Inpatient Pharmacy October 2008

Objectives IV Clean Up RPMS Inpatient Medications – Unit Dose RPMS Automatic Replenishment Ward Stock Bar Code Medication Administration (BCMA)

IV Clean Up

Why clean up the IV package? IHS first starting using the RPMS IV package over 20 years ago Lack of training on proper entry Changes required for pharmacy v5.0 Need for provider IV medication orders to work properly

Step 1 – Create a list of all active IV additives at your site Select VA FileMan Option: SEarch File Entries OUTPUT FROM WHAT FILE: IV ADDITIVES -A- SEARCH FOR IV ADDITIVES FIELD: INACTIVATION DATE -A- CONDITION: NULL -B- SEARCH FOR IV ADDITIVES FIELD: IF: A// INACTIVATION DATE NULL STORE RESULTS OF SEARCH IN TEMPLATE: SORT BY: PRINT NAME// START WITH PRINT NAME: FIRST// FIRST PRINT FIELD: PRINT NAME THEN PRINT FIELD: GENERIC DRUG THEN PRINT FIELD: Heading (S/C): IV ADDITIVES SEARCH// DEVICE: 0;;999  Don’t hit the enter key until after you capture the search, name the file & save it to your desktop (next 2 slides)

Capture the search to a file

Name the file and save it

Run the search, then stop file capture DEVICE: 0;;999 VIRTUAL TERMINAL Right Margin: 80//

Step 2 – Create a list of all active IV solutions at your site Select VA FileMan Option: SEarch File Entries OUTPUT FROM WHAT FILE: IV SOLUTIONS -A- SEARCH FOR IV ADDITIVES FIELD: INACTIVATION DATE -A- CONDITION: NULL -B- SEARCH FOR IV ADDITIVES FIELD: IF: A// INACTIVATION DATE NULL STORE RESULTS OF SEARCH IN TEMPLATE: SORT BY: PRINT NAME// START WITH PRINT NAME: FIRST// FIRST PRINT FIELD: PRINT NAME 1 PRINT NAME 2 PRINT NAME {2} CHOOSE 1-2: 1 PRINT NAME THEN PRINT FIELD: GENERIC DRUG THEN PRINT FIELD: Heading (S/C): IV ADDITIVES SEARCH// DEVICE: 0;;999  Don’t hit the enter key until after you capture the search, name the file & save it to your desktop (next 2 slides)

Capture the search to a file

Name the file and save it

Run the search, then stop file capture DEVICE: 0;;999 VIRTUAL TERMINAL Right Margin: 80//

Step 3 - Use the 2 search reports to check and update all IV additives and solutions

Review each Generic Drug Select Core Applications Option: PDM Pharmacy Data Management Select Pharmacy Data Management Option: DRUG ENTer/Edit Select DRUG GENERIC NAME: FLUOROURACIL 500MG/10ML Lookup: GENERIC NAME FLUOROURACIL 500MG/10ML INJ AN OK? Yes// ******************************************************************************* This entry is marked for the following PHARMACY packages: Outpatient Unit Dose Non-VA Med  Notice anything missing? GENERIC NAME: FLUOROURACIL 500MG/10ML INJ Replace

Generic drug review GENERIC NAME: FLUOROURACIL 500MG/10ML INJ Replace VA CLASSIFICATION: AN300// DEA, SPECIAL HDLG: 6P// NATIONAL FORMULARY INDICATOR: YES LOCAL NON-FORMULARY: VISN NON-FORMULARY: Select DRUG TEXT ENTRY: Select FORMULARY ALTERNATIVE: Select SYNONYM: // SYNONYM: // INTENDED USE: DRUG ACCOUNTABILITY// NDC CODE: // Select SYNONYM:

Generic drug review (cont.) MESSAGE: CHEMOTHERAPY AGENT// RESTRICTION: FSN: INACTIVE DATE: WARNING LABEL: ORDER UNIT: BX// DISPENSE UNIT: ML// DISPENSE UNITS PER ORDER UNIT: 100// NDC: // PRICE PER ORDER UNIT:  Good idea to put your acquisition price here. LAST PRICE UPDATE: MAR 26,1993// AWP PER ORDER UNIT: 37.5// AWP PER DISP UNIT is SOURCE OF SUPPLY: DISPENSING LOCATION: STORAGE LOCATION: PRICE PER DISPENSE UNIT:

Generic drug review (cont.) points to FLUOROURACIL 50MG/ML INJ in the National Drug file. This drug has already been matched and classified with the National Drug file. In addition, if the dosage form changes as a result of rematching, you will have to match/rematch to Orderable Item. Do you wish to match/rematch to NATIONAL DRUG file? No//

Generic drug review (cont.) Just a reminder...you are editing FLUOROURACIL 500MG/10ML INJ. Strength from National Drug File match => 50 MG/ML Strength currently in the Drug File => 50 Strength => 50 Unit => POSSIBLE DOSAGES: DISPENSE UNITS PER DOSE: 1 DOSE: 50MG/1ML PACKAGE: I DISPENSE UNITS PER DOSE: 2 DOSE: 100MG/2ML PACKAGE: I LOCAL POSSIBLE DOSAGES: LOCAL POSSIBLE DOSAGE: 1 ML PACKAGE: OI LOCAL POSSIBLE DOSAGE: 2 MLS PACKAGE: OI LOCAL POSSIBLE DOSAGE: 1 MG PACKAGE: OI LOCAL POSSIBLE DOSAGE: 2 MGS PACKAGE: OI LOCAL POSSIBLE DOSAGE: 1 GRAM PACKAGE: OI LOCAL POSSIBLE DOSAGE: 2 GRAMS PACKAGE: OI Do you want to edit the dosages? N// YES

Generic drug review (cont.) Changing the strength will update all possible dosages for this Drug. STRENGTH: 50// Select DISPENSE UNITS PER DOSE: This drug has the following Local Possible Dosages: 1 ML PACKAGE: OI 2 MLS PACKAGE: OI 1 MG PACKAGE: OI 2 MGS PACKAGE: OI 1 GRAM PACKAGE: OI 2 GRAMS PACKAGE: OI Do you want to merge new Local Possible Dosages? Y// NO Strength: 50 Unit: MG/ML

Generic drug review (cont.) Select LOCAL POSSIBLE DOSAGE: ? Answer with LOCAL POSSIBLE DOSAGE Choose from: 1 GRAM OI 1 MG OI 1 ML OI 2 GRAMS OI 2 MGS OI 2 MLS OI You may enter a new LOCAL POSSIBLE DOSAGE, if you wish Answer must be 1-60 characters in length. Select LOCAL POSSIBLE DOSAGE: 1 GRAM OI LOCAL POSSIBLE DOSAGE: 1 SURE YOU WANT TO DELETE THE ENTIRE '1 GRAM' LOCAL POSSIBLE DOSAGE? Y (Yes) Strength: 50 Unit: MG/ML

IV Additive review This entry is marked for the following PHARMACY packages: Outpatient Unit Dose Non-VA Med MARK THIS DRUG AND EDIT IT FOR: O - Outpatient U - Unit Dose I - IV W - Ward Stock D - Drug Accountability C - Controlled Substances X - Non-VA Med A - ALL

IV Additive review (cont) Enter your choice(s) separated by commas : I I - IV ** You are NOW editing IV fields. ** AN IV ITEM? No// Y (Yes) Edit Additives or Solutions: Select one of the following: A ADDITIVES S SOLUTIONS Enter response: ADDITIVES Select IV ADDITIVES PRINT NAME: 5-FLUOROURACIL PRINT NAME: 5-FLUOROURACIL// GENERIC DRUG: FLUOROURACIL 500MG/10ML INJ// USED IN IV FLUID ORDER ENTRY:  When should you answer Yes?

IV Additive review (cont.) DRUG UNIT: MG// NUMBER OF DAYS FOR IV ORDER: USUAL IV SCHEDULE: ADMINISTRATION TIMES: Select QUICK CODE: AVERAGE DRUG COST PER UNIT:  This would be cost per MG Select ELECTROLYTE: Select SYNONYM: 5FU// DRUG INFORMATION: No existing text Edit? NO// INACTIVATION DATE: CONCENTRATION: MESSAGE: Edit Additives or Solutions: Select one of the following: A ADDITIVES S SOLUTIONS Enter response:

Orderable Item verification ** You are NOW in the ORDERABLE ITEM matching for the dispense drug. ** FLUOROURACIL 500MG/10ML INJ is already matched to FLUOROURACIL INJ,SOLN Do you want to match to a different Orderable Item? NO//

Use your lists to clean up IV additives and solutions

RPMS Inpatient Medications – Unit Dose Set up procedures

1. Enter all inpatient medications into RPMS, including floor stock drugs. Non-injectable medications that will be used for inpatients should be marked for unit dose package use under the Drug Enter/Edit option. Injectable medications that aren’t processed through the IV package should be marked for unit dose use. A unit dose drug should have the same orderable item as its corresponding outpatient drug.

2. Enter Unit Dose System Parameters Select Unit Dose Medications Option: SUPervisor's Menu Select Supervisor's Menu Option: PARameters Edit Menu Select PARameters Edit Menu Option: Systems Parameters Edit NON-FORMULARY MESSAGE: No existing text Edit? NO// PRINT 6 BLOCKS FOR THE PRN MAR: YES PRINT DIET ABBR LABEL ON MAR: MAR SORT: Sort by order's Medication Names. ATC SORT PARAMETER: CALC UNITS NEEDED PRN ORDERS: YES DAYS UNTIL STOP FOR ONE-TIME: 1 ROUND ATC PICK LIST UNITS:

3. Enter Inpatient User Parameters for each pharmacist Select PARameters Edit Menu Option: IUP Inpatient User Parameters Edit Select INPATIENT USER: GOOD,PHARMACIST...OK? Yes// (Yes) This user is a PHARMACIST. ALLOW AUTO-VERIFY FOR USER: Y YES ORDER ENTRY PROCESS: R REGULAR

4. Enter Inpatient Ward Parameters for each ward. Select PARameters Edit Menu Option: IWP Inpatient Ward Parameters Edit Select WARD: MEDICALSURGICAL...OK? Yes// (Yes) DAYS UNTIL STOP DATE/TIME: 100 DAYS UNTIL STOP FOR ONE-TIME: 1 SAME STOP DATE ON ALL ORDERS: NO TIME OF DAY THAT ORDERS STOP: 1700 DEFAULT START DATE CALCULATION: USE CLOSEST ADMIN TIME AS DEFAULT

4. Enter Inpatient Ward Parameters for each ward (cont.) START TIME FOR 24 HOUR MAR: 2200 LABEL FOR WARD STAFF: NO LABELS WARD LABEL PRINTER: LABEL FOR PHARMACY: FIRST LABEL ON ORDER ENTRY/EDIT PHARMACY LABEL PRINTER: name of inpatient dot-matrix label printer (must keep MAR labels in this printer at all times) LABEL ON AUTO-DISCONTINUE: NO MAR HEADER LABELS: YES DAYS NEW LABELS LAST: 5 MAR ORDER SELECTION DEFAULT: 2,3 PRINT PENDING ORDERS ON MAR: YES 'SELF MED' IN ORDER ENTRY: YES PRE-EXCHANGE REPORT DEVICE: HOME

5. Auto-Discontinue Set-Up Select PARameters Edit Menu Option: AUTO- Discontinue Set-Up Do you want the instructions for auto-discontinue set-up? Yes// This option can be pretty confusing so read the instructions before you go through it. It’s strongly recommended that you do NOT set up any orders to be auto-discontinued on ward or service transfers even if that is your hospital’s policy. It could result in missed doses. Go ahead and enter the From Ward but don’t enter anything for To Ward.

5. Auto-Discontinue Set-Up (continued) Do you want the package to set-up all of your wards for auto-discontinue? N0 (Action on WARD transfer) Select FROM WARD: MEDICALSURGICAL FROM WARD: MEDICALSURGICAL// 'ON PASS' ACTION: NO ACTION ACTION ON AUTHORIZED ABSENCE: NO ACTION ACTION ON UNAUTHORIZED ABSENCE: DISCONTINUE ORDERS Select TO WARD: Don’t enter anything here

5. Auto-Discontinue Set-Up (continued) After you’ve gone through all of the wards and entered the From information you’ll get this prompt: (Action on SERVICE transfer) Select FROM SERVICE:  Don’t enter anything here

