July 2012 Pharmacy Data Management Associated Files

Examine the need for complete and accurate support files in an information system. Determine the benefits from efficient functioning and the risks associated with errors. Defend the notion that time spent configuring the drug file properly will save time and effort in other uses of the medical information system. Explain national standards as they relate to medications and drug files: consider ISMP recommendations for Sound Alike/Look Alike medications and abbreviations forbidden by national standards bodies such as The Joint Commission or ISMP and recommend an implementation plan. Recognize how an order is constructed in the system (schedule, dosage form, etc.) and the interrelationship between supporting files. Defend the reasons for the way inpatient and outpatient pharmacy quick orders are built and used. Course Objectives

Menu Options Dosages... Drug Enter/Edit Drug Interaction Management... Electrolyte File (IV) Lookup into Dispense Drug File Medication Instruction File Add/Edit Medication Route File Enter/Edit Orderable Item Management... Orderable Item Report Formulary Information Report Drug Text Enter/Edit Drug Text File Report Pharmacy System Parameters Edit Standard Schedule Edit Synonym Enter/Edit Controlled Substances/PKI Reports…

Dosages File The following options are available: Auto Create Dosages Dosage Form File Enter/Edit Enter/Edit Dosages Most Common Dosages Report Noun/Dosage Form Report Review Dosages Report

Dosage Form File Enter/Edit Need to go into “Dosages” Menu to find it Edits here affect EVERY drug with that dosage form! Can associate one or more ROUTES Can change the VERB Must remove the PREPOSITIONs Can edit the NOUNS

Dosage Form File, cont. NAME: TAB  comes from matching, do not edit Select MED ROUTE FOR DOSAGE FORM: ORAL//  can have more than one here VERB: TAKE//  this will be on the label, so should be patient friendly OTHER LANGUAGE VERB:  LEAVE BLANK! PREPOSITION:  LEAVE BLANK! OTHER LANGUAGE PREPOSITION:  LEAVE BLANK! Select NOUN: TABLET(S)//  can have more than one, will have doses of 1 and 2 of most noun(s) here created NOUN: TABLET(S)// OTHER LANGUAGE NOUN:  LEAVE BLANK! PACKAGE: Both//  usually both Select NOUN: CONJUNCTION:  not usually used, but might be for topicals that have a %strength

Dosage Form File, cont. NAME: INHL,ORAL Select MED ROUTE FOR DOSAGE FORM: ORAL// VERB: INHALE// OTHER LANGUAGE VERB: PREPOSITION: OTHER LANGUAGE PREPOSITION: Select NOUN: PUFF(S)// NOUN: PUFF(S)// OTHER LANGUAGE NOUN: PACKAGE: Both// Select NOUN: CONJUNCTION:

Dosage Form File, cont. NAME: OPHTHALMIC,CRC Select MED ROUTE FOR DOSAGE FORM: IN BOTH EYES// VERB: PLACE// OTHER LANGUAGE VERB: PREPOSITION: OTHER LANGUAGE PREPOSITION: Select NOUN: CONJUNCTION:

Dosages Enter/Edit Dosages –Possible Dosages Single entity tablets & capsules, and some other single entity agents Auto Creation –Creates 1 and 2 (units) –May have to edit if 2 is inappropriate or add more dosages Can add/edit Enter Package use Inpatient and/or Outpatient (if allowed) –Local Possible Dosages All other drugs ie creams, susp, MDIs Add/edit individual (local) dosages

Adding New Dosages Dosages are ONLY for Single Entity tablets and capsules PDM  Dosages  Dosages Enter/Edit Select Drug: HALOPERIDOL 10MG TAB CN709 Strength from National Drug File match=> 10 MG Strength currently in the Drug File=> 10 MG Edit Strength? N// Strength => 10 Unit => MG Select DISPENSE UNITS PER DOSE: ?? Choose from: 1 10 IO 2 20 IO Select DISPENSE UNITS PER DOSE: 3 Are you adding '3' as a new POSSIBLE DOSAGES (the 3RD for this DRUG)? No//Y Enter an 'I' for Inpatient, 'O' for Outpatient, 'IO' for both. PACKAGE: IO Strength => 10 Unit => MG Don’t add LPDs to get more choices for single entity tablets & capsules –Won’t be selectable (even though you will be able to add them) Dosages can not be imprecise i.e. 1-2 tablets (LPDs can) Don’t use a leading 0 for fractions of a dispense unit –i.e. ½ tablet would be.5 NOT 0.5 RARELY edit the strength here! Some apparent utility with very select IV push drugs when used with automated systems such as Pyxis – but may change with BCMA. Automatically created when drug was matched to the NDF DOES NOT mean they make sense so review (i.e 1600 mg of ibuprofen)

Deleting Inappropriate Dosages The system automatically generates 1 and 2 on single entity solid oral dosage forms. Sometimes 2 is inappropriate. PDM  Dosages  Dosages Enter/Edit Select Drug: 1457 NITROGLYCERIN 0.4MG TAB,S.L CV250 Strength from National Drug File match=> 0.4 MG Strength currently in the Drug File => 0.4 MG Edit Strength? N// Strength => 0.4 Unit => MG Select DISPENSE UNITS PER DOSE: ?? Choose from: IO IO Select DISPENSE UNITS PER DOSE: 2 DISPENSE UNITS PER DOSE: SURE YOU WANT TO DELETE THE ENTIRE '2' DISPENSE UNITS PER DOSE? Y Select DISPENSE UNITS PER DOSE:. PACKAGE: IO Strength => 0.4 Unit => MG Enter/Edit Local Possible Dosages? N // Select Drug:

For all other Drugs LPDs apply **Even if they have dosages associated with them PDM  Dosages  Dosages Enter/Edit Enter past the Dosages section if it appears Add any LPDs you will want to use in the Sigs Include –article if needed (A, THE) –Quantity (1, 2 etc.) –Noun (TABLET, CAPSULE, SUPPOSITORY, ML) –Avoid “Teaspoonful”, “Tablespoonful”, etc (Use “ML”) »Evidence suggests this leads to medication errors Delete superfluous LPDs –2 suppositories etc. Adding Local Possible Dosages What you type is what you get – Abbreviations do NOT expand MG do NOT calculate

Adding LPDs PDM  Dosages  Dosages Enter/Edit Select Drug: 2432 ACETAMINOPHEN/BUTALBITAL/CAFFEINE TAB CN103 This entry is marked for the following PHARMACY packages: Outpatient Select LOCAL POSSIBLE DOSAGE: ? Answer with LOCAL POSSIBLE DOSAGE Choose from: 1 CAPSULE IO 2 CAPSULES IO You may enter a new LOCAL POSSIBLE DOSAGE, if you wish (1-60 characters in length) Select LOCAL POSSIBLE DOSAGE: 1-2 CAPSULES Are you adding '1-2 CAPSULES' as a new LOCAL POSSIBLE DOSAGE (the 3RD for this DRUG)? No// Y LOCAL POSSIBLE DOSAGE: 1-2 CAPSULES// PACKAGE: IO Can select specific Drugs with the IEN (# column from the NSYN report) Include number, noun, and article (if needed)

PDM  Dosages  Enter/Edit Dosages Select Drug: 1595 BISACODYL 10MG SUPP,RTL Strength from National Drug File match=> 10 MG Strength currently in the Drug File => 10 MG Edit Strength? N// Strength => 10 Unit => MG Select DISPENSE UNITS PER DOSE: ?? Choose from: 1 10 IO 2 20 IO Select DISPENSE UNITS PER DOSE: Select LOCAL POSSIBLE DOSAGE: ? Answer with LOCAL POSSIBLE DOSAGE Choose from: 1 SuppositoryIO 2 SuppositoriesIO LOCAL POSSIBLE DOSAGE : SURE YOU WANT TO DELETE THE ENTIRE '2 SUPPOSITORIES‘ AS A LOCAL POSSIBLE DOSAGE? Y Select DISPENSE UNITS PER DOSE:. PACKAGE: IO Strength => 0.4 Unit => MG Enter/Edit Local Possible Dosages? N // Select Drug: Ready to edit next Drug Deleting LPDs

Look Up into Dispense Drug File Snapshot of medication information –Cost –Synonyms –NDC –Dosages –VA Drug Class Code Can be of use for non-pharmacy staff to look up meds (billing)

