Troubleshooting Pharmacy Issues January 2012

Session Content This presentation shows some common issues that may happen with EHR and Pharmacy. It is NOT a comprehensive list of potential issues. The solutions proposed represent the most common causes of the listed issues, and again, are NOT comprehensive. This presentation is designed to develop basic troubleshooting skills for Pharmacy Informaticists.

Issue: Inactivated Medication When attempting to order a medication from the quick order menu the user receives a message stating that the item “has been inactivated and may not be ordered anymore.”

Check both drug and orderable item for an inactive date REMOVE inactive dates to make item active again—NEVER set a future date! Check quick orders—if a new NDC was put in as a new drug instead of editing the existing entry, will need to change all the quick orders. Potential Solution: Inactivated Medication

Select Pharmacy Data Management Option: Drug Enter/Edit Select DRUG GENERIC NAME: FOSINOPRIL 10MG TAB (90'S) CV *************************************************************************** This entry is marked for the following PHARMACY packages: Outpatient GENERIC NAME: FOSINOPRIL 10MG TAB (90'S) Replace … [pharmacy package stuff not applicable here] … INACTIVE DATE: NOV SURE YOU WANT TO DELETE? Y (Yes) … [more pharmacy stuff not applicable here] … ** You are NOW in the ORDERABLE ITEM matching for the dispense drug. ** FOSINOPRIL 10MG TAB (90'S) is already matched to FOSINOPRIL TAB This Orderable Item has an Inactive Date. *** NOV 27, 2008 To modify the Orderable Item, use the 'Edit Orderable Item' option. Do you want to match to a different Orderable Item? NO// Potential Solution: Inactivated Medication, continued

Select Pharmacy Data Management Option: ORDERABLE ITEM Management Edit Orderable Items Dispense Drug/Orderable Item Maintenance Orderable Item/Dosages Report Patient Instructions Report Select Orderable Item Management Option: EDit Orderable Items This option enables you to edit Orderable Item names, Formulary status, drug text, Inactive Dates, and Synonyms. Select PHARMACY ORDERABLE ITEM NAME: FOSIN 1 FOSINOPRIL TAB FOSINOPRIL/HYDROCHLOROTHIAZIDE TAB N/F CHOOSE 1-2: 1 FOSINOPRIL TAB Orderable Item -> FOSINOPRIL Dosage Form -> TAB Dispense Drugs: FOSINOPRIL= 10MG TABS NOV 27, 2008 FOSINOPRIL= 20MG TABS NOV 27, 2008 FOSINOPRIL= 40MG TABS NOV 27, 2008 FOSINOPRIL 10MG TAB (90'S) FOSINOPRIL 20MG TAB (90'S) NOV 27, 2008 FOSINOPRIL 40MG TAB (90'S) NOV 27, 2008 Are you sure you want to edit this Orderable Item? NO// YES Potential Solution: Inactivated Medication, continued

Now editing Orderable Item: FOSINOPRIL TAB Orderable Item Name: FOSINOPRIL// This Orderable Item is Formulary. Select OI-DRUG TEXT ENTRY: INACTIVE DATE: NOV 27, Inactive Date deleted! DAY (nD) or DOSE (nL) LIMIT: MED ROUTE: SCHEDULE TYPE: SCHEDULE: DAILY// PATIENT INSTRUCTIONS: FOR KIDNEY PROTECTION AND BLOOD PRESSURE Replace There are inactive drugs, matched to this Pharmacy Orderable Item. Do you want to reactivate all Drugs/Additives/Solutions that are matched to this Orderable Item?: (Y/N/L): N// NO Select SYNONYM: Potential Solution: Inactivated Medication, continued

Issue: No Doses in the Quick Order User is attempting to order Losartan but discovers there are no available doses in the quick order. Note that in addition to the empty dosage box, there is no indication of a tablet strength in the preview box.

Providers can free text a dose into the dosage field in order to complete the medication quick order. This will NOT work for e-Rx meds, and is a temporary solution ONLY Note there is still no tablet strength indication in the preview box. See next slide for more Potential Solution: No Doses in the Quick Order

Issue: Local Possible Dosages are Confusing Is it one puff of the 250/50mcg inhaler or one puff at the 500/50mcg inhaler? Note: the orderable item is generic, “FLUTICASONE/SALMETEROL INHL, ORAL”

Solution: Local Possible Dosages are Confusing Separate out the orderable items, “FLUTICASONE 250MCG/SALMETEROL 50MCG INHL, ORAL

Recommendation: Separate Descriptive Orderable Items It is important to use separate descriptive orderable items that include strength as part of the orderable name in the following circumstances: Drugs that have local possible dosages (combo drugs, topicals, ophthalmics, inhalers, etc.) Drugs where the strength is expressed as a percentage (i.e IV solutions, topicals, etc) IV Additives where there is more than one strength used at the facility (i.e. Cefazolin 1gm and Cefazolin 2gm) Medications that may be dispensed from Omnicell/Pyxis when the pharmacy is not open.

Issue: Standard Schedule NOT Available Why is the Standard Schedule of “AC TID” not showing as an available option?

*************************************************************************** Select Pharmacy Data Management Option: STANdard Schedule Edit Select ADMINISTRATION SCHEDULE: AC TID Are you adding 'AC TID' as a new ADMINISTRATION SCHEDULE (the 82ND)? No// Y (Yes) NAME: AC TID// OUTPATIENT EXPANSION: 3 TIMES A DAY BEFORE MEALS OTHER LANGUAGE EXPANSION: TYPE OF SCHEDULE: CONTINUOUS// CONTINUOUS STANDARD ADMINISTRATION TIMES: FREQUENCY (IN MINUTES): 1440// Select WARD: Potential Solution The administration schedule needs to be built into the Standard Schedule File located under Pharmacy Data Management (PDM)

Issue: Standard Schedule is NOW Available

Issues: Unknown Quantity when Ordering Medication Provider goes to “All Other Meds” to order a medication, but it not sure what to put for the QTY?

Possible Solution: Add a “QTY Dispense Message” Enter your choice(s) separated by commas : O O - Outpatient ** You are NOW editing OUTPATIENT fields. ** AN Outpatient Pharmacy ITEM? Yes// Y (Yes) CORRESPONDING INPATIENT DRUG: MAXIMUM DOSE PER DAY: STANDARD SIG: AP TO FACE HS UD LOCAL NON-FORMULARY: NORMAL AMOUNT TO ORDER: SOURCE OF SUPPLY: 3// CURRENT INVENTORY: // ACTION PROFILE MESSAGE (OP): MESSAGE: QUANTITY DISPENSE MESSAGE: 1 BOTTLE=60ML OP EXTERNAL DISPENSE:

Possible Solution: Add a “QTY Dispense Message”

Issue: “Pop-up” Fatigue Providers can start to experience “Pop-up” Fatigue if too many pops occur while trying to order medications, labs, etc. “Pop-ups” should be kept to a minimum and only used when absolutely necessary

Possible Solution: Use Drug Text to Minimize “Pop-ups” CMOP Mark/Unmark (Single drug) DOS Dosages... DRED Drug Enter/Edit Drug Interaction Management... Electrolyte File (IV) Lookup into Dispense Drug File Medication Instruction File Add/Edit Medication Route File Enter/Edit OIM 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...

Possible Solution: Use Drug Text to Minimize “Pop-ups”

The pharmacist making the inpatient quick orders calls with the above question…what is the difference between these types of quick orders and which one should be used when? Issue: Do we use quick order type “Inpatient Medications” or “Unit Dose”

Potential Solution: Do we use quick order type “Inpatient Medications” or “Unit Dose” There is no functional difference between the two types – Sites may choose to use either type for all non- infusion quick orders – Sites may decide to locally determine which type should be used for which item – Would only be useful if using Quick Order Wizard or performing Fileman searches for specific types of quick orders

Issue: The route of “IM” is not available Provider wants to order a one- time dose of Ceftriaxone to be given “IM” but that route is not available

Potential Solution: The route of “IM” is not available Solution: RPMS  PDM  Dosages  Dosage Form File Enter/Edit ************************************************** Select DOSAGE FORM NAME: INJ,SOLN 1 INJ,SOLN 2 INJ,SOLN,SA CHOOSE 1-2: 1 INJ,SOLN NAME: INJ,SOLN Select MED ROUTE FOR DOSAGE FORM: IV PIGGYBACK// INTRAMUSCULAR 1 INTRAMUSCULAR IM Are you adding 'INTRAMUSCULAR' as a new MED ROUTE FOR DOSAGE FORM (the 4TH for this DOSAGE FORM)? No// YES

Potential Solution: The route of “IM” is NOW available

Issue: Unable to Transfer from Inpatient to Outpatient

Potential Solution: Unable to Transfer from Inpatient to Outpatient One Orderable Item is required for both the Bulk Outpatient Dispense Drug and the Unit Dose Inpatient Dispense Drug ************************************************************ Orderable Item -> CITALOPRAM Dosage Form -> TAB Dispense Drugs: CITALOPRAM 40MG TAB CITALOPRAM 20MG TAB CITALOPRAM 20MG U/D TAB CITALOPRAM 10MG TAB

Issue: Transfer to Outpatient Dialog Setting Defaults Why are the fields “Pick Up” and “Refills” not filled in?

Issue: No Dispense Drug Selected Pharmacy has received a notice that they need to process an order for Lisinopril. As they begin to process they notice a message in the drug field: No Dispense Drug Selected Pending OP Orders (ROUTINE) Jan 25, :06:59 Page: 1 of 3 DEMO,ALLERGY CHARLES PID: XXX-XX-5701 (HRN: ) Ht(cm): (08/04/2011) DOB: NOV 2,1969 (42) Wt(kg): (09/28/2003) + *(1) Orderable Item: LISINOPRIL TAB (2) Drug: No Dispense Drug Selected Verb: TAKE (3) *Dosage: 1 TABLET *Route: ORAL *Schedule: QDAY (4) Pat Instruct: FOR HIGH BLOOD PRESSURE Provider Comments: Instructions: TAKE 1 TABLET PO QDAY SIG: TAKE 1 TABLET BY MOUTH EVERY DAY FOR HIGH BLOOD PRESSURE (5) Patient Status: OUTPATIENT (6) Issue Date: JAN 25,2012 (7) Fill Date: JAN 25,2012 (8) Days Supply: 30 (9) QTY ( ): 30 Provider ordered 3 refills + Enter ?? for more actions BY Bypass DC Discontinue ED Edit FN Finish Select Item(s): Next Screen//

Check drug entry for correct doses (PDM  Dosages  Enter/edit dosages) Check for both Possible Doses and Local Possible Doses: – setting both works in Pharmacy package but NOT in EHR – EHR will only see local doses if they are set – EHR will show possible doses if no local doses set Check quick order: (BEH  ORD  MNU  QOC) – Matched to old agent? – Dose not selected from list? Potential Solution: No Dispense Drug Selected

Local doses were set: Select Dosages Option: enter/Edit Dosages Select Drug: LISINOPRIL 10MG TAB CV This entry is marked for the following PHARMACY packages: Outpatient Non-VA Med LISINOPRIL 10MG TAB Inactive Date: This drug has no Local Possible Dosages, do you want to create them? Y// Y YES Setting Local Possible Dosages.. Press Return to continue: Strength: Unit: Select LOCAL POSSIBLE DOSAGE: ? Answer with LOCAL POSSIBLE DOSAGE Choose from: 1 TABLET IO 2 TABLETS IO

Possible Doses were set: Select Drug: IBUPROFEN 400MG TAB MS102 N/F This entry is marked for the following PHARMACY packages: Outpatient IBUPROFEN 400MG TAB *N/F* Inactive Date: Strength from National Drug File match => 400 MG Strength currently in the Drug File => 400 MG Edit Strength? N// O Strength => 400 Unit => MG Select DISPENSE UNITS PER DOSE: ? Answer with POSSIBLE DOSAGES DISPENSE UNITS PER DOSE Choose from: IO IO You may enter a new POSSIBLE DOSAGES, if you wish Type a Number between 0 and , 4 Decimal Digits Select DISPENSE UNITS PER DOSE:

A Local dose in addition to Possible doses (must remove local possible dose): Enter/Edit Local Possible Dosages? N// YES Strength: 400 Unit: MG Select LOCAL POSSIBLE DOSAGE: ? Answer with LOCAL POSSIBLE DOSAGE: 1-2 TABLETS IO You may enter a new LOCAL POSSIBLE DOSAGE, if you wish Answer must be 1-60 characters in length. Select LOCAL POSSIBLE DOSAGE: 1-2 TABLETS IO LOCAL POSSIBLE DOSAGE: 1-2 SURE YOU WANT TO DELETE THE ENTIRE '1-2 TABLETS' LOCAL POSSIBLE DOSAGE? Y (Yes) Strength: 400 Unit: MG Select LOCAL POSSIBLE DOSAGE:

Check quick order: Create/Modify Quick Orders Select QUICK ORDER NAME: PSOZ LOSARTAN 50MG DAILY NAME: PSOZ LOSARTAN 50MG DAILY Replace DISPLAY TEXT: Losartan 50mg DAILY// VERIFY ORDER: YES// DESCRIPTION: No existing text Edit? NO// Medication: LOSARTAN TAB // Complex dose? NO// Dose: 50MG// ? Enter the dosage instructions for this order, as a dose or amount. Dose: 50MG// Route: ORAL// Schedule: DAILY// ACE FAILURE Patient Instructions: FOR KIDNEY PROTECTION AND/OR BLOOD PRESSURE Include Patient Instructions in Sig? YES//

Chronic Med?// Days Supply: 30// Quantity (TAB): 30// Refills (0-11): 11// Pick Up: WINDOW// Priority: ROUTINE// Comments: Edit? No// (No) Medication: LOSARTAN TAB 50MG Dispense Drug: LOSARTAN K= 50MG TAB Instructions: 50MG ORAL DAILY Sig: TAKE ONE TABLET BY MOUTH DAILY Patient Instructions: FOR KIDNEY PROTECTION AND/OR BLOOD PRESS... Days Supply: 30 Quantity (TAB): 30 Refills (0-11): 11 Pick Up: WINDOW Priority: ROUTINE Comments:

Issue: Provider Requested Refill Too Soon Pharmacy is screening today’s orders in OERR when they notice that the provider put in a refill request for a patient who recently had this medication filled. The pharmacist can not process it due to the 30 day billing policy – so the pharmacist asks you how can they cancel the request without changing the original order. Medication Profile Jan 25, :35:08 Page: 1 of 1 DEMO,PATIENT ALONZO PID: XXX-XX-5296 (HRN: ) Ht(cm): (09/06/2002) DOB: AUG 2,1952 (59) Wt(kg): (09/06/2002) SEX: MALE ISSUE LAST REF DAY ACTIVE BB-LISINOPRIL 10MG TAB 30 A PENDING BB-LISINOPRIL 10MG TAB Refill Request Rx #: Enter ?? for more actions PU Patient Record Update NO New Order PI Patient Information SO Select Order Select Action: Quit//

Potential Solution: Provider Requested Refill Too Soon At the “Select Action” prompt, type in “DC” and then choose the line item you need to discontinue. Enter a comment, and use yourself as the requesting provider. This discontinues the REQUEST only, and not the original ORDER. Medication Profile Jan 25, :35:08 Page: 1 of 1 DEMO,PATIENT ALONZO PID: XXX-XX-5296 (HRN: ) Ht(cm): (09/06/2002) DOB: AUG 2,1952 (59) Wt(kg): (09/06/2002) SEX: MALE ISSUE LAST REF DAY ACTIVE BB-LISINOPRIL 10MG TAB 30 A PENDING BB-LISINOPRIL 10MG TAB Refill Request Rx #: Enter ?? for more actions PU Patient Record Update NO New Order PI Patient Information SO Select Order Select Action: Quit// DC DC Select Orders by number: (1-2): 2 Comments: TOO SOON TO FILL, LAST FILLED 1/10/2012 Nature of Order: SERVICE CORRECTION// S Requesting PROVIDER: NIESEN,MARY ANN PHARM D//

Issue: Orders exist in EHR but are not showing in the Pharmacy Package A Pharmacist contacts you about orders in EHR that are not showing up in RPMS. They were not aware of any problems until patients started to present to pharmacy about the long wait for their prescriptions. They don’t understand why the orders are not showing up in the pharmacy package and request your help in solving this mystery.

Look at the “CPRS ORDERING INSTITUTION” field in your Outpatient Pharmacy Site Parameters. You may have a division that orders medications in EHR that the pharmacy package is not set-up to receive orders from. Potential Solution: Orders exist in EHR but are not showing in the Pharmacy Package

Issue: Inpatient sig codes are not expanding The Pharmacist calls to report that the codes used to build the sig in the orders expands properly on the outpatient side but is NOT expanding on the inpatient side...for example, “BID” will show on the outpatient label as “two times each day” but still says “BID” on the inpatient MAR that was printed from RPMS. What is wrong?

Issue: Inpatient sig codes are not expanding This is intentional…expansion is needed on the outpatient side since these need to be “patient- friendly”. Inpatient instructions will be used by other medical personnel, who should be familiar with the abbreviations used, and it will save space and prevent formatting issues on the printed MARs – Pharmacy package set up of these codes should take into account the “approved abbreviations” and/or “unapproved abbreviations” lists for the facility and medication safety organizations – Non-standard abbreviations should be avoided (e.g. “BTID” to mean “two to three times each day”)

A User calls and states that “Delayed Orders” now shows at the top of the list of options on the orders tab…what is it? Can you move it to the bottom because I don’t like it there… Issue: A new option suddenly showed up in the orders tab called “Delayed Orders”

Potential Solution: Delayed Orders “Delayed Orders” is related to admissions, to allow the provider write orders that will not be active until the patient is actually admitted to the unit It will always occupy the top position

Issue: How do I view JUST the discharge medications in EHR? The billing office calls stating they need to get a list of medications that ONLY includes those ordered at discharge…how can they get such a list?

Issue: How do I view JUST the discharge medications in EHR? Users can customize the ORDER view to show only outpatient pharmacy orders from a certain date or date range

Issue: Option to Finish as an IV is Missing DC Discontinue FL Flag ED Edit FN Finish Select Item(s): Next Screen// FN Finish COMPLETE THIS ORDER AS IV OR UNIT DOSE? IV// The last prompt is missing for some orders.

Potential Solution: Option to Finish as an IV is Missing This is fixed in the Medication Routes File: Select MEDICATION ROUTES NAME: IVPB IV PIGGYBACK IVPB NAME: IV PIGGYBACK// ABBREVIATION: IVPB// PACKAGE USE: ALL PACKAGES// OUTPATIENT EXPANSION: IVPB// OTHER LANGUAGE EXPANSION: IV FLAG: YES//

Many different scenarios….. IV Flag in the Medication Routes File Dispense Drug’s Application Use Which Order View screen will be displayed to the user Special Processing YesIV None YesUnit Dose Prompt User to Finish Order as IV or Unit Dose YesIV and Unit DoseIVPrompt User to Finish Order as IV or Unit Dose NoIV Prompt User to Finish Order as IV or Unit Dose NoUnit Dose None NoIV and Unit DoseUnit DosePrompt User to Finish Order as IV or Unit Dose

Issue: Solution/Additive not Available when making an “IV Medication” Quick Order Pharmacist is building an IV Quick Order for SODIUM CHLORIDE 0.9% with 40MEQ KCL When building the quick order the Solution isn’t listed Select QUICK ORDER NAME: PSIVZ SODIUM CHLORIDE 0.9% W/40MEQ KCL NAME: PSIVZ SODIUM CHLORIDE 0.9% W/40MEQ KCL Replace DISPLAY TEXT: KCL 40mEq in 0.9% NS Replace VERIFY ORDER: YES// DESCRIPTION: No existing text Edit? NO// Solution: SODIUM CHLORIDE 0.9% W/40MEQ KCL ?? Enter a base solution for this order.

Potential Solution: Solution/Additive not Available when making an “IV Medication” Quick Order AN IV ITEM? Yes// Y (Yes) Edit Additives or Solutions: Select one of the following: A ADDITIVES S SOLUTIONS Enter response: SOLUTIONS Select IV SOLUTIONS PRINT NAME: SODIUM CHLORIDE CHOOSE 1-15: 15 SODIUM CHLORIDE 0.9% 40MEQ KCL 1000 ML PRINT NAME: SODIUM CHLORIDE 0.9% 40MEQ KCL Replace PRINT NAME {2}: GENERIC DRUG: SOD. CHL. 0.9% W/ 40MEQ KCL 1000ML (INJ) VOLUME: 1000 ML// Select ELECTROLYTES: CHLORIDE// ELECTROLYTES: CHLORIDE// CONCENTRATION:.04 MEQ/ML// Select ELECTROLYTES: Select SYNONYM: DRUG INFORMATION: No existing text Edit? NO// AVERAGE DRUG COST:.01679// INACTIVATION DATE: USED IN IV FLUID ORDER ENTRY: NO// This field should be set to “Yes”

Potential Solution: Solution/Additive not Available when making an “IV Medication” Quick Order When should the Prompt “Used in IV Fluid Order Entry” be Marked “Yes”? – All Additives and Solutions that are Continuous/Intermittent IV Infusions Typically Large Volume Admixtures – Not for Scheduled IVPBs

Potential Solution: Transfer to Outpatient Dialog Setting Defaults Solution: There is none! – No default exists in the inpatient order file to convert data when transferring from inpatient to outpatient – Computer fills in what it can from the inpatient order – Provider must fill in the information upon ordering the medication

Issue: Units Per Dose (U/D) in the Dispense Drug Field Inaccurate Scenario: – An inpatient is on Carvedilol 6.25mg PO BID – Computer wants to use ½ tablet of Carvedilol 12.5mg Unit Dose as the dispense drug – Pharmacy has Carvedilol 6.25mg Unit Dose tablets available in the Omni-Cell/Pyxis – Why is this happening?

DEMO,PATIENT INPATIENT Ward: 2S MED/ CWA HRN: Room-Bed: Ht(cm): /12/2010 DOB: 05/19/50 (59) Wt(kg): /05/2010 (1)Orderable Item: CARVEDILOL TAB Instructions: (2)Dosage Ordered: 6.25MG (3)Start: 02/10/10 21:00 (4) Med Route: ORAL (5) Stop: 05/21/10 16:00 (6) Schedule Type: CONTINUOUS (8) Schedule: BID (9) Admin Times: (10) Provider: STEARLE,CARLA D DURATION: (11) Special Instructions: (12) Dispense Drug U/D Inactive Date CARVEDILOL 12.5MG TAB U/D 0.5 Issue: Units Per Dose (U/D) in the Dispense Drug Field Inaccurate, continued

Potential Solution: Units Per Dose (U/D) in the Dispense Drug Field Inaccurate Check the Possible Dosages in Drug Enter/Edit – Unit Dose Entries should typically only have one possible dosage Carvedilol 6.25mg U/D – Possible Dosage: 6.25mg=1 tablet Carvedilol 12.5mg U/D – Possible Dosage: 12.5mg=1 tablet