112 Pharmacy Applications Enhancements Overview

1
112 Pharmacy Applications Enhancements Overview

• Jamie Crumley
• Jesse Staab
• Elaine White

2
Agenda

• Remote Data Interoperability (RDI)
• General Outpatient Pharmacy
• Support for EVC
• CPRS GUI v27 Pharmacy Changes
• Inpatient Medications Project Initiatives
• General BCMA
• Project Initiatives
• QA

3
Remote Data InteroperabilityOutpatient Pharmacy

• Elaine White
• Outpatient Pharmacy Developer

4
RDI - Background and Context

• The 2003 Congress mandated that the Department of
  Defense (DoD) and Department of Veterans Affairs
  (VA) exchange clinical data for shared patients.
  To accomplish this it was necessary to
• Centralize standardized VA patient record data
  into the Health Data Repository (HDR) for allergy
  and outpatient pharmacy (HDR project).
• Extend the existing local order checks to include
  all remote data now housed in the HDR (RDI
  project).
• Include DoD data stored in the HDR for order
  checks against VA med orders. (CHDR project)

5
How Does Remote Order Checking Work?

• When new order processed by provider or
  pharmacist, retrieves Outpatient Pharmacy and
  Allergy data from the Health Data Repository
  (HDR) for drug-drug and drug-allergy order
  checking.
• If HDR is not reachable, order checks made
  against local data only
• Remote Data Views (RDV) or VistaWeb can be used
  to see more details for medications or allergies.

6
CPRS Order Check Example
Order checking dialog with the name of the
originating site for the data displayed.
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Inpatient Medication Order Checks Before RDI

• Order Checks Performed Against
• IV and Unit Dose Orders
• Pending
• Active
• Non-Verified
• Renewed
• Outpatient
• Active

8
Inpatient Medications Remote Order Checks Process

• When HDR is available, order checks will be done
  as before and will also be performed against
  outpatient prescriptions and allergies from
• Other VAMCs
• DoD (after implementation of CHDR)
• Order checks against all Outpatient Orders
• Regardless of status (except DELETED (entered in
  error))
• Expired or discontinued prescriptions are
  included in order checks if expired or
  discontinued within the last 30 days.

9
Inpatient Medications New Display
10
Outpatient Pharmacy Remote Duplicate Drug Class

• Enter an order for CLOZAPINE (MYLAN) 100MG TAB
• Now doing remote order checks. Please wait...
  ? remote Rx data is retrieved
• 
  at this point if not already in cache
• --------------------------------------------------
  ----------------------------
• SAME CLASS OF DRUG IN REMOTE RX FOR
  CLOZAPINE (CLOZARIL) 100MG TAB
• gtgt CHEYENNE HDR SQA
• CLASS CN709
• Rx 787641
• Status ACTIVE
  Issued 08/01/07
• SIG TAKE ONE TABLET BY MOUTH
  EVERY DAY
• QTY 14
• Provider PROVIDER,REMOTE Refills
  remaining 0
• 
  Last filled on 08/01/07
• 
  Days Supply 14
• Press Return to continue...

11
Outpatient Pharmacy Local and remote drug-drug
interaction
gtgt EVANSVILLE OPC CRITICAL DRUG-DRUG
interaction CIMETIDINE WARFARIN Remote RX
46309524 Drug WARFARIN NA 10MG TAB
Status ACTIVE
Issued 09/17/06 SIG TAKE
ONE-HALF TABLET BY MOUTH EVERY EVENING
QTY 45 Provider OPPHYS,REMOTE

Refills remaining 3
Last filled on
09/17/06
Days Supply 90 Do you want
to Process medication CIMETIDINE 400MG TAB P//
ROCESS Enter your Current Signature Code
SIGNATURE VERIFIED Now creating Pharmacy
Intervention for CIMETIDINE 400MG TAB
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Backdoor Profiles Show Remote Allergies

• Example of Outpatient Pharmacy Patient
  Information Screen
• Prescription Mail Delivery Regular Mail
  
  
  
• Allergies No Allergy Assessment
  
  
• Remote ASPIRIN, PENICILLIN-G RELATED PENICILLINS
• Adverse Reactions
• 
  
• Enter ?? for more actions
  
• EA Enter/Edit Allergy/ADR Data PU
  Patient Record Update
• DD Detailed Allergy/ADR List EX
  Exit Patient List
• Select Action Quit// QUIT

13
Example Patient Prescription Processing HDR
Unreachable

• Select PATIENT NAME OPPATIENT,ONE OPPATIENT,ONE
  4-0-41 000006802
• YES SC VETERAN
• OPPATIENT,ONE (000-00-6802)
• No Allergy Assessment!
• Press Return to continue ltEntergt
• Remote data not available - Only local order
  checks processed.
• Press Return to continue...

14
RDI/CHDR - Things to Be Aware of

• Remote drug class order checks are performed when
  a new order is placed for a drug that is not
  matched to the NDF. (e.g. new or investigational
  drug). Future patches will also send/receive the
  drug class for these local drugs to the HDR. Then
  it will be possible for other VAMCs to do
  duplicate drug class checks against these
  non-standardized drugs.
• Non-VA meds are not transmitted to the HDR
• Some DoD data visible in VistaWeb (BHIE data) may
  not be used in order checks because it is not
  standardized and stored in the HDR
• There is no automated method for communicating
  with ordering providers at remote sites
• Discussions are underway to determine a solution
  to provide this sort of communication capability

15
General Outpatient Pharmacy

• Behind the scenes enhancements including VMP
  Outpatient PSIs
• Quarterly enhancements including development
  Outpatient Pharmacy PSIs

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Behind the scenes enhancements

• PSO7257 PSI-06-177 Med status of renewed
  past stop date
• Update nightly expire job to keep track of last
  time that it ran and run from that date
• In nightly expire and manual auto-expire, send
  expiration update to CPRS and the HDR if CPRS is
  not already expired, discontinued, or cancelled
• Post-install clean-up
• calculate and set expiration date, if missing
• Set active Rxs to expired if past expiration
  date
• Update CPRS and the HDR to expired if backdoor is
  already expired, but CPRS is still active

17
Outpatient Pharmacy Vista Maintenance Patches
with PSIs

• VMP Released patches
• PSO7255 PSI-06-086 Send additional drug
  names to OPAI vendors to match VAs local or CMOP
  labels
• PSO7259 PSI-06-046 - MailMan alert sent to
  members of PSO EXTERNAL DISPENSE ALERTS if OPAI
  releases fill that has been DCd
• PSO7265 PSI-07-029 Prevent incomplete
  non-VA med entries (caused by semicolon in dosage
  or schedule field)

18
Outpatient Pharmacy Vista Maintenance Patches
(continued)

• VMP Under development patches
• PSO7271 expiration date calculation Remedy
  ticket 193305. Related to PSI-07-099
• PSO7169PSS178 Remedy ticket 67766 -
  PSI-06-015 Add a space between dosage and units
  for Possible Dosages. Also, if the Possible
  Dosage is fractional, add a zero (e.g. 0.5 MG)
• PSO7248 PSI-05-119 Order check changes for
  DCd/expired Rxs.
• PSO7206 PSS1126 DEA codes

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Outpatient Pharmacy Vista Maintenance Patches
(continued)

• PSO7206 PSS1126 Remedy ticket 68224
• DEA codes not working correctly
• Example Drugs with 3A should be renewable and
  refillable (is, if its made 3AB)
• PSS1126 will identify any drug with 3A, 4A, or
  5A and send a message to holders of the PSNMGR
  key to re-evaluate how they are handling refills
  and renews on these particular drugs.
• Before installing PSO7206, be sure PSS1126 is
  installed and drugs requiring DEA code changes
  are verified

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Outpatient Pharmacy Vista Maintenance Patches
(continued)

• DEA, SPECIAL HDLG 4AB// ?
• ANSWER MUST BE 1-6 CHARACTERS IN LENGTH
• THE SPECIAL HANDLING CODE IS A 2 TO 6 POSTION
  FIELD. IF APPLICABLE,
• A SCHEDULE CODE MUST APPEAR IN THE FIRST
  POSITION. FOR EXAMPLE,
• A SCHEDULE 3 NARCOTIC WILL BE CODED '3A', A
  SCHEDULE 3 NON-NARCOTIC WILL BE
• CODED '3C' AND A SCHEDULE 2 DEPRESSANT WILL BE
  CODED '2L'.
• THE CODES ARE
• 0 MANUFACTURED IN PHARMACY
• 1 SCHEDULE 1 ITEM
• 2 SCHEDULE 2 ITEM
• 3 SCHEDULE 3 ITEM
• 4 SCHEDULE 4 ITEM
• 5 SCHEDULE 5 ITEM
• 6 LEGEND ITEM
• 9 OVER-THE-COUNTER
• L DEPRESSANTS AND STIMULANTS
• A NARCOTICS AND ALCOHOLS

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Outpatient Pharmacy Vista Maintenance Patches
(continued)

• DEA, SPECIAL HDLG 4AB// ??
• DEA CODE TABLE
• CODE ALLOW RENEWS ALLOW REFILLS
• 1 NO NO
  
• 2 NO NO
• 2A NO NO
• 3 YES YES
• 3A YES NO
• 3AB YES YES
• 4 YES YES
• 4A YES NO
• 4AB YES YES
• 5 YES YES
• 5A YES NO
• 5AB YES YES
• ADDING W TO A SCHED. 3,4,OR 5 CODE DISALLOWS
  RENEWS.
• ADDING F TO A SCHED. 3,4,OR 5 CODE DISALLOWS
  REFILLS.

22
Outpatient Pharmacy Quarterly Enhancements

• Work discussed/refined/prioritized with Pharmacy
  Workgroup
• PBM provides advisory when patches released
• Regular release schedule every quarter for
  identified tasks
• FY07 Q1 PSO7258
• FY07 Q2 PSO7200PSS1122
• FY07 Q3 PSO7268PSS1125PSA364PSD366
• FY07 Q4 PSO7264 PSX258

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FY07 Q2 PSO7200PSS1122

• Outpatient Pharmacy Automation Interface (OPAI)
• Send new warning label text from commercial data
  source to OPAI
• Bad Address Indicator info sent to OPAI
• Laser labels
• print last 4 digits of SSN instead of last 6
• Signature log enhancements

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FY07 Q2 PSO7200PSS1122 (continued)

• E3R 19820
• Add capability to tie a ScripTalk printer to a
  regular pharmacy printer to control where the
  ScripTalk label prints for multi-divisional sites
• Add new FINISH DATE/TIME field to the
  PRESCRIPTION file
• If patient has Bad Address Indicator or is set to
  Do Not Mail
• If routing is mail, do not print from suspense.
  Update activity log and send MailMan message
  first time

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FY07 Q3 - PSO7268

• Cache v5 locking
• Display patient eligibility before Rx patient
  status prompt
• SERVICE REJECT Nature of Order
• PSI-06-186 edit of dispense drug SIG
• PSI-06-184 No Allergy Assessment
• RDI - Local order checks only message at patient
  selection instead of each order

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FY07 Q3 - PSO7268 (continued)

• Example 1 - Patient Prescription Processing
• Select Action Next Screen// NO New Order
• Eligibility SERVICE CONNECTED 50 to 100
  SC 60
• RX PATIENT STATUS AUTH ABS -96// SC
• 1 SC
• 2 SC LESS THAN 50
• CHOOSE 1-2 1 SC

27
FY07 Q3 - PSO7268 (continued)

• Example 2 - Complete Orders from OERR
• Select By (PA/RT/PR/CL/E) PATIENT// ROUTE
• Route (W/M/C/E) WINDOW// MAIL
• OPPATIENT,ONE (666-00-0777)
• No Allergy Assessment!
• Eligibility NSC
• RX PATIENT STATUS SC// OPT NSC

