single dose – this is the individual dose amount, whether it is given once a day or 24 times a day • Total daily dose – Dose x Frequency (per 24h) • General Dosage Range – Is provided when there is a problem with the order and dosage checks cannot be performed

  5. CPRS Dose Checks for an Outpatient Order

  6. Outpatient Single Dose Warning Order details: Orderable Item: METFORMIN HCL TAB,ORAL Dosage Ordered: 3000 (MG) Dispense Units: 6 Noun: TABLETS Route: ORAL (BY MOUTH) Schedule: BID-WF Dose warning text: METFORMIN HCL 500MG TAB: Single dose amount of 3000 MILLIGRAMS exceeds the maximum single dose amount of 1000 MILLIGRAMS.

  7. Dose Warning for Multi-Ingredient Drug Order details: Orderable Item: CARBIDOPA/LEVODOPA TAB,SA Dosage Ordered: 5 TABLETS Route: ORAL (BY MOUTH) Schedule: TID SIG: TAKE 5 TABLETS BY MOUTH THREE TIMES DAILY Dose warning text: CARBIDOPA 25/LEVODOPA 100MG TAB: Single dose form amount of 5 TABLET(S) exceeds the maximum single dose form amount of 2 TABLET(S).

  8. Dose Checks Calculations Dependent on Body Surface Area or Weight Data Patient data: DOB: MAR 13,1944 (66) Ht(cm): 182.88 (12/04/2010) Wt(kg): 81.82 (12/04/2010) Dose warning text: ENOXAPARIN 40MG/0.4ML INJ SYRINGE 0.4ML: Single dose amount of 400 MILLIGRAMS exceeds the maximum single dose amount of 129 MILLIGRAMS.

  9. Error Message for Dose Not Performed Order details: Orderable Item: METOPROLOL TAB Dosage Ordered: 500MG Route: ORAL (BY MOUTH) Schedule: Before sunrise SIG: TAKE TESTING DOSE TABLET(S) BY MOUTH TWICE A DAY Dose warning text: Dosing Checks could not be performed for Drug: METOPROLOL SUCCINATE 100MG SA TAB Reason(s): Invalid or Undefined Frequency General dosing range for METOPROLOL SUCCINATE 100MG SA TAB (ORAL): 12.5 MG/DAY to 400 MG/DAY

  10. Factors Used to Derive a Recommended Dose • Patient Age • Height/Weight/BSA (when applicable) • Dose Form • Dose Unit • Medication Route • Frequency

  11. Factor: Patient Age • Recommended doses vary according to a patient’s age • FDB stores dose data according to patient age • Doses are not always established and available for a certain age, but this is more common with pediatric dosing than geriatric dosing

  12. Factor: Patient Height, Weight, BSA • Calculated doses for specific drugs are done when a weight or BSA value is relevant in the determination of an appropriate dose • Some drug dosages are only weight/BSA dependent for specific age groups (i.e. weight may be relevant on a 90 year old, but not on a 50 year old

  13. Factor: Dose Form • Doses are stored differently based on the drug’s dosage form (i.e. oral, IV, transdermal) • Some dosage forms are excluded from order checks (i.e. creams, ointments)

  14. Factor: Dose Units • The dose unit on an order must either match the unit that FDB has stored, or else be able to convert to that unit. • If the dose unit does not match the FDB dose unit, then the order check will not occur and an error message will display • FDB stores 2 different types of dose units in their dosing table – “Mass type”units and “Dose form” type units

  15. Sub-factor: Mass Type Dose Units • Generally used for single ingredient drugs that are administered via po, SC, or IM • The most common type of dose unit (mg, gm, units) • Possible types of FDB Dose Unit Conversions • Metric conversions – wide range (i.e.. mcg to mg) • Numeric conversions between standard units and metric units (i.e. Cm to In, Oz to Tsp, Tsp to mL, MMU to IU)

  16. Sub-factor: Dose Form Type Dose Units • Dose form type units – Used for non-posolids (patches, inhalers), multi-ingredient drugs • FDB selects the type of dose units for an item • Patch dose unit is “ 1 patch”, rather than 75mcg • Inhaler dose units are variable and include inhalations, sprays, puffs, etc. Currently, they sometimes also include metric doses. • On the contrary, drug that dosage forms of suppositories or packets, are dosed in “mass type” units

  17. Possible Dose Units Conversions • Metric conversions – wide range (i.e.. mcg to mg) • Numeric conversions between standard units and metric units (i.e. Oz to Tsp, Tsp to mL, MMU to IU) • Non-metric allowable conversions: • “EA” is a flexible term relating to the dose form. If dose form is packet, then “EA” is considered to be 1 unit of that dose form(i.e. EA to Packet) • FDB has a limited capability to convert from one dose form type unit to another dose-form type unit (spray=inhalation=puff)

  18. Non-Standard Doses • Fractional doses – no problem • Free-text doses – different assumptions in CPRS vs. backdoor, because of the way that a dispense drug is selected in each package • The pharmacy packages can perform some sophisticated auto-population logic for free-text doses (i.e. three and one-half tablets = 3.5 tablets). If a match cannot be determined, then no order check will be performed

  19. Factor: Medication Route • If a medication route is not accurately mapped, then a dose check will not occur • FDB Doses are tied to specific routes (IV vs IM), error messages will display if an invalid route is selected • Sometimes FDB is too limiting with its expected med route. • Ie. Transdermal vs. Topical (Patches) • Ie. Nebulization vs. Inhalation (Albuterol Solution)

  20. Factor: Frequency • Used to calculate a total daily dose • If an order for a long acting injectable drug is written with a schedule that is too frequent, then the user will be warned of the frequency issue. • Two new fields were created in file 51.1 • EXCLUDE FROM ALL DOSING CHECKS: • EXCLUDE FROM DAILY DOSE CHECK:

  21. Dose Check Exclusions • Supplies (bandages, syringes) • Compounded items not matched to NDF • Large volume IV solutions • Items that don’t require a dose check, but that have a dosage form that does generate checks • Drugs with excluded dosage forms (i.e.. creams, ointments) but, the exclusion can be overridden at the NDF level

  22. MOCHA 2 Preparation Summary Review and update the following: • Unmatched drug file entries • DEA/special handling field • Standard schedule file • Med route mappings • Orderable item medication route defaults for potentially problematic dosage forms • Local possible doses Guidance lists for FDB exceptions will be provided…

  23. Pharmacy Reengineering Overview Inpatient Pharmacy MOCHA v2.0

  24. Inpatient Pharmacy Dosage Checks • Same factors as Outpatient (backdoor VistA or CPRS order entry) • Patient age • Height/Weight/BSA (when applicable) • Dose form • Dose unit • Medication Route • Frequency • Duration • Rate

  25. Inpatient Dosage Check Triggers (1) Note that the triggers for dosing are different than triggers for MOCHA v1.0 enhanced order checks • Entering a new IV or Unit Dose medication order through pharmacy options • Finishing a pending IV or Unit Dose medication order • Renewing an IV or Unit Dose order • Creating a new Unit Dose order when editing the orderable item (to a new orderable item) through pharmacy options • When editing the IV additive fields (changing existing additive or adding new additive) for an IV order through pharmacy options • When editing the IV solution fields (changing existing solution or adding a new solution) for an IV order through pharmacy options -This applies only to IV solutions marked as a PreMix. • Entering a new Unit Dose medication order through pharmacy options using order sets

  26. Inpatient Dosage Check Triggers (2) • Editing the following for a Unit Dose order: • Dosage Ordered • Units per Dose (for Dispense Drug) • Med Route • Schedule • Editing the following for an IV order • Infusion rate (only applies to IV types of ‘Admixture’, ‘Hyperal’, ‘Chemotherapy Admixture’, ‘Continuous Syringe’ or ‘Chemotherapy Continuous Syringe’) • Schedule (only applies to IV types of ‘Piggyback’, ‘Intermittent Syringe’, ‘Chemotherapy Piggyback’, or ‘Chemotherapy Intermittent Syringe’) • Med Route • Volume (does not apply to orders with IV types of ‘Piggyback’, ‘Intermittent Syringe’, ‘Chemotherapy Piggyback’, or ‘Chemotherapy Intermittent Syringe’ with IV Solution not marked as PreMix)

  27. CPRS Dose Checks - Inpatient

  28. CPRS Dose Checks - Inpatient Order #1

  29. CPRS Dose Checks - Inpatient Order #1

  30. CPRS Dose Checks - Inpatient Order #1

  31. Inpatient Order #1 MJMTESTFRANK,SIX F Ward: C MEDIC PID: 666-66-6696 Room-Bed: 327-1 Ht(cm): 172.72 (03/24/10) DOB: 06/06/21 (90) Wt(kg): 60.45 (03/24/10) Sex: MALE Admitted: 03/24/10 Dx: ADVANCED PSYCHOSIS Last transferred: ******** - - - - - - - - - - - - - - - - - A C T I V E - - - - - - - - - - - - - - - - - 1 ASPIRIN TAB,EC C 06/28 07/28 A Give: 325MG PO QD-(EVERY DAY) - - - - - - - - - - - - - - - - P E N D I N G - - - - - - - - - - - - - - - - 2 LITHIUM CARBONATE CAP,ORAL ? ***** ***** P Give: 600MG PO BID-WF Enter ?? for more actions PI Patient Information SO Select Order PU Patient Record Update NO New Order Entry Select Action: Quit//

  32. Inpatient Order #1 MJMTESTFRANK,SIX F Ward: C MEDIC PID: 666-66-6696 Room-Bed: 327-1 Ht(cm): 172.72 (03/24/10) DOB: 06/06/21 (90) Wt(kg): 60.45 (03/24/10) Sex: MALE Admitted: 03/24/10 *(1)Orderable Item: LITHIUM CARBONATE CAP,ORAL Instructions: 600MG *(2)Dosage Ordered: 600MG Duration: (3)Start: 07/13/11 14:22 *(4) Med Route: ORAL (BY MOUTH) REQUESTED START: 07/13/11 17:30 (5) Stop: 08/12/11 18:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: BID-WF (9) Admin Times: 0730-1730 *(10) Provider: MARTINKO,MICHAEL [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date LITHIUM CARBONATE 300MG CAP 2 (7)Self Med: NO Entry By: MARTINKO,MICHAEL Entry Date: 07/13/11 14:22

  33. Inpatient Order #1 CPRS Order Checks: LITHIUM CARBONATE CAP,ORAL : Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Overriding Provider: MARTINKO,MICHAEL Overriding Reason: High Dose testing purposes MJM ORDER NOT VERIFIED Enter ?? for more actions BY Bypass FL Flag DC Discontinue FN Finish Select Item(s): Quit//

  34. Inpatient Order #1 CPRS Order Checks: LITHIUM CARBONATE CAP,ORAL : Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Overriding Provider: MARTINKO,MICHAEL Overriding Reason: High Dose testing purposes MJM ORDER NOT VERIFIED Enter ?? for more actions BY Bypass FL Flag DC Discontinue FN Finish Select Item(s): Quit// FN Finish

  35. Inpatient Order #1 CPRS Order Checks: LITHIUM CARBONATE CAP,ORAL : Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Overriding Provider: MARTINKO,MICHAEL Overriding Reason: High Dose testing purposes MJM ORDER NOT VERIFIED Enter ?? for more actions BY Bypass FL Flag DC Discontinue FN Finish Select Item(s): Quit// FN Finish Now Processing Enhanced Order Checks! Please wait... Press Return to continue...

  36. Inpatient Order #1 CPRS Order Checks: LITHIUM CARBONATE CAP,ORAL : Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Overriding Provider: MARTINKO,MICHAEL Overriding Reason: High Dose testing purposes MJM ORDER NOT VERIFIED Enter ?? for more actions BY Bypass FL Flag DC Discontinue FN Finish Select Item(s): Quit// FN Finish Now Processing Enhanced Order Checks! Please wait... Press Return to continue... LITHIUM CARBONATE 300MG CAP: Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Do you want to Continue? NO//

  37. Inpatient Order #1 CPRS Order Checks: LITHIUM CARBONATE CAP,ORAL : Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Overriding Provider: MARTINKO,MICHAEL Overriding Reason: High Dose testing purposes MJM ORDER NOT VERIFIED Enter ?? for more actions BY Bypass FL Flag DC Discontinue FN Finish Select Item(s): Quit// FN Finish Now Processing Enhanced Order Checks! Please wait... Press Return to continue... LITHIUM CARBONATE 300MG CAP: Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Do you want to Continue? NO// YES

  38. Inpatient Order #1 Do you want to Continue? NO// YES Now creating Pharmacy Intervention For LITHIUM CARBONATE 300MG CAP PROVIDER:

  39. Inpatient Order #1 Do you want to Continue? NO// YES Now creating Pharmacy Intervention For LITHIUM CARBONATE 300MG CAP PROVIDER: PROVIDER: MARTINKO,MICHAEL MJM 192 OI&T STAFF RECOMMENDATION: NO CHANGE See 'Pharmacy Intervention Menu' if you want to delete this intervention or for more options. Would you like to edit this intervention? N// YES PROVIDER: MARTINKO,MICHAEL// PHARMACIST: MARTINKO,MICHAEL// DRUG: LITHIUM CARBONATE 300MG CAP// INSTITUTED BY: PHARMACY// INTERVENTION: MAX SINGLE DOSE// <<<<<<<<<<<<<<<<<< DOSE// <<<<<

  40. CPRS Dose Checks - Inpatient Order #2

  41. CPRS Dose Checks - Inpatient Order #2

  42. CPRS Dose Checks - Inpatient Order #2

  43. Inpatient Order #2 MJMTESTFRANK,SIX F Ward: C MEDIC PID: 666-66-6696 Room-Bed: 327-1 Ht(cm): 172.72 (03/24/10) DOB: 06/06/21 (90) Wt(kg): 60.45 (03/24/10) Sex: MALE Admitted: 03/24/10 Dx: ADVANCED PSYCHOSIS Last transferred: ******** - - - - - - - - - - - - - - - - - A C T I V E - - - - - - - - - - - - - - - - - 1 ASPIRIN TAB,EC C 06/28 07/28 A Give: 325MG PO QD-(EVERY DAY) - - - - - - - - - - - - - - - - P E N D I N G - - - - - - - - - - - - - - - - 2 in NITROGLYCERIN 25MG/D5W 250 ML TITRATE ? ***** ***** P Enter ?? for more actions PI Patient Information SO Select Order PU Patient Record Update NO New Order Entry Select Action: Quit//

  44. Inpatient Order #2 MJMTESTFRANK,SIX F Ward: C MEDIC PID: 666-66-6696 Room-Bed: 327-1 Ht(cm): 172.72 (03/24/10) DOB: 06/06/21 (90) Wt(kg): 60.45 (03/24/10) Sex: MALE Admitted: 03/24/10 *(1) Additives: Type: ADMIXTURE *(2) Solutions: NITROGLYCERIN 25MG/D5W 250 ML IV Limit: 3 days (4) Start: 07/14/11 10:42 *(3) Infusion Rate: TITRATE@1 *(5) Med Route: IV (6) Stop: 07/17/11 24:00 *(7) Schedule: Last Fill: ******** (8) Admin Times: Quantity: 0 *(9) Provider: MARTINKO,MICHAEL [es] Cum. Doses: (10) Other Print: (11) Remarks : IV Room: CHEYENNE RM#272 Entry By: MARTINKO,MICHAEL Entry Date: 07/14/11 10:42 DC Discontinue FL Flag ED Edit FN Finish Select Item(s): Next Screen//

  45. Inpatient Order #2 CPRS Order Checks : Maximum Single Dose Check could not be done for Drug: NITROGLYCERIN 25MG/D5W INJ,SOLN 250 ML, please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL Enter ?? for more actions DC Discontinue FL Flag ED Edit FN Finish Select Item(s): Quit//

  46. Inpatient Order #2 CPRS Order Checks : Maximum Single Dose Check could not be done for Drug: NITROGLYCERIN 25MG/D5W INJ,SOLN 250 ML, please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL Enter ?? for more actions DC Discontinue FL Flag ED Edit FN Finish Select Item(s): Quit// FN Finish IV TYPE: ADMIXTURE// Select ADDITIVE:

  47. Inpatient Order #2 CPRS Order Checks : Maximum Single Dose Check could not be done for Drug: NITROGLYCERIN 25MG/D5W INJ,SOLN 250 ML, please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL Enter ?? for more actions DC Discontinue FL Flag ED Edit FN Finish Select Item(s): Quit// FN Finish IV TYPE: ADMIXTURE// Select ADDITIVE: Now Processing Enhanced Order Checks! Please wait... Press Return to continue...

  48. Inpatient Order #2 CPRS Order Checks : Maximum Single Dose Check could not be done for Drug: NITROGLYCERIN 25MG/D5W INJ,SOLN 250 ML, please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL Enter ?? for more actions DC Discontinue FL Flag ED Edit FN Finish Select Item(s): Quit// FN Finish IV TYPE: ADMIXTURE// Select ADDITIVE: Now Processing Enhanced Order Checks! Please wait... Press Return to continue... Maximum Single Dose Check could not be performed for Drug: NITROGLYCERIN 25MG/D5W 250 ML Reason: Unable to convert rate. Press Return to continue...

  49. CPRS Dose Checks - Inpatient Order #3

  50. CPRS Dose Checks - Inpatient Order #3

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