1. Quick Orders and Order Menus

2. Orders Package The Orders package in RPMS provides a number of functions including: –Ability for users to enter, process, and discontinue electronic orders –Control who can act on orders with OR keys –Order checking –Delayed release of orders (inpatient using ADT) –Auto-discontinue orders (inpatient using ADT

3. Order Keys ORES – Assigned to providers who are authorized to independently write orders (typically physicians, nurse practitioners, physician assistants, podiatrists etc.). ORELSE – Assigned to users who are authorized to take and release verbal and telephone orders from providers who hold the ORES key, or who can enter policy orders (typically registered nurses, pharmacists).

4. OREMAS – Assigned to users who transcribe written orders into RPMS-EHR (typically only given to inpatient ward clerks). A user must hold only one order key or they will not be able to process any orders at all You can check to see if users hold multiple order keys with this menu: ORD > KEY > CHK Order Keys (cont.)

5. RPMS-EHR provides management of orders on the Orders Tab. The Orders Tab provides the ability to add, change, discontinue, and print. The Orders Tab allows EHR users to sort by column headings or customize the view of orders displayed. Order Management

6. Orders Tab

7. Medication Order Management It is recommended that all prescriptions be entered and managed on the Meds tab. The Meds tab provides a better overview of medications. The Meds tab provides easy access to the change, renew, refill, or discontinue actions for effective management of medications.

8. Medications Tab Note that not all levels are available for all parameters, but only those that make sense for that particular item.

9. Order Entry New orders are entered into RPMS-EHR via order menus. Order menus are organized groupings of quick orders and other menus. Order menus can be customized to meet local needs. Usually, order menus are created with groups of similar quick orders.

10. Order Menus Order menus should be designed by target end users, not by package informaticists (i.e., by physicians who will enter orders, not by pharmacists, laboratory information specialists, or radiology technologists). Once designed, order menus are built by package informaticists.

11. Order Menu

12. Quick Orders Quick Orders are electronic orders with ALL the data elements correctly preconfigured. Order menus are organized groupings of quick orders to make provider order entry more convenient and efficient.

13. Quick Orders Well designed order menus and quick orders provide the clinician with proper choices and helpful information, and promote entry of correctly formed electronic orders. Incorrectly entered electronic orders require additional work to clarify and correct and may delay or impede patient care.

14. Quick Order Dialog

15. Quick Order Creation While order menus should be designed by end user clinicians, the quick orders and order menus should be built by package informaticists to ensure that they are correctly constructed.

16. Quick Order Creation Quick Orders should not be built by CACs or Informaticists from another discipline who do not have the knowledge background for that package. In other words, only a pharmacy informaticist should build pharmacy quick orders, and only a laboratory informaticist should build laboratory quick orders, and so on.

17. Orderable Item Creation Prior to creating a quick order, the orderable item to be used must already exist. The process of adding a new drug to the drug file creates a new orderable item. The process of adding a new test in the laboratory file creates a new orderable item. The process of constructing a new exam in the radiology-nuclear medicine procedure file creates a new orderable item.

18. Orderable Item Creation If the order is for nursing or patient care, then the orderable item must be created manually using this menu: OIC Create/Modify Orderable Items

19. Create a Nursing Orderable Item

20. Recommendation is to create nursing orderable items in ALL CAPS. Keep nursing orderable items general so they can be re- used in multiple quick orders (e.g. WOUND CARE vs. TELFA 4x4)

21. RPMS Namespacing Software packages in RPMS have designated namespaces It is recommended that quick orders for RPMS-EHR utilize the recognized namespaces Use of namespaces aids in the future management of these quick orders by local informaticists and by area and national helpdesk staff.

22. Naming Convention

23. Conventions for quick orders and menus: –Namespace + Z = Quick Order –Namespace + ZM = Menu –Namespace + ZSET = Order Set –Use IP to differentiate Inpatient Orders (esp. Lab and Nursing)

24. Naming Convention Additional suggested namespace: PSJIVZ for IV piggybacks to differentiate from oral unit dose and IV fluids

25. Naming Convention Examples: ORZ WOUND CARE [Outpatient Nursing] PSOZ ATENOLOL 25MG DAILY [Outpatient Med] PSJZ CARVEDILOL 6.25MG BID [Inpatient Med] LRZ HGBA1C [Laboratory] RAZ FOREARM 2 VIEWS [Radiology] ORZ IP COLD PACKS [Inpatient Nursing] PSOZM DIABETES MEDS [Outpatient Pharmacy Menu] LRZMER LABS[Laboratory Menu] RAZMRADIOLOGY[Radiology Menu] ORZMIP RESPIRATORY[Inpatient Nursing Menu] ORZSET COLONOSCOPY PREP [Order Set]

26. Quick Order Construction From the standard RPMS-EHR Configuration Master Menu: ORD > MNU > QOC

27. Quick Order Types Activity Consult Imaging Inpatient Medications IV Medications Laboratory Nursing Outpatient Medications

28. Quick Order Types There appear to be other Order Types available of: Diet and Vital/Measurements, but these should not be used. The Dietetics Package is not an IHS supported package. These Vital/Measurements orders point to the VA Vitals package and not the IHS Measurements File.

29. Creating Quick Orders

30. Laboratory Quick Orders Select QUICK ORDER NAME: LRZ CALCIUM TODAY Are you adding 'LRZ CALCIUM TODAY' as a new ORDER DIALOG? No// Y (Yes) TYPE OF QUICK ORDER: LAB LABORATORY

31. TYPE OF QUICK ORDER: ? Choose from: ACTIVITY ALLERGIES CONDITION CONSULTS DIAGNOSIS DIET ADDITIONAL ORDERS DIET ORDERS EARLY/LATE TRAYS GENERAL RADIOLOGY IMAGING INPATIENT MEDICATIONS IV MEDICATIONS LABORATORY NURSING OUTPATIENT MEDICATIONS PRECAUTIONS PROCEDURES SUPPLIES/DEVICES TUBEFEEDINGS UNIT DOSE MEDICATIONS VITALS/MEASUREMENTS

32. Laboratory Quick Orders Select QUICK ORDER NAME: LRZ CALCIUM TODAY Are you adding 'LRZ CALCIUM TODAY' as a new ORDER DIALOG? No// Y (Yes) TYPE OF QUICK ORDER: LAB LABORATORY NAME: LRZ CALCIUM TODAY// DISPLAY TEXT: Calcium Today VERIFY ORDER: y YES DESCRIPTION: Calcium level done for outpatients for today ENTRY ACTION: Lab Test: CALCIUM Collected By: SP Send patient to lab SP Send patient to lab WC Ward collect & deliver LC Lab blood team Collection Sample: BLOOD// Collection Date/Time: TODAY (MAR 23, 2004) How often: ONCE ONCE

33. Lab Schedule ONCE must be setup as a laboratory administration schedule. Lab menu option is LRZM LAB TESTS Select ADMINISTRATION SCHEDULE: ONCE ONE-TIME NAME: ONCE// TYPE OF SCHEDULE: ONE-TIME//

34. Review Order ------------------------------------------------------------- Lab Test: CALCIUM Collected By: Send patient to lab Collection Sample: BLOOD Specimen: BLOOD Collection Date/Time: TODAY How often: ONCE ------------------------------------------------------------- (P)lace, (E)dit, or (C)ancel this quick order? PLACE// Auto-accept this order? NO//

35. Quick Orders - Radiology Select QUICK ORDER NAME: RAZ ELBOW XRAY Are you adding 'RAZ ELBOW XRAY' as a new ORDER DIALOG? No// Y (Yes) TYPE OF QUICK ORDER: IMAGING NAME: RAZ ELBOW XRAY// DISPLAY TEXT: Elbow Xray VERIFY ORDER: Y DESCRIPTION: No existing text Edit? NO// Select one of the following imaging types: ANGIO/NEURO/INTERVENTIONAL GENERAL RADIOLOGY ULTRASOUND Select IMAGING TYPE: general RADIOLOGY

36. Quick Orders - Radiology Radiology Procedure: 14 ELBOW 2 VIEWS Procedure Modifier: History and Reason for Exam: No existing text Edit? No// Category: OUTPATIENT Is this patient scheduled for pre-op? NO// Date Desired: TODAY// Mode of Transport: AMBULATORY Is patient on isolation procedures? Urgency: ROUTINE//

37. Review Order ---------------------------------------------------------- Radiology Procedure: ELBOW 2 VIEWS Category: OUTPATIENT Date Desired: TODAY Mode of Transport: AMBULATORY Urgency: ROUTINE Submit request to: X-RAY ---------------------------------------------------------- (P)lace, (E)dit, or (C)ancel this quick order? PLACE// Auto-accept this order? NO//

38. Quick Order – Outpt Meds NAME: PSOZ AMOXICILLIN 500MG BID 7D Replace DISPLAY TEXT: Amoxicillin 500mg bid 7 days Replace VERIFY ORDER: YES// DESCRIPTION: No existing text Edit? NO// Y Amoxicillin 500mg BID outpatient for 7 days ENTRY ACTION: Medication: AMOXICILLIN CAP,ORAL // Complex dose? NO// Dose: 500MG// The dose should have been set up by pharmacy Route: ORAL// Setup by pharmacy

39. Quick Order – Outpt Meds Days Supply: 7// Quantity (CAP): 14// Refills (0-11): 0// Schedule: BID// Pick Up: WINDOW// Priority: ROUTINE// Comments: No existing text Edit? No// (No) Select ADMINISTRATION SCHEDULE:

40. Review Order ---------------------------------------------------------- Medication: AMOXICILLIN CAP,ORAL 500MG Instructions: 500MG ORAL BID Days Supply: 7 Quantity (CAP): 14 Refills (0-11): 0 Pick Up: WINDOW Priority: ROUTINE ---------------------------------------------------------- (P)lace, (E)dit, or (C)ancel this quick order? PLACE// P Place to save quick order

41. Special Med Quick Orders Clinic Meds (In-House Meds) –Pick up is ADMINISTERED IN CLINIC –Status is ASAP or STAT, not DONE Prescriptions for outside pharmacies –Make orders just like meds on formulary. (If med is not in Drug File, then use a med called OUTSIDE RX, until Pharmacy adds to Drug File). Provider fills in data, and it is printed as an RX Prescriptions received from outside providers –Must be entered into RPMS. User may have to edit Drug File

42. Review Order ---------------------------------------------------- Medication: CEFTRIAXONE INJ,SOLN 1GM/VIAL Instructions: 1 GRAM 1GM/VIAL INTRAMUSCULAR Q12H Days Supply: 1 Quantity (VL): 1 Pick Up: ADMINISTERED IN CLINIC Priority: STAT ---------------------------------------------------- (P)lace, (E)dit, or (C)ancel this quick order? PLACE//

43. Quick Orders - Nursing TYPE OF QUICK ORDER: NURSING NAME: ORZ FOLEY CATHETER// DISPLAY TEXT: Foley Catheter to Drainage VERIFY ORDER: DESCRIPTION: No existing text Edit? NO// ENTRY ACTION: Patient Care: CATHETER Instructions: Empty Foley Catheter to drainage bag q shift Start Date/Time: NOW// Stop Date/Time: N+7

44. Review Order ----------------------------------------------------------------- Patient Care: FOLEY CATHETER Instructions: Empty Foley Catheter to drainage bag q shift Start Date/Time: NOW Stop Date/Time: 7 DAYS FROM NOW ----------------------------------------------------------------- (P)lace, (E)dit, or (C)ancel this quick order? PLACE//

45. Quick Orders - Consults Select QUICK ORDER NAME: GMRCZ PHYSICAL THERAPY NAME: GMRCZ PHYSICAL THERAPY DISPLAY TEXT: Physical Therapy Consult VERIFY ORDER: YES// DESCRIPTION: Quick order for physical therapy consult Edit? NO// ENTRY ACTION: Consult to Service/Specialty: PHYSICAL THERAPY// Consult Type: Reason for Request: No existing text Edit? No// N (No) Category: OUTPATIENT// Urgency: ROUTINE// Place of Consultation: Consultant's Choice// Attention: Provisional Diagnosis:

46. Review Order ------------------------------------------------------------ Consult to Service/Specialty: PHYSICAL THERAPY Category: OUTPATIENT Urgency: ROUTINE Place of Consultation: Consultant's Choice ------------------------------------------------------------ (P)lace, (E)dit, or (C)ancel this quick order? PLACE//

47. Order Sets Select ORDER SET NAME: LRZ DIABETIC TESTS ORDER SET NAME: LRZ DIABETIC TESTS ORDER SET Replace DISPLAY TEXT: Diabetic Yearly tests Replace DESCRIPTION: No existing text Edit? NO// ENTRY ACTION: EXIT ACTION: ORDER SET COMPONENTS: 1 LRZ HGBA1C OUTPT 2 LRZ LIPID PANEL 3 LRZ TSH OUTPT Select COMPONENT SEQUENCE#:

48. Quick Order Restrictions

49. Problem: Ordering a Med to be given in Clinic If only a Pharmacy Order is used, how is Nursing notified to give the med? If only Nursing Order is used, Medication is not processed in Pharmacy package

50. Pharmacy Order (“real” Medication) Priority: ASAP, or STAT Pickup: Clinic Med Tab: Yes Health Summary: Yes Allergy Check: Yes Drug interaction: Yes Nursing Order (text only) Allergy Check: No Drug interaction: No Med Tab: No Health Summary: No Generic Order (text only) Free text entry of order Allergy Check: No Drug interaction: No Med Tab: No Health Summary: No Comparison of Order Types used to order a Medication Order checking: No Verification: No

51. Solution: Order Set containing both Pharmacy and Nursing Orders NURSING QUICK ORDER: ORZ ALBUTEROL NEB RX Give an Albuterol Neb Treatment in Room #. Use 0.25ml/3ml Saline PHARMACY QUICK ORDER: PSOZ ALBUTEROLNEB RX TWO TYPE ORDERS IN ONE SET: Nursing orders: one and Pharmacy Orders: one Med Tab: Yes Health Summary: Yes Allergy Check: Yes Drug interaction: Yes Bill through POS or J-Codes

52. Hands-on Exercise 1.Create nursing orderable item and nursing quick order for ??? 2. Create laboratory quick order for ??? 3. Create outpatient med quick order for ??? 4. Create radiology quick order for ???

53. Questions and Discussion