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FY07 Q3 - PSO7268 (continued)

• Add SERVICE REJECT to current list of selections
  for Nature of Order prompt (requires provider
  signature)
• Nature of Order WRITTEN// ?
• Choose from
• 1 WRITTEN W
• 2 VERBAL V
• 3 TELEPHONED P
• 4 SERVICE CORRECTION S
• 5 POLICY I
• 6 DUPLICATE D
• 12 SERVICE REJECT R

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FY07 Q3 PSO7268 PSI-06-186

• Dispense drug edit prompt to edit SIG
• Remedy ticket 170298
• Restrict editing of dispense drug to same
  orderable item in Patient Prescription Processing
  option.
• Complete Orders from OERR - If dispense drug is
  changed, redisplay the SIG before prompting Do
  You want to Edit the SIG? YES//

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FY07 Q3 - PSO7268 PSI-06-184

• No Allergy Assessment
• Remedy ticket 169850
• When selecting patient, display No allergy
  assessment! after patient name and SSN.
• Display ltNO ALLERGY ASSESSMENTgt in reverse video
  on header line.
• Display No Allergy Assessment in allergy
  section of Patient Information screen.
• If user proceeds to place a new order, Prompt for
  intervention.

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FY07 Q3 - PSO7268 PSI-06-184(continued)

• Example 1
• Select PATIENT NAME OPPATIENT,ONE
  8-0-19 000000779 NO NSC V
• ETERAN OPPROVIDER,ONE
• OPPATIENT,ONE (000-00-0779)
• No Allergy Assessment!
• Press Return to continue
• Example 2
• Patient Information Jul 07,
  2007_at_075033 Page 1 of 1
• OPPATIENT,ONE
  ltNO ALLERGY ASSESSMENTgt
• PID 000-00-0779
  Ht(cm) _______ (______)
• DOB AUG 0,1919 (87)
  Wt(kg) _______ (______)

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FY07 Q3 - PSO7268 PSI-06-184 (continued)

• Example 3
• Prescription Mail Delivery DO NOT MAIL Expire
  Date DEC 16, 2007
• 
  
• Allergies No Allergy Assessment
  
• Adverse Reactions
  
• Example 4
• Now doing drug interaction and allergy checks.
  Please wait...
• There is no allergy assessment on file for this
  patient.
• You will be prompted to intervene if you continue
  with this prescription
• Do you want to Continue? N// YES
• Now creating Pharmacy Intervention
• for BACITRACIN OINTMENT 1OZ
• PROVIDER

33
FY07 Q4 PATCHES

• PSO7264PSX258
• Internet Refill Automation and Reporting
• Refill Processing separate CNH and
  Inpatient
• Mailouts FOREIGN ADDRESS
• Add indicator for Bad Address, Do Not Mail, or
  Foreign address to Log of Suspended Rx's by Day
  (this Division) option
• Queuing/Requeuing CMOP Rx

34
FY07 Q4 PSO7264 (continued)

• Internet Refill Automation and Reporting
• All entries in the PRESCRIPTION REFILL REQUEST
  file (52.43) will be processed and placed on
  suspense for the appropriate calculated fill date
  and a routing of Mail.
• Separate site parameters will process inpatient
  or CNH prescriptions (Yes or No.

35
FY07 Q4 PSO7264 (continued)

• Barcode Batch Prescription Entry - Example

36
FY07 Q4 PSO7264 (continued)

• For patients whose mailing address is foreign,
  FOREIGN ADDRESS will print on the
  mailing label and the rest of the address will
  not print.
• The Print from Suspense File option is modified
  to not send the Rx fill to the automated filling
  equipment or print a label if the address is
  foreign and the routing is not Window.

37
FY07 Q4 - PSX258

• Remove "B" (Bad Address Indicated) from status
  column when transmitted to CMOP.
• Keep BAI Rx's on CMOