Steve Bowman R. Ph. Information Systems Consulting Pharmacy Data Management

Describe the PDM –Environment –Terminology –Tools Tips for proper set up & maintenance Identify common pharmacy problems in EHR Review solutions Course Objectives

Proper pharmacy package configuration Foundation for E.H.R. Crucial to successful P.O.E Impacts all disciplines Providers Nurses Pharmacy Overview

Configuration Files More than just the Drug file – 6 files involved Each file is responsible for the components required to –Build Sigs in the prescription processing –Interface correctly with other RPMS components Point of Sale (POS) Physician Order Entry (POE)

Configuration Files

Terminology - Routes The Medication Route file –Must contain all routes that a site wants to use on their Rx labels Standard List in Appendix A of Pharmacy 5-7 Handbook Forbidden Abbreviations must be modified or deleted –AU, AS, OU, OS etc. –Use Med Route/Instructions Table Maintenance option on PDM to set up –Outpatient Expansion field  Text that will print on the label Includes any prepositions needed for I.E. ORAL, should be BY MOUTH instead of MOUTH –Delete all prepositions from the Dosage Form File –Package Use field  ALL (inpatient & outpatient) Two types of routes –Routes – that are associated with Dosage Forms (only used for Oral drugs) –Default routes – that are associated with Pharmacy Orderable Items (for all non-orals) –If a Drug has a Default Route that is what appears on the label (the routes column is ignored) –All non Oral drugs need a default route manually entered for them even if they have what appears to be an appropriate entry in the Route column (NSYN) Drugs/Orderables can only have one route value –e.g. Ophthalmic drops would default to Affected Eye(s) but could manually change to Left or right eye as needed Can manually change a route during prescription processing or in Quick Order Creation

The Administration Schedule file –Must contain all schedules that a site wants to use on their Rx labels Standard List in Appendix A of Pharmacy 5-7 Handbook Must Delete/Edit forbidden Abbreviations –QOD, QD, etc. –Use Standard Schedule Edit on PDM to set up –Key Fields Outpatient Expansion  Text that will print on the label Type of Schedule –CONTINUOUS takes place on a regular basis i.e. 'three times a day' or 'once every two days' –DAY OF THE WEEK takes place only on specific days of the week »should have admin times (If not, the start time of the order is used) »Name must be in the form of 'MO-WE-FR‘ (first 2 letters of the day) –ONE-TIME takes place once only at a specific date and time. Frequency  # of times dose will be given per day divided into 1440 minutes »BID = 1440/2 = 720 TID = 1440/3 = 480 »Used to calculate quantity dispensed Standard Administration Times  Used for Inpatient »i.e Terminology – Standard Schedules

The Medication Instructions file –Only used by the outpatient module –Contains abbreviations for patient information that appears at the end of the Rx label i.e FPA  FOR PAIN TWF  TAKE WITH FOOD Standard List in Appendix A of Pharmacy 5-7 Handbook –Use Medication Instruction File Add/Edit on PDM menu –Key Fields Medication Instruction Name  The abbreviation Expansion  Text that will print on the label Package Use  ALL (inpatient & outpatient) Leave other fields blank (Synonym, Med Route, Schedule) Terminology–Medication Instructions

Two Uses –Drug File– Quick Codes  Not seen in EHR for use by Pharmacy to select drugs quickly Use Drug Enter/Edit to add/modify the Synonym(s) –If enter Trade Name type here it does NOT show up in EHR –Do NOT enter the NDC here use NDC field further down –Pharmacy Orderable Item File (Trade Names) Used by Providers to select meds in POE/EHR Use Edit Orderable Items to add/modify the Synonym field Terminology – Synonyms

Correct setup & maintenance is critical for successful POE Two Types –Dosages Single entity tablets & capsules Comprised of - Strength – Dispense Units – Package Use A dosage of 1 and 2 is automatically created when adding new items with Drug Enter/Edit –Must manually add any others i.e..5, 3, 4 etc. –PDM  Dosages  Dosages Enter/Edit –Local Possible Dosages (LPDs) All other Drug file entries Combination drugs (tabs & Caps)Liquids (suspensions, syrups, solutions) Drugs with % strengthsOphthalmics/Otics InhalersTopicals Rectal/VaginalInjections Comprised of - Quantity – Noun – Package Use –Should include article where needed for label »A THIN LAYER or THE ENTIRE CONTENTS Must enter these in manually –PDM  Dosages  Dosages Enter/Edit won't display for drugs that use Dosages –i.e. single Entity tablets and capsules Terminology – Dosages

Associated with Orderable Items Dosage Form File holds Nouns Verbs Routes Prepositions PDM  Dosages  Dosage Form File Enter/Edit Delete prepositions (should all have been deleted via FM Loop Delete) –when sigs have double prepositions i.e. BY BY MOUTH Delete inappropriate routes Modify missing or incorrect verbs or nouns Appendix B of Handbook (recommended verb changes) PDM  Orderable Item Maintenance  Dispense Drug/Orderable Item Maintenance To change an incorrect dosage form for an orderable Item –i.e. from TAB to TAB,EC Terminology – Dosage Form Defaults for Orderable items to build SIGS Must all be deleted (are included in routes)

Pharmacy Orderable Items The pivotal file for POE/EHR –Quick orders are created from this file –Contains all of the defaults for SIGs (except dosages) –Providers select items from this file to create orders if no QO PDM  Orderable Item Management  Edit Orderable Items to edit/add: Name Drug Text Inactive Date Route Schedule Pt. Instructions Synonyms These values show up when creating QOs or when Providers select meds in POE

The Drug File Key Fields –Dosages –DEA Special Handling –VA Drug Class Code –Inactive Date –POS information Dispense Units Order Units NDC Dispense Unit/Order Unit

The Fileman Searches Menu KIDS file –azpdrug0141.k –Site Manager install Assign AZPSCBDRUGSEARCH option as a secondary Menu or add it to PDM Used to assess and the status of Pharmacy support file configuration –Pharmacy Orderable Items –Routes –Med Instructions –Schedules

Create a HyperTerminal Connection NSYN is 380 columns –NetTerm Truncates the report All other Reports work fine with NetTerm or TeraTerm Click Start  Programs  Accessories  Communications  HyperTerminal

In connection Description window Type RPMS for a Name  Select an Icon  click OK In the Connect to window Go to the connect using dropdown and switch to TCP/IP  Type the IP address for your RPMS server in the Host address box  click OK Save a shortcut Icon for this on your Desktop Create a HyperTerminal Connection

How to Screen Capture an RPMS Report Select report to print At the DEVICE prompt enter in 0 to print to screen and any formatting needed Above example is for 80 columns & rows Before hitting the enter key Select Transfer  Capture  name the file & where to save it

Once the report completes Choose Transfer  Stop  Hit Enter after doing these

Formatting a captured report Open MS Excel –Choose the DATA dropdown  GET EXTERNAL DATA  IMPORT TEXT FILE At FILES OF TYPE, select ALL FILES Go to the directory where you saved the file, click to open

The Text Import Wizard will open Select Fixed with Click Next Move the Break lines to set up correct columns Click Finish

For Routes, Schedules, & Med. Instructions Can quit or use Auto-format to make it easier to read Highlight the entire Sheet and choose Format  then auto-format Click – OK on the IMPORT DATA screen Select one that will help make the lines easier to read (I like List 1 or 3D Effects 2) - Click OK

Format an RPMS Report in Excel MEDICATION ROUTESOUTPATIENT EXPANSION BLOOD TESTFOR BLOOD TESTING BLOOD TEST DEVICETO MONITOR GLUCOSE BLOOD TEST SOLN, GLUCOSEIN BLOOD GLUCOSE MONITOR BOTH EARSINTO BOTH EARS BOTH EYESINTO BOTH EYES BUCCALBETWEEN CHEEK AND GUM UNTIL DISSOLVED BUCCAL ORALBETWEEN THE CHEEK & GUM ON EACH SIDE OF BUCCAL_ORALTO AFFECTED AREA ON CHEEK OR GUM CHEST WALLTO THE CHEST WALL CONDOMFOR CONTRACEPTIVE PURPOSES CONTROL SOLUTIONIN METER DENTALTO GUMS & TEETH AS DIRECTED DENTAL ORAL TOPICALTO AFFECTED GUMS DENTAL RINSEFOR 30 SECONDS & SPIT OUT DENTAL SWISHAROUND IN MOUTH FOR 30 SECONDS & SPIT DENTAL TOPICALTO GUMS DENTAL TOPICAL BUCCALTO AFFECTED AREAS ON CHEEKS OR GUMS DISINTIGRATING_ORALON THE TONGUE DISINT_ORALBY MOUTH EACH_ORALINTO EACH SIDE OF THE MOUTH ENEMA,RTLINTO THE RECTUM GRANULES_ORALIN WATER AND DRINK

For Pharmacy Orderables (NSYN report) Need to do more formatting Select the Print Preview Icon to get to the page layout screens Click on Setup, then Select Landscape, Select the Margins tab Set left, right, top, and bottom margins to.01 and the header and footer to zero. then click OK and then close the Page set up page to return to the main spreadsheet

From the View dropdown Select Page Break Preview and move the dotted line to the right of the Pt. Instructions column. Then go back to View and select Normal Can then choose to –Center Columns –Auto-format as with Routes etc. –Split window

