Pharmacy Package Parameters for BCMA Coordinators: An Overview BCMA National Call – January 5, 2015 Steve Corma, RPh Pharmacist Consultant Bar Code Resource Office Office of Informatics and Analytics

Objectives Following this presentation, attendees will be able to: Describe the various Pharmacy package parameters , settings, & work processes that impact BCMA. Identify the accepted default settings in use today (where applicable) & the impact of alternative settings. Assist in identifying & troubleshooting issues that may arise as a result of Pharmacy package settings & work processes.

Parameters & Settings for Discussion Parameters Edit Menu (UD) Auto-Discontinue Set-Up Inpatient Ward Parameters Edit Clinic Definition Systems Parameters Edit Site Parameters (IV) Individual Labels (IV) Medication Route File Enter/Edit Synonym Enter/Edit Enter/Edit Dosages Edit Orderable Items Please note that we will not be discussing each item in detail. Some parameters have been added only as a teaching point for troubleshooting purposes.

Parameter Menu Edit (UD) Auto-Discontinue Set-Up Description: This allows the site to determine if patients' Inpatient Medications (IV and Unit Dose) orders are d/c'd when the patient is transferred between wards, between services, or to authorized absence. This determination can be made on a ward-by-ward and/or service-by-service basis. Replaced by CPRS Auto D/C business rules, however this parameter is still active & may in use at some sites. Recommendation: Only utilize CPRS Auto D/C rules & delete all settings for this parameter. *CAUTION* - use of this parameter in conjunction with CPRS Auto D/C business rules will cause unintended consequences if not in “sync” This is a very old pharmacy parameter that existed prior to the introduction of CPRS. It was used by pharmacy service to control auto d/c actions on patient movements in the pharmacy profile. Order actions would take place based on transferring location, service change, or both, depending on hospital & business office policies. The CPRS Auto D/C business rules essentially copy this same functionality but is set up through CPRS & easier to perform. If CPRS Auto D/C rules are in conflict with pharmacy auto D/C settings, pharmacy settings will prevail – CPRS first performs order actions based on its auto D/C rules, then pharmacy (VISTA) settings will activate & override CPRS rules if they are not set up the same. If order actions are not performing as expected based on auto D/C rules set up by CAC, check this parameter with pharmacy ADPAC. If your system is currently performing as expected, ***DO NOT MESS WITH IT*** CACs should control order actions on transfer as they are more aware of business office & hospital policy changes than pharmacy ADPAC would be.

Parameter Menu Edit (UD) Continued Inpatient Ward Parameters Edit Description: Allows user to edit the Inpatient Ward Parameters. These parameters determine how the Inpatient Medications package (& BCMA to some extent) will react for users acting on patients who reside on the corresponding wards. Primarily controls default start & stop dates on orders placed through CPRS or “backdoor pharmacy” There are many settings listed under this parameter which will not be discussed as they are specific to pharmacy only (example: choosing default printers) or no longer apply (example: settings for printing labels for paper MARs)

Inpatient Ward Parameters Edit Description DAYS UNTIL STOP DATE/TIME: DAYS UNTIL STOP FOR ONE-TIME: SAME STOP DATE ON ALL ORDERS: This is the number of days a standard order should last. Typically set to 30 days for acute care ward & 90 days for CLC. the number of days a one-time order should last. The number can be from 1-100, however, it cannot exceed the number of days that standard orders last (DAYS UNTIL STOP DATE/TIME). Typically set to 1 day. This is a flag, that if found to be YES, uses the STOP DATE/TIME from the patient's first order as a default value for the STOP DATE/TIME of all of the patient's following orders. Typically set to “NO” DAYS UNTIL STOP DATE/TIME: If left blank, system defaults to 14 days DAYS UNTIL STOP FOR ONE-TIME: If left blank, system will default to 24 hours SAME STOP DATE ON ALL ORDERS: Never used to my knowledge

Inpatient Ward Parameters Edit Description TIME OF DAY THAT ORDERS STOP: DEFAULT START DATE CALCULATION: SELF MED' IN ORDER ENTRY: This is a time of day that, if found, will be used in calculating the default value for the STOP DATE/TIME of patients' orders. Typically individualized for each site. This field allows the ward to tell the package how the default start date for orders should be calculated. The default may use the next admin time, the closest admin time, or the current time (now) as the default start date for Unit Dose and IV orders. Typically set to “use now as default”. If `YES' (or a 1) is entered here, the regular order entry process will prompt the user for SELF MED and HOSPITAL SUPPLIED SELF MED for each order entered. 1) TIME OF DAY THAT ORDERS STOP: if left blank will cause order to expire at the same time of day the order was entered. For example, if an order was placed at 3am by hospitalist on an acute care ward, the order would expire in 30 days at 3am provided no other limits applied. It is not a good practice to have an order expire at odd times of the day when providers may not be available to address it. Some sites have chosen 12 noon so the expiring order is addressed on day shift Some sites have chosen late afternoon or evening times to give providers time to address it so the order does not expire before they can renew it (example: 8pm) Each site should look at their providers ordering practices & allow enough time to let them renew order prior to expiration. 2) DEFAULT START DATE CALCULATION: Closest – the risk is the start date/time will have past when it is appropriate to administer, e.g. an order entered @0700 for bedtime (admin time of 2200) – this will calculate to start at bedtime for the previous evening (back timing of orders) Next – order become active at the Next ADMIN time Now – Now is based on the time that the order was signed off by the provider, start date/time will effectively be now, however the first administration due will be the closest admin time after the order was signed. 3) SELF MED' IN ORDER ENTRY: Self med means patient will bring in own med & administer him/herself pursuant to a provider’s order (example: herbal meds). Hospital supplied self med (HSM) means the medical center will supply the med but the patient will administer it him/herself pursuant to a provider’s order (example: inhalers, certain creams & lotions).

Parameter Menu Edit (UD) Continued Clinic Definition: This option allows the site to define how Inpatient Orders for Outpatients will behave and be handled on a clinic-by-clinic basis. Parameter Description NUMBER OF DAYS UNTIL STOP: AUTO-DC IMO ORDERS: This is the number of days to default the length of an order. Cannot exceed 365 days. Typically, “one-time” visits (e.g. ED) would be set to 1 day. This field gives the site the ability to define, by clinic, whether or not inpatient orders for outpatients should be auto-d/c'd on patient movements. This field will only affect those orders where Inpatient Medications V. 5.0 controls the discontinue action. If the patient movement discontinue action is handled by any other package, this field will have no effect. Typically set to “yes” NUMBER OF DAYS UNTIL STOP: Repeat visits to clinic (e.g. chemo, dialysis) would be set longer. Sites must make determination on length of order duration based on clinic & providers needs as well as hospital policy. AUTO-DC IMO ORDERS: This parameter comes into play when no other business rule applies to discontinue the order on patient movement (e.g. CPRS). There has been much discussion when it comes to the ED as to whether or not this parameter should be set to “no”. Setting to “no” would allow existing ED orders to carry over to inpatient so nurse can view & continue ED meds until hospitalist can rewrite orders for inpatient admission, however orders could only be viewed under “clinic mode” in BCMA & would have to expired or be D/C’d by admitting provider. ED provider or hospitalist placing delayed orders for admission might be better option. There is no firm consensus yet as clinic orders in ED has not been widely used pending release of CPRS v30b.

Parameter Menu Edit (UD) Continued Description SEND TO BCMA?: MISSING DOSE PRINTER: PRE-EXCHANGE REPORT DEVICE: This field will determine if inpatient orders for outpatients in this clinic will be made available to the Bar Code Medication Administration package. Typically, set to “yes” once clinic is set up. This is the print device that this Clinic will use to print Missing Dose requests. This device overrides the default "Clinic Missing Dose Request Printer:" device (stored as an XPAR Division parameter), set by the BCMA Site Parameters GUI Client, for Clinics. Site to determine. The device most frequently used to print the Pre-Exchange Report for this CLINIC. This device will be shown as the default for the 'Select DEVICE for PRE-EXCHANGE UNITS REPORT:' prompt when printing the Pre-Exchange Report. SEND TO BCMA?: Clinic set up – please refer to BCRO SharePoint & review “Operational Guidelines for Successful Implementation of Clinic Orders” & “lessons learned” documents. MISSING DOSE PRINTER & PRE-EXCHANGE REPORT DEVICE: Used by pharmacy Staff to differentiate between devices used for clinics & wards.

Parameter Menu Edit (UD) Continued Description IMO DC/EXPIRED DAY LIMIT: Systems Parameters Edit This field contains the number of days that DC/Expired orders will be included in the enhanced order checks for drug interaction and therapeutic duplications for clinic orders. If this field is left blank, a default value of 30 days will be used. Typically, a minimum of 30 days is recommended but a site may choose a longer length of time (e.g. 120 days) to account for expired outpatient prescriptions that the patient may still be taking. This allows the user (supervisor or coordinator) to edit parameters that affect the Inpatient Medications package as a whole. Systems Parameters Edit: this is a compilation of miscellaneous parameters that have no relationship to BCMA. There is one parameter for DAYS UNTIL STOP FOR ONE-TIME contained here which comes into play only if the same parameter is not set for the individual ward.

Site Parameters (IV) Parameter Description LVP'S GOOD FOR HOW MANY DAYS: HYPERAL GOOD FOR HOW MANY DAYS This number is used when the stop date of a new order is computed. In other words, if Large Volume IV's are good for 14 days and a new order is input with a start date of today, the stop date will be 'T+14'. Type a Number between 1 and 31. This number is used when the stop date of a new order is computed. In other words, if a hyperal order is good for 14 days and a new order is entered today, the default stop date will be 14 days from today. Typically, most sites use 1 day to allow for daily evaluation of labs. LVP'S GOOD FOR HOW MANY DAYS: This parameter can be highly individualized by site. Most sites will choose a longer duration for large volume IVs without additives (such as 7 days), but limit critical care infusions to 1 day. This is done by setting this parameter to 7 days while also setting the orderable item limit for selected drugs to 1 day. In the hierarchy of parameters, the orderable item limit will supersede this parameter & apply the shorter stop date.

Site Parameters (IV) Continued Description PB'S GOOD FOR HOW MANY DAYS: SYRN'S GOOD FOR HOW MANY DAYS: CHEMO'S GOOD FOR HOW MANY DAYS: STOP TIME FOR ORDER: This number is used when the stop date of a new order is computed. In other words, if a piggyback order is good for 14 days and a new order is entered today, the default stop date will be 14 days from now. Typically, 30 days is used. Type a Number between 1 and 31. This field is used to determine the stop date for the Syringes order. Typically, 30 days is recommended. This field is used to determined the stop date for the Chemo order. Highly variable by site. Enter the TIME of the day that orders should end. For example if IV's are good for 14 days and an order's start date/time is MAY 01 1985@1200 and 2200 is entered at this prompt, then the default stop date/time will be MAY 14 1985@22:00. PB'S GOOD FOR HOW MANY DAYS: Most sites will set for 30 days, but combine with orderable item limit parameter to shorten order duration for those drugs that require it (example: 10 days on antibiotics) STOP TIME FOR ORDER: serves same function as the UD parameter of the same name but applies to IVs.

Site Parameters (IV) Continued Description EXPIRE ALL ORDERS ON SAME DAY: Individual Labels (IV) (note: this is an option, not parameter) Enter a '1' to stop all IV orders automatically on the same day. The day the orders are stopped will be the 'STOP DATE' of the FIRST ACTIVE IV order found in the file. The stop/date that is found will be shown as a default for the stop/date of the IV ORDER. Typically set to “no”. Print New Labels or Reprint IV Labels: for Pharmacy compounded IV’s, once printed, that bag is “available” to nursing to administer, whether that bag is physically on the unit or not. Nurse can only scan “available” bags - bags do not have to be scanned in sequence. EXPIRE ALL ORDERS ON SAME DAY: same as UD parameter of the same name but for IVs. Labels reprinted in pharmacy – the previous barcode will not be available any longer on BCMA VDL. If NEW label is generated, the original barcode will remain available, but the available bag list will continue to grow.

Medication Route File Enter/Edit This option provides the ability to edit data for entries in the MEDICATION ROUTES (#51.2) File. Example: IV Piggyback Select MEDICATION ROUTES NAME: IV PIGGYBACK IVPB NAME: IV PIGGYBACK// ABBREVIATION: IVPB// PACKAGE USE: ALL PACKAGES// IV FLAG: YES// This field shall designate IV medication routes. This will help determine how Inpatient Medication orders entered through CPRS will be finished in the Pharmacy package. PROMPT FOR INJ. SITE IN BCMA: YES The purpose of this field is to provide a way to indicate that a medication route needs to have a prompt for injection site in BCMA. DISPLAY ON IVP/IVPB TAB IN BCMA?: YES

Synonym Enter/Edit The option provides easy access to update the synonym information for an entry in the local DRUG file. For the purposes of BCMA, the synonym is the “scanned bar code” for a particular dispense drug & strength Example: Acetaminophen 325mg tab Select DRUG GENERIC NAME: ACETAMINOPHEN 325MG TAB CN103 Select SYNONYM: TYLENOL// INTENDED USE: TRADE NAME// NDC CODE: Select SYNONYM: ? Answer with SYNONYM Choose from: 1 000839508016 2 TYLENOL You may enter a new SYNONYM, if you wish. ANSWER MUST BE 1-40 CHARACTERS IN LENGTH Synonyms are typically the national drug code (NDC) number for an individual drug & strength. They are coded into bar codes which are then scanned into the matching pharmacy drug file entry. Pharmacy & nursing must use the same type of bar code scanner to eliminate discrepancies caused by different scanner programming (i.e., item scans in pharmacy but not on ward) The same bar coded drugs from multiple manufacturers can all be scanned into one drug file entry allowing for different bar codes to be associated with one drug file entry for BCMA. When troubleshooting medications “unable to scan”, be sure to save the package of the item that would not scan & supply to pharmacy. This ensures you are testing the same product from the same manufacturer as there may be multiple manufacturer’s stock available.

