Meditechnicalities The IN Group MUSE International May 30, 2012

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

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)

PHA Drug Dictionary

PHA Drug - Dispensing

PHA Drug – Ordering (INJ)

Order Strings – For Location

Pharamcy Location

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

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

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.

PHA Rules

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

Back Order Warning

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

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

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

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

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

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

Duplicate Generic 12 hr Check

Duplicate Generic 24 hr Check

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

The setup and the attribute used are shown below:

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

PCS Assessments

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.

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

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

Black Box Warning (eMAR)

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

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.

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

Interaction Conflict Group

Default POM Order Type

Protocol Tables

Dosing Sets

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 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.

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

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

Black Box Warning –POM

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

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

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

Pediatric Specific

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

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

< 13YO – Dose as Adult

6.x Changes

CS PHA 9808:Attach a CDS-type Protocol to Medication Orders With this enhancement, Pharmacy is able to display a CDS type protocol on an order ordered from Order Management (OM).

FOC OM Ability to View Order/Amb Order Option Details Prior to Selection Allow for a complete detailed view of an order/ambulatory order option without selecting the option. This view will be accessible by clicking on the Detail cell for any Orders/Amb Orders options displaying on a selection table.

FOC OM 3425: Enhancements to Amb Orders / Convert / Reconcile This DTS introduces a small portion of Development Design Project which supports several access and user interface (UI) changes to the Reconcile and Convert screens. Specifically, the following changes were made with this DTS: 1.OM Access Dictionary - Lookup options for Reconcile were changed from Yes/No to Edit/View/No. 2.OM Access Dictionary - Lookup options for Convert were changed from Yes/No to Edit/No** 3.OM Reconcile - A View version of the Reconcile screen was created. 4.Ambulatory Medications - The ability to enter PRN Reason directly from Manage Amb Order List screen (and other related Amb med screens) was added. ** The remaining portion of Development Design Project will introduce a View option for Convert**

FOC OM 5119: CPOE Streamlining - Red Edit Button and Keyboard Shortcuts Enhancement A change has been made to replace all instances of the old Blue Edit Required icon in OM have been replaced with the new Red Edit Required icon.

FOC OM Reflex Set Dictionary: Arrange Screen Functionality This enhancement will allow Reminders to be added to Reflex Sets as well as provide the ability for the full use of the Arrange screen in the Reflex Set Dictionary.

FOC OM x OM: Allow for Weight Based IV Fluid Calculation This introduces the ability to calculate a total IV fluid Volume based on a patients weight using the dose calculator. The dose calculator will now be available in the lookup of the IV Fluid field. The information used to calculate the dose will be displayed on the details screen. This also introduces the dose calculator for fluids in dose sets.

Other Vendor Order Sets Other Vendor Sets should not be imported if they contain “blanks” due to unmapped items Systematic versioning should be included in the mnemonic (External ID) so importing new versions will not over-write previous versions Suggest – save a set immediately once imported

OE Reflex Dictionary Reflex Orders are your Friend Use reflex Orders to Order secondary orders that support other processes, i.e.: –Saline Flush reflexed from IV start order –Patch Removal Order reflexed from Patch Order –Respiratory Treatment from Medication –Radiology Prep from Exam Order

EDM Facilitating Look-up of Medications Use fo Favorite Order Sets to enhance Order Set Menu Separate Site ?? (will this work?) Verified Orders Pyxis Settings – to Profile or not to Profile Rules

Ordered from ED comment Adds “Ordered for ED Only” to label comments

OTO – ONE (SCH) Check Makes sure OTO orders are not ordered with a schedule of SCH (they don’t DC)

Warning for Patients if Drug Class + Wt + LOC Specific for ped patients for specific drug types in specific location of ED

Dose Restriction Rule Uses Drug CDS top control partial doses of oral forms

Restrict to Specialist MD Designed to limit ordering of medication to specific physicians

Metformin Rule RESIII#"2,"^TMIII, [f z.cc.calc](SRCRI,PTURN,MED)^CALCRESI, [f z.cc.calc](SRCRII,PTURN,MED)^CALRESII, [f z.cc.calc](SRCRIII,PTURN,MED)^CALRESIII, CALCRESI|0^CRCLI, CALCRESII|0^CRCLII, CALRESIII|0^CRCLIII, IF{((SEX="M")&(SRCRI>1.4))!((SEX="F")&(SRCRI>1.3)) 1;""}^OK, IF{OK [ord pom]("IN.MET",1);1}; Message: Metformin is contraindicated in this patient based on the patient's serum creatinine of [f SRCRI] Previous CrCls: [f CRCLI] on [f [f TMI] [f CRCLII] on [f [f TMII] [f CRCLIII] on [[f [f TMIII] MU Rule per medical staff, modification of Creatinine Clearance Rule

Orders Restricted to Paper Temporary limitation of POM to adults

Ped IV Rate Calculation Uses a formula based on patient weight to calculate rate – this was also for ED

RXM / AOM Identification of linked medications Continuation of Certain Medications Transfer Routine Rules

AOM/RXM Drugs Dictionary

AOM/RXM STRINGS ADD STRINGS FOR OTHER STRENGTHS ??

AOM/RXM DRUG LINK

Med Rec Check Works in Theory – but not used Additional rule should be developed to ensure continuation of specific meds i.e. Beta Blockers

Transfer Routine Be very careful Should be completed immediately Physician understanding of functionality critical to satisfaction

Questions & Discussion Contact information:  Bruce Matthias  Penny Hilton  Steve Botwinski  Jose Castro Presentation available at: