Inpatient Medication Order Processing for BCMA (IHS)

General Considerations Active medication orders are basis of BCMA Orders do not appear on BCMA VDL until verified How the order is finished affects what the Nurse sees in BCMA – Start time of an order is important How the order is finished can impact med access from automated dispensing cabinets (Pyxis, Omnicell, etc – “profile” system) All medication packages must be bar coded, either from the manufacturer or by the Pharmacy staff VA/IHS BCMA 2013/20142

Inpatient Ward Parameters DAYS UNTIL STOP FOR ONE-TIME: ? Enter 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). DEFAULT START DATE CALCULATION: USE NOW AS DEFAULT // ?? 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. Choose from: 0 USE CLOSEST ADMIN TIME AS DEFAULT 1 USE NEXT ADMIN TIME AS DEFAULT 2 USE NOW AS DEFAULT DEFAULT START DATE CALCULATION: USE NOW AS DEFAULT VA/IHS BCMA 2013/20143

Finishing Orders *Start / stop dates/times Schedule type / One -time Schedule / Administration times (standard times setup) “Now” dose too close to next scheduled dose *Dispense drug / number of units dispensed Provider comments *Particularly important relative to BCMA VA/IHS BCMA 2013/20144

Start date/time – Admin Time *(1)Orderable Item: FOLIC ACID ORAL TAB Instructions: 1MG *(2)Dosage Ordered: 1MG Duration: *(3)Start: 03/19/13 09:14 *(4) Med Route: ORAL REQUESTED START: 03/20/13 09:00 *(5) Stop: 04/18/13 12:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: DAILY (9) Admin Times: 0900 *(10) Provider: PROVIDER, ONE [es] (11) Special Instructions: VA/IHS BCMA 2013/20145 NOTE: The dose is the Expected First dose This dose would be visible on the BCMA Cover sheet on 3/19/13, but not on the VDL until 3/20/13

Start date/time – Admin Time *(1)Orderable Item: DOCUSATE CAP Instructions: 100 MG *(2)Dosage Ordered: 100 MG Duration: *(3)Start: 03/19/13 09:14 *(4) Med Route: ORAL REQUESTED START: 03/19/13 17:00 *(5) Stop: 04/18/13 12:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: BID (9) Admin Times: *(10) Provider: PROVIDER, ONE [es] (11) Special Instructions: VA/IHS BCMA 2013/20146 NOTE: The dose is the Expected First dose

Day-of-the-week Schedule VA/IHS BCMA 2013/20147 *(1)Orderable Item: CLONIDINE PATCH Instructions: ONE PATCH *(2)Dosage Ordered: ONE PATCH Duration: *(3)Start: 03/19/13 09:14 *(4) Med Route: TRANSDERMAL REQUESTED START: 03/19/13 12:00 *(5) Stop: 04/18/13 12:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: WEEKLY (9) Admin Times: 1200 *(10) Provider: PROVIDER, ONE [es] (11) Special Instructions: Give on Monday (12) Dispense Drug U/D Inactive Date CLONIDINE PATCH 0.1MG/24HOURS 1 NOTE: The 03/19/13 is a Tuesday, the Start date MUST be changed to 3/25/13 (with an Admin Time before 1200 – e.g. in order for the order to scheduled weekly on a Monday.

Day-of-the-week Schedule VA/IHS BCMA 2013/20148 *(1)Orderable Item: CLONIDINE PATCH Instructions: ONE PATCH *(2)Dosage Ordered: ONE PATCH Duration: *(3)Start: 03/19/13 09:14 *(4) Med Route: TRANSDERMAL REQUESTED START: 03/25/13 09:00 *(5) Stop: 04/18/13 12:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: (9) Admin Times: 0900 *(10) Provider: PROVIDER, ONE [es] (11) Special Instructions: Give on Monday (12) Dispense Drug U/D Inactive Date CLONIDINE PATCH 0.1MG/24HOURS 1 NOTE: The Requested Start will automatically default to the next Monday date with a schedule of

M-W-F Schedule VA/IHS BCMA 2013/20149 *(1)Orderable Item: PREDNISONE TAB Instructions: 10MG *(2)Dosage Ordered: 10MG Duration: *(3)Start: 03/19/13 09:14 *(4) Med Route: ORAL REQUESTED START: 03/20/13 09:00 *(5) Stop: 04/18/13 12:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: (9) Admin Times: 0900 *(10) Provider: PROVIDER, ONE [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date CLONIDINE PATCH 0.1MG/24HOURS 1 NOTE: The Requested Start will automatically default to the next Monday date with a schedule of

“Odd” Schedule VA/IHS BCMA 2013/ *(1)Orderable Item: BISACODYL SUPP Instructions: 10 MG *(2)Dosage Ordered: 10 MG Duration: *(3)Start: 03/19/13 09:14 *(4) Med Route: RECTAL REQUESTED START: 03/22/13 09:00 *(5) Stop: 04/18/13 12:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: Q3D (9) Admin Times: 0900 *(10) Provider: PROVIDER, ONE [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date BISACODYL SUPP 10 MG SUPP 1 NOTE: the Requested Start is “+3” if the order was entered after the scheduled Admin Time.

“Odd” Schedule VA/IHS BCMA 2013/ *(1)Orderable Item: BISACODYL SUPP Instructions: 10 MG *(2)Dosage Ordered: 10 MG Duration: *(3)Start: 03/20/13 10:00 *(4) Med Route: RECTAL REQUESTED START: 03/23/13 09:00 *(5) Stop: 04/18/13 12:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: Q3D (9) Admin Times: 0900 *(10) Provider: PROVIDER, ONE [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date BISACODYL SUPP 10 MG SUPP 1 NOTE: the Requested Start is “+3” if the order was entered after the scheduled Admin Time.

Dispense Drug – U/D Dispense Drug Units / Dispense Drug Impacts directly what the nurse is asked to scan VA/IHS BCMA 2013/201412

Dispense Drug – U/D VA/IHS BCMA 2013/ *(1)Orderable Item: CLONIDINE TAB Instructions: 0.1MG *(2)Dosage Ordered: 0.1MG Duration: *(3)Start: 03/20/13 17:00 *(4) Med Route: ORAL *(5) Stop: 04/18/13 12:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: BID (9) Admin Times: *(10) Provider: PROVIDER, ONE [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date CLONIDINE 0.2MG 1/2 NOTE: The Drug provided MUST be what the order states.

Dispense Drug – U/D VA/IHS BCMA 2013/ (11) Special Instructions:[15mg = 1.5 X 10mg tab] (12) Dispense Drug U/D Inactive Date SIMVASTATIN 10MG TAB 1.5 (11) Special Instructions:[15mg = 10mg + 5mg] (12) Dispense Drug U/D Inactive Date SIMVASTATIN 10MG TAB 1 SIMVASTATIN 5MG TAB 1 2 different strengths were dispensed to satisfy the dosage ordered (11) Special Instructions:[15mg = 3 x 5mg tab] (12) Dispense Drug U/D Inactive Date SIMVASTATIN 5MG TAB 3 NOTE: The Drug(s) provided MUST be what the order states.

Provider comments PROVIDER COMMENTS: Pain > 3/10 Select one of the following: Y Yes (copy) N No (don't copy) ! Copy and flag for display in a BCMA Message Box E Copy and Edit Copy the Provider Comments into Special Instructions (Yes/No/!/E): y Yes (copy) VA/IHS BCMA 2013/ NOTE: Depending on which Inpatient Med patches you have installed, you may not see “E – copy and edit” as an option.

Copy Provider comments Select Item(s): Next Screen// fn Finish PROVIDER COMMENTS: For gastric distress. Select one of the following: Y Yes (copy) N No (don't copy) ! Copy and flag for display in a BCMA Message Box E Copy and Edit Copy the Provider Comments into Special Instructions (Yes/No/!/E): Y VA/IHS BCMA 2013/201416

Special Instructions – “!” ! – will generate a pop-up box for the nurse in BCMA to alert him/her of the special instructions What should be flagged? Determined by policy or pharmacist’s judgment Check pulse? Insulin sliding scale? Take with food? VA/IHS BCMA 2013/201417

Complex Orders P E N D I N G C O M P L E X PREDNISONE TAB ? ***** ***** P Give: 20MG PO DAILY PREDNISONE TAB ? ***** ***** P Give: 10MG PO DAILY PREDNISONE TAB ? ***** ***** P Give: 5MG PO DAILY RECENTLY DISCONTINUED/EXPIRED (LAST 24 HOURS) HEPARIN UNITS C 04/17 04/17 DF in 5% DEXTROSE INJECTION 250 ML SEE COMMENTS VA/IHS BCMA 2013/201418

Start date/time – Admin Time *(1)Orderable Item: PREDNISONE TAB Instructions: 20MG *(2)Dosage Ordered: 20MG Duration: 3 days *(3)Start: 03/19/13 09:00 *(4) Med Route: ORAL Calc Start: 03/18/13 13:23 *(5) Stop: 03/22/13 09:00 (6) Schedule Type: CONTINUOUS Calc Stop: 04/17/13 12:00 *(8) Schedule: DAILY (9) Admin Times: 0900 *(10) Provider: PROVIDER, ONE [es] (11) Special Instructions: then stop (12) Dispense Drug U/D Inactive Date PREDNISONE 20MG TAB 1 VA/IHS BCMA 2013/ NOTE: the Start and Stop dates are calculated for each component of the complex order. NO dose is due actually due for the Stop date/time.

Start date/time – Admin Time *(1)Orderable Item: PREDNISONE TAB Instructions: 10MG *(2)Dosage Ordered: 10MG Duration: 3 days *(3)Start: 03/22/13 09:00 *(4) Med Route: ORAL Calc Start: 03/18/13 13:23 *(5) Stop: 03/25/13 09:00 (6) Schedule Type: CONTINUOUS Calc Stop: 04/17/13 12:00 *(8) Schedule: DAILY (9) Admin Times: 0900 *(10) Provider: PROVIDER, ONE [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date PREDNISONE 5MG TAB 2 VA/IHS BCMA 2013/ NOTE: the Start and Stop dates are calculated for each component of the complex order.

Start date/time – Admin Time *(1)Orderable Item: PREDNISONE TAB Instructions: 5MG *(2)Dosage Ordered: 5MG Duration: 2 days *(3)Start: 03/25/13 09:00 *(4) Med Route: ORAL Calc Start: 03/18/13 13:23 *(5) Stop: 03/27/13 09:00 (6) Schedule Type: CONTINUOUS Calc Stop: 04/17/13 12:00 *(8) Schedule: DAILY (9) Admin Times: 0900 *(10) Provider: PROVIDER, ONE [es] (11) Special Instructions: then stop (12) Dispense Drug U/D Inactive Date PREDNISONE 5MG TAB 1 VA/IHS BCMA 2013/ NOTE: the Start and Stop dates are calculated for each component of the complex order.

Complex Orders 7 PREDNISONE TAB C 03/19 03/22 A Give: 20MG PO DAILY 8 PREDNISONE TAB C 03/22 03/25 A Give: 10MG PO DAILY 9 PREDNISONE TAB C 03/25 03/27 A Give: 5MG PO DAILY then stop RECENTLY DISCONTINUED/EXPIRED (LAST 24 HOURS) HEPARIN UNITS C 04/17 04/17 DF in 5% DEXTROSE INJECTION 250 ML SEE COMMENTS VA/IHS BCMA 2013/201422

Additional Dose NOW RPMS EHR identifies the next expected administration time upon provider order entry, if the dose is required before that time, the provider has the opportunity to order an additional/“now” dose Generates 2 orders for pharmacy Check the Admin Times for the NOW dose relative to the next scheduled Admin Time VA/IHS BCMA 2013/201423

Additional Dose NOW Continued A C T I V E FLUCONAZOLE ORAL TAB C 05/03 06/02 A Give: 100MG PO QHS P E N D I N G FUROSEMIDE ORAL TAB ? ***** ***** P Give: 40MG PO NOW Additional Dose Now 3 FUROSEMIDE ORAL TAB ? ***** ***** P Give: 40MG PO BID VA/IHS BCMA 2013/201424

Additional Dose NOW Continued *(1)Orderable Item: FUROSEMIDE ORAL TAB Instructions: 40MG *(2)Dosage Ordered: 40MG Duration: (3)Start: 05/13/13 13:16 *(4) Med Route: ORAL REQUESTED START: 05/13/13 13:16 (5) Stop: 05/14/13 13:16 (6) Schedule Type: ONE TIME *(8) Schedule: NOW (9) Admin Times: *(10) Provider: PROVIDER,ONE [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date FUROSEMIDE 40MG TAB 1 VA/IHS BCMA 2013/201425

Additional Dose NOW Continued “regular” order *(1)Orderable Item: FUROSEMIDE ORAL TAB Instructions: 40MG *(2)Dosage Ordered: 40MG Duration: (3)Start: 05/13/13 13:16 *(4) Med Route: ORAL REQUESTED START: 05/13/13 18:00 (5) Stop: 06/12/13 12:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: BID (9) Admin Times: *(10) Provider: PROVIDER,ONE [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date FUROSEMIDE 40MG TAB 1 VA/IHS BCMA 2013/201426

Schedule Types – O vs OC VA/IHS BCMA 2013/ One-TimeOn Call Default Stop1 day (24 hours)Standard default (30 days) Once administeredFalls off of BCMA VDL Will expire in RPMS EHR Pharmacy Will remain in RPMS EHR Pharmacy until the default expiration OI / Dispense drug restriction – auto- stop, e.g., 7 days Easily allow a one-time order to remain active for more than 24 hours, e.g., Flu vaccine

Sliding scale insulin Continuous order – will remind nurse to check glucose as scheduled, documenting “0” units administered if no insulin required, or dose may be Held PRN order – does not require administration documentation if none administered, but will require nurse to have an alternate process to schedule glucose checks VA/IHS BCMA 2013/201428

IV’s in BCMA IVP/IVPB tab – shows IV push (finished in Unit dose) and IV piggybacks orders IV tab – shows continuous infusion IV solutions (no “schedule”), “non- intermittent” syringe (PCA); – IVs will NOT appear on Missed Med Report since they are not “scheduled” – “one-time IV’s” will NOT go off profile after given (will go off profile when order expires – NO Last Action column – admin record part of each “bag” record Barcode for IV bags consists of the patient’s IEN followed by a “V”, then a sequential number, calculated from the number of labels printed. Ward stock IV bags – MUST be bar-coded, before delivery to wards if none from manufacturer VA/IHS BCMA 2013/201429

IV’s in BCMA (cont’d) Label printing – 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. 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. “Cancel or Recycled Labels” - these labels are no longer available to nurses. As far as statistics, Cancel & Recycle will also “cancel” workload. “Destroy” label will not cancel workload. VA/IHS BCMA 2013/201430

IV’s in BCMA (cont’d) Components may be scanned to make up IV – e.g., Cefazolin 1gm vial & D5W 50ml bag to make up Cefazolin 1gm in D5W 50ml IVPB order. Orders still must be finished by pharmacists first. Components will not work if the order is finished as a pre-mixed product IV infusions must be scanned when done to “complete” bag before starting next bag. If not completed on discharge, the IV bag will re-appear on re-admission. ODD schedules (e.g. Q7D) – remember to use “start time” to control the Admin time VA/IHS BCMA 2013/201431

Pending IV Orders 3 FUROSEMIDE ORAL TAB O 05/13 05/14 A Give: 40MG PO NOW P E N D I N G POTASSIUM CHLORIDE 20 MEQ ? ***** ***** P in 5% DEXTROSE & 0.9% SOD CL INJ 1000 ML 80 ml/hr VA/IHS BCMA 2013/ CEFAZOLIN INJ ? ***** ***** P Give: IVPB Q8H 6 CEFAZOLIN INJ ? ***** ***** P Give: 1 GRAM IVPB Q8H 7 in KCL 20mEq INJ in D5/0.45NACL 1L ? ***** ***** P 125 ml/hr

VA/IHS BCMA 2013/ IV Piggyback Order (IV quick order) Orderable Item: CEFAZOLIN INJ Give: IVPB Q8H WD 1A 11/23/13 BCMA,PATIENT ONE CEFAZOLIN 1 GM 5% DEXTROSE INJECTION 100 ML INFUSE OVER 30 Minutes Q8H KEEP REFRIGERATED RETURN TO PHARMACY IF NOT USED - FILLED:___ CHECKED:___ 1[1] Start date: NOV 23, :47 Stop date: DEC 3, :00 Expected First Dose: NOV Is this O.K.? YES//

IV Infusion Order *(1) Additives: Type: ADMIXTURE POTASSIUM CHLORIDE 20 MEQ *(2) Solutions: 5% DEXTROSE & 0.9% SOD CL INJ 1000 ML Duration: (4) Start: 05/13/13 13:38 *(3) Infusion Rate: 80 ml/hr *(5) Med Route: IV (6) Stop: 06/12/13 24:00 *(7) Schedule: Last Fill: ******** (8) Admin Times: Quantity: 0 *(9) Provider: PROVIDER,ONE [es] Cum. Doses: (10) Other Print: Provider Comments: (11) Remarks : IV Room: PERRY POINT IV Select Item(s): Next Screen// fn Finish Remote data not available - Only local order checks processed. VA/IHS BCMA 2013/201434

VA/IHS BCMA 2013/ IV Infusion (Premix) *(1) Additives: Type: ADMIXTURE *(2) Solutions: KCL 40mEq INJ in D5/0.45NACL 1L Duration: (4) Start: 11/23/13 12:33 *(3) Infusion Rate: 125 ml/hr *(5) Med Route: IV (6) Stop: 12/23/13 24:00 *(7) Schedule: Last Fill: ******** (8) Admin Times: Quantity: 0 *(9) Provider: PROVIDER, ONE [es] Cum. Doses: (10) Other Print: Start date: NOV 23, :33 Stop date: DEC 23, :00 Expected First Dose: NOV

Other IV Consideration MVI in one bag/day can be done with one order in order entry More complex IV therapies may require separate orders VA/IHS BCMA 2013/201436

Q1H vs multiple ONE-time orders VA/IHS BCMA 2013/ A C T I V E in POTASSIUM CHLORIDE 10mEq (RTU) 100 C 11/23 11/23 A ML Q1H 2 in POTASSIUM CHLORIDE 10mEq (RTU) 100 O 11/23 11/24 A ML ONCE 3 in POTASSIUM CHLORIDE 10mEq (RTU) 100 O 11/23 11/24 A ML ONCE 4 in POTASSIUM CHLORIDE 10mEq (RTU) 100 O 11/23 11/24 A ML ONCE

IV labels Auto-cancel of orders on transfer – since order is discontinued, IV bags are no longer available New label – will create a new IV bag number, including a “V” Reprint label – will create a new IV bag number, but will also invalidate the original bag number VA/IHS BCMA 2013/201438

PCA Infusion As IV Fluid – easier for documentation As PRN IV Push med – will require a one-time PRN effectiveness documentation in BCMA (not complete/accurate assessment of pain relief over the course of the infusion) Flow sheet or progress note for further documentation would be necessary. VA/IHS BCMA 2013/201439

BCMA Medication Administration Menu Pharmacy 1.Medication Administration Log 2.Missed Medications 3.Due List 4.Medication Administration History (MAH) 5.Missing Dose Request 6.Missing Dose Follow-up 7.Missing Dose Report 8.Label Print 9.Drug File Inquiry VA/IHS BCMA 2013/201440

Potential Nurse Concerns Bar code won’t scan Order is not in BCMA Administered med on Missed Med report Order “doesn’t make sense” After scanning, patient refused, cannot find order to “undo given” Patient was just admitted, but BCMA indicates patch needs to be removed VA/IHS BCMA 2013/201441

Bar code won’t scan (multiple scanning problems) Check scanner -Is it charged? -wireless scanner matched to right base? -recalibration needed? -Scan in notepad Problematic location – on ward -“dead” zone? -Survey access points VA/IHS BCMA 2013/201442

Bar code won’t scan (Cont’d) Identify drug – Manufacturer or pharmacy package/bar code? – Check stock in the Pharmacy – attempt to scan Manufacturer bar code – Bar code type – linear or multi-dimensional (recalibrate or upgrade scanners) – Is bar code in the Drug File? (Scan bar code into Drug File synonym) – Is the IEN listed as a synonym of another drug? – Bar code on reflective packaging (re-label or purchase alternate product) VA/IHS BCMA 2013/201443

Bar code won’t scan (Cont’d) Pharmacy automation packaged / manually bar coded packages – Check for obvious defects in bar code – too much white space, blots, wrinkles over bar code, etc. especially with linear bar codes Pharmacy relabeled – ophthalmic products, insulin, topical products – Bar code around curve? – Bar code folded or wrinkled? – Bar code worn? VA/IHS BCMA 2013/201444

Bar Code won’t scan (Cont’d) IV labels – Valid order – “Available” bag – label must be printed VA/IHS BCMA 2013/201445

Bar code won’t scan(Cont’d) Bar code scans, but error message “Drug Not Found” – Check Med order, dispense drug, strength of med dispensed – wrong drug dispensed? – Repackaged drug – label is correct – wrong IEN / bar code? – If order & manufacturer bar code are correct, check that the drug dispensed is marked for unit dose – Drug File Inquiry – Check the synonym field to assure that the bar code is associated with only one drug – Synonym Enter/Edit [PSS SYNONYM EDIT] VA/IHS BCMA 2013/201446

Order is not in BCMA/VDL Check med order – pending vs. finished Check start date / time (BCMA Cover sheet) Check administration time / VDL window time Schedule type check on VDL (One-time order / On-call orders) Med location – UD / IVPush / IV Text orders Check to see if error received from BCMA VA/IHS BCMA 2013/201447

Administered Med Appearing on “Missed Med” Report Med may appear on the MISSED MED report Due to Admin Time change on an active order – (noted: *Administration Times have been edited*) Pharmacist may copy the order to create a new order - adjust the Admin Time, Start date/time and Stop date/time (to the original stop) & discontinue original order VA/IHS BCMA 2013/201448

Order doesn’t make sense VA/IHS BCMA 2013/ Widen the “active medication” column to see the full order / details

Order doesn’t make sense(Cont’d) When was the last action? VA/IHS BCMA 2013/201450

Special considerations Pharmacist Auto-verification – Allow “accept” and “verify” of order in one step – Must be set for individual pharmacist – If order is left unverified – if verified by a nurse (on EHR) it will become active and available on BCMA Not 24/7 Pharmacy coverage – Remote Pharmacy finishing – RN Finish – CPRS Med Order button – Automated Dispensing Cabinets / Ward Stock VA/IHS BCMA 2013/201451

Special considerations Contingency Plan Problem orders – Flagging orders (red flag in EHR) – Holding order (RPMS) – greyed out in BCMA VA/IHS BCMA 2013/201452

Policy considerations Variable doses Variable schedules PRN orders / indications Split tablets Training / Competencies VA/IHS BCMA 2013/201453

Pharmacist Concerns BCMA GUI should be available within Pharmacy Communication Pharmacist must READ / review the entire order before verification Provider comments VA/IHS BCMA 2013/201454

Bar Codes All meds must be bar coded Populate (Scan if possible) manufacturer bar codes of new drug items on order check-in – Individual dispense unit, not package Check bar codes on repackaging Bar code “scannability” VA/IHS BCMA 2013/201455