1. MOCHA Enhancements Looking Toward the Horizon Presented by Amy K. Colón, R.Ph. Michael J. Martinko, R.Ph. JUNE 27. 2012

2. VETERANS HEALTH ADMINISTRATION MOCHA 1.0 Enhancements Increment 1 Contains enhancements and fixes to issues that were reported through testing Pharmacy Reengineering (PRE) MEDICATION ORDER CHECK HEALTHCARE APPLICATION (MOCHA) 1.0. Will be released in a set of 5 patches PSJ*5*260, PSJ*5*268, PSO*7*390, PSS*1*164, and PSS*1*169 Work is being done concurrently with MOCHA V. 2.0 by a separate team of developers and test sites Release is expected to occur Summer 2012 No additional hardware is required Changes affect both the inpatient and outpatient pharmacy packages Increment 2 is currently in the midst of a 6 month development period 1

3. VETERANS HEALTH ADMINISTRATION MOCHA 1.0 Enhancements Increment 1 Displays additional fields to the Drug-Allergy order check warnings – Historical/Observed, Severity, Signs/Symptoms A Drug-Allergy Reaction exists for this medication and/or class! Prospective Drug: AMOXICILLIN 250MG CAP Causative Agent: PENICILLIN Historical/Observed: OBSERVED Severity: SEVERE Signs/Symptoms: ANAPHYLAXIS Drug Class: AM110 PENICILLIN-G RELATED PENICILLINS (LOCAL) Provider Override Reason: NOT READING ORDER CHECKS TODAY 2

4. VETERANS HEALTH ADMINISTRATION MOCHA 1.0 Enhancements Increment 1 Stores Drug –Allergy order check details with the applicable order Select Item(s): Next Screen// DA Display Drug Allergies Drug Allergy Occurrence Event for Rx#: 2055124 Causative Agent: ERYTHROMYCIN Historical/Observed: OBSERVED Severity: MODERATE Ingredient: ERYTHROMYCIN Signs/Symptoms: DIARRHEA, NAUSEA AND VOMITING Drug Class: AM200 ERYTHROMYCINS/MACROLIDES Provider Override Reason: OK TO GIVE, DISCUSSED WITH PATIENT 3

5. VETERANS HEALTH ADMINISTRATION MOCHA 1.0 Enhancements Increment 1 Adds a field on the patient medication profile header for display of CRCL and BSA, when available 4 Patient Information May 09, 2012@12:03:19 Page: 1 of 1 Name: Ward: PID: Room-Bed: Ht(cm): DOB: Wt(kg): Sex: Admitted: Dx: Heart Ache Last transferred: ******** CrCL: 117.6(est.) (CREAT:1.0mg/dL 2/26/12) BSA (m2): 2.04

6. VETERANS HEALTH ADMINISTRATION MOCHA 1.0 Enhancements Increment 1 Provides an option on the medication profile to allow a user to check for drug-drug interactions and allergies before the drug is entered for that patient Help Text: – “The following list of order checks is a comprehensive report of all Outpatient, Non-VA, and Clinic medication orders on this patient's profile. It may include orders that are local, remote, active, pending, recently discontinued, or expired. Please note that the sort order and format displayed in this report differs from the display of MOCHA 1.0 order checks which occurs during order processing.” 5

7. VETERANS HEALTH ADMINISTRATION MOCHA 1.0 Enhancements Increment 1 Sample of hidden option “DX Check Interactions” Drug: ERYTHROMYCIN STEARATE 250MG TAB 6 *** DRUG INTERACTION(S) *** ============================================================ *** Critical*** with WARFARIN (COUMADIN) NA 5MG (PEACH) TAB and ERYTHROMYCIN STEARATE 250MG TAB CLINICAL EFFECTS: Concurrent use of a macrolide antibiotic may result in increased effects of the anticoagulant with possible elevated INR and/or bleeding. =============================================================

8. VETERANS HEALTH ADMINISTRATION MOCHA 1.0 Enhancements Increment 1 Provides an option independent of a patient profile which checks drug interactions on 2 or more meds. The option is placed on each of these menus: – PDM Manager Menu, Outpatient Pharmacy Manager Menu, Pharmacist Menu, Unit Dose Medications Menu, and IV Menu Check Drug Interaction Drug 1: SELEGILINE HCL 5MG Drug 2: FLUOXETINE HCL 20MG CAP Drug 3: Now Processing Enhanced Order Checks! Please wait... *** DRUG INTERACTION(S) *** ***Critical*** with FLUOXETINE HCL 20MG CAP and SELEGILINE HCL 5MG CAP CLINICAL EFFECTS: Concurrent use... 7

9. VETERANS HEALTH ADMINISTRATION MOCHA 1.0 Enhancements Increment 1 Simplifies the prompts seen in Inpatient Pharmacy, when a therapeutic duplication message allows an existing order to be discontinued This patient is already receiving the following INPATIENT and/or OUTPATIENT order(s) for a drug in the same therapeutic class(es) as FLUOXETINE 20MG CAP: ClomiPRAMINE HCL CAP,ORAL C 05/09 06/08 A Give: 25MG PO QHS (BEDTIME) Class(es) Involved in Therapeutic Duplication(s): Antidepressants ====================================================================== Do you wish to continue with the current order? YES// ClomiPRAMINE HCL CAP,ORAL C 05/09 06/08 A Give: 25MG PO QHS (BEDTIME) Enter DC to discontinue the above order or press to continue: 8

10. VETERANS HEALTH ADMINISTRATION MOCHA 1.0 Enhancements Increment 1 Provides order checks against IMO Clinic Orders in the Inpatient pharmacy. This will include recently discontinued and/or expired clinic orders that have a stop date within the last 90 days. Unit Dose Example: ====================================================================== This patient is already receiving the following INPATIENT and/or OUTPATIENT order(s) for a drug in the same therapeutic class(es) as RISPERIDONE 50MG INJ SA 50MG/ML INJ : Clinic Order: RISPERIDONE 25MG INJ SA(DISCONTINUED) Schedule: Q30D Dosage: 25MG Start Date: JUN 7, 2012@13:00 Stop Date: JUN 15, 2012@15:22:27 9

11. VETERANS HEALTH ADMINISTRATION MOCHA 1.0 Enhancements Increment 1 Decouples the automated dispensing machine interface calls from the current Inpatient Medication (IP) package routines. – The beneficiaries of this enhancement will be the IRM departments of sites with interfaces for inpatient automated dispensing machines – These sites will not have to recreate local medications for numerous routines whenever PRE releases new versions of these routines Adds order checks to the verification process when verification is being done as a separate (re-entry of patient record) function from order acceptance Adds new report in the PEPS Services option to list the Vendor Interface unavailable times Provides the ability to print the ‘Check PEPS Services Setup’ messages 10

12. VETERANS HEALTH ADMINISTRATION Introduction to MOCHA 2.0 Functionality MOCHA V. 2.0 uses the same interface to First Databank (FDB) as MOCHA V. 1.0. MOCHA V. 2.0 implements the first increment of dosage checks Maximum Single Dose Checks for simple and complex orders are introduced for both Outpatient Pharmacy and Inpatient Medications applications. Text of Single Dose Warning Message: METFORMIN HCL 500MG TAB: Single dose amount of 3000 MILLIGRAMS exceeds the maximum single dose amount of 1000 MILLIGRAMS. 11

13. VETERANS HEALTH ADMINISTRATION MOCHA 2.0 Functionality In the pharmacy packages, when a Maximum Single Dose Order Check cannot be performed, then a detailed Order Level Error Messages (with reasons ) is provided Maximum Single Dose Check could not be performed for Drug: LOMUSTINE 100MG CAP Reason: Body surface area required 12

14. VETERANS HEALTH ADMINISTRATION MOCHA 2.0 Functionality In CPRS, when a Maximum Single Dose Order Check cannot be performed, then a generic Order Level notice is provided 13

15. VETERANS HEALTH ADMINISTRATION MOCHA 2.0 Functionality Creates a new Pharmacy Data Management (PDM) option called Lookup Dosing Check Info for Drug so that a user can view all data that can affect dosing checks for a drug. The screen shot is abbreviated to fit this slide. WARFARIN (COUMADIN) NA 1MG (PINK) TAB (GCNSEQNO: 014198) ========================================================================== VA PRODUCT NAME: WARFARIN NA 1MG TAB NDF DOSAGE FORM: TAB DEA, SPECIAL HDLG: 6PR VA DRUG CLASS: BL110 EXCLUDE DOSAGE FORM FROM DOSAGE CHECKS: NO OVERRIDE DOSAGE FORM DOSE CHECK EXCLUSION FOR VA PRODUCT: NO ***DRUG ELIGIBLE FOR DOSAGE CHECKS*** 14

