Paperless Refill

1. Paperless Refill LCDR Robin A. Bartlett, PharmD Clinical Applications Coordinator Cherokee Indian Hospital

2. Objectives • How to activate paperless refill pharmacy site parameter option • How to process pharmacy-only medication refills utilizing paperless refill • How to process outpatient clinic-initiated paperless refill requests • How to approach coding queue issues with paperless refill implementation • How to reconcile missing purpose of visits associated with paperless refill

3. Work Flow Considerations • May need to change pharmacy refill policies facility-wide to ensure refills available to optimize paperless refill processing • Cherokee implemented for all new prescriptions: • 30 days supply with 11 refills with billable insurance and • 90 days supply with 3 refills for patients without insurance • EHR Med Quick Orders designed to reflect this policy • Pharmacist data entry essential – may require work flow redesign to assign new technician duties • Check EHR pending order queue for clinic refill requests on regular basis • Pharmacy visits with unspecified diagnosis and missing POV may increase medical records coding queue error report volume

4. Advantages • Eliminates need for paper documentation of pharmacy only or outpatient clinic-initiated refill visits (PCC or PCC+) • Automatically prompts pharmacist to select POV for each medication refill processed • Purpose of Visit (POV) options pull from patient-specific problem list • Automatically populates necessary EHR fields to complete pharmacy visit

5. Activating Paperless Refill • CORE • HEAL – Health systems… • IHSP – IHS Specific Pharmacy Site Parameters • IHS – IHS Pharmacy Site Parameters • Paperless refill option: “YES” • Pharmacy visit location: “Pharmacy”

6. Processing Refills • Outpatient Pharmacy Manager • Select IHS Kernel Option: CORE • Select IHS Core Option: HEAL • Select Health Systems Option: PSM OR • Select IHS Kernel Option: (shift 6) ^PSM Outpatient Pharmacy Manager • (Your facility may have different acronym) Outpatient Pharmacy software - Version 7.0 Division: CIHA 7247 You are logged on under the CIHA division. Number of Days For Chronic Med Profile: (1-999): 90// Pre-Select PMI/Chronic Med Profile Device? (Y/N) ? No// (No) Select LABEL PRINTER: HOME// VT Right Margin: 80// OK to assume label alignment is correct? YES// Select Outpatient Pharmacy Manager Option: RX (Prescriptions)

7. Processing Refills • Rx (Prescriptions…) • Patient Prescription Processing • Barcode Rx Menu ... • Complete Orders from OERR • Discontinue Prescription(s) • Edit Prescriptions • List One Patient's Archived Rx's • Reprint an Outpatient Rx Label • View Prescriptions • Select Rx (Prescriptions) Option: Patient Prescription Processing • Select PATIENT NAME: DEMO,GEORGE

8. Patient Information DEMO,GEORGE <A> PID: 123-12-1234 (HRN: 9) Ht(cm): 152.40 (04/11/2005) DOB: JAN 1,1930 (77) Wt(kg): 72.27 (03/29/2005) SEX: MALE Eligibility: CHS AND DIRECT vs. DIRECT ONLY vs. PENDING VERIFICATION Insurance Information: PRIVATE - RX PAID PRESCRIPTIONS - Grace Period: L.L.C - Grace Period: 3 KANAWHA-NON-BEN - Grace Period: 3 Disabilities: P.O. BOX 0000 CHEROKEE PHONE: NORTH CAROLINA 28719 Prescription Mail Delivery: Regular Mail Select Action: Next Screen// Allergies Verified: PEANUT OIL, BEE POLLEN, Adverse Reactions Pending Clinic Appointments: FEB 15,2007@15:30 WILDCATT-PEDIATRIC/WCC NEW-30 (24 days) EA Enter/Edit Allergy/ADR Data PU Patient Record Update DD Detailed Allergy/ADR List EX Exit Patient List Select Action: Quit//

9. Patient Medication Profile ISSUE LAST REF DAY # RX # DRUG QTY ST DATE FILL REM SUP 1 2635654 FERROUS SULFATE= 325MG TAB 90 A 12-22 12-22 11 30 2 2623397 FOSINOPRIL= 40 MG TAB 30 A 11-29 11-29 11 30 3 2635647 GLYBURIDE= 5MG TAB 360 A 12-22 12-22 3 90 4 2635648 HYDROCHLOROTHIAZIDE= 25MG TAB 30 A 12-22 12-22 11 30 5 2635649 LEVOTHYROXINE= 0.1 MG TAB 30 A 01-22 01-22 11 30 6 2635650 METFORMIN 500MG *XR* TAB 120 A 12-22 12-22 11 30 7 2623398 METHOCARBAMOL 750MG TAB 40 A 11-29 11-29 1 10 8 2635651 METOPROLOL= 50 MG TAB 60 A 12-22 12-22 11 30 9 2635652 PIOGLITAZONE= 30MG TAB 30 A 12-22 12-22 11 30 10 2635653 SIMVASTATIN= 40MG TAB 30 A 12-22 01-22 10 30 PU Patient Record Update NO New Order PI Patient Information SO Select Order Select Action: Next Screen// ??

10. Additional Options Select Action: Next Screen// ?? The following actions are also available: RP Reprint (OP) DN Down a Line LS Last Screen RN Renew (OP) RD Re Display Screen FS First Screen DC Discontinue (OP) PT Print List GO Go to Page RL Release (OP) PS Print Screen + Next Screen RF Refill (OP) > Shift View to Right - Previous Screen PP Pull Rx (OP) < Shift View to Left ADPL Auto Display(on/off) IP Inpat. Profile (OP) SL Search List UP Up a Line OTH Other OP Actions QU Quit Enter RETURN to continue or '^' to exit: Select Action: Next Screen// RF

11. Refill Processing Select Action: Next Screen// RF RF Barcode Refill? NO// Select Orders by number: (1-13): 10 FILL DATE: (12/22/2006 - 1/22/2007): TODAY// (JAN 22, 2007) MAIL/WINDOW: WINDOW// WINDOW METHOD OF PICK-UP: CLERK: RAB// RAB EXPIRES: (1/22/2007 - 12/31/2699): T+6M// (JUL 21, 2007) BILL STATUS: AUTO BILL// AUTO BILL WANT TO ADD/EDIT INSURER INFO// NO// Now refilling Rx# 2635653 Drug: SIMVASTATIN= 40MG TAB *** NO RESULTS FOR ALT/SGPT SINCE 01-22-06***(LAB) Qty: 30 Sig: TAKE ONE TABLET BY MOUTH EVERY EVENING TO LOWER CHOLESTEROL

12. Pharmacy Only POVs Is this a Pharmacy Only Visit (Paperless refill)?? Yes// Historical POVs: 1) 427.31 Atrial Fibrillation 2) 989.81 Toxic Effect of Asbestos 3) 401.9 hypertension 4) 250.0 diabetes 5) 272.4 Hyperlipidemia Please select the appropriate Problem List diagnosis for the drug prescribed.: (1-5): ^ (Use shift 6 (up-hat) if there are no POV present to match diagnosis) Active Problem list: 1) 427.31 Atrial Fibrillation 2) 989.81 Toxic Effect of Asbestos 3) .9999 hypertension 4) .9999 diabetes 5) 272.4 Hyperlipidemia 6) 314.01 ADHD 7) 304.00 NO NARCOTICS PER PAIN GROUP 8) .9999 no opiods!!! 9) 381.4 otitis media 10) 493.90 asthma Please select the appropriate Problem List diagnosis for the drug prescribed.: (1-10): 5 or ^ (Use shift 6 (up-hat) if there are no POV present to match diagnosis)

13. Diagnosis Narrative • Please enter a narrative describing the diagnosis. • Diagnosis Narrative: • ^ (DO NOT Shift 6 (up-hat) – Leads to missing POV or narrative uncoded diagnosis .9999 – coding will send back • Type narrative for preexisting condition (i.e. Hyperlipidemia) – Coding can replace .9999 uncoded diagnosis code with appropriate ICD-9 code • Do not “GUESS” with non-obvious medications (i.e. amitriptyline – sleep disorder, neuropathic pain, depression, etc.) • Unless you “KNOW” that the patient has this diagnosis, you should NOT choose a common use [May be adding diagnosis to patient’s historical POV list that patient doesn’t actually exhibit (i.e. fosinopril – hypertension vs. microalbuminuria)] • Refer back to patient’s Problem list and Historical POVs in EHR to choose an appropriate diagnosis • If appropriate diagnosis NOT present, choose a previously entered diagnosis for this refill (i.e. fosinopril – diabetes) • Designated refill POV does NOT associate specifically with med refilled

15. Paper vs. Paperless Refill Documentation • Think about how you would have documented refill via Pharmacy Only Visit on paper • PCC form • PCC plus form • Same basic concepts with paperless refill system • Specific diagnosis NOT needed for each medication diagnosis when not present in patient’s active problem list or historical POVs

18. Routing Slip • Patient Registration Requested Refills

19. Routing Slip • Clinic EHR, Paperless Refill, Automated Refill Line Refill Requests

20. Clinic Refill Processing Rx (Prescriptions…) • Patient Prescription Processing • Barcode Rx Menu ... • Complete Orders from OERR • Discontinue Prescription(s) • Edit Prescriptions • List One Patient's Archived Rx's • Reprint an Outpatient Rx Label • View Prescriptions Select Rx (Prescriptions) Option: Complete Orders from OERR

21. Clinic Requested Refills Select Rx (Prescriptions) Option: Complete Orders from OERR Select By: (PA/RT/PR/CL/E): PATIENT// All Patients or Single Patient: (A/S/E): SINGLE// Select Patient: ?? Please enter a minimum of two (2) characters. Enter Patient's name whose med orders are to be completed. DEMO,GEORGE Select Patient:

22. EHR Pharmacy Orders

23. Pending EHR Refill Orders -------------------------------------------PENDING------------------------------------------ 15 FERROUS SULFATE= 325MG TAB Refill Request Rx #: 2635654 Select Action: Quit// 15 Processing Refill Request for Rx 2635654 FILL DATE: (12/22/2006 - 1/22/2007): TODAY// (JAN 22, 2007) MAIL/WINDOW: WINDOW// WINDOW METHOD OF PICK-UP: Now refilling Rx# 2635654 Drug: FERROUS SULFATE= 325MG TAB Qty: 90 Sig: TAKE ONE TABLET BY MOUTH THREE TIMES A DAY WITH FOOD FOR IRON REPLACEMENT; MAY COLOR STOOLS BLACK Is this a Pharmacy Only Visit (Paperless refill)?? Yes// NO ISSUE LAST REF DAY # RX # DRUG QTY ST DATE FILL REM SUP 2 2635654 FERROUS SULFATE= 325MG TAB 90 A 12-22 01-22 10 30

24. Pharmacy Statistics

25. Rx Refills

26. Pharmacy Only Visits

27. Coding Queue Issues • Primary vs. Secondary Diagnosis • Medication diagnosis = primary POV • Issue of repeat prescriptions = secondary POV • Automatic priority setting with Paperless Refill • Pharmacy Only – Non-billable visit • Uncoded Diagnosis (0.9999) • Missing Purpose of Visits • Multiple visits or locations with same visit date • clinic + pharmacy or 2 pharmacy visits • Primary Provider Errors • technician vs. pharmacist • Lock-out 30days after visit

28. Error Reports HEAL Health Systems ... PCC Patient Care Component ... MGR PCC Manager Menu ... PCC Patient Care Data Entry Menu ... DEU Data Entry Utilities ... SUP Data Entry SUPERVISORY Options and Utilities ... VRR Visit Review Report ...

29. Error Reports ZERO Visits with a Zero Dependent Entry Count PPPV Visits with No Primary Provider and/or POV MRG Multiple Visits on one day - Potential Merges TXER Data Transmission Transaction Errors INP Inpatient Visit Review ALL All of the Above ECD Visit Error Code Description Menu ... CINC Scheduling Check-In Created Visits Not Yet Coded DTCR DTC Visits with No Billing Link V12 Visits at 12:00 with No Billing Link

30. Error Tracking

31. Error Tracking

32. RX Errors

33. Organizing Error Reports • Separate by each pharmacist • Patient chart number • Patient name • Date of Service

34. Coding Queue Reports HEAL Health Systems ... PCC Patient Care Component ... MGR PCC Manager Menu ... PCC Patient Care Data Entry Menu ... ENT Enter/Modify/Append PCC Data ... EHRC EHR/PCC Coding Audit Menu ... EHRD EHR/PCC Coding Audit for Visits in Date Range

35. Coding Queue Reports You should limit your date range to no more than 7 days. Viewing more than 7 days worth of visits may take a while to process. Enter Beginning Visit Date: 1/1/07 (JAN 01, 2007) Enter Ending Visit Date: 1/7/07 (JAN 07, 2007) Enter a code indicating what LOCATIONS/FACILITIES are of interest: A// Enter a code indicating what CLINICS (IHS clinic code) are of interest: A// Enter a code indicating what HOSPITAL LOCATIONS are of interest: A// Enter a code indicating which providers are of interest: A// Select visits based on chart deficiency reason: D/ Do you wish to continue? Y//

36. Visit Sort Options Select one of the following: N Patient Name H HRN D Date of Visit T Terminal Digit of HRN S Service Category L Location of Encounter C Clinic O Hospital Location P Primary Provider A Chart Audit Status R Chart Deficiency Reason (Last one entered) I Has Medicare/Medicaid or PI How would you like the list of visits sorted: H// D

37. Coding Queue Actions # VISIT DATE PATIENT NAME HRN FAC HOSP LOC CL INS PRIM PROV STATU D Display Visit S Status Update X Visit Delete N Note Display R Resort List B B Merge 2 Diff Dates M Modify Visit C Chart Audit History F F Move V File A Append to Visit H Health Summary E E Move V File 2 Dates G Visit Merge O One Patient's Visits T Change Date/Time

38. Pharmacy POV Reconciliation • Missing POV Error Report • Each pharmacist should reconcile their own missing purpose of visits • Missing pharmacy POV report multi-factorial • Paperless Refill • Outside provider new prescription • Release returned to stock medications • Release from hold medications • Outlying clinics

39. POV Reconciliation • Selecting appropriate EHR Visit (date ranges) • EHR Medication Management Tab • Look at issue and last refill dates for desired date • May need to double click on each medication that has previous issue date and scroll to refill dates to find • Clinical Reports Tab – Pharmacy – All Outpatient Meds • Problem List/POV Tab • Select corresponding diagnosis from historical POV or problem list and designate new vs. refill • Working with locked-out visits

40. QUESTIONS ?