Medication Instruction Select MEDICATION INSTRUCTION NAME: ?? Choose from: (M) (MUST SEE PROVIDER FOR MORE REFILLS) A/A **AVOID ALCOHOL** AH **AVOID ALCOHOL** AOOH AT ONSET OF HEADACHE DD **DOSE DECREASED** DIN **DOSE INCREASED** FALL FOR ALLERGIES FAN FOR ANXIETY FAR FOR ARTHRITIS FAS FOR ASTHMA FAX FOR ANXIETY FBC FOR BIRTH CONTROL FBP FOR HIGH BLOOD PRESSURE FBR FOR BREATHING FCA FOR CALCIUM FCH FOR CHOLESTEROL CONTROL FCIRC FOR CIRCULATION Generally for patient instructions Not for schedules (BID, Q12H, etc) –Those go in standard schedules

Medication Instruction, cont. NAME: FFL//  the abbreviation you will use SYNONYM:  if you want more than one abbreviation EXPANSION: FOR FLUID//  how it will look on labels and reports PLURAL:  not usually used INTENDED USE: OUTPATIENT ONLY//  Inpatient, Outpatient, or both FREQUENCY (IN MINUTES):  no longer needed NAME: AH// SYNONYM: EXPANSION: **AVOID ALCOHOL**// PLURAL: INTENDED USE: OUTPATIENT ONLY// FREQUENCY (IN MINUTES): NAME: WF// SYNONYM: WFM// EXPANSION: WITH FOOD OR MILK// PLURAL: INTENDED USE: IN & OUTPATIENT// FREQUENCY (IN MINUTES):

Medication Instruction File Enter/Edit common instructions –PM = Evening –AM = Morning –AP = Apply Used in the EDIT ORDERABLE ITEMS option

Medication Routes Select MEDICATION ROUTES NAME: ?? Choose from: BLOOD TEST BUCCAL BUCC BUCCAL DENTAL INFILTRATION BUCCDENTIF BUCCAL ORAL BUCCORAL BUCCAL SUBLINGUAL BUCCSL BY MOUTH BYMO CATHETER CAUDAL BLOCK CAUD CAUDAL EPIDURAL CAUDED CAUDAL EPIDURAL MISCELLANEOUS CAUDED MISC CAUDAL SUBCUTANEOUS INFILTRATI CAUDSC IF CHEW CHEW DEEP IM DENTAL DENT DENTAL INFILTRATION DENTIF DENTAL INTRAMUSCULAR DENTALIM DENTAL ORAL DENTORAL DENTAL ORAL TOPICAL DENTORALTOP DENTAL SUBCUTANEOUS DENTSC

Medication Routes, cont. NAME: ORAL//  full name ABBREVIATION: PO//  abbreviation used in prescriptions PACKAGE USE: ALL PACKAGES//  ”National Drug File Only” will hide it from use locally OUTPATIENT EXPANSION: BY MOUTH//  include preposition, will show on label OTHER LANGUAGE EXPANSION:  LEAVE BLANK! IV FLAG:  mark “yes” if will process in the IV Package in RPMS NAME: TOPICAL// ABBREVIATION: TOP// PACKAGE USE: ALL PACKAGES// OUTPATIENT EXPANSION: TO AFFECTED AREA// OTHER LANGUAGE EXPANSION: IV FLAG: NAME: OPHTHALMIC// ABBREVIATION: OPH// PACKAGE USE: ALL PACKAGES// OUTPATIENT EXPANSION: INTO AFFECTED EYE(S) Replace OTHER LANGUAGE EXPANSION: IV FLAG:

Medication Route File Enter/Edit common routes –Ophthalmic = In Affected Eyes –Topical = To Affected Area The most common route (just one) can be added under “Edit Orderable Items” Routes can be tied to Dosage Forms* so that only certain ones show in the EHR for a given Dosage Form (so providers can’t choose “IV” for an oral tablet, for example) *this can be helpful, but editing can also have unintended consequences

Orderable Item Management Edit/Enter several pertinent fields –Assign Drug Text Entry for provider viewing if desired –Med Route –Schedule Type* –Schedule –Patient Instructions –Synonym (for EHR med ordering selection) *Can cause problems. Best to leave blank, especially for drugs used in inpatient.

