CPRS/Pharmacy Laboratory Monitoring Project Duane E. Machaj, R Ph.; Jesse Brown VA Medical Center, Chicago, Illinois Robert Silverman, Pharm D.; Pharmacy Benefits Management/Clinical Informatics

Background: Appropriate laboratory monitoring is important for safe and effective medication management. However, laboratory information was previously only available in the pharmacy action profiles (which are no longer used at most sites) or within the Labs tab of CPRS. The challenge was to develop a means for physicians and pharmacists to readily view labs when prescribing or finishing outpatient medication orders. The outpatient pharmacists are required to monitor lab tests for patients on various medications. This was cumbersome as the pharmacists needed to toggle between a VistA session of outpatient prescriptions and a CPRS session to find the lab value. If the laboratory values were out of range or not available, the pharmacists would need to contact the physician with recommendations to order lab tests or to change the medication therapy. Many of the physicians were unaware of which labs would be beneficial to monitor to assess appropriate outcomes for medication prescribed. The CPRS software did not correlate any laboratory values with medications ordered.

Objectives: The ability to associate a laboratory test result with drug file entries already existed in Pharmacy Data Management software. The programming code necessary to display lab values on medication profiles already existed but not within the format of the “electronic” medical record. The objective was to incorporate the laboratory monitoring functionality into both CPRS and Pharmacy software. Monitoring labs associated with medication therapy reduces the risk of adverse reactions and toxicity. The laboratory values can be used to gauge the safety and efficacy of the drugs. The CPRS component will display a designated lab value to the physician when ordering medications.

Methods: The pharmacy component of this application uses existing code from the “Action Profile” option PSO ACTION PROFILE and places this code in 5 pharmacy routines. This allows the lab values to display on screen for nearly all options associated with processing and viewing prescriptions. The designation of labs associated with individual drugs takes place in the existing functionality of the DRUG ENTER/EDIT [PSS DRUG ENTER/EDIT] option. The fields used for this purpose include LAB TEST MONITOR; SPECIMEN TYPE; and MONITOR MAX DAYS. At Jesse Brown VAMC, we have these markings applied to 750 drugs. Since these markings are done on the local drug file, each facility can customize the scope of their program.

Sample of current display from Class I Action Profile

This is set up in the Drug File (file 50) by marking the item for Lab Monitoring. You can enter one individual test, specimen type, and number of day to search back. You cannot mark for multiple tests or panel tests. (i.e. LFT)

Sample of some of the 757 drug markings in use at Jesse Brown VAMC

Sample of Outpatient Prescriptions with addition of laboratory value

Sample of display when laboratory test was not performed

The CPRS component uses similar code to display the lab value in a message box when the physician selects a medication orderable item during the ordering process. A TIU object was also developed with this same code to display the laboratory value in the provider comments field of an outpatient medication order when the object is placed within the quick order. The object is universal and pulls the laboratory value based on whatever laboratory test is designated within the drug file.

Shown here is a screen capture of the display for a selected order within the context of CPRS GUI.

Laboratory value display when orderable item is selected

Since the message box in CPRS only displays when the orderable item is selected and closes when a dosage is selected, this would not display for quick orders. A CPRS object was created which could be placed in the provider comment field of the quick order to display whatever lab value the dispense drug is marked for in file 50. The CPRS component also does not currently display lab values for Change orders and Renewal orders. This did not preclude workgroup endorsement of the product.

Laboratory value display when TIU object placed in quick order

Sample of display when laboratory test was not performed

Results: Pharmacy component – in production at Jesse Brown VAMC since 2003. Pharmacy staff reported increased efficiency in monitoring therapeutic outcomes of their patients. The need to toggle between the Pharmacy (VistA) applications and CPRS GUI was significantly reduced. CPRS component – in production at Hines VA Hospital and Jesse Brown VAMC since early 2009. Physicians reported greater awareness of how availability of laboratory data can facilitate better informed medication selection and dosing.

This project was submitted as a single New Service Request since the CPRS and Pharmacy components compliment each other. The goal is to provide the same functionality for both the physicians and pharmacists. Since both users see the laboratory values, it enhances communication and discussion of drug therapy. This also serves to educate both physicians and pharmacists by providing a tool to gauge the safety and efficacy of the medication regimen. It also enhances the potential to slow disease progression and minimize drug toxicity.

Conclusion: This project started as Class III software and was proposed for Class I conversion under New Service Request (NSR) 20090403. At the assessment stage of the review process, the NSR was reviewed by the OHI IT Patient Safety team and given a high patient safety score. The committee recommended a “MANDATED” status for the request which should lead to future implementation in the national software. http://vista.med.va.gov/nsrd/Tab_GeneralInfoView.asp?RequestID=20090403

Acknowledgement and Appreciation to the Clinical Pharmacy Staff at Jesse Brown VA Medical Center who researched the recommended laboratory tests to associate with the drug file. Including (but not limited to): Thani Misra, Pharm.D. Karine Rozenberg-Ben-Dror, Pharm.D. Patrick Waters, Pharm.D. Donna Givone, Pharm.D.