Resource and Patient Management Systems (RPMS) Adverse Reaction Tracking (GMRA)

1. Resource and Patient Management Systems (RPMS)Adverse Reaction Tracking (GMRA) Documenting Reaction Data 2011

2. Course Objectives At the end of this session, participants should be able to: • Document an Adverse Reaction in RPMS and in the Electronic Health Record (EHR). • Discuss process for requesting a new reactant or sign/symptom to be added to RPMS. • Compare and contrast “Entered in Error” and “Inactive.” • Document “unable to assess.” • Utilize the chart review functionality in EHR.

3. Entering Anew adverse reaction

4. Where can Reactions be Entered? • In RPMS • Through the Adverse Reaction Tracking package • Through prescription processing functions of the Pharmacy package (or through the inpatient pharmacy functions) • Through Patient Care Component (PCC) data entry (ALG mnemonic) • In EHR • Through the adverse reaction component

5. ART MenuOptions Adverse Reaction Tracking (ART) Enter/Edit Site Configurable Files ... Adverse Reaction Tracking User Menu ... Adverse Reaction Tracking Clinician Menu ... Adverse Reaction Tracking Verifier Menu ... P&T Committee Menu ...

6. Adverse Reaction Tracking User Menu Enter/Edit Patient Reaction Data Active Listing of Patient Reactions Edit Chart and ID Band List by Location of Unmarked ID Bands/Charts Patient Allergies Not Signed Off List by Location of Undocumented Allergies Print Patient Reaction Data Online Reference Card ART User Menu

7. ART Allergy Entry Enter Causative Agent: IBUPROFEN Checking existing PATIENT ALLERGIES (#120.8) file for matches... Now checking GMR ALLERGIES (#120.82) file for matches... Now checking the National Drug File - Generic Names (#50.6) 1 IBUPROFEN 2 IBUPROFEN/PSEUDOEPHEDRINE CHOOSE 1-2: 1 IBUPROFEN IBUPROFEN OK? Yes// (Yes) SOURCE: ? Only allow items designates as a source of information Answer with BEH ALLERGY VALUES NAME Do you want the entire BEH ALLERGY VALUES List? Y (Yes) Choose from: CHART REVIEW EXTERNAL SOURCE FAMILY FRIEND MEDICAL PROVIDER OTHER SOURCE PATIENT SPOUSE

8. ART Allergy Entry No signs/symptoms have been specified. Please add some now. The following are the top ten most common signs/symptoms: 1. ANXIETY 7. HIVES 2. ITCHING 8. DYSPEPSIA 3. SWELLING (NON-SPECIFIC) 9. ANAPHYLAXIS 4. DROWSINESS 10. RASH 5. NAUSEA,VOMITING 11. OTHER SIGN/SYMPTOM 6. DIARRHEA Enter from the list above : 11 Select SIGN/SYMPTOMS NAME: GI REACTION NATIONAL SIGN/SYMPTOM Select SIGN/SYMPTOMS NAME: Date(Time Optional) of appearance of Sign/Symptom(s): 4-4-1973 (APR 04, 1973) Select source: ? Answer with BEH ALLERGY VALUES NAME Do you want the entire BEH ALLERGY VALUES List? Y (Yes) Choose from: CHART REVIEW EXTERNAL SOURCE FAMILY FRIEND MEDICAL PROVIDER OTHER SOURCE PATIENT SPOUSE

9. ART Allergy Entry The following is the list of reported signs/symptoms for this reaction: Signs/Symptoms Date Observed -------------------------------------------------------------------- 1 GI REACTION Apr 04, 1973 Select Action (A)DD, (D)ELETE OR <RET>: SNOMED EVENT: ?? Choose from: ALLERGY TO SUBSTANCE DRUG ALLERGY DRUG INTOLERANCE FOOD ALLERGY FOOD INTOLERANCE PROPENSITY TO ADVERSE REACTIONS PROPENSITY TO ADVERSE REACTIONS TO DRUG PROPENSITY TO ADVERSE REACTIONS TO FOOD PROPENSITY TO ADVERSE REACTIONS TO SUBSTANCE COMMENTS: No existing text Currently you have verifier access. Would you like to verify this Causative Agent now? Yes// N (No) OBS/ REACTANT SOURCE VER. MECH. HIST TYPE -------- ------ ---- ------- ---- ---- BEN-GAY YES UNKNOWN HIST DRUG IBUPROFEN SPOUSE NO PHARM HIST DRUG Reactions: GI REACTION(Source: SPOUSE)

10. Prescription Processing Option is available from the patient information screen when processing prescriptions: EA Enter/Edit Allergy/ADR Data: Enter/Edit or Remove a reaction from a patient Can be accessed anywhere prescriptions can be processed Once selected, displays the same entry interface as when using the ART Package

11. PCC Data Entry • Using the ALG mnemonic • User must have GMRA-USER key • Mnemonic must be allowed • Once the ALG mnemonic is invoked, displays the same entry interface as when using the ART package

12. Adverse Reaction Trackingin EHR Providers can enter Adverse Reactions (ADR) in the EHR using the right click menu on the Adverse Reaction component Enter a new reaction Edit an existing reaction Delete their own unsigned reaction Mark a reaction “entered-in-error” Mark a reaction as inactive, or reactivate a reaction Document the inability to assess reactions Document chart review functions (reviewed or no active allergies)

13. Allergy Entry - EHR Right click in a blank part of the adverse reaction component and select New Adverse Reaction. Enter a few characters of the causative agent (watch for misspellings). For medications, choose from the National Drug File entries. For foods or other non-drug substances, choose from the VA Allergies file. The local drug file will not be selectable; drug ingredients and VA Drug class should only be used as a last resort.

14. EHR Allergy Dialog Box Enter the required information. Nature of Reaction will be set by the causative agent chosen, and cannot be changed. Event Code, Source of Information, and Signs/Symptoms are required (use “Possible Reaction” if symptoms are not known). Date and time and source of the signs/symptoms are optional. Comments may be added as needed to provide additional information.

15. Requesting a new reactant

16. What if the reactant is not available? • IHS is adding more than 700 entries to the allergy file with GMRA patches 1001 and 1002. • An additional 16,000+ entries will be added with GMRA patch 1003. • However, IHS has created a feedback mechanism to request additional reactants beyond these.

17. Requesting a New Reactant • In both RPMS and EHR, if the desired reactant is not found, the user will be offered the option to send a message to request the new reactant. • Although the text states this is an email, it is really a mailman bulletin: • Therefore, it cannot be directed outside the facility. • A package coordinator will need to check these messages routinely and send information to the feedback mechanism.

18. RPMS Could not find SPONGEBOB in any files. Before sending an email requesting the addition of a new reactant, please try entering the first 3 or 4 letters of the reactant to search for the desired entry. Would you like to send an email requesting SPONGEBOB be added as a causative agent? Send email? NO// YES You may now add any comments you may have to the message that is going to be sent with the request to add this reactant. You may want to add things like sign/symptoms, observed or historical, etc that may be useful to the reviewer. Enter RETURN to continue or '^' to exit: ==[ WRAP ]==[ INSERT ]============< >===========[ <PF1>H=Help ]==== THIS PATIENT REPORTS A VIOLENT REACTION TO WATCING SPONGEBOB. <=====T=====T======T======T======T======T======T======T======T>===== Message sent - NOTE: This reactant was NOT added for this patient. Enter another Causative Agent? YES// NO

19. EHR Click Yes to open the Enter Optional Comments dialog.

20. Entering Feedback • Go to:http://www.ihs.gov/RPMS/index.cfm?module=feedback&option=add&newquery=1 • Optionally, go to http://www.ihs.gov/RPMS and click Feedback in the left-hand menu • Fill out the available form, using the RPMS Application “Pharmacy – New Reactant/Symptom Request (PRSR)” • These will be reviewed promptly, and will be added through patch updates on a regular basis as needed

22. Entered in error & Inactivating/Reactivating

23. Reactions Entered In Error • Entered in Error may be used when the reaction entry was a mistake (wrong patient, wrong causative agent): • Wrong causative agent will require a new entry for the correct agent • Entering comments is strongly recommended to allow auditors, surveyors, and other providers to know what was done with the reaction and why. • NOT for reactions that the patient no longer has (e.g. Ibuprofen caused stomach upset once but is now taken regularly, or patient has undergone de-sensitization therapy).

24. REACTANT VER. MECH. HIST TYPE -------- ---- ------- ---- ---- MOTRIN YES PHARM HIST DRUG (IBUPROFEN) Reactions: PENICILLIN V POTASSIUM YES ALLERGY HIST DRUG (PENICILLIN) Reactions: APNEA, SWELLING-THROAT RITALIN YES ALLERGY HIST DRUG (METHYLPHENIDATE) Reactions: TACHYCARDIA Enter Causative Agent: MOTRIN <A> M 05-16-1983 XXX-XX-3440 CI 142507 MOTRIN OK? Yes// <enter>(Yes) PATIENT: DEMO,PATIENT ALLEN CAUSATIVE AGENT: MOTRIN INGREDIENTS: IBUPROFEN VA DRUG CLASSES: NONSALICYLATE NSAIs,A ORIGINATOR: USER,YSTUDENT ORIGINATED: MAY 19, 2010@10:45:20 SIGN OFF: YES OBS/HIST: HISTORICAL ID BAND MARKED: CHART MARKED: SIGNS/SYMPTOMS: (May 19, 2010@10:45:20) MECHANISM: PHARMACOLOGIC VERIFIER: USER,YSTUDENT VERIFIED: MAY 19, 2010@13:37:26 Is the reaction information correct? Yes// N (No) Mark this reaction as 'Entered-in-Error'? YES COMMENTS: 1>WRONG PATIENT 2> EDIT Option: Enter another Causative Agent? YES// NO

25. Select Entered in Error from the right click menu to display the Confirm dialog Click Yes to remove the adverse reaction

26. Inactivating reactions • Used for situations where the patient has previously reported a reaction but is now able to tolerate the causative agent or is no longer allergic: • Retains a record of the reaction that is visible in EHR but clearly marked as “inactive.” • Can be reactivated as needed. • Retains record of when and who inactivated and reactivated the reaction.

27. Inactivating reactions OBS/ REACTANT SOURCE VER. MECH. HIST TYPE -------- ------ ---- ------- ---- ---- WALNUTS PATIENT NO UNKNOWN HIST FOOD Reactions: HIVES(Source: PATIENT) Enter Causative Agent: WALN Checking existing PATIENT ALLERGIES (#120.8) file for matches... <A> F 10-24-1933 XXX-XX-4127 WW 110211 WALNUTS WALNUTS OK? Yes// <enter> (Yes) PATIENT: DEMO,ALLERGY CONNIE CAUSATIVE AGENT: WALNUTS SOURCE OF INFORMATION: PATIENT ORIGINATOR: NIESEN,MARY ANN ORIGINATED: Apr 27, 2011@09:58 SIGN OFF: YES OBS/HIST: HISTORICAL EVENT: FOOD INTOLERANCE CODE: 235719002  ID BAND MARKED: CHART MARKED: Apr 27, 2011@09:59:49 SIGNS/SYMPTOMS: HIVES (Jan 29, 2010) SOURCE: PATIENT MECHANISM: UNKNOWN Is the reaction information correct? Yes// N (No) Mark this reaction as 'Entered-in-Error'? NO Inactivate this reaction? YES Select reason: ?? Choose from: NO LONGER ALLERGIC REACTION IS TOLERABLE Select reason: NO LONGER ALLERGIC Enter another Causative Agent? YES// NO

28. Inactivating reactions Select Inactivate Adverse Reaction on the right-click menu to open the Confirm dialog. Click Yes to open the Reason Prompt dialog.

29. Unable to assess

30. Unable to Assess • Sometimes, the patient or proxy may not be able to relate their adverse reaction history. • There is now a way to document that the attempt was made but could not be completed. • It does NOT mean that NO reaction history is available, just that the user is unable to determine if the listed information is current and correct.

31. Unable to Assess • This information will remain until some other action is performed on the adverse reactions: • Review • Add/Edit • Inactivate/Mark “entered-in-error” • This information is retained for auditing purposes. • This may be marked several times: • For example, once each nursing shift or when handing off care in an emergency room.

32. Select Adverse Reaction Tracking Clinician Menu Option: 7 Unable to assess allergies Select PATIENT NAME: DEMO,ALLERGY CHARLES OBS/ REACTANT SOURCE VER. MECH. HIST TYPE -------- ------ ---- ------- ---- ---- ASPIRIN FAMILY YES UNKNOWN HIST DRUG Reactions: ANAPHYLAXIS(Source: EXTERNAL SOURCE) BEE STINGS CHART REVIEW AUTO UNKNOWN HIST OTHER Reactions: HIVES(Source: CHART REVIEW) Do you want to mark this patient as being unable to assess for allergies?? NO//Y ES Select reason: ?? Choose from: ALTERED MENTAL STATUS CAREGIVER DOES NOT KNOW LANGUAGE BARRIER OTHER PATIENT DOES NOT KNOW UNCONSCIOUS Select reason: UNCONSCIOUS Patient has been marked unasessable Press RETURN to continue

33. Select Inability to Assess from the right-click menu to open the Reason Prompt dialog. Select a reason, type a comment, and click OK to complete the action. or

34. Chart Review Functions

35. Chart Review • Allows for the documentation of a review of reported adverse reactions or “no active allergies” (once the initial entry of “No Known Allergies” has been completed). • Assists providers in meeting Meaningful Use criteria as well as in documentation needed for many accrediting organizations. • Documentation is per visit, per user: • For example, can be documented by both the nurse and the physician for the same visit

36. Chart Review • Can be accessed through the chart review component (see EHR patch 8 notes), OR • Through the right-click menu in the adverse reactions component • “No active allergies” can only be chosen when there are no active reactions documented • “Reviewed” can be chosen when reactions exist, but will also be added when marking “no active” • An additional status of “Updated” will be stored when reactions are added, deleted, or otherwise manipulated.

37. The chart review component is usually located in the header bar area. Clicking on the button gives the options of “Reviewed” or “No Active” as appropriate. The button caption changes as actions are marked or taken (for example, the user here selected “no active” which updated the button to show that the list was both reviewed and found to have no active reactions. The caption is shown with brackets until the actions are signed by the user, after which only the letters will show. The chart review options can also be accessed from the cover sheet components. The buttons on the chart review component will update as above. Again, the options available depend on whether the patient has active reactions or not.

38. Questions?