PDM Tools Standard Files (Schedules, Routes, Pt. Instructions) SIG Defaults

PDM  Med. Route/Instructions Table Maintenance Adding Medication Routes Select MEDICATION ROUTES NAME: TOPICAL SOAK Are you adding 'TOPICAL SOAK ' as a new MEDICATION ROUTES (the 250TH)? No// Y MEDICATION ROUTES ABBREVIATION: NAME: TOPICAL SOAK// ABBREVIATION: PACKAGE USE: ALL ALL PACKAGES OUTPATIENT EXPANSION: IN WATER, SOAK THE AFFECTED AREA Would you like to update the Dosage Form file? Y// NO Include the Preposition Standard Files

Adding/Editing Schedules PDM  STANDARD SCHEDULE EDIT Select ADMINISTRATION SCHEDULE: QDAY Are you adding 'QDAY' as a new ADMINISTRATION SCHEDULE (the 14TH)? No// Y (Yes) NAME: QDAY// OUTPATIENT EXPANSION: EVERY DAY TYPE OF SCHEDULE: CONTINUOUS TYPE OF SCHEDULE: CONTINUOUS// CONTINUOUS STANDARD ADMINISTRATION TIMES: FREQUENCY (IN MINUTES): 1440// Select WARD: NAME: “MO-WED-FRI” OUTPATIENT EXPANSION: ON MONDAYS, WEDNESDAYS, AND FRIDAYS TYPE OF SCHEDULE: CONTINUOUS// DAY OF THE WEEK STANDARD ADMINISTRATION TIMES: FREQUENCY (IN MINUTES): 1440 Select WARD: Can force an entry by using “ ”i.e. if MO was already in the file Standard Files

PDM  Medication Instruction File Add/Edit Adding Med Instructions Select MEDICATION INSTRUCTION NAME: SWB NAME: SWB// SYNONYM: EXPANSION: **SHAKE WELL BEFORE USING** Replace PLURAL: INTENDED USE: IN & OUTPATIENT// MED ROUTE: Leave Blank SCHEDULE: Leave Blank Standard Files

Setting Up the SIG defaults Ensure accurate orders from providers Edit Orderable Items to add/correct –Default route (all non-orals) –Schedule –Pt. Instructions –Synonym (Trade Names – to assist providers) Drug Enter/Edit –For Dosages/LPDs –NDF Matching –POS Fields Dosages Enter/Edit –For Dosages/LPDs Dosage Form Edit –To correct verbs/nouns –To remove prepositions

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

Changing Incorrect Dosage Forms If Orderable Item has an incorrect dosage Form –Nouns, verbs may be wrong in SIGS –Ensure that Drug is correctly matched to the NDF –Must rematch the dispense drug to a different orderable item or create a new one –Use the Dispense Drug/Orderable Item Maintenance option Example  ASPIRIN 325MG TAB,EC matched to dosage form TAB want it matched to TAB,EC PDM  Orderable Item Maintenance  Dispense Drug/Orderable Item Maintenance Select DISPENSE DRUG: ASPIRIN 325MG TAB,EC ASPIRIN 325MG E.C. TAB is already matched toASPIRIN TAB Do you want to match to a different Orderable Item? NO// YES Choose Dosage Form: TAB,EC 1 TAB,EC 2 TAB,EC (DELAYED RELEASE) CHOOSE 1-2: 1 TAB,EC Dose Form -> TAB,EC Match to another Orderable Item with same Dosage Form? NO// Dosage Form -> TAB,EC Dispense Drug -> ASPIRIN 325MG E.C. TAB Orderable Item Name: ASPIRIN 325MG Matching ASPIRIN 325MG E.C. TAB to ASPIRIN 325MG TAB,EC Is this OK? YES// Match Complete! Now editing Orderable Item: ASPIRIN 325MG TAB,EC FORMULARY STATUS:

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 Never edit the strength here! Automatically created when drug was matched to the NDF

For all other Drugs LPDs apply Even in 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) 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)

Deleting Dosages 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:

PDM  Dosages  Dosages Enter/Edit 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: Shows possible doses (only for Inpatient use) Ready to edit next Drug Deleting LPDs

Drug Enter/Edit GENERIC NAME: DORZOLAMIDE 2% SOL,OPH Are you adding 'DORZOLAMIDE 2% SOL,OPH' as a new DRUG (the 2632ND)? No// Y DRUG NUMBER: 85620// DRUG VA CLASSIFICATION: DRUG FSN: DRUG NATIONAL DRUG CLASS: DRUG CURRENT INVENTORY: DRUG LOCAL NON-FORMULARY: DRUG INACTIVE DATE: DRUG MESSAGE: DRUG RESTRICTION: GENERIC NAME: DORZOLAMIDE 2% SOL,OPH Replace VA CLASSIFICATION: DEA, SPECIAL HDLG: 6P NATIONAL FORMULARY INDICATOR: Not Matched To NDF LOCAL NON-FORMULARY: VISN NON-FORMULARY: Select DRUG TEXT ENTRY: Select FORMULARY ALTERNATIVE: Select SYNONYM: MESSAGE: RESTRICTION: FSN: INACTIVE DATE: Generic Name, Strength, dosage form Automatically assigned by FM WILL DISPLAY TO PROVIDER ON POE- restrictions like outside Rx only, or limited to 3rd party pay Leave blank – not seen in EHR – use OI synonym Do not use the NDC field here- Enter it further Down Don’t enter manually, NDF match will add this 6=legend, 9=OTC I-IV for scheduled, need B to allow RF, P= dated item Date item no longer stocked –NOT the expiration date! Never delete a Drug – Use this field to make them non-selectable

WARNING LABEL: ORDER UNIT: BT DISPENSE UNIT: ML DISPENSE UNITS PER ORDER UNIT: 10 NDC: PRICE PER ORDER UNIT: LAST PRICE UPDATE: AWP PER ORDER UNIT 7.25: AWP PER DISP UNIT is: SOURCE OF SUPPLY: DISPENSING LOCATION: STORAGE LOCATION: PRICE PER DISPENSE UNIT: Do you wish to match/rematch to NATIONAL DRUG file? Yes// Deleting Possible Dosages... Match local drug DORZOLAMIDE 2% SOL,OPH ORDER UNIT: BT DISPENSE UNITS/ORDER UNITS: 10 DISPENSE UNIT: ML I will try to match NDC: to NDF. No match on that NDC.... I will attempt to match the NDCs from your SYNONYMS. No match by Synonym NDC... now first word Match made with DORZOLAMIDE 2% SOL,OPH Now select VA Product Name 1 DORZOLAMIDE HCL 2% SOLN,OPH SOLN,OPH OP109 D0286 Enter your choice: 1 Must use Use leading 0 if needed Dose of the order unit i.e. GM, ML, TAB, CAP Container item purchased in Will print with VA laser labels, Enter the #s separated by commas Must match to NDF to get VA Drug Class Automatically populated if matched based upon the NDC & Dispense Units Per Order Unit Will create multiple OIs if add new strength of Drug that had not been marched to NDF

Is this a match : Y CHOOSE FROM: 1 10 ML BOTTLE 2 3 X 5 ML BOTTLE 3 5 ML BOTTLE 4 OTHER OTHER Enter Package Size & Type Combination: 1 Local drug DORZOLAMIDE 2% SOL,OPH matches DORZOLAMIDE HCL 2% SOLN,OPH PACKAGE SIZE: 10 ML PACKAGE TYPE: BOTTLE OK? : Y LOCAL DRUG NAME: DORZOLAMIDE 2% SOL,OPH ORDER UNIT: BT DISPENSE UNITS/ORDER UNITS: 10 DISPENSE UNIT: ML VA PRODUCT NAME: DORZOLAMIDE HCL 2% SOLN,OPH VA PRINT NAME: DORZOLAMIDE HCL 2% OPH SOLN CMOP ID: D0286 VA DISPENSE UNIT: ML MARKABLE FOR CMOP: YES PACKAGE SIZE: 10 ML PACKAGE TYPE: BOTTLE VA CLASS: OP109 ANTIGLAUCOMA,OTHER CS FEDERAL SCHEDULE: INGREDIENTS: DORZOLAMIDE HYDROCHLORIDE 2 % NATIONAL FORMULARY INDICATOR: YES NATIONAL FORMULARY RESTRICTION: Is this a match ? Y Must say yes to each prompt or match will or complete

You have just VERIFIED this match and MERGED the entry. Resetting Possible Dosages..Press Return to continue: Do you want to edit Local Possible Dosages? N// Y Strength: 2 Unit: % Select LOCAL POSSIBLE DOSAGE: 1 DROP Are you adding ‘1 DROPS' as a new LOCAL POSSIBLE DOSAGE (the 1ST for this DRUG)? No// Y PACKAGE: OI Both LOCAL POSSIBLE DOSAGE: 2 DROPS Are you adding '2 DROPS' as a new LOCAL POSSIBLE DOSAGE (the 2ND for this DRUG)? No// Y PACKAGE: OI Both Select LOCAL POSSIBLE DOSAGE: 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 Enter your choice(s) separated by commas : O,X ** You are NOW editing OUTPATIENT fields. ** AN Outpatient Pharmacy ITEM? No// Y (Yes) CORRESPONDING INPATIENT DRUG: MAXIMUM DOSE PER DAY: LOCAL NON-FORMULARY: NORMAL AMOUNT TO ORDER: Now prompted to ad Dosage or, in this case LPDs Put in all appropriate codes, use X to allow use of upcoming Outside Rx functions. Do NOT mark for Ward stock here

SOURCE OF SUPPLY: CURRENT INVENTORY: ACTION PROFILE MESSAGE (OP): MESSAGE: QUANTITY DISPENSE MESSAGE: OP EXTERNAL DISPENSE: Do you wish to mark/unmark as a LAB MONITOR or CLOZAPINE DRUG? Enter Yes or No: N ** You are NOW Marking/Unmarking for NON-VA MEDS. ** A Non-VA Med ITEM? No// Y (Yes) ** You are NOW in the ORDERABLE ITEM matching for the dispense drug. ** There are other Dispense Drugs with the same VA Generic Name and same Dose Form already matched to orderable items. Choose a number to match, or enter '^' to enter a new one. Disp. drug -> DORZOLAMIDE 2% SOL,OPH 1 DORZOLAMIDE SOLN,OPH Choose number of Orderable Item to match, or '^' to enter a new one: 1 Matching DORZOLAMIDE 2% SOL,OPH to DORZOLAMIDE SOLN,OPH Is this OK? YES// Match Complete! Now editing Orderable Item: DORZOLAMIDE SOLN,OPH FORMULARY STATUS: Clozapine always No. Can link drugs to specific lab tests (not panels) Now linking item to OI for POE

Select OI-DRUG TEXT ENTRY: INACTIVE DATE: DAY (nD) or DOSE (nL) LIMIT: MED ROUTE: OPHTHALMIC// SCHEDULE TYPE: SCHEDULE: Q8H// PATIENT INSTRUCTIONS: FGL Select SYNONYM: TRUSOPT SYNONYM: TRUSOPT// Select SYNONYM: Blank = PO If have created a Drug Text entry (dosing Table etc), can attach it to OI here Expands to FOR GLAUCOMA Add Trade Names to assist providers with item selection in POE

Troubleshooting Order Entry problems

Problem  Missing Dosage Cause  Dosages not set up Normally expect Dosages of 1 and 2 to be automatically created when new single entity tablet is added

GENERIC NAME: DIVALPROEX// DIVALPROEX 500MG VA CLASSIFICATION: DEA, SPECIAL HDLG: 6P// NATIONAL FORMULARY INDICATOR: LOCAL NON-FORMULARY: ^ST Storage Location: Do you wish to match/rematch to NATIONAL DRUG file? Yes// Deleting Possible Dosages... Match local drug DIVALPROEX 500MG (DELAYED RELEASE) ORDER UNIT: BT DISPENSE UNITS/ORDER UNITS: 1 DISPENSE UNIT: TAB I will try to match NDC: to NDF. No match on that NDC DIVALPROEX NA 500MG TAB,EC TAB,EC (DELAYED RELEASE) CN400 D0566 Enter your choice: 1 Is this a match : Y CHOOSE FROM: BOTTLE UNIT DOSE BOTTLE 4 OTHER OTHER Enter Package Size & Type Combination: 1 Solution  Add Dosages Two Tools Drug Enter/Edit Enter/Edit Dosages Not Matched To NDF PDM  Drug Enter/Edit

Do you wish to match/rematch to NATIONAL DRUG file? Yes// Deleting Possible Dosages... Match local drug DIVALPROEX 500MG (DELAYED RELEASE) ORDER UNIT: BT DISPENSE UNITS/ORDER UNITS: 1 DISPENSE UNIT: TAB I will try to match NDC: to NDF. No match on that NDC DIVALPROEX NA 500MG TAB,EC TAB,EC (DELAYED RELEASE) CN400 D0566 Enter your choice: 1 Is this a match : Y CHOOSE FROM: BOTTLE UNIT DOSE BOTTLE 4 OTHER OTHER Enter Package Size & Type Combination: 1 Local drug DIVALPROEX 500MG (DELAYED RELEASE) matches DIVALPROEX NA 500MG TAB,EC PACKAGE SIZE: 100 PACKAGE TYPE: BOTTLE OK? : Y LOCAL DRUG NAME: DIVALPROEX 500MG (DELAYED RELEASE) ORDER UNIT: BT DISPENSE UNITS/ORDER UNITS: 1 DISPENSE UNIT: TAB Run Through NDF Match to get to Dosages