PDM  Orderable Item Management  Edit Orderable Items Select PHARMACY ORDERABLE ITEM NAME: IBUPROFEN Orderable Item -> IBUPROFEN Dosage Form -> TAB List all Drugs/Additives/Solutions tied to this Orderable Item? YES// Dispense Drugs: IBUPROFEN 200MG TAB IBUPROFEN 400MG TAB IBUPROFEN 600MG TAB IBUPROFEN 800MG TAB Are you sure you want to edit this Orderable Item? NO// YES Now editing Orderable Item: IBUPROFEN TAB Orderable Item Name: IBUPROFEN// This Orderable Item is Formulary. This Orderable Item is marked as a Non-VA Med. Select OI-DRUG TEXT ENTRY: INACTIVE DATE: DAY (nD) or DOSE (nL) LIMIT: MED ROUTE: SCHEDULE TYPE: SCHEDULE: Q6H// PATIENT INSTRUCTIONS: WF FPA// Select SYNONYM: ?? Choose from: ADVIL MOTRIN You may enter a new SYNONYM, if you wish Select SYNONYM: Lists all of the Drug File Entries that are linked to this OI Could change the OI name (for typos) Can associate drug text (dosing tables etc) with an OI. Displays in EHR for providers to review If blank will default to ORAL(can’t put ORAL in here) All non-orals must have a route entered here Leave Schedule type blank for Outpatient Can have as many as you want- Usually all Trade Names. Some sites use classes for some drugs i.e. OCP or STATINS

Drug Text Enter/Edit Enter Text that can be viewed. –Enter for viewing under Orderable Item Edit –Can enter multiple texts under Orderable Item –Providers can view on EHR med order entry –Pharmacist can view on rpms med order entry –Drug Texts longer than one line are viewed under heading “Restriction/Guidelines” –Can cut and paste dosing tables if they are in text format –Recommended over using Drug Message –Details are in the “Drug Text creation editing and usage” power-point

Standard Schedule Select Pharmacy Data Management Option: standard Schedule Edit Select ADMINISTRATION SCHEDULE: ?? Choose from: (5) TIMES/DAY PM 1500 AC AC BID AC TID AC&HS ACCU-CHEK AC&HS BB 0700 BDA BID BID (DIURETIC) BID (HYPOGLYCEMIC) BID (INSULIN) BIW BL 1100 BS 1630 DAILY 1000

Standard Schedule, cont. NAME: TID//  the “shortcut” abbreviation OUTPATIENT EXPANSION: THREE TIMES A DAY//  how it looks in the Rx OTHER LANGUAGE EXPANSION:  LEAVE BLANK! TYPE OF SCHEDULE: CONTINUOUS//  Cont, day of week, or one-time STANDARD ADMINISTRATION TIMES: //  not needed if not inpatient at your facility FREQUENCY (IN MINUTES): 480//  minutes between doses, calculated as if split evenly through a 24 hour day Select WARD:  not needed if not inpatient at your facility NAME: WEDNESDAY// OUTPATIENT EXPANSION: EVERY WEDNESDAY// OTHER LANGUAGE EXPANSION: TYPE OF SCHEDULE: DAY OF THE WEEK// STANDARD ADMINISTRATION TIMES: 1000// Select WARD: NAME: ONCE// OUTPATIENT EXPANSION: ONCE// OTHER LANGUAGE EXPANSION: TYPE OF SCHEDULE: ONE-TIME//

Standard Schedule Edit Inpatient and Outpatient dosing schedule –Sets administration times for standard schedules, ie. Daily=0900 –Inpatient schedules should match facility administration policy –Obsolete schedules should be deleted Used in the EDIT ORDERABLE ITEMS option

Putting it all together With drug file entry, creates a prescription and (if using) a label So…where are the nouns, verbs, and routes seen?

Dosage Form Routes: Only routes you have linked to the dosage form show here Standard Schedules Medication Instructions, shows expanded in EHR Verb (in the dosage form file) Noun (in the dosage form file)

DEMO,PATIENT INFANT TAKE ONE (1) CAPSULE BY MOUTH THREE TIMES A DAY FOR INFECTION TREATMENT; TAKE UNTIL FINISHED MRx0 AMOXICILLIN 250MG CAP #30 CAP Rx MAMN PROVIDER,M CHM Verb (from Dosage form file) Noun (from Dosage form file) Route (note preposition in the route expansion, not in the field “preposition”) Standard schedule, expanded