16. VETERANS HEALTH ADMINISTRATION MOCHA 2.0 Functionality Lookup Dosing Check Info for Drug (Continued) Strength: 1 Unit: MG POSSIBLE DOSAGES: DISPENSE UNITS PER DOSE: 1 DOSE: 1MG PACKAGE: IO BCMA UNITS PER DOSE: FDB ROUTES: ORAL FDB DOSE UNITS: EA, MG BSA REQUIRED FOR DOSAGE CHECKS: NO WEIGHT REQUIRED FOR DOSAGE CHECKS: YES for Age in Days: 0-4744 (ORAL) 30-4744 NO for Age in Days: 23725-40150 (ORAL) 6570-23724 (ORAL) 4745-6569 (ORAL) 6570-23725 23726-40150 15

17. VETERANS HEALTH ADMINISTRATION How Dosage Checks are Excluded 16 Dosage Form Field – EXCLUDE FROM DOSAGE CHECKS VA Product Field – OVERRIDE DF DOSE CHK EXCLUSION Dosage Check Performed? (Y/N) YesNo Yes No Yes NoYesNo No dosing checks will be performed on supply items. No dosing checks will be performed on items with excluded dosage forms, unless an individual override is set at the product level Conversely, dosing checks will be performed on items with dosage forms that are marked for dosing checks, unless and individual exclusion is set at the product level

18. VETERANS HEALTH ADMINISTRATION MOCHA 2.0 Specifics Dosage checks occur after all enhanced order checks (clozapine, allergy, aminoglycosides, dangerous meds for patients >64, metformin lab results, drug level errors, local and remote drug interactions, local and remote duplicate therapy) If a dosage check cannot be done, then an order level error message occurs after all other enhanced order checks If a dosage is within range, then no dose message will appear The most recent values for height and weight found in the VITALS application are used to calculate the BSA in m 2 for a patient 17

19. VETERANS HEALTH ADMINISTRATION Data Required for Dose Checks to be Performed Patient Parameters: (Age, Weight and Body Surface Area (BSA in m 2 ) Drug Single Dose Amount Dose Unit (FDB Equivalent) Dose Rate Unit Dose Route (FDB Equivalent) Dose Type Frequency Duration Duration Rate 18

20. VETERANS HEALTH ADMINISTRATION How FDB Interprets Possible Doses Dosage Single Dose Dose Unit FDB Dose Unit Ordered Amount ===================================================== 325MG 325 MG MILLIGRAMS 0.5GM 0.5 GM GRAMS 1 TABLET 1 TABLET(S) TABLET(S) 20MEQ 20 MEQ MILLIEQUIVALENTS 10ML 10 ML MILLILITERS 19

21. VETERANS HEALTH ADMINISTRATION How FDB Interprets Doses for Solutions Marked as Premixes IV Type Volume Infusion Drug Single Dose FDB Dose Rate Unit Amount Unit ======================================================== Piggyback 20 ML 20 MILLILITERS Admixture 125 ML 125 MILLILITERS 20

22. VETERANS HEALTH ADMINISTRATION How FDB interprets Local Possible Doses for Single Ingredient Products 21

23. VETERANS HEALTH ADMINISTRATION Further Commentary on FDB Dose Units 22

24. VETERANS HEALTH ADMINISTRATION How FDB interprets Local Possible Doses for Multi Ingredient Products 23

25. VETERANS HEALTH ADMINISTRATION How FDB interprets Dosages for Continuous IVs 24

26. VETERANS HEALTH ADMINISTRATION MOCHA Credits by Lina Bertuzis 25 Portions of the previous MOCHA 2.0 slides were excerpted from documentation prepared by Lina Bertuzis. Lina’s PRE team work is largely done behind the scenes. She is extremely talented at defining pharmacy functionality and has written a requirements document that is greater than 700 pages in length. Many thanks to Lina!

27. VETERANS HEALTH ADMINISTRATION Comparing Enhanced & Dosing Order Checks Enhanced Order Checks (MOCHA v1.0) MOCHA v1.0 enhanced order checks consist of duplicate drug, therapeutic duplication, and drug interaction order checks based on FDB data. Usually occur after a dispense drug or orderable item have been identified. A message is displayed before the order checks occur: Now Processing Enhanced Order Checks! Please Wait... Order checks can be triggered by: – New order entry via backdoor pharmacy options – Finishing a pending order – Renewing an order – Copying an order – Editing an order which results in creation of a new order – Reinstating an order 26

28. VETERANS HEALTH ADMINISTRATION Comparing Enhanced & Dosing Order Checks Dosing Order Checks (MOCHA v2.0) MOCHA v2.0 dosing order checks will consist of a maximum single dose order check based on the patients demographics (age, weight, body surface area) pertinent to that medication. Dosing order checks will have some differences from the enhanced order checks. In CPRS will be displayed along with enhanced order checks. In backdoor pharmacy will occur AFTER the enhanced order checks, many times after the “accept” prompt. NO message is displayed before the dosing order checks occur. If no dose warning or error message is displayed (dosage entered is within normal limits), the order check is invisible to the user. Dosing checks have different triggers than the enhanced order checks. 27

29. VETERANS HEALTH ADMINISTRATION Comparing Enhanced & Dosing Order Checks Dosing Order Checks (MOCHA v2.0) Dosing order checks are generated by all of the actions that trigger the enhanced order checks, PLUS: 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) 28

30. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Dosing Order Checks (MOCHA v2.0) Dosing examples will be created utilizing a 75 year old female test patient with a height of 71 inches (180.3cm) a weight of 206.5 lb (93.7 kg) and a calculated body surface area (BSA) of 2.14 (using the system’s Dubois formula). 29

31. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks CPRS Dosing Order Checks (MOCHA v2.0) Example #1 30 Entering an inpatient medication order for lisinopril 80mg.

32. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks CPRS Dosing Order Checks (MOCHA v2.0) Example #1 31 A dosing warning message is displayed.

33. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks CPRS Dosing Order Checks (MOCHA v2.0) Example #2 32 Entering an inpatient medication order for lithium carbonate 600mg.

34. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks CPRS Dosing Order Checks (MOCHA v2.0) Example #2 33 A drug interaction warning message and a dosing warning message are displayed.

35. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks CPRS Dosing Order Checks (MOCHA v2.0) response required 34

36. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 35 XXXXXXXXXXXXXXXXXXXXX Ward: C MEDIC D PID: 999-99-9999 Room-Bed: XXXXX Ht(cm): 180.34 (00/00/00) DOB: 00/00/00 (75) Wt(kg): 93.86 (00/00/00) Sex: MALE Admitted: 00/00/00 Dx: PHLEBITIS/ STABLE Last transferred: ******** - - - - - - - - - - - - - - - - P E N D I N G - - - - - - - - - - - - - - - - 1 LISINOPRIL TAB ? ***** ***** P Give: 80MG PO QD-(EVERY DAY) 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//

37. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 36 *(1)Orderable Item: LISINOPRIL TAB Instructions: 80MG *(2)Dosage Ordered: 80MG Duration: (3)Start: 04/23/12 14:03 *(4) Med Route: ORAL (BY MOUTH) REQUESTED START: 04/24/12 09:00 (5) Stop: 05/23/12 18:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: QD-(EVERY DAY) (9) Admin Times: 09 *(10) Provider: XXXXXXXXXXXX [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date LISINOPRIL 40MG TAB 2 + Enter ?? for more actions BY Bypass FL Flag DC Discontinue FN Finish Select Item(s): Next Screen//

38. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 37 CPRS Order Checks: LISINOPRIL 40MG TAB: Single dose amount of 80 MILLIGRAMS exceeds the maximum single dose amount of 40 MILLIGRAMS. Overriding Provider: XXXXXXXXXXX Overriding Reason: these are the provider comments SIGNIFICANT drug-drug interaction: LISINOPRIL 40MG TAB and LITHIUM CARBONATE 300MG CAP [UNRELEASED] - Concurrent use of ACE inhibitors or ARBs may result in elevated lithium levels and lithium toxicity. - Monograph Available Overriding Provider: XXXXXXXXXXXX ORDER NOT VERIFIED Enter ?? for more actions BY Bypass FL Flag DC Discontinue FN Finish Select Item(s): Quit// FN Finish

39. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 38 Now Processing Enhanced Order Checks! Please wait... ================================================================================ This patient is receiving the following order(s) that have a SIGNIFICANT Drug Interaction with LISINOPRIL 40MG TAB: LITHIUM CARBONATE CAP,ORAL ? ***** ***** P Give: 600MG PO BID-WF *** REFER TO MONOGRAPH FOR SIGNIFICANT INTERACTION CLINICAL EFFECTS ================================================================================ Display Professional Interaction Monograph(s)? NO//

40. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 39 Now Processing Enhanced Order Checks! Please wait... ================================================================================ This patient is receiving the following order(s) that have a SIGNIFICANT Drug Interaction with LISINOPRIL 40MG TAB: LITHIUM CARBONATE CAP,ORAL ? ***** ***** P Give: 600MG PO BID-WF *** REFER TO MONOGRAPH FOR SIGNIFICANT INTERACTION CLINICAL EFFECTS ================================================================================ Display Professional Interaction Monograph(s)? NO// Do you want to Intervene with LISINOPRIL 40MG TAB? NO//

41. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 40 Now Processing Enhanced Order Checks! Please wait... ================================================================================ This patient is receiving the following order(s) that have a SIGNIFICANT Drug Interaction with LISINOPRIL 40MG TAB: LITHIUM CARBONATE CAP,ORAL ? ***** ***** P Give: 600MG PO BID-WF *** REFER TO MONOGRAPH FOR SIGNIFICANT INTERACTION CLINICAL EFFECTS ================================================================================ Display Professional Interaction Monograph(s)? NO// Do you want to Intervene with LISINOPRIL 40MG TAB? NO// NO

42. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 41 LISINOPRIL 40MG TAB: Single dose amount of 80 MILLIGRAMS exceeds the maximum single dose amount of 40 MILLIGRAMS. Do you want to Continue? NO//

43. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 42 LISINOPRIL 40MG TAB: Single dose amount of 80 MILLIGRAMS exceeds the maximum single dose amount of 40 MILLIGRAMS. Do you want to Continue? NO// YES Now creating Pharmacy Intervention For LISINOPRIL 40MG TAB PROVIDER:

44. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 43 LISINOPRIL 40MG TAB: Single dose amount of 80 MILLIGRAMS exceeds the maximum single dose amount of 40 MILLIGRAMS. Do you want to Continue? NO// YES Now creating Pharmacy Intervention For LISINOPRIL 40MG TAB PROVIDER: PROVIDER: XXXXXXXXXXXX RECOMMENDATION: 8 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// O

45. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 44 XXXXXXXXXXXXXXXXXXXXX Ward: C MEDIC D PID: 999-99-9999 Room-Bed: XXXXX Ht(cm): 180.34 (00/00/00) DOB: 00/00/00 (75) Wt(kg): 93.86 (00/00/00) *(1)Orderable Item: LISINOPRIL TAB Instructions: 80MG *(2)Dosage Ordered: 80MG Duration: (3)Start: 04/23/12 14:03 *(4) Med Route: ORAL (BY MOUTH) REQUESTED START: 04/24/12 09:00 (5) Stop: 05/23/12 18:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: QD-(EVERY DAY) (9) Admin Times: 09 *(10) Provider: XXXXXXXXXXXX [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date LISINOPRIL 40MG TAB 2 ED Edit AC ACCEPT Select Item(s): Next Screen//

46. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 45 *(1)Orderable Item: LISINOPRIL TAB Instructions: 80MG *(2)Dosage Ordered: 80MG Duration: (3)Start: 04/23/12 14:03 *(4) Med Route: ORAL (BY MOUTH) REQUESTED START: 04/24/12 09:00 (5) Stop: 05/23/12 18:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: QD-(EVERY DAY) (9) Admin Times: 09 *(10) Provider: XXXXXXXXXXXX [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date LISINOPRIL 40MG TAB 2 ED Edit AC ACCEPT Select Item(s): Next Screen // 8 Order Check Overrides/Interventions exist for this order. Display? (Y/N)? Y//

47. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 46 *(1)Orderable Item: LISINOPRIL TAB Instructions: 80MG *(2)Dosage Ordered: 80MG Duration: (3)Start: 04/23/12 14:03 *(4) Med Route: ORAL (BY MOUTH) REQUESTED START: 04/24/12 09:00 (5) Stop: 05/23/12 18:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: QD-(EVERY DAY) (9) Admin Times: 09 *(10) Provider: XXXXXXXXXXXX [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date LISINOPRIL 40MG TAB 2 ED Edit AC ACCEPT Select Item(s): Next Screen // 8 Order Check Overrides/Interventions exist for this order. Display? (Y/N)? Y// NO SCHEDULE: QD-(EVERY DAY)// Q4H 01-05-09-13-17-21 NOTE: This change in schedule also changes the ADMIN TIMES and SCHEDULE TYPE. Enter RETURN to continue or '^' to exit:

48. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 47 XXXXXXXXXXXXXXXXXXXXX Ward: C MEDIC D PID: 999-99-9999 Room-Bed: XXXXX Ht(cm): 180.34 (00/00/00) DOB: 00/00/00 (75) Wt(kg): 93.86 (00/00/00) *(1)Orderable Item: LISINOPRIL TAB Instructions: 80MG *(2)Dosage Ordered: 80MG Duration: (3)Start: 04/23/12 14:03 *(4) Med Route: ORAL (BY MOUTH) REQUESTED START: 04/24/12 09:00 (5) Stop: 05/23/12 18:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: Q4H (9) Admin Times: 01-05-09-13-17-21 *(10) Provider: XXXXXXXXXXXX [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date LISINOPRIL 40MG TAB 2 + This change will cause a new order to be created. ED Edit AC ACCEPT Select Item(s): Next Screen//

49. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 48 LISINOPRIL 40MG TAB: Single dose amount of 80 MILLIGRAMS exceeds the maximum single dose amount of 40 MILLIGRAMS. Do you want to Continue? NO//

50. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 49 LISINOPRIL 40MG TAB: Single dose amount of 80 MILLIGRAMS exceeds the maximum single dose amount of 40 MILLIGRAMS. Do you want to Continue? NO// YES Now creating Pharmacy Intervention For LISINOPRIL 40MG TAB PROVIDER:

51. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 50 LISINOPRIL 40MG TAB: Single dose amount of 80 MILLIGRAMS exceeds the maximum single dose amount of 40 MILLIGRAMS. Do you want to Continue? NO// YES Now creating Pharmacy Intervention For LISINOPRIL 40MG TAB PROVIDER: XXXXXXXXXXXX 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// O NATURE OF ORDER: SERVICE CORRECTION// S...discontinuing original order......creating new order...(you will now work on this new order).

52. VETERANS HEALTH ADMINISTRATION Examples of Dosing Order Checks Backdoor Pharmacy Dosing Order Checks (MOCHA v2.0) 51 XXXXXXXXXXXXXXXXXXXXX Ward: C MEDIC D PID: 999-99-9999 Room-Bed: XXXXX Ht(cm): 180.34 (00/00/00) DOB: 00/00/00 (75) Wt(kg): 93.86 (00/00/00) *(1)Orderable Item: LISINOPRIL TAB Instructions: *(2)Dosage Ordered: 80MG Duration: (3)Start: 04/23/12 14:03 *(4) Med Route: ORAL (BY MOUTH) (5) Stop: 05/23/12 18:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: Q4H (9) Admin Times: 01-05-09-13-17-21 *(10) Provider: XXXXXXXXXXXX [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date LISINOPRIL 40MG TAB 2 + Enter ?? for more actions HD (Hold) RN (Renew) FL Flag VF Verify Select Item(s): Next Screen//

53. VETERANS HEALTH ADMINISTRATION Key Ingredients for Successful Dosing Checks Staying away from dosing error messages Site file set up plays a critical role in successful dosing checks. – Dose units file, local possible doses, correct default medication routes, matched medication routes and drug file entries. See previous presentation “Site Readiness for MOCHA drug dose package” by Jim Hewins & Dionne Roney for file set up hints and FAQs A FAQ document is being prepared and will be circulated before implementation. 52

54. VETERANS HEALTH ADMINISTRATION MOCHA v2.0 Implementation Lessons Learned from the MOCHA v1.0 Roll Out MOCHA v2.0 dosing order checks will be “rolled out” instead of one set implementation date. System performance and network traffic predicted & monitored before release – Server monitoring software applications in place System performance monitored during rollout Functionality emergency back-out strategy Pre-implementation participation of the VHA Office of Health Information’s Product Effectiveness group – Interviews documenting MOCHA v1.0 implementation results – Creating a site operational readiness assessment – Available to support future site deployments 53

55. VETERANS HEALTH ADMINISTRATION Release Date & Implementation Schedule Dosing Order Checks (MOCHA v2.0) MOCHA v2.0 maximum single dose order check functionality – Training schedule – Release date – Implementation schedule 54

56. VETERANS HEALTH ADMINISTRATION Dosing Order Checks Beyond MOCHA v2.0 Future Proposed Dosing Releases MOCHA v2.0 MOCHA Dosing UFT-2 MOCHA Dosing UFT-3 MOCHA Dosing UFT-4 Maximum Single Dose Order Checks Maximum Daily Dose Range Order Checks (simple orders only) Maximum Daily Dose Range Order Checks (complex orders) Enhancements to previous increments 55

57. VETERANS HEALTH ADMINISTRATION MOCHA Enhancements Looking Toward the Horizon Questions or Comments? 56