VA PRODUCT NAME: DIVALPROEX NA 500MG TAB,EC VA PRINT NAME: DIVALPROEX 500MG EC(DELAYED RELEASE) TAB CMOP ID: D0566 VA DISPENSE UNIT: TAB MARKABLE FOR CMOP: YES PACKAGE SIZE: 100 PACKAGE TYPE: BOTTLE VA CLASS: CN400 ANTICONVULSANTS CS FEDERAL SCHEDULE: INGREDIENTS: NATIONAL FORMULARY INDICATOR: YES NATIONAL FORMULARY RESTRICTION: Is this a match ? Y You have just VERIFIED this match and MERGED the entry. Resetting Possible Dosages.. Press Return to continue: Just a reminder...you are editing DIVALPROEX 500MG (DELAYED RELEASE). LOCAL POSSIBLE DOSAGES: Do you want to edit Local Possible Dosages? LOCAL POSSIBLE DOSAGES: PACKAGE: IO Editing Dosages with Drug Enter/Edit Normally expect single entity Tabs/Caps to allow entry of Dosages (dispense Units)

Do you want to edit Local Possible Dosages? N// YES Strength: 500 Unit: MG Select LOCAL POSSIBLE DOSAGE: 500MG Are you adding '500MG' as a new LOCAL POSSIBLE DOSAGE (the 2ND for this DRUG)? No// Y LOCAL POSSIBLE DOSAGE: 500MG// PACKAGE: OI Both Strength: 500 Unit: MG Select LOCAL POSSIBLE DOSAGE: 1000MG Are you adding '1000MG' as a new LOCAL POSSIBLE DOSAGE (the 3RD for this DRUG)? No// Y LOCAL POSSIBLE DOSAGE: 1000MG// PACKAGE: OI Both Strength: 500 Unit: MG These LPDs will not expand correctly

Select Drug: DIVALPROEX 500MG (DELAYED RELEASE) CN This entry is marked for the following PHARMACY packages: Outpatient DIVALPROEX 500MG (DELAYED RELEASE) Inactive Date: This drug has the following Local Possible Dosages: 500MG PACKAGE: OI 1000MG PACKAGE: OI Do you want to merge new Local Possible Dosages? Y// NO Select LOCAL POSSIBLE DOSAGE: 1 TABLET Are you adding '1 TABLET' as a new LOCAL POSSIBLE DOSAGE (the 4TH for this DRUG)? No// Y (Yes) LOCAL POSSIBLE DOSAGE: 1 TABLET// PACKAGE: OI Both Strength: 500 Unit: MG Select LOCAL POSSIBLE DOSAGE: 2 TABLETS Are you adding '2 TABLETS' as a new LOCAL POSSIBLE DOSAGE (the 5TH for this DRUG)? No// Y (Yes) LOCAL POSSIBLE DOSAGE: 2 TABLETS// PACKAGE: OI Both Editing Dosages with Enter/Edit Dosages PDM  Dosages  Dosages Enter/Edit These LPDs will expand correctly

Dosages Now Appear

No Route Drug is missing a verb & noun Problem  Missing Verb, Route, Noun Cause  Dosage Form is missing data Check the NDF match for this item - if it’s OK – Enter/Edit Dosage Form

PDM  Dosages  Dosage Form File Enter/Edit Select DOSAGE FORM NAME: TAB 1 TAB 2 TAB (DELAYED RELEASE) 3 TAB,BUCC,SA 4 TAB,BUCCAL 5 TAB,CHEWABLE CHOOSE 1-5: 2 TAB (DELAYED RELEASE) Select MED ROUTE FOR DOSAGE FORM: ORAL 1 ORAL PO 2 ORAL (TOPICAL) PO TOPICAL 3 ORAL GASTRIC TUBE OG TUBE 4 ORAL INHALATION ORALINHL 5 ORAL INHALATION INHL(PO) CHOOSE 1-5: 1 ORAL PO Are you adding 'ORAL' as a new MED ROUTE FOR DOSAGE FORM (the 1ST for this DOSAGE FORM)? No// Y VERB: TAKE OTHER LANGUAGE VERB: PREPOSITION: SURE YOU WANT TO DELETE? Y OTHER LANGUAGE PREPOSITION: Select NOUN: TABLET CONJUNCTION: All Prepositions must be deleted from the DF file Solution  Edit Dosage Form

The route now appears Verb “take” automatically populates the quick order dialog box. Note the noun does not appear until a dose has been selected. Solution  Fixing Verb, Route, Noun

Default schedule is not set Patient Instructions are missing Problem  Missing Schedule Pt. Instructions

Orderable Item -> DIVALPROEX Dosage Form -> TAB,EC (DELAYED RELEASE) Dispense Drugs: DIVALPROEX 500MG (DELAYED RELEASE) Are you sure you want to edit this Orderable Item? NO// YES Now editing Orderable Item: DIVALPROEX TAB,EC (DELAYED RELEASE) Orderable Item Name: DIVALPROEX// 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: DAILY Outpatient Expansion: EVERY DAY PATIENT INSTRUCTIONS: TPS TO PREVENT SEIZURES SYNONYM: DEPAKOTE Solution  Edit The Orderable Item PDM  Orderable Item Management  Edit Orderable Items

