5 th Annual PBM Pharmacy Informatics Conference

1. 5th Annual PBM Pharmacy Informatics Conference Are You Ready for MOCHA V 2.0? Jim Hewins, Kansas City MO Dionne Roney, Charleston SC DATE/MONTH 2012

2. MOCHA 2.0 Objectives • Discuss the timeline the sites will need to consider prior to implementing MOCHA V 2.0 • Explain the tasks that need to be completed prior to implementing MOCHA V 2.0 • Describe the setup for doses to enable the dose checks to occur properly • Explain how to trouble shoot problem order checks

3. 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

4. MOCHA 2.0 – four increments • Increment A - Maximum single dose check for simple and complex medication orders. First increment to be released • Increment B - Daily dose range check. Includes general dosing information when a dosing check cannot be performed – simple orders only • Increment C - Daily dose range for complex orders. Includes general dosing information when a dosing check cannot be performed • Increment D - TBD

5. MOCHA 2.0 • Both Outpatient Pharmacy and Inpatient Medications • Provides error messages with reasons at the order level when a Maximum Single Dose Order Check cannot be performed for Pharmacy users • Provides a generic error message at the order level when Maximum Single Dose Order Check cannot be performed for CPRS users • Adds a check during installation to see if Pre-Release setup work has been completed (PSS*1*129 & PSS*1*147, PRE v0.5 PRE-RELEASE patches).

6. MOCHA 2.0 • Adds new fields to the Administration Schedule file (#51.1) • Modify Standard Schedule Edit (PSS Schedule Edit) option to allow editing of the new dosing exclusion fields • Modify Administration File Report (PSS Schedule Report) • Apply the ‘all Dosage Checks exclusion’ for a schedule when processing outpatient and inpatient medication orders • Creates a new Pharmacy Data Management (PDM) option called Lookup Dosing Check Info for Drug • Adds new entries to the VistA DOSE UNIT file (51.24)

7. CPRS versus Vista Order Checks Maximum Single Dose Check could not be performed for Drug: IPRATROPIUM BROMIDE 17MCG 200D ORAL INHL Reason: No dosing information found in database.

8. Dose Warning for Single Ingredient Drug Order details: Orderable Item: METFORMIN HCL TAB,ORAL Dosage Ordered: 3000 (MG) Dispense Units: 3 Noun: TABLETS Route: ORAL (BY MOUTH) Schedule: BID-WF Dose warning text: METFORMIN HCL 1000MG TAB: Single dose amount of 3000 MILLIGRAMS exceeds the maximum single dose amount of 1000 MILLIGRAMS.

9. Dose Warning for Multi-Ingredient Drug Order details: Orderable Item: HYDROCHLOROTHIAZIDE/LISINOPRIL Dosage Ordered: 5 TABLETS Route: ORAL (BY MOUTH) Schedule: QAM SIG: TAKE 5 TABLETS BY MOUTH EVERY MORNING FOR BLOOD PRESSURE Dose warning text: HCTZ 12.5/LISINOPRIL 20MG TAB: Single dose form amount of 5 TABLET(S) exceeds the maximum single dose form amount of 4 TABLET(S).

10. Dose Checks Calculations Dependent on Body Surface Area or Weight Data Patient data: DOB: SEP 6,1946 (65) Ht(cm): 129.54 (03/13/2012) Wt(kg): 64.04 (03/14/2012) Dose warning text: ENOXAPARIN 150MG/ML INJ SYRINGE 1ML: Single dose amount of 150 MILLIGRAMS exceeds the maximum single dose amount of 105.66 MILLIGRAMS.

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

12. 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

13. 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

14. 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 dosing order checks (i.e. creams, ointments)

15. Dose Check Exclusions • Supplies (bandages, syringes) • Compounded items not matched to NDF • Large volume IV solutions – non Premix • 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

16. Lookup Dosing Check Info For Drug

17. Dose Check Exclusions

18. 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

19. Dose Units for Single Ingredient Drugs • 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)

20. Dose Units (continued) • Dose form type units – Used for non-po solids (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.

21. Non-Standard Doses • Fractional doses – no problem • Free-text doses – different assumptions in CPRS versus. 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

22. Dose Unit versus FDB Dose Unit

23. 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 versus IM), error messages will display if an invalid route is selected • Sometimes FDB is too limiting with its expected med route. • Patches – must be transdermal not topical • Inhalers – Nebulization versus Inhalation; Oral Inhalation versus Oral (Albuterol Solution)

24. Medication Route Issues Maximum Single Dose Check could not be performed for Drug: DIGOXIN (LANOXIN) 0.25MG TAB Reason(s): Invalid or Undefined Dose Route

25. Medication Route Issues NAME: NEBULIZATION// Already mapped to: Stnd Route: 'INHALATION' FDB Route: 'INHALATION‘ Order Check Returned: Maximum Single Dose Check could not be performed for Drug: ALBUTEROL 0.5% (MULTI-DOSE) INHL SOLN Reason: No dosing information specific to maximum single dose is available from the database. Local Route: 'NEBULIZATION' has been remapped to Stnd Route: 'NEBULIZATION' FDB Route: 'NEBULIZATION‘ Order Check Returned: ALBUTEROL 0.5% (MULTI-DOSE) INHL SOLN: Single dose form amount of 3 MILLILITERS exceeds the maximum single dose form amount of 2 MILLILITERS.

26. Factor: Frequency • Used to calculate a total daily dose • Two new fields were created in file 51.1 • EXCLUDE FROM ALL DOSING CHECKS: • EXCLUDE FROM DAILY DOSE CHECK:

27. IV Orders • IV orders based on various business rules, the single dose amount (SDA) and Dose Unit (DU) could be derived from • IV solution volume • IV Additive strength/unit • Infusion Rate • Calculated via a formula

28. IV Orders (continued) IV Orders

29. IV orders (continued) • Intermittent Order: • Cefazolin 10 gms in Dextrose 5% 100 ml IVPB over 60 minutes q12h • Single dose amount: 10 • Drug unit: grams • Intermittent Order marked as Premix: • Cefazolin 10 gms in Dextrose 5% 500 ml IVPB over 60 minutes q12h • Single dose amount: 500 • Drug unit: milliliters

30. IV orders (continued) • Continuous Order marked as Premix: • Cefazolin 10 gms in Dextrose 5% 500 ml IV at 100 ml/hr • No dosing information in FDB • Continuous Order marked as Premix: • Heparin 20,000 units in 500 ml 42ml/hr

31. IV Orders (continued) If the Drug can be administered via a ‘CONTINUOUS’ FDB Dose Route, the single dose amount shall be derived using the following formula: Single Dose Amount/Dose Rate = (IV Additive Strength & Unit/Volume of IV Solution) * Infusion rate (ML/HR) Example: (20000Units/500ML) * 42ML/HR = 1680 Units/HR Single Dose Amount = 1680 Dose Units = Units (FDB EQUIVALENT is UNIT(S)) Dose Rate Unit = HOUR

32. Free Text Infusion Rates • If the infusion rate is in the free text format of ‘XML/HR@0’ • ‘X’ = single dose amount • The FDB equivalent of ‘ML’ shall be sent to the interface for the Dose Unit • Applies to CPRS and Pharmacy backdoor • Continuous Order marked as Premix: • Heparin 20,000 units in 500 ml Infuse at 42 ml/hr@0

33. Free Text Infusion Rates con’t • If the infusion rate in the format ‘XY/P/R@N’ or ‘X<space>Y/P/R@N’ • ‘X’ shall represent the numeric dose • ‘Y’ shall represent the dose unit • ‘P’ shall represent a patient parameter • If the values for ‘P’ are ‘KG’ or ‘M2’, the software will multiply the parameter value for the patient by the numeric dose to calculate the single dose amount sent into the interface • ‘R’ shall represent the dose rate unit/duration rate • If the values for ‘R’ are ‘MIN’, ‘HR’ or ‘DAY’, the software shall set the Dose Rate Unit/Duration Rate equal to ‘MINUTE’, ‘HOUR’ or ‘DAY’ respectively. • ‘N’ shall represent a numeric value • Applies to CPRS entered order only

34. Free Text Infusion Rates con’t

35. Free Text Infusion Rate Example • Free Text Infusion rate: • Dobutamine 1000 in 250 ml Premix IV at 42 mcg/kg/min@0 • Pt 129.09 kg • Finishing it in Vista Backdoor Vista: Rate: 42mcg/kg/min ml/hr

36. What do I need to do? • Local Medication Route Mapping • As you are changing medication routes, remember to check orderable items as well as CPRS quick orders that may be using old/invalid medication routes • Local Possible Dosage Setup • FDB uses dose units to calculate and match a dose from their database. • Review Local Possible Dosages Report (PSS LOCAL POSSIBLE DOSAGES ) option to verify • Populate the dose Unit and corresponding Numeric Dose field • Frequency Review • Enter/Edit Additive Frequency for IV Additives

37. Local Possible Dosage Report (10167) TESTOSTERONE (ANDROGEL) 1% 2.5GM/PKT GEL *N/F* INJECTION, THEN PATCH, THEN GEL Strength: Units: Application Package: XOUN Local Possible Dosages: ONE PACKET (2.5 GMS) Numeric Dose: Dose Unit: Package: IO VA PRODUCT MATCH: TESTOSTERONE (ANDROGEL) 1% 2.5GM/PKT GEL,TOP

38. Error Message – Local Possible Dose Dosing Checks could not be performed for Drug: TESTOSTERONE (ANDROGEL) 1% 2.5GM/PKT GEL Reason: No dosing information found in database. Dosing Checks could not be performed for Drug: TESTOSTERONE (ANDROGEL) 1% 2.5GM/PKT GEL Reason(s): Free Text Dosage could not be evaluated

39. Fixing Local Possible Dose TESTOSTERONE (ANDROGEL) 1% 2.5GM/PKT GEL *N/F* Inactive Date: This drug has the following Local Possible Dosages: ONE PACKET (2.5 GMS) PACKAGE: IO BCMA UNITS PER DOSE: NUMERIC DOSE: DOSE UNIT: Do you want to merge new Local Possible Dosages? Y// NO Strength: 1 Unit: % Select LOCAL POSSIBLE DOSAGE: ONE PACKET (2.5 GMS) IO LOCAL POSSIBLE DOSAGE: ONE PACKET (2.5 GMS) Replace PACKAGE: Both// BCMA UNITS PER DOSE: DOSE UNIT: GMS GRAM(S) NUMERIC DOSE: 2.5 Strength: 1 Unit: %

40. Dosage Unit for Inhaler IPRATROPIUM BROMIDE 17MCG 200D ORAL INHL 1 PUFF NUMERIC DOSE: 17 DOSE UNIT: MICROGRAM(S) Order Check Returned: Maximum Single Dose Check could not be performed for Drug: IPRATROPIUM BROMIDE 17MCG 200D ORAL INHL Reason: No dosing information found in database. IPRATROPIUM BROMIDE 17MCG 200D ORAL INHL 1 PUFF NUMERIC DOSE: 1 DOSE UNIT: INHALATION(S) Order Check Returned: IPRATROPIUM BROMIDE 17MCG 200D ORAL INHL: Single dose form amount of 12 PUFF(S) exceeds the maximum single dose form amount of 8 PUFF(S).

41. What happens if you can’t figure out the dosage unit? Dispense Drug: FENTANYL 50 MCG/HR PATCH Local Possible Dose: 50 MCG/HR (1 PATCH) Dose Unit: Micrograms Schedule: q72h Numeric Dose: 50 Route: Topical Order Check Text: PECS Information:

42. Dosepacks Dispense Drug: METHYLPREDNISOLONE 4MG TAB DOSEPAK,21 Local Possible Dose: TABLET(S) Dose Unit: Each Schedule: As Directed Numeric Dose: 1 Route: Oral PECS Information:

43. No information in PECS Dispense Drug: MAGNESIUM CITRATE LIQUID 300ML Local Possible Dose: 300 Dose Unit: Milliliters Schedule: Once Numeric Dose: 300 Route: Orally Order Check Text:

44. Review and Update • Unmatched drug file entries • DEA/Special handling field • Med route mappings • Orderable item medication route defaults for potentially problematic dosage forms • Local Possible Doses • Edit any quick orders that might be affected • Process for staff to report any issues and error messages • CPRS Parameters – as of right now, dosing is an order check that can be turned off. This may become mandatory in the future or you may want to make it mandatory at your site.

45. QUESTIONS? Please use the Q&A Function on Live Meeting OR Email: Rosemary.Grealish@va.gov Debra.Macdonald@va.gov