1. Pharmacy Reengineering Update August 2011 Amy K. Colón, R.Ph. Clinical Analyst, PBM Michael J. Martinko, R.Ph. Clinical Analyst, PBM

2. PRE-MOCHA Medication Order Check Healthcare Application MOCHA is the first increment of Pharmacy Reengineering to be released to VAMCs Data comes from a commercial database, First DataBank (FDB), and from a VA Pharmacy Enterprise Customization System (PECS) – MOCHA 1 - Non-dosing, enhanced order checks – MOCHA 2 - Dosing checks

3. Pharmacy Reengineering Overview Outpatient Pharmacy MOCHA v2.0

4. Types of Dosage Information Max single dose – this is the individual dose amount, whether it is given once a day or 24 times a day Total daily dose – Dose x Frequency (per 24h) General Dosage Range – Is provided when there is a problem with the order and dosage checks cannot be performed

5. CPRS Dose Checks for an Outpatient Order 5

6. Outpatient Single Dose Warning Order details: Orderable Item: METFORMIN HCL TAB,ORAL Dosage Ordered: 3000 (MG) Dispense Units: 6 Noun: TABLETS Route: ORAL (BY MOUTH) Schedule: BID-WF Dose warning text: METFORMIN HCL 500MG TAB: Single dose amount of 3000 MILLIGRAMS exceeds the maximum single dose amount of 1000 MILLIGRAMS. 6

7. Dose Warning for Multi-Ingredient Drug Order details: Orderable Item: CARBIDOPA/LEVODOPA TAB,SA Dosage Ordered: 5 TABLETS Route: ORAL (BY MOUTH) Schedule: TID SIG: TAKE 5 TABLETS BY MOUTH THREE TIMES DAILY Dose warning text: CARBIDOPA 25/LEVODOPA 100MG TAB: Single dose form amount of 5 TABLET(S) exceeds the maximum single dose form amount of 2 TABLET(S). 7

8. Dose Checks Calculations Dependent on Body Surface Area or Weight Data Patient data: DOB: MAR 13,1944 (66) Ht(cm): 182.88 (12/04/2010) Wt(kg): 81.82 (12/04/2010) Dose warning text: ENOXAPARIN 40MG/0.4ML INJ SYRINGE 0.4ML: Single dose amount of 400 MILLIGRAMS exceeds the maximum single dose amount of 129 MILLIGRAMS. 8

9. Error Message for Dose Not Performed Order details: Orderable Item: METOPROLOL TAB Dosage Ordered: 500MG Route: ORAL (BY MOUTH) Schedule: Before sunrise SIG: TAKE TESTING DOSE TABLET(S) BY MOUTH TWICE A DAY Dose warning text: Dosing Checks could not be performed for Drug: METOPROLOL SUCCINATE 100MG SA TAB Reason(s): Invalid or Undefined Frequency General dosing range for METOPROLOL SUCCINATE 100MG SA TAB (ORAL): 12.5 MG/DAY to 400 MG/DAY 9

10. Factors Used to Derive a Recommended Dose Patient Age Height/Weight/BSA (when applicable) Dose Form Dose Unit Medication Route Frequency

11. Factor: Patient Age Recommended doses vary according to a patient’s age FDB stores dose data according to patient age Doses are not always established and available for a certain age, but this is more common with pediatric dosing than geriatric dosing

12. Factor: Patient Height, Weight, BSA Calculated doses for specific drugs are done when a weight or BSA value is relevant in the determination of an appropriate dose Some drug dosages are only weight/BSA dependent for specific age groups (i.e. weight may be relevant on a 90 year old, but not on a 50 year old

13. Factor: Dose Form Doses are stored differently based on the drug’s dosage form (i.e. oral, IV, transdermal) Some dosage forms are excluded from order checks (i.e. creams, ointments)

14. Factor: Dose Units The dose unit on an order must either match the unit that FDB has stored, or else be able to convert to that unit. If the dose unit does not match the FDB dose unit, then the order check will not occur and an error message will display FDB stores 2 different types of dose units in their dosing table – “Mass type”units and “Dose form” type units

15. Sub-factor: Mass Type Dose Units Generally used for single ingredient drugs that are administered via po, SC, or IM The most common type of dose unit (mg, gm, units) Possible types of FDB Dose Unit Conversions Metric conversions – wide range (i.e.. mcg to mg) Numeric conversions between standard units and metric units (i.e. Cm to In, Oz to Tsp, Tsp to mL, MMU to IU)

16. Sub-factor: Dose Form Type Dose Units Dose form type units – Used for non-po solids (patches, inhalers), multi-ingredient drugs FDB selects the type of dose units for an item Patch dose unit is “ 1 patch”, rather than 75mcg Inhaler dose units are variable and include inhalations, sprays, puffs, etc. Currently, they sometimes also include metric doses. On the contrary, drug that dosage forms of suppositories or packets, are dosed in “mass type” units

17. Possible Dose Units Conversions Metric conversions – wide range (i.e.. mcg to mg) Numeric conversions between standard units and metric units (i.e. Oz to Tsp, Tsp to mL, MMU to IU) Non-metric allowable conversions: “EA” is a flexible term relating to the dose form. If dose form is packet, then “EA” is considered to be 1 unit of that dose form (i.e. EA to Packet) FDB has a limited capability to convert from one dose form type unit to another dose-form type unit (spray=inhalation=puff)

18. Non-Standard Doses Fractional doses – no problem Free-text doses – different assumptions in CPRS vs. backdoor, because of the way that a dispense drug is selected in each package The pharmacy packages can perform some sophisticated auto-population logic for free- text doses (i.e. three and one-half tablets = 3.5 tablets). If a match cannot be determined, then no order check will be performed

19. Factor: Medication Route If a medication route is not accurately mapped, then a dose check will not occur FDB Doses are tied to specific routes (IV vs IM), error messages will display if an invalid route is selected Sometimes FDB is too limiting with its expected med route. Ie. Transdermal vs. Topical (Patches) Ie. Nebulization vs. Inhalation (Albuterol Solution)

20. Factor: Frequency Used to calculate a total daily dose If an order for a long acting injectable drug is written with a schedule that is too frequent, then the user will be warned of the frequency issue. Two new fields were created in file 51.1 EXCLUDE FROM ALL DOSING CHECKS: EXCLUDE FROM DAILY DOSE CHECK:

21. Dose Check Exclusions Supplies (bandages, syringes) Compounded items not matched to NDF Large volume IV solutions Items that don’t require a dose check, but that have a dosage form that does generate checks Drugs with excluded dosage forms (i.e.. creams, ointments) but, the exclusion can be overridden at the NDF level

22. MOCHA 2 Preparation Summary Review and update the following: Unmatched drug file entries DEA/special handling field Standard schedule file Med route mappings Orderable item medication route defaults for potentially problematic dosage forms Local possible doses Guidance lists for FDB exceptions will be provided…

23. Pharmacy Reengineering Overview Inpatient Pharmacy MOCHA v2.0

24. Inpatient Pharmacy Dosage Checks Same factors as Outpatient (backdoor VistA or CPRS order entry) – Patient age – Height/Weight/BSA (when applicable) – Dose form – Dose unit – Medication Route – Frequency – Duration – Rate

25. Inpatient Dosage Check Triggers (1) Note that the triggers for dosing are different than triggers for MOCHA v1.0 enhanced order checks Entering a new IV or Unit Dose medication order through pharmacy options Finishing a pending IV or Unit Dose medication order Renewing an IV or Unit Dose order Creating a new Unit Dose order when editing the orderable item (to a new orderable item) through pharmacy options When editing the IV additive fields (changing existing additive or adding new additive) for an IV order through pharmacy options When editing the IV solution fields (changing existing solution or adding a new solution) for an IV order through pharmacy options -This applies only to IV solutions marked as a PreMix. Entering a new Unit Dose medication order through pharmacy options using order sets

26. Inpatient Dosage Check Triggers (2) Editing the following for a Unit Dose order: – Dosage Ordered – Units per Dose (for Dispense Drug) – Med Route – Schedule Editing the following for an IV order – Infusion rate (only applies to IV types of ‘Admixture’, ‘Hyperal’, ‘Chemotherapy Admixture’, ‘Continuous Syringe’ or ‘Chemotherapy Continuous Syringe’) – Schedule (only applies to IV types of ‘Piggyback’, ‘Intermittent Syringe’, ‘Chemotherapy Piggyback’, or ‘Chemotherapy Intermittent Syringe’) – Med Route – Volume (does not apply to orders with IV types of ‘Piggyback’, ‘Intermittent Syringe’, ‘Chemotherapy Piggyback’, or ‘Chemotherapy Intermittent Syringe’ with IV Solution not marked as PreMix)

27. CPRS Dose Checks - Inpatient 27

28. CPRS Dose Checks - Inpatient Order #1 28

29. CPRS Dose Checks - Inpatient Order #1 29

30. CPRS Dose Checks - Inpatient Order #1 30

31. Inpatient Order #1 MJMTESTFRANK,SIX F Ward: C MEDIC PID: 666-66-6696 Room-Bed: 327-1 Ht(cm): 172.72 (03/24/10) DOB: 06/06/21 (90) Wt(kg): 60.45 (03/24/10) Sex: MALE Admitted: 03/24/10 Dx: ADVANCED PSYCHOSIS Last transferred: ******** - - - - - - - - - - - - - - - - - A C T I V E - - - - - - - - - - - - - - - - - 1 ASPIRIN TAB,EC C 06/28 07/28 A Give: 325MG PO QD-(EVERY DAY) - - - - - - - - - - - - - - - - P E N D I N G - - - - - - - - - - - - - - - - 2 LITHIUM CARBONATE CAP,ORAL ? ***** ***** P Give: 600MG PO BID-WF Enter ?? for more actions PI Patient Information SO Select Order PU Patient Record Update NO New Order Entry Select Action: Quit//

32. Inpatient Order #1 MJMTESTFRANK,SIX F Ward: C MEDIC PID: 666-66-6696 Room-Bed: 327-1 Ht(cm): 172.72 (03/24/10) DOB: 06/06/21 (90) Wt(kg): 60.45 (03/24/10) Sex: MALE Admitted: 03/24/10 *(1)Orderable Item: LITHIUM CARBONATE CAP,ORAL Instructions: 600MG *(2)Dosage Ordered: 600MG Duration: (3)Start: 07/13/11 14:22 *(4) Med Route: ORAL (BY MOUTH) REQUESTED START: 07/13/11 17:30 (5) Stop: 08/12/11 18:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: BID-WF (9) Admin Times: 0730-1730 *(10) Provider: MARTINKO,MICHAEL [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date LITHIUM CARBONATE 300MG CAP 2 (7)Self Med: NO Entry By: MARTINKO,MICHAEL Entry Date: 07/13/11 14:22

33. Inpatient Order #1 CPRS Order Checks: LITHIUM CARBONATE CAP,ORAL : Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Overriding Provider: MARTINKO,MICHAEL Overriding Reason: High Dose testing purposes MJM ORDER NOT VERIFIED Enter ?? for more actions BY Bypass FL Flag DC Discontinue FN Finish Select Item(s): Quit//

34. Inpatient Order #1 CPRS Order Checks: LITHIUM CARBONATE CAP,ORAL : Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Overriding Provider: MARTINKO,MICHAEL Overriding Reason: High Dose testing purposes MJM ORDER NOT VERIFIED Enter ?? for more actions BY Bypass FL Flag DC Discontinue FN Finish Select Item(s): Quit// FN Finish

35. Inpatient Order #1 CPRS Order Checks: LITHIUM CARBONATE CAP,ORAL : Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Overriding Provider: MARTINKO,MICHAEL Overriding Reason: High Dose testing purposes MJM ORDER NOT VERIFIED Enter ?? for more actions BY Bypass FL Flag DC Discontinue FN Finish Select Item(s): Quit// FN Finish Now Processing Enhanced Order Checks! Please wait... Press Return to continue...

36. Inpatient Order #1 CPRS Order Checks: LITHIUM CARBONATE CAP,ORAL : Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Overriding Provider: MARTINKO,MICHAEL Overriding Reason: High Dose testing purposes MJM ORDER NOT VERIFIED Enter ?? for more actions BY Bypass FL Flag DC Discontinue FN Finish Select Item(s): Quit// FN Finish Now Processing Enhanced Order Checks! Please wait... Press Return to continue... LITHIUM CARBONATE 300MG CAP: Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Do you want to Continue? NO//

37. Inpatient Order #1 CPRS Order Checks: LITHIUM CARBONATE CAP,ORAL : Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Overriding Provider: MARTINKO,MICHAEL Overriding Reason: High Dose testing purposes MJM ORDER NOT VERIFIED Enter ?? for more actions BY Bypass FL Flag DC Discontinue FN Finish Select Item(s): Quit// FN Finish Now Processing Enhanced Order Checks! Please wait... Press Return to continue... LITHIUM CARBONATE 300MG CAP: Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Do you want to Continue? NO// YES

38. Inpatient Order #1 Do you want to Continue? NO// YES Now creating Pharmacy Intervention For LITHIUM CARBONATE 300MG CAP PROVIDER:

39. Inpatient Order #1 Do you want to Continue? NO// YES Now creating Pharmacy Intervention For LITHIUM CARBONATE 300MG CAP PROVIDER: PROVIDER: MARTINKO,MICHAEL MJM 192 OI&T STAFF RECOMMENDATION: NO CHANGE See 'Pharmacy Intervention Menu' if you want to delete this intervention or for more options. Would you like to edit this intervention? N// YES PROVIDER: MARTINKO,MICHAEL// PHARMACIST: MARTINKO,MICHAEL// DRUG: LITHIUM CARBONATE 300MG CAP// INSTITUTED BY: PHARMACY// INTERVENTION: MAX SINGLE DOSE// <<<<<<<<<<<<<<<<<< DOSE// <<<<<

40. CPRS Dose Checks - Inpatient Order #2 40

41. CPRS Dose Checks - Inpatient Order #2 41

42. CPRS Dose Checks - Inpatient Order #2 42

43. Inpatient Order #2 MJMTESTFRANK,SIX F Ward: C MEDIC PID: 666-66-6696 Room-Bed: 327-1 Ht(cm): 172.72 (03/24/10) DOB: 06/06/21 (90) Wt(kg): 60.45 (03/24/10) Sex: MALE Admitted: 03/24/10 Dx: ADVANCED PSYCHOSIS Last transferred: ******** - - - - - - - - - - - - - - - - - A C T I V E - - - - - - - - - - - - - - - - - 1 ASPIRIN TAB,EC C 06/28 07/28 A Give: 325MG PO QD-(EVERY DAY) - - - - - - - - - - - - - - - - P E N D I N G - - - - - - - - - - - - - - - - 2 in NITROGLYCERIN 25MG/D5W 250 ML TITRATE ? ***** ***** P Enter ?? for more actions PI Patient Information SO Select Order PU Patient Record Update NO New Order Entry Select Action: Quit//

44. Inpatient Order #2 MJMTESTFRANK,SIX F Ward: C MEDIC PID: 666-66-6696 Room-Bed: 327-1 Ht(cm): 172.72 (03/24/10) DOB: 06/06/21 (90) Wt(kg): 60.45 (03/24/10) Sex: MALE Admitted: 03/24/10 *(1) Additives: Type: ADMIXTURE *(2) Solutions: NITROGLYCERIN 25MG/D5W 250 ML IV Limit: 3 days (4) Start: 07/14/11 10:42 *(3) Infusion Rate: TITRATE@1 *(5) Med Route: IV (6) Stop: 07/17/11 24:00 *(7) Schedule: Last Fill: ******** (8) Admin Times: Quantity: 0 *(9) Provider: MARTINKO,MICHAEL [es] Cum. Doses: (10) Other Print: (11) Remarks : IV Room: CHEYENNE RM#272 Entry By: MARTINKO,MICHAEL Entry Date: 07/14/11 10:42 DC Discontinue FL Flag ED Edit FN Finish Select Item(s): Next Screen//

45. Inpatient Order #2 CPRS Order Checks : Maximum Single Dose Check could not be done for Drug: NITROGLYCERIN 25MG/D5W INJ,SOLN 250 ML, please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL Enter ?? for more actions DC Discontinue FL Flag ED Edit FN Finish Select Item(s): Quit//

46. Inpatient Order #2 CPRS Order Checks : Maximum Single Dose Check could not be done for Drug: NITROGLYCERIN 25MG/D5W INJ,SOLN 250 ML, please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL Enter ?? for more actions DC Discontinue FL Flag ED Edit FN Finish Select Item(s): Quit// FN Finish IV TYPE: ADMIXTURE// Select ADDITIVE:

47. Inpatient Order #2 CPRS Order Checks : Maximum Single Dose Check could not be done for Drug: NITROGLYCERIN 25MG/D5W INJ,SOLN 250 ML, please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL Enter ?? for more actions DC Discontinue FL Flag ED Edit FN Finish Select Item(s): Quit// FN Finish IV TYPE: ADMIXTURE// Select ADDITIVE: Now Processing Enhanced Order Checks! Please wait... Press Return to continue...

48. Inpatient Order #2 CPRS Order Checks : Maximum Single Dose Check could not be done for Drug: NITROGLYCERIN 25MG/D5W INJ,SOLN 250 ML, please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL Enter ?? for more actions DC Discontinue FL Flag ED Edit FN Finish Select Item(s): Quit// FN Finish IV TYPE: ADMIXTURE// Select ADDITIVE: Now Processing Enhanced Order Checks! Please wait... Press Return to continue... Maximum Single Dose Check could not be performed for Drug: NITROGLYCERIN 25MG/D5W 250 ML Reason: Unable to convert rate. Press Return to continue...

49. CPRS Dose Checks - Inpatient Order #3 49

50. CPRS Dose Checks - Inpatient Order #3 50

51. Inpatient Order #3 CPRS Order Checks: Maximum Single Dose Check could not be done for Drug: ACETAMINOPHEN/CODEINE ELIXIR, please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL BY Bypass FL Flag DC Discontinue FN Finish Select Item(s): Quit//

52. Inpatient Order #3 CPRS Order Checks: Maximum Single Dose Check could not be done for Drug: ACETAMINOPHEN/CODEINE ELIXIR, please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL BY Bypass FL Flag DC Discontinue FN Finish Select Item(s): Quit// FN Finish PLEASE NOTE: This order must have at least one DISPENSE DRUG before it can be finished. CHOOSE FROM: 1. CODEINE 12/ACET 120MG/5ML ELIX 120ML 2. ACETAM/CODEINE 120/12MG 5ML SOLN (ML) Select DISPENSE DRUG(S) for this order:

53. Inpatient Order #3 CPRS Order Checks: Maximum Single Dose Check could not be done for Drug: ACETAMINOPHEN/CODEINE ELIXIR, please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL BY Bypass FL Flag DC Discontinue FN Finish Select Item(s): Quit// FN Finish PLEASE NOTE: This order must have at least one DISPENSE DRUG before it can be finished. CHOOSE FROM: 1. CODEINE 12/ACET 120MG/5ML ELIX 120ML 2. ACETAM/CODEINE 120/12MG 5ML SOLN (ML) Select DISPENSE DRUG(S) for this order: 1 CODEINE 12/ACET 120MG/5ML ELIX 120ML: Single dose form amount of 30 MILLILITERS exceeds the maximum single dose form amount of 25 MILLILITERS.

54. CPRS Dose Checks - Inpatient Order #4 54

55. CPRS Dose Checks - Inpatient Order #4 55

56. Inpatient Order #5 Select DRUG: SIMVASTAT SIMVASTATIN 20MG TAB CV350 VISN RESTR *** AUTOMED & SCRIPTPRO *** Now Processing Enhanced Order Checks! Please wait... Press Return to continue... Available Dosage(s) 1. 20MG 2. 40MG Select from list of Available Dosages or Enter Free Text Dose: 5 TABLETS <<<<<<<<<<<<

57. Inpatient Order #5 Select DRUG: SIMVASTAT SIMVASTATIN 20MG TAB CV350 VISN RESTR *** AUTOMED & SCRIPTPRO *** Now Processing Enhanced Order Checks! Please wait... Press Return to continue... Available Dosage(s) 1. 20MG 2. 40MG Select from list of Available Dosages or Enter Free Text Dose: 5 TABLETS Select Item(s): Next Screen// AC ACCEPT SIMVASTATIN 20MG TAB: Single dose form amount of 5 TABLET(S) exceeds the maximum single dose form amount of 2 TABLET(S). Do you want to Continue? NO//

58. CPRS Dose Checks - Inpatient Order #6 58

59. CPRS Dose Checks - Inpatient Order #6 59

60. CPRS Dose Checks - Inpatient Order #7 60

61. CPRS Dose Checks - Inpatient Order #7 61

62. MOCHA v2 Implementation So when will we be seeing this new software at the sites?

63. MOCHA v2 in the PRE Schedule

64. MOCHA v2 Drug Dosing Order Checks  MOCHA v2.0 Incremental Delivery  Increment A - Maximum Single Dose Check Warning  Increment B - Daily Dose Range Check Warning  Increment C - Daily Dose Range Check Complex  Increment D - TBD

65. MOCHA v2 Schedule Apr JunAugOctDecFebAprJunAug 2011 Oct iA - Max Single Dose Check Warning iB - Daily Dose Range Check Warning Simple iC- Daily Dose Range Check Warning Complex Nov 1 National Release March 31 National Release Aug 31 National Release 2012

66. ‘Frequently Asked Questions’ Document Based on PRE test site experiences… A Frequently Asked Questions (FAQ) document was prepared and disseminated prior to MOCHA v1.0 release. There are plans to create similar documents for MOCHA v2.0 releases.

67. Product Effectiveness Team PBM is working with the VHA Office of Health Information’s Product Effectiveness group to support the Pharmacy Reengineering (PRE) Medication Order Check Healthcare Application (MOCHA) v2.0. As part of this support, Product Effectiveness is conducting an operational readiness assessment to ensure each respective medical center is ready to receive MOCHA v2.0. The Product Effectiveness team will also be gathering lessons learned around these operational readiness assessments and MOCHA v2.0 activities in order to support future site deployments. 67

68. Roundtable Discussion Questions on presentation? Comments on MOCHA? Concerns about new FDB data? PECS data customization and requests Helpful hints and FAQ Thank You for your participation