Schedule is defaulted for the quick order now Patient Instructions are now an option and the provider can decide to leave them on the final drug label or uncheck the box

Problem  QO Defaults not set Days Supply Quantity Pick up Refills Priority

NAME: PSOZ DIVALPROEX (DEPAKOTE) 500MG (2X250MG) (DELAYED RELEASE) DISPLAY TEXT: Divalproex (Depakote) 500mg BEDTIME (DELAYED RELEASE) VERIFY ORDER: YES// DESCRIPTION: No existing textEdit? NO// ENTRY ACTION: Medication: DIVALPROEX TAB,SA,24HR (EXTENDED RELEASE) // Complex dose? NO// Dose: 2 TABLETS 250MG// Route: ORAL// Schedule: DAILY// Patient Instructions: TO PREVENT SEIZURES Include Patient Instructions in Sig? YES// Chronic Med?YES// Days Supply: 30// Quantity (TABLET): 60// Refills (0-11): 11// Pick Up: WINDOW// Priority: ROUTINE// Comments: No existing text Edit? No// (No) Solution  Edit the Quick Order Medication: DIVALPROEX TAB,SA,24HR (EXTENDED RELEASE) 250MG Instructions: 2 TABLETS 250MG ORAL DAILY Patient Instructions: TO PREVENT SEIZURES Days Supply: 30 Quantity (TABLET): 60 Refills (0-11): 11 Pick Up: WINDOW Priority: ROUTINE (P)lace, (E)dit, or (C)ancel this quick order? PLACE//

Pop up boxes can display messages to remind providers of various dosage forms, hard copy’s must be signed, etc This currently only appears if the provider EDITS the quick order! Request for fix has been submitted. Problem  Providers sending orders that can’t be finished electronically

GENERIC NAME: MORPHINE 15MG SR TAB Replace VA CLASSIFICATION: CN101// DEA, SPECIAL HDLG: 2AP// NATIONAL FORMULARY INDICATOR: YES LOCAL NON-FORMULARY: VISN NON-FORMULARY: Select DRUG TEXT ENTRY: Select FORMULARY ALTERNATIVE: Select SYNONYM: MESSAGE: MUST have Hand Signed Hard Copy to Process!!! RESTRICTION: INACTIVE DATE: WARNING LABEL: 1,8,18,20// ORDER UNIT: BT// Solution  Add a message for the Drug Careful not to create too many pop- ups – Will irritate providers

Problem  Order does not have a dispense Drug Cause  Provider entered an unrecognized Dose

For Single Entity Tabs/Caps Delete all Possible Dosages Add required Local Possible Dosages Solution  Allow imprecise doses PDM  Dosages  Dosages Enter/Edit Select Drug: IBUPROFEN 200MG TAB (KB) MS This entry is marked for the following PHARMACY packages: Outpatient Non-VA Med Strength from National Drug File match => 200 MG Strength currently in the Drug File => 200 MG Edit Strength? N// DISPENSE UNITS PER DOSE: SURE YOU WANT TO DELETE THE ENTIRE '1' DISPENSE UNITS PER DOSE? Y Strength => 200 Unit => MG Select DISPENSE UNITS PER DOSE: IO DISPENSE UNITS PER DOSE: SURE YOU WANT TO DELETE THE ENTIRE '2' DISPENSE UNITS PER DOSE? Y Select DISPENSE UNITS PER DOSE: Select LOCAL POSSIBLE DOSAGE: 1 TABLET Are you adding '1 TABLET' as a new LOCAL POSSIBLE DOSAGE (the 1st for this DRUG)? No// Y PACKAGE: OI LOCAL POSSIBLE DOSAGE: 2 TABLETS Are you adding '2 TABLETS' as a new LOCAL POSSIBLE DOSAGE (the 2ND for this DRUG)? No// Y PACKAGE: OI Select LOCAL POSSIBLE DOSAGE: 1-2 TABLETS Are you adding ‘1-2 TABLETS' as a new LOCAL POSSIBLE DOSAGE (the 3RD for this DRUG)? No// Y PACKAGE: OI Select LOCAL POSSIBLE DOSAGE

Problem: Duplicate Drugs tied to the same Orderable Item- Provider’s Confused!

Drug File has multiple entries for 8OOMG TABS

PDM  Orderable Item Management  Edit Orderable Items Orderable Item -> IBUPROFEN Dosage Form -> TAB Dispense Drugs: IBUPROFEN 400MG TAB 30'S JAN 19, 2006 IBUPROFEN 400MG TAB BULK IBUPROFEN 800MG TAB BULK IBUPROFEN 800MG TAB 100'S IBUPROFEN 400MG TAB 100'S JAN 19, 2007 IBUPROFEN 200MG TAB 24'S MAY 06, 2007 IBUPROFEN 200MG TAB 50'S Are you sure you want to edit this Orderable Item? NO// y YES Tip: Inactivate multiple NDC and package size entries in your drug file Could separate them into different orderable items, but this can create other problems.

Problem  Ordered Dosage does not expand as expected PATIENT STATUS: OUTPATIENT// OUTPATIENT DRUG: PYRAZINAMIDE 500MG TAB (ST)...OK? Yes// Now doing order checks. Please wait... VERB: TAKE Available Dosage(s) MG Select from list of Available Dosages, Enter Free Text Dose or Enter a Question Mark (?) to view list: Cause  * Provider manually entered the dosage * Need additional Dosages set up for drug or won’t expand for label

Add in the required dosages (either POSSIBLE DOSAGES OR LOCAL POSSIBLE DOSAGES) Solution: Edit Dosages PDM  Dosages  Dosages Enter/Edit Select Drug: PYRAZINAMIDE 500MG TAB (ST) AM500 This entry is marked for the following PHARMACY packages: Outpatient Non-VA Med This drug can have Possible Dosages, but currently does not have any. Create Possible Dosages for this drug? N// YES Resetting Possible Dosages.. Strength from National Drug File match => 500 MG Strength currently in the Drug File => 500 MG Edit Strength? N// Strength => 500 Unit => MG Select DISPENSE UNITS PER DOSE: IO Are you adding ‘2' as a new POSSIBLE DOSAGES (the 2nd for this DRUG)? No// Y DISPENSE UNITS PER DOSE: 2// PACKAGE: IO// Strength => 500 Unit => MG Select DISPENSE UNITS PER DOSE: 3 Are you adding '3' as a new POSSIBLE DOSAGES (the 3RD for this DRUG)? No// Y Dosage = 1500MG POSSIBLE DOSAGES DOSE: 1500// (No Editing) DISPENSE UNITS PER DOSE: 3// PACKAGE: OI Strength => 500 Unit => MG Select DISPENSE UNITS PER DOSE:

Select QUICK ORDER NAME: PSOZ PZA 1500MG QDAY NAME: PSOZ PZA 1500MG QDAY Replace DISPLAY TEXT: PZA 1500MG QDAY// VERIFY ORDER: YES// DESCRIPTION: No existing text Edit? NO// Medication: PYRAZINAMIDE TAB // Complex dose? NO// Dose: TIP: Must re-edit the QO to link the new Dosage Re-check for the new dosages you just added

New Dosages are now selectable

Looks at all entries in the Pharmacy Orderable Item File including Synonyms Problem: Cluttered Medication Order Tab

Solution: Edit Orderable Items  Delete Quick Codes Select OI-DRUG TEXT ENTRY: INACTIVE DATE: DAY (nD) or DOSE (nL) LIMIT: MED ROUTE: SCHEDULE TYPE: PRN// SCHEDULE: TID PRN// PATIENT INSTRUCTIONS: TWF/ Select SYNONYM: ? Answer with SYNONYM Choose from: I 25 I-25 I25 INDOCIN PDM  Orderable Item Management  Edit Orderable

I don’t think so! Problem: Incorrect Routes

Solution: Delete Inappropriate Routes PDM  Dosages  Dosage Form File Enter/Edit Select DOSAGE FORM NAME: INJ,SUSP Select MED ROUTE FOR DOSAGE FORM: SUBCUTANEOUS// ? Answer with MED ROUTE FOR DOSAGE FORM Choose from: INTRAVENOUS INTRAMUSCULAR Select MED ROUTE FOR DOSAGE FORM: INTRAVENOUS MED ROUTE FOR DOSAGE FORM: INTRAVENOUS SURE YOU WANT TO DELETE THE ENTIRE MED ROUTE FOR DOSAGE FORM? Y Select MED ROUTE FOR DOSAGE FORM: INTRAMUSCULAR// VERB: INJECT// OTHER LANGUAGE VERB: PREPOSITION: OTHER LANGUAGE PREPOSITION: Select NOUN: CONJUNCTION:

Limit number of staff making quick orders Limit drug file access to a few trained people Conduct random quick order checks Use your colleagues for input Subscribe to the IHSRX Listserv! Recommendations

Resources FTP Site ftp://ftp.ihs.gov/rpms/Pharmacy%205-7 Specific questions regarding drug file preparation Steve Bowman,

EHR web site: