1. Medication Management Enhancements Preparation Pharmacy Data Management (PDM) Urban Health Programs August 2010

2. Section Objectives Describe and manage potential Drug File problems in preparation for Outside Medications package Describe and manage set up of system for Prescription Auto-finish Demonstrate impact on medication reconciliation Describe and manage potential Drug File problems in preparation for ePrescribing

3. Outside Medications ONLY to document those medications neither prescribed nor filled at your facility –Includes OTCs, herbals, traditional medications, etc. NOT for medications your facility is prescribing that the patient will fill elsewhere

4. Outside Medications, cont. Drugs that will be used in the Outside Medications package must be marked as Non-VA –This will probably not be every drug –Consider adding common herbals and OTCs (can mark ONLY for Non-VA if desired) to the drug file See VA sample lists of items they entered Ensure appropriate doses are populated –Maximize use of Possible doses and minimize use of Local possible doses

5. Outside Medications, cont. Determine if your site will use the default name Outside Medications or create a custom title Determine if the available statements/ explanations will be sufficient: –Outside medication not recommended by provider –Outside medication recommended by provider –Patient buys OTC/Herbal product without medical advice –Medication prescribed by another provider

6. Outside Medications, cont. Consider how to handle known issue with medication data objects in health summaries and wellness handouts –TIU objects are NOT affected –Free text or missing doses causes outside med to not display in these –See EHR patch 6 notes and set up information for alternatives until fixed

7. Outside Medications, cont. How will you alert pharmacy if provider needs to enter an outside med that is not in the database? –Consider flagging an orderable item Outside Med Miscellaneous and assigning a pharmacist/pharmacy package coordinator to reconcile these (Appendix A in patch guide)

8. Clinical indicator Determine if site will turn on this option Behaves like the Lab clinical indicator –once you select a clinical indicator, it pre-populates the next order dialog For meds, however, once you pick an indication it is tied to that prescription –Pharmacy can't change it if its wrong –When copied, renewed, changed, etc. the clinical indicator follows For patients with chronic conditions in theory the provider only has to assign the indication when they start the patient on therapy If wrong, though, will be wrong until a new prescription is entered Many feel like the behavior should be different for the Pharmacy order (that EACH med order should require selection of the indication - no pre-population) Plan is to ask the field for input. Will be insurance/state specific whether the indication is mandatory

9. Auto-Finish Set Up Identify where prescriptions will print Obtain the correct Rx paper Find out your states requirement for printing an acceptable Rx format Review print formats in EHRv1.1 Patch 6 manual Figures 5-18 and 5-19 and determine if you will use Windows format (Multipage) or RPMS format (Single) –Single can be configured locally using RPMS print formats to meet state specific requirements for paper prescription

10. Auto-Finish Set Up, cont. EHRv1.1 Patch 6 guide section 5.0 If your pharmacy package is already set up, these should already be in place. Review and check for the highlighted fields in manual. –Review/Update Outpatient Site file (5.0) –Review/Update APSP Control Pharmacy File (5.1) –Review/Update address in the Institution file (5.2) –Review/Update addresses in the Location file (5.2)

11. Auto-Finish Set Up, cont. BEHORX Parameter set up (5.4) BEHORX PRINT SCRIPT –Setting this parameter to 1 (multipage) or 2 (single page) turns on print script functionality enabling the Prescription button when the PRINT button on the meds tab is used –ALL pending prescriptions will auto-finish if this print button is used –This is ONLY desirable at a site with NO in- house pharmacy

12. Auto-Finish Set Up, cont. If using the multipage Windows Format: BEHORX PRINT SCRIPT –Set at System or Division level to 2 Multipage BEHORX PRINT SCRIPT MAX –Set to max # scripts per page Controlled substances will always print on separate page from legend drugs BEHORX PRINT DEFAULT –Set at System, Division or Location –Set for Detailed list, Brief list, Prescription or Label

14. Auto-Finish Set Up, cont. If using the single page RPMS Format: BEHORX PRINT SCRIPT –Set at System or Division level to 2 Single page If you want to use custom print format, you set the following 4 parameters: BEHORX SCRIPT CUSTOM FORMAT BEHORX SCRIPT HEADER BEHORX SCRIPT FORMAT BEHORX SCRIPT FOOTER

15. Auto-Finish Set Up, cont. If using the single page RPMS Format: BEHORX SCRIPT CUSTOM FORMAT may be set for the system level --- Setting BEHORX SCRIPT CUSTOM FORMAT for System: TEST-HC.PRT.IHS.GOV --- Value: D FAXRX~APSPELRX// M code to generate a prescription format. Specifying a routine in this parameter will supercede the use of OE/RR Print Formats Use @ at the prompt to remove the M code and then set up the BEHORX SCRIPT HEADER, BEHORX SCRIPT FORMAT, BEHORX SCRIPT FOOTER with the OE/RR Print Formats you wish to use

16. Auto-Finish Set Up, cont. If using the single page RPMS Format: Now enter the RPMS header, format and footers print formats you want to use BEHORX SCRIPT HEADER Prescription Header ------ Setting BEHORX SCRIPT HEADER for System: YAKIMA- HC.PRT.IHS.GOV ------ PRESCRIPTION HEADER: OUTSIDE RX HEADER// BEHORX SCRIPT FORMAT Prescription Format ------ Setting BEHORX SCRIPT FORMAT for System: YAKIMA- HC.PRT.IHS.GOV ------ PRESCRIPTION FORMAT: PHARM WORK BODY// BEHORX SCRIPT FOOTER Prescription Footer ------ Setting BEHORX SCRIPT FOOTER for System: YAKIMA- HC.PRT.IHS.GOV ------ PRESCRIPTION FOOTER: OUTSIDE RX FOOTER//BEHORX SCRIPT

18. Auto-Finish Known Bugs Auto-finish of renewed medications does not auto-discontinue the original order Problem –Renewed medications do not discontinue the original order when auto-finished. Furthermore, the original order that was renewed cannot be discontinued from the EHR Medication or Order tab. Interim Solution –Discontinue is possible through the RPMS Pharmacy package. Alternately use the change function. *** Strongly consider delaying implementation of auto-finish until APSP 1009 is released which contains the fix for this problem. This patch will enter beta testing when EHRv1.1p6 is released and should be generally released in 2 months or less. *** Fix –APSP 1009 (anticipated release 2 months or less after EHRv1.1 Patch 6 release) will fix this bug.

19. Auto-Finish Known Bugs Dosages that are not selected from the dropdown in the order menu will fail to auto-finish Problem –Doses are tied to the dispense drug (not the orderable item) so the pharmacy package doesnt know what drug to tie the prescription to. It drops the dispense drug and cannot create a prescription. Interim Solution –Take the time to review your quick orders and ensure that nearly all the time, your providers can select from the dropdown for doses –Train users to look at the status of the medications and/or the notifications tab to verify the med order processed correctly Fix –Largely a configuration issue –Requested enhancements to add more real time feedback for providers to prevent the problem from happening –Ongoing analysis and feedback from early adopters will improve this for ePrescribing coming out later this year

20. Pharmacy Suite Lessons Learned Orderable Item –All drugs must be linked to an orderable item –Do not want individual orderable item for each dispense drug –Must be up-to-date on latest NDF patch and maintain Orderable Items when new NDF patches are released X in application packages –Every drug that will be utilized for Outside Medications or e-Rx needs to be flagged as Non VA Dispense Unit –Need to clearly define the unit (tab, cap, etc.) Dispense Unit NCPDP code –Need to review for missing data –Need to review current data and verify that drug is marked appropriately Dispense Units per Order Unit –Review for missing data –Review current data and verify accuracy

21. Pharmacy Suite Lessons Learned DEA, Special Handling –Review for missing data –Review current data and verify that drug is marked appropriately critical for narcotics Doses –Review for missing data –Review current data and verify that its appropriately dosed –Enough doses for provider to select from dropdown Drugs with symbols –Remove special characters from dispense drug names including: (* = +) MAY be OK to have if these items will NOT be used in ePrescribing and are matched to a separate orderable item, neither of which are marked as Non-VA VA Drug Class –Critical to order checks including allergy checking –Should be filled in if drug is matched to the National Drug File Ensure all drugs that can be match ARE matched Verify allergy system has been setup correctly