Enter/Edit Dosages This option allows you to edit Possible Dose fields and Local Possible Dose fields for a selected entry from the DRUG (#50) File. When setting up doses, the system associates it with the correct number of dispense drug units when the POSSIBLE DOSAGES field is populated. Local possible dosages are set up in the same manner when more customization is needed. There is also a field called “BCMA UNITS PER DOSE” which controls the number of times a dispense drug unit needs to be scanned in BCMA independent of how many dispense drug units are actually needed. If set improperly, it will prompt the nurse to scan too many or too few times to deliver the needed dose. It is recommended that this field be left blank in almost all cases to allow the system to use the correct number of dispense units associated with the dose. The BCMA UNITS PER DOSE sub-field (#3) of the POSSIBLE DOSAGES multiple (#903) of the DRUG file (#50) and the BCMA UNITS PER DOSE sub-field (#2) of the LOCAL POSSIBLE DOSAGE multiple (#904) of the DRUG file (#50) are used by Inpatient Medications to populate the Units Per Dose information for Unit Dose orders. This value will determine the number of times a medication must be scanned in order to document a medication administration through Bar Code Medication Administration (BCMA). This field is not required and an entry should be made only when multiple scans through BCMA appear to document erroneous dosages.

Edit Orderable Items Parameters Description DAY (nD) or DOSE (nL) LIMIT: If found when this drug is ordered, this is used to calculate a DEFAULT value for the STOP DATE prompt of the order. If the number entered here is followed by a "D", that NUMBER OF DAYS will be added to the START DATE to calculate the STOP DATE. If the number entered is followed by an "L", the number is used as the NUMBER OF DOSES to calculate the STOP DATE. This is best used for NARCOTICS and ANTIBIOTICS. DAY (nD) or DOSE (nL) LIMIT: In the hierarchy of pharmacy parameters, this one is ranked the highest & will supersede all other stop date/time parameters. It is useful when used in conjunction with inpatient ward parameters to the standard stop date/time for a ward when a shorter length of order duration is required for certain drugs by hospital policy (i.e., 10 days on antibiotics, 3 days on CII narcotics, etc.) It can also present problems when the orderable item limit is set to a time period longer that the standard stop date/time parameter as it will extend the active order longer than expected. This scenario recently came to light with the advent of clinic orders. If the clinic order stop date time is set for 1 day but the orderable item limit is set to 7 days for a particular drug, the 7 day stop date/time will be used. To date, a remedy ticket has been entered to correct the issue.

Edit Orderable Items Continued Parameter Description DEFAULT MED ROUTE: USE DOSAGE FORM MED ROUTE LIST: SYNONYM: If a MED ROUTE is entered here, that med route is used as a DEFAULT value during order entry when this drug is selected. If you answer YES to the prompt, the DEFAULT MED ROUTE (if populated) and the list of med routes associated with the DOSAGE FORM of the orderable item (if populated) will be displayed as selectable med routes during medication ordering dialog. If you answer NO, the DEFAULT MED ROUTE (if populated) and POSSIBLE MED ROUTES list will be displayed instead. Used to populate trade names to make drug selection easier for providers. This is NOT used to add bar codes for scanning USE DOSAGE FORM MED ROUTE LIST: In most cases, this should always be set to “yes” so the provider can see the recommended default route & other possible choices. If “no”, provider may only see default med route & choose that in error.

Summary There are many parameters/settings/options in pharmacy packages that are the foundation for inpatient ward & clinic order behavior. Most of these have been in place for years & are probably working well at your site (IF IT AIN’T BROKE, DON’T FIX IT!). Most new challenges come from setting up new wards or making changes to existing ones. Look at the parameters already set up for a similar existing ward & copy when possible to get the same results. Rule out human error - is it a person issue or system issue? Don’t try to troubleshoot issues in a silo – involve your pharmacy ADPAC &/or CAC. There’s help out there – BCRO SharePoint discussion board, “ask a question of BCRO”, BCMA Coordinators mail group, Vista Documentation Library, etc.

Questions