6. Set up a Ward Group Select Unit Dose Medications Option: SUPervisor's Menu Select Supervisor's Menu Option: WARD Groups Select WARD GROUP NAME: HOSPITAL Are you adding 'HOSPITAL' as a new WARD GROUP (the 1ST)? No// Y (Yes) WARD GROUP TYPE: P PHARMACY WARD GROUP ATC DEVICE POINTER: NAME: HOSPITAL// Select WARD: ICU Are you adding 'ICU' as a new WARD (the 1ST for this WARD GROUP)? No// Y (Yes) Select WARD: OBSTETRICS Are you adding 'OBSTETRICS' as a new WARD (the 2ND for this WARD GROUP)? No// Y (Yes) Select WARD: NEWBORN Are you adding 'NEWBORN' as a new WARD (the 3RD for this WARD GROUP)? No// Y (Yes) Select WARD:

6. Set up a Ward Group (cont.) LENGTH OF PICK LIST (in hours): 24 PICK LIST - OMIT WARD SORT: NO NO (SORT BY WARD) PICK LIST - OMIT ROOM-BED SORT: NO NO (SORT BY ROOM-BED) PICK LIST - ROOM/BED SORT: ROOM ROOM-BED PICK LIST - FORM FEED/PATIENT: N NO PICK LIST - FORM FEED/WARD: Y YES PICK LIST - LINES ON FORM FEED: Y YES PRINT NON-ACTIVE ORDERS FIRST: NO NO BAXTER ATC DEVICE: USE OLD ATC INTERFACE:

Next step – set up the ARWS package Automatic Replenishment/Ward stock is a separate RPMS package. You’ll need to set some things up in ARWS in order for the Unit Dose package to work properly.

References for Inpatient Medication – Unit Dose package 1.Pharmacy Data Management User Manual 2.Inpatient Pharmacy User Manual Both of these manuals can be found at ftp://ftp.ihs.gov/rpms/Pharmacy%205- 7/Manuals/ ftp://ftp.ihs.gov/rpms/Pharmacy%205- 7/Manuals/

RPMS Automatic Replenishment/Ward Stock Set up procedures

ARWS Introduction This is a complicated package that was originally designed for manual entry of all ward stock transactions. It was developed prior to the use of automated dispensing machines. Do only the recommended set up steps so that the unit dose package will work properly. Check with your site manager if you don’t see the following option on your menu : ARWS Automatic Replenishment...

1. Set up Site Parameters Select Automatic Replenishment Option: SUPervisor's Menu Select Supervisor's Menu Option: SET Up AR/WS (Build Files) Select Set Up AR/WS (Build Files) Option: SITE Parameters

1. Set up Site Parameters (cont.) Select INPATIENT SITE NAME: TEST SITE MERGE INV. SHEET AND PICK LIST: YES PRINT RETURN COLUMNS?: YES BEGIN COLLECTING AMIS DATA NOW?: NO  Be sure to answer NO here IS SITE SELECTABLE FOR AR/WS?: YES

2. Enter/Edit Inventory Types Select Set Up AR/WS (Build Files) Option: ENTER/Edit Inventory Types Select AOU INVENTORY TYPE NAME: ? Answer with AOU INVENTORY TYPE NAME Choose from: C-2 C-3 C-4 C-5 OTC-9 RX-6 You may enter a new AOU INVENTORY TYPE, if you wish Answer must be 3-30 characters in length

2. Enter/Edit Inventory Types (cont) Select AOU INVENTORY TYPE NAME: RISK Are you adding 'RISK' as a new AOU INVENTORY TYPE (the 7TH)? No// Y (Yes) NAME: RISK// TYPE DESCRIPTION: No existing text Edit? NO// Select AOU INVENTORY TYPE NAME:

3. Item Location Codes – Enter/Edit Select Set Up AR/WS (Build Files) Option: ITEM Location Codes - Enter/Edit Select AOU ITEM LOCATION ITEM ADDRESS CODE: ? Answer with AOU ITEM LOCATION ITEM ADDRESS CODE Choose from: MC MEDICINE CABINET OMN OMNICELL You may enter a new AOU ITEM LOCATION, if you wish Answer must be 1-3 characters in length

3. Item Location Codes – Enter/Edit (cont.) Select AOU ITEM LOCATION ITEM ADDRESS CODE: REF Are you adding 'REF' as a new AOU ITEM LOCATION (the 3RD)? No// Y (Yes) AOU ITEM LOCATION CODE EXPANSION: REFRIGERATOR ITEM ADDRESS CODE: REF// CODE EXPANSION: REFRIGERATOR// Select AOU ITEM LOCATION ITEM ADDRESS CODE:

