Meditechnicalities

1. Meditechnicalities The IN Group MUSE International May 30, 2012

2. Background Every implementation gives additional insight into technical issues that need to be addressed to optimize the MEDITECH environment. This session will focus on lessons learned in Magic, CS and 6.0 installations of Pharmacy and pharmacy related modules. It will include discussion on how to add additional functionality and improve patient safety with eMAR, POM, and RXM . WE will also discuss recent and upcoming enhancements

3. Pharmacy • Multiple Sites/Facilites now or later • Build for each site not .dft • Order From POM = Y • Additive = Y • Items flagged as “Y” do not need to have an IV route associated in the routes fo administration field. If something is always an additive removing the IV routes will prevent a physician from changing the route to IV on a MED type order. • IV Fluid = Y • Premix = Y • Premix Piggyback Iv’s are problematic in that they need to be ordered in mg or grams rather than volume (mls). Meditech discouraged the use of a dummy carrier but could not provide a better solution. • IV Order Strings – where to build • Intermittent IV’s (IV Type by SIG) • Continuous IV’s (IV Type by Rate)

4. PHA Drug Dictionary

5. PHA Drug - Dispensing

6. PHA Drug – Ordering (INJ)

7. Order Strings – For Location

8. Pharamcy Location

9. Nomenclature Dictionary Multiple codes per drug only one in pharmacy – watch DR reports!

10. PHA Drug Ingredients RxCUI is a multiple field for NPR reports even though only one populates

11. CS PHA 8496 (new) When there are multiple routes defined on a drug, then the system defaults in a new standard ".ROUTE" for these DM override orders.   The new .ROUTE is not allowed to be attached to a drug in the route lookup in the Drug Dictionary. The .ROUTE value is also unavailable in the Order Type Dictionary, Pharmacy - Oncology - Drug Mapping Dictionary, Drug - Quick Add Non Formulary dictionary. CS PHA 8496 introduced the ability to specify routes for IV orders. In the releases without CS PHA 8496 this solution only applies to MED type orders. Dispensing Machine orders that use an IV order type (created from drugs flagged as IV Fluid) use the Route defined in the Order Type Dictionary. The releases with CS PHA 8496 the orders look to the Drug Dictionary and set up ".ROUTE" for all orders. In 6.x releases the .ROUTE is added to the Route of Admin Dictionary and you are able to add eMAR Assessments to it.

12. PHA Rules

13. Start Date Check – Go-Live You only need this once - hopefully

14. Back Order Warning This medication contains a Black Box Warning, please review additional information using the external links - Black Box Warnings

15. Black Box Warning (w/link) This medication contains a Black Box Warning, please review additional information uses web link

16. Dispense Check Please enter a quantity to dispense” Prompts user to dispense a quantity > 0 for PRN orders

17. Dose per kg Comment This will calculate and display mg/kg DOSE for order

18. File Mg/Kg in comments This will file the DOSE in mg/kg in the label comments for the order

19. Multiple Site INV Check This will confirm the appropriate inventory is associated with a given order – Prevents Ordering at wrong SITE hopefully

20. Duplicate Generic 2 hr check This is a more “in your face” duplicate generic check Should also be built as POM Rule – attached to specific medications

21. Duplicate Generic 12 hr Check

22. Duplicate Generic 24 hr Check

23. Order Set of Origin from POM • A CDS attached in the Order Type dictionary can allow the OE order set name to be displayed in PHA under the Queries tab, so the pharmacist will know which set the order originated from

24. The setup and the attribute used are shown below:

28. eMAR / BMV • Settings in Pharmacy Drug Dictionary are global for ALL Sites/Locations of Database

29. PCS Assessments

30. eMAR / BMV RULES • Override setting for particular sites or location with the use of RULES • Replace common medication comments related to administration with rules – i.e. do not exceed amount of acetaminophen in 24 hours - use rules to total acetaminophen content and display for user administering medication when approaching do not exceed amount – additional rule with BMV could prevent administration if certain amounts exceeded. • Prevent administration that could cause a potential ADE.

31. Acetaminophen 24 hour rule Displays cumulative acetaminophen dose for past 24 hrs once past trigger value

32. Check Number of Doses and Levels This rule displays the number of doses administered and previous levels if done.

33. Black Box Warning (eMAR)

34. PCS • IV Flow sheet • Use rules to monitor and notify pharmacy when new IV bag is needed. • Surveillance - Trigger Clinical Notifications – send to Nursing status Board

35. PCS – Surveillance (Sepsis) If 2 or more of section A marked……message sent to nursing (Risk of SIRS) If 2 or more section A and 1 (except “None”) from section C then nursing and pharmacy get message Severe Sepsis Screening.

36. POM Order Sets • Create Style Guide – consistency from set to set is important. • Headers / Order of Sections / Order of items within sections • Medications – grouped by drug class or not – alphabetical or importance • Pain scales – separate sections for each?, be consistent • IV Solutions – 0 ml/hr plus POM RULE to force change • Pom Display Names • All order sets should be restricted to appropriate OE site – failure to restrict may effect the filing time for modifications to the set. • Use Taper to DC orders in hours rather than days • Use of Protocol Tables • Dosing Sets precautions • Multi-facility Systems should consider separate Order Sets for each facility. • MIS and Pharmacy Dictionary settings drive functionality • POM Rules

37. Interaction Conflict Group

38. Default POM Order Type

39. Protocol Tables

40. Dosing Sets

41. Overriding the Default IV Type • To control the Order Type for IV’s with Additives when entered via OE sets. • Example of NS 250 mL with an additive such as KCL. Additive could be in Primary or Intermittent IV. • When an OE set for an IV is built with these items the order type will default to IVPB, from the CDP setting. • To change the order type to a continuous IV type (CONTIV) the order in the set can be modified. • On the General Information tab, change the procedure to <MED> and enter the same additive as a Medication and the enter the same dose . • Go to the Pha IV tab and enter the IV fluid of NS5. (A lookup here will show what IV fluids have been defined in the Drug Dictionary under the IV Fluid Strings tab.) • You now have access to the Med Order Type tab and can enter the CONTIV order type. • Go back to the General Information screen and change the Procedure back to <IV>.

42. Check for Allergy Rule Please update patient's allergy before proceeding

43. Check IV Rate not 0 ml/hr All maintenance fluids on Orders sets set to 0 m/hr – required physician to change from 0 before filing

44. Black Box Warning –POM

45. POM Order Check for Appropriate Route Drug specific – not to allow certain IV routes – can also be controlled by additive = “Y”

46. Medication Location Restriction Utilizes Drug CDS to control where medication can be ordered

47. Check Duplicate PRN Reason Doesn't account for free text, etc. But in theory is good

48. Pediatric Specific

49. Required PT Weight Hard Stop – weight required for PEDS Created Override for certain meds

50. Rounding Warning (Dosing Set) Warning to remove “rounding” feature of Dosing Set for patients < 5 Kg