0. 7th Annual
Pharmacy Informatics Conference
Clinic Orders – Impact on Pharmacy Processes and Overview of the Controlled Implementation Effort
Stephen Corma, RPh
Pharmacist Consultant , Bar Code Resource Office
Office of Informatics & Analytics
April 3, 2014

1. Clinic Orders
Inpatient Medications for Outpatients (IMO) allowed providers to order inpatient medications for outpatients through CPRS
Supported pharmacy dispensing
Did not support medication administration through BCMA
Clinic Orders is the nationally supported solution allowing inpatient medications to be administered to outpatients using BCMA.
Inpatient Medications for Outpatients (IMO) was designed to allow providers to order inpatient medications for outpatients through CPRS. IMO supported Pharmacy dispensing but did not support the documentation of medication administration through BCMA. Clinic Orders is the nationally supported solution allowing inpatient medications to be administered to outpatients using BCMA. The purpose of this presentation is to review the new Clinic Orders functionality and the impact on pharmacy processes, outline quick order modifications required for successful implementation, and describe the controlled implementation effort currently under way led by the Bar Code Resource Office. The controlled implementation effort will generate lessons learned which will be available through an online resource created to provide ongoing support for future site implementations of Clinic Orders.

2. Presentation Objectives:
Following this presentation, attendees will:
Understand how IMO & clinic orders differ
Outline Quick Order modifications required for successful
implementation
Examine the Impact of clinic orders on pharmacy processes
Identify how to obtain additional implementation support

3. IMO vs. Clinic Orders IMO Clinic Orders
works directly in the clinic where the medication is ordered
Medications administered in clinics using BCMA are recorded in the same file as in the inpatient setting
Does not require the use of workarounds to link IMO and BCMA
A new view was added to BCMA and displays clinic orders separately
Provided the ability to order inpatient medications for outpatients
Was not designed to work with BCMA
Local workaround created to link IMO and BCMA together (pseudo-wards)
IMO
Inpatient Medication Orders for Outpatients (IMO) was released several years ago and gave the providers the ability to order inpatient medications for outpatients. However, IMO is only for the ordering side of the process, not on the administration side of the process. IMO was not designed to work with BCMA; however, some facilities created a local workaround to link IMO and BCMA together. This workaround involved setting up pseudo-wards, admitting patients to these wards, and then deleting the admissions before midnight. That process was a local workaround which was not supported nationally, but it was embraced at several sites.
Clinic Orders
Clinic Orders works directly in the clinic where the medication is ordered and does not require the use of pseudo-wards or other workarounds previously used to link IMO and BCMA. Medications administered in clinics using BCMA are recorded in the same file as those administered in the inpatient setting, which helps to provide a seamless medication administration record.
New elements were added in BCMA and CPRS to help nurses distinguish between inpatient and outpatient medications. A new view was added to BCMA and displays the availability of clinic orders. The view is selected automatically according to the admission status of the patient, but the nurse can manually select a view at any time. A new display group for Clinic Orders has been added to CPRS

4. Clinic Order Pathway -ORDER DIALOG- PSJ PAT OE PAT LOCATION (FILE #44)
ADMIN IP MEDS??
Appointment D/T
Today or Future?
CLINIC ORDER!
(UD OR IV) Y N
ONLY IV ORDERABLE ITEM SELECTABLE
-OPT IV/INFUSION- NOT A CLINIC ORDER!
PATIENT ADMITTED?
IP MED

5. What Clinic Orders is not…
Not mandated for use by any national office or directive
Not the ultimate solution for documentation of medication administration in all settings
Not compatible with non-traditional workflows
Sites will need to evaluate their workflows to determine if a possible Clinic Order site can implement from a practical perspective, or can they modify their current workflow to accommodate clinic orders
Clinic Orders is not mandated for use by any national office or directive because Clinic Orders is not the ultimate solution for documentation of medication administration in all settings. The first version of Clinic Orders was released under the premise that it will allow documentation of medication administration in areas where the workflow is similar to the workflow in the inpatient setting

6. Traditional Inpatient Workflow
The inpatient workflow of BCMA relies on computerized provider order entry, pharmacist finishing and verification, nurse verification, and medication administration using BCMA, in that order.

7. Examples of Non-Traditional Workflow
Any area where medications are ordered verbally and administered by the nurse at the bedside without pharmacy involvement
Procedural areas where the provider and nurse are at the patient’s bedside
Areas that work from ‘standing orders’ such as flu clinics
NOTE: Future versions will work to provide a solution to using Clinic Orders in areas with a non-traditional workflow.
Clinic Orders will likely not work in areas that cannot support this Inpatient workflow; for example, any area where medications are ordered verbally and administered by the nurse at the bedside without pharmacy involvement. If the order is not entered in the computer, it cannot be finished by the pharmacy and will not appear in BCMA. Other examples where Clinic Orders may not work well might be procedural areas where the provider and nurse are at the patient’s side, it is unlikely the provider will stop in the middle of the procedure to enter an order for a medication being used during the procedure or areas that work from ‘standing orders’ such as flu clinics, since these areas do not require a provider’s order to be entered as a medication order. Future versions will work to provide a solution to using Clinic Orders in areas with a non-traditional workflow.

8. Quick Order Modifications
Existing UD and IV quick orders (for IP MEDS) will function for clinic orders
You build a Clinic UD/IV order exactly the same way that an Inpatient UD/IV quick order is built-they are interchangeable
Prerequisites:
the patients can’t be admitted
the patient location must be an authorized clinic
the appointment date/time is either today, now or in the future
Existing UD and IV quick orders (for IP MEDS) will function for clinic orders. For a UD or IV quick order to generate a clinic order, the patients can’t be admitted, the PATIENT LOCATION must be an authorized clinic and the appointment date/time is either Today, NOW or in the future. You build a Clinic UD/IV order exactly the same way that an Inpatient UD/IV quick order is built. They are interchangeable.

9. Quick Order Modifications (Considerations)
Evaluate each clinic area to understand the current medication ordering process
Determine what modifications may be required to implement Clinic Orders in that area
Coordinate with the Clinical Applications Coordinator for changes to existing Quick Order dialogues
Changes can include linking the medications quick orders to the updated Clinic order medication order screen
Create new medication orders if orders are currently done via a nursing text order, administered in clinic (with or without status of “done”)
You will need to evaluate each area to understand the current medication ordering process to determine what modifications may be required to implement Clinic Orders in that area. It may be necessary to coordinate with the Clinical Applications Coordinator any changes to existing Quick Order dialogues to link the medications to the updated Clinic order medication order screen or create new medication orders if medication orders are currently done via a nursing text order, administered in clinic (with or without status of “done”).

10. Quick Order Modifications (Considerations)
Important Notes:
A Quick Order type of “Clinic Order” does not yet exist
The CPRS development team is currently working on creating one, along with a tool that can be used to convert existing UD & IV Quick Orders types to a clinic order type
Nursing text and Pharmacy orders created as “administered in clinic” (with or without status of done) will have to be manually converted
A method to identify nursing text orders and “administered in clinic”
orders is also being considered

11. Impacts to Pharmacy Work Flow
Clinic Orders must be entered through CPRS
Pharmacy cannot enter clinic medications through “Back Door” Pharmacy
Pharmacy cannot edit the location chosen by provider during finishing/verification
Some sites still use alternative processes for order entry other than CPOE (paper orders, printed consults, printed progress notes, etc. that print in Pharmacy for “Back Door entry”)
PHARMACY CANNOT “BACK-DOOR” ENTER CLINIC MEDICATIONS (UD or IV); NOR CAN WE EDIT THE LOCATION CHOSEN BY THE PROVIDER during finishing/verification.

12. Impacts to Pharmacy Work Flow
Process needs to be evaluated and modified as needed:
Pharmacists would have to enter orders directly into CPRS and be
given necessary keys & options to do so
Conversion to Quick Orders for providers is another option
Use of COTS software (example – Vista Chemotherapy Manager for
Oncology clinic)
Orders entered by pharmacist through CPRS by Pharmacists done as “signed on chart”
If hand written paper copy is used, it must be scanned into chart also.

13. Impacts to Pharmacy Work Flow
2) Clinic orders currently cannot be entered on an admitted patient
CPRS v30b will introduce a new order dialog for CLINIC ORDERS that will allow the ordering of CLINIC orders on admitted patients
The release date for CPRS v30b has yet to be determined
Education to providers is key as CPRS does not “block” them from entering a clinic order on an inpatient
A warning is presented to the provider on the chosen location, but that may not be sufficient to prevent errors without proper training
CPRS v29 will automatically “add” the patients ward location and remove the clinic appointment date/time when it sends the order to pharmacy.
CPRS converts the clinic order to an inpatient order.

14. Impacts to Pharmacy Work Flow
3) The Clinic must be set to allow Clinic Orders (IMO)
A Clinic Order is a unit dose or IV order entered into a clinic that has been configured to allow clinic medications
The way you set up IMO is the same way you set up Clinic Orders
Consideration: should orders be allowed to survive through an admission/Parameters to control this are in the clinic definition file In most cases, the answer is “no”, but there may be exceptions – ED, Dialysis, Oncology
This is set-up by your ADPAC or CAC (in File #44 and file #53.46) .  The clinic set-up has NOT changed in this functionality.
Patients who are admitted but get sent to clinic for treatment then return to unit afterwards may require to have Clinic Orders survive admission

15. Impacts to Pharmacy Work flow
4) Finishing/verification of Clinic Orders
Staffing: Who will finish/verify Clinic Orders?
Where will missing dose requests & pre-exchange reports print? Same printer as inpatient or separate printer in different location?
Do you have dedicated (separate) staff for inpatient & outpatient Pharmacies or does staff rotate through all areas?
Are pharmacists who will be assigned to finish/verify the orders competent or require additional training on UD & IV orders?
Can the Pharmacists assigned to Clinic Orders handle the additional workload or do resources need to be realigned?
Training modules for UD & IV orders can be found on the PBM Informatics Moodle Site.
Most facilities have pharmacists working in both inpatient and outpatient settings. Pharmacists working in the inpatient settings are very familiar with BCMA and the process for finishing and verifying inpatient medication orders. Pharmacists who work in the outpatient setting typically have a different workflow and may spend much of their time finishing and verifying outpatient medication prescriptions. In many facilities pharmacists rotate between the inpatient and outpatient settings. However, not all pharmacists at all facilities rotate positions. The processes in the inpatient and outpatient settings are very different, so much so, that if inpatient and outpatient pharmacists do not rotate, it may be more feasible for inpatient pharmacists to take on the workload of finishing clinic orders rather than training the outpatient pharmacists how to finish clinic orders.

16. Impacts to Pharmacy Work Flow
5) Workload Determinations
There is not a standard mechanism for obtaining the number of medication orders written in a particular clinic due to the variety of ways those orders can be entered
One solution - estimate workload by obtaining the number of medications dispensed from an Automated Dispensing Cabinet (Pyxis, Omnicell) in an area to get the number of medications dispensed from a particular cabinet per day
If your facility does not have an Automated Dispensing Cabinet (ADC), a representative sample of progress notes that contained medication administrations could be obtained and manually counted as an estimate
Many Facilities also have Pandora software, a commercial off the shelf (COTS) software product, that provides breakdown of dispenses by hour reports, which can then be plotted on a graph. In areas such as the Emergency Room, workload was shown to be in a flattened bell curve, increasing around 10 AM, peaking around 3 PM, and tapering off at 10 PM. A sample of 10 facilities of varying sizes and complexity was obtained that showed the average number of medications dispensed per hour ranged from 1-4 per hour except at peak time around 3 PM when the number of medications dispensed averaged approximately 10 per hour.

17. Impacts to Pharmacy Work Flow
6) Automated Dispensing Cabinets (Pyxis/Omnicell)
Are automated dispensing cabinets stocked with all the meds the clinic needs?
What is your process for supplying meds not normally stocked?
How do you handle meds in short supply, on recall, or out of stock?
Is there a master list or a direct lookup of drugs available for each of the automated dispensing cabinets readily available to Pharmacists as a reference?
Are drugs stocked in cabinets marked as ward stock in drug file? ( option located under menus for auto replenishment)
The pharmacist ensures the medication can be dispensed as ordered (setting up the “dispense drug” to match the medications available for administration). For example, the provider’s order calls for 20mg of lisinopril. The computer will pre-populate the “units” field with one (20mg) tablet. However, due to a national shortage of lisinopril, the facility only has 10mg tablets on hand. The pharmacist must manually correct the order from one 20mg tablet to two 10mg tablets in order for BCMA to correctly recognize the medication upon documentation of administration. If automated  dispensing cabinets are used (Pyxis, Omnicell), pharmacists should have a master list or lookup as to what is carried in the clinic dispensing cabinet so as to not finish the medication with a strength that is not stocked or needs to be sent separately

18. Impacts to Pharmacy Work Flow
7) Policies & Procedures
What will constitute early or late administrations?
How long will the medication stay active?
Typically, administration frequencies for outpatient areas will be “now” or “once”. Explore other situations that may be specific for a particular area such as monthly or day-of-week schedules may be appropriate
Will there be a need to create additional clinic specific frequencies? If yes, what will those be?
Prior to implementing CO in an outpatient location, the local medication administration policy and/or procedure will need to be reviewed and updated.
Early/late administrations - take into account when appointments are moved for administrative reasons or the patient cancels or is a no-show.
Medications active - What will be the process for calling providers and have them enter a new order, and so forth.
Administration frequencies – examples - Testosterone injections are done monthly or Hemodialysis where medications are often scheduled M-W-F or T-Th-Sa.
In BCMA, the clinic order date defaults to Today’s date regardless of whether or not there are active clinic orders to be administered today. Clinic Orders are based on dates active orders are due to be administered and is not so concerned with the time the medications are given. You can see active clinic orders that were due prior to today so that you can administer medications to a patient who arrives late for an appointment. You can also see active clinic orders that are due after today, so that you can administer medications to a patient who arrives early for an appointment.

19. What is the ‘Controlled Implementation’?
The Bar Code Resource Office will be responsible for providing implementation support to the facilities
Since BCRO staff were not directly involved in the testing and implementation of the patches, it is important for BCRO to work with the sites to see “first- hand” the steps and processes needed to get Clinic Orders up and running at a facility
The technical documentation released with the software does not address pitfalls and problems sites may run into during implementation
The team goal is to identify these pitfalls and problems, document them, and publish them as “Lessons Learned” that other sites can be aware of prior to their implementations
Since BCMA IMR 6 is only a patch (or set of patches) to an existing application, OIT does not provide direct support for implementation.

20. Controlled Implementation Status
Currently 11 sites participating
The controlled implementation is well under way and the team expects to complete the effort by the end of March When the effort has completed, local BCMA Coordinators will be made aware and may begin local implementation should the site choose to do so.

21. Additional Implementation Support
BCRO has created a SharePoint site to house implementation documents and lessons learned to support future implementations, and authored the “Operational Guidelines for Successful Implementation of Clinic Orders”. Education regarding all features of IMR 5 and IMR 6 has been presented on monthly Bar Code Medication Administration National Calls.
Additional information should be obtained from your local BCMA Coordinator. General information is available from the BCRO Website -
BCRO Clinic Orders SharePoint rs.aspx

22. Additional Implementation Support
VA Documentation library, which can be found at
Pharmacist training for completion of UD and IV orders can be found at the PBM education site on Moodle:
How do I get more help if needed?
If the issue is a purely technical issue (installation problems, error messages, etc.), you should enter a Remedy ticket (or have your local IT support person enter it for you if you do not have access to Remedy).
For any other issues, send a message to the Bar Code Resource Office (BCRO) and our office will review the issue and provide further assistance.

23. Questions?