4. Create the Area of Use Select Set Up AR/WS (Build Files) Option: CREATE the Area of Use Select PHARMACY AOU STOCK AREA OF USE (AOU): ? Answer with PHARMACY AOU STOCK AREA OF USE (AOU), or WARD (FOR ITEM), or ON-DEMAND REQUEST DATE/TIME Do you want the entire 3-Entry PHARMACY AOU STOCK List? Y (Yes) Choose from: ANES ICU LD You may enter a new PHARMACY AOU STOCK, if you wish Answer must be 2-30 characters in length

4. Create the Area of Use (Cont.) Select PHARMACY AOU STOCK AREA OF USE (AOU): ICU (ICU) Are you adding 'ICU' as a new PHARMACY AOU STOCK (the 4TH)? No// Y (Yes) AREA OF USE (AOU): ICU// INPATIENT SITE: ? Enter the INPATIENT SITE that will receive credit for the AMIS statistics for this AOU. Enter "^" to Exit option. Select only sites that are 'Selectable for AR/WS' in file #59.4. Answer with INPATIENT SITE NAME: DEMO HOSPITAL

4. Create the Area of Use (Cont.) INPATIENT SITE: DEMO HOSPITAL RETURNS CREDITED TO: AUTO AUTOMATIC REPLENISHMENT COUNT ON AMIS?: N NO ASK EXPIRATION DATE?: N NO CRASH CART FLAG: Select WARD/LOCATION (FOR PERCENTAGE): ICU Are you adding 'ICU' as a new WARD/LOCATION (FOR PERCENTAGE) (the 1ST for this PHARMACY AOU STOCK)? No// Y (Yes) WARD/LOCATION % OF USE: 100 Select SERVICE: Select WARD/LOCATION (FOR PERCENTAGE): Select PHARMACY AOU STOCK AREA OF USE (AOU):

5. Stock Items – Enter/Edit Select Set Up AR/WS (Build Files) Option: STOCK Items - Enter/Edit Select PHARMACY AOU STOCK AREA OF USE (AOU): ICU Select ITEM: MORPHINE 15MG TAB U/D CN101 Are you adding 'MORPHINE 15MG TAB U/D' as a new ITEM (the 1ST for this PHARMACY AOU STOCK)? No// Y (Yes) ITEM STOCK LEVEL: 10 ITEM LOCATION: OMN  optional STOCK LEVEL: 10// REORDER LEVEL: 5  optional MINIMUM QUANTITY TO DISPENSE: 1 Select TYPE: C-2  optional Select TYPE: LOCATION: OMN// Select WARD (FOR ITEM): ICU  Important for Pick List accuracy. You could set up 1 AOU that could be used by multiple wards. Select WARD (FOR ITEM):

5. Stock Items – Enter/Edit (cont.) Select ITEM: MORPHINE 15MG TAB U/D CN101...OK? Yes// N (No)  We want to add a second Morphine drug item. If you just type part of the drug name you’ll first see drugs that have already been added. MORPHINE 1 MORPHINE SO4 PF 1MG/ML 2ML CN101 2 MORPHINE SULFATE 10MG SYRINGE INJ CN101 CHOOSE 1-2: 2 MORPHINE SULFATE 10MG SYRINGE INJ Are you adding 'MORPHINE SULFATE 10MG SYRINGE INJ' as a new ITEM (the 2ND for this PHARMACY AOU STOCK)? No// Y (Yes) ITEM STOCK LEVEL: 10 ITEM LOCATION: STOCK LEVEL: 10// REORDER LEVEL: MINIMUM QUANTITY TO DISPENSE: Select TYPE: LOCATION: Select WARD (FOR ITEM): ICU Select WARD (FOR ITEM):

Remove an item from Ward Stock You can’t delete items from an AOU but you can inactivate them so that they won’t show up as Ward Stock. Select Set Up AR/WS (Build Files) Option: INACT 1 Inactivate AOU 2 Inactivate AOU Stock Item CHOOSE 1-2: 2 Inactivate AOU Stock Item You may inactivate a Stock Item for a single AOU, or enter "^ALL" to inactivate the Item in ALL AOUs.

Remove an item from Ward Stock (cont.) Select PHARMACY AOU STOCK AREA OF USE (AOU): ICU Select ITEM: MORPHINE SULFATE 10MG SYRINGE INJ//  Defaults to the most recently entered item. INACTIVATION DATE: T-1 (APR 21, 2008) INACTIVATION REASON: ? Choose from: N NOT USED O OTHER DF DELETED FROM FORMULARY INACTIVATION REASON: N NOT USED Select ITEM: Select PHARMACY AOU STOCK AREA OF USE (AOU):

Don’t try to mark drugs as Ward Stock using the Drug Enter/Edit option ******************************************************************************* This entry is marked for the following PHARMACY packages: Unit Dose Controlled Substances MARK THIS DRUG AND EDIT IT FOR: O - Outpatient U - Unit Dose I - IV W - Ward Stock  Do not select this. Go to the AR/WS menu. D - Drug Accountability C - Controlled Substances X - Non-VA Med A - ALL Enter your choice(s) separated by commas :

Reference 1.Automatic Replenishment/Ward Stock User Manual ocs/psj/wsuser.pdfhttp:// ocs/psj/wsuser.pdf

Bar Code Medication Administration (BCMA) Pre-Implementation Recommendations

Current status in RPMS A candidate patch has been submitted to the VA that will allow RPMS BCMA sites to use HRNs instead of SSNs The patch will also allow RPMS sites to look at vitals entered into PCC We are working with the VA to establish a support agreement (similar to VistA Imaging)

Current status in RPMS BCMA is currently installed at one RPMS site and may be installed in a second site prior to the VA adoption of the IHS patch changes

General Requirements Implement new processes and procedures Address administrative and technical issues EHR must be installed prior to using BCMA software BCMA software is only for inpatient facilities

Uniform Order Entry Pharmacy must finish orders in a standardized format Pharmacy and Nursing must work together to coordinate order entry methodology and order interpretation using the computer-generated MAR prior to using BCMA

Inaccurate Administration BCMA may identify inaccurate med administration Pharmacy can encourage reporting by adopting a positive review process (trending of root cause) Consider this to be the end result of a chain of events (poorly designed processes, procedures, or med delivery mechanisms)

Bar Code Types BCMA can read any bar code that is a unique number, including the drug internal entry number from RPMS Make sure that only 1 selection is available for order entry selection within the Unit Dose package Restrict access to the Drug file to prevent problems

Bar Code Types (cont.) If you are planning to use manufacturer’s bar codes, these barcodes must be scanned into the Synonym field of each drug The Intended Use field for the synonym should be set to ‘Quick Code’

Pharmacy Responsibilities Ensure that all drug products sent to the wards for administration to patients are properly labeled with readable bar codes Work together with Nursing to resolve scanning issues: Pharmacy should view the order to ensure that the dispensed drug was correctly dispensed as a first step when medications don’t scan properly

Pharmacy Responsibilities (cont.) Designate a person to be responsible for bar code labeling requirements Readable bar codes must be applied to bulk containers if the manufacturer’s container doesn’t contain a bar coded NDC number Proper attachment of bar code labels to products (do not curve, don’t apply over manufacturer’s exp. date, lot #, drug name or strength) Manufacturer’s bar codes must be scanned into the Synonym field of the drug file if these are to be used during medication administration

Resolving Inconsistencies (1) An order is manually written for Warfarin 5mg po NOW and DAILY. The order was written at 0900 and the standard administration time for Warfarin is at A one-time order is entered for the NOW dose and administered at When should the DAILY dose begin? At 1300 today or at 1300 tomorrow?

Resolving Inconsistencies (2) An order is written for Furosemide 40mg po DAILY. The order is written at 1100 and the standard administration time for DAILY is When should the first dose of the medication begin? What are the provider’s expectations? Should the order begin at 0900 tomorrow unless the provider specifically writes to begin today?

Administration Times Work with Nursing to establish standardized administration times for all approved administration schedules (can be different for different wards) Discourage deviation from the standard times Don’t make manual changes to the computer-generated MAR – remember, BCMA won’t pick these up

Variable Frequency and Dose These can both cause problems Work to try to eliminate or reduce these at your facility (P&T Committee) Q4-6H PRN: If a dose can be given as often as every 4 hours it can also be given less frequently so there is no need to include the 6H.

Questions?

Discussion Really Powerful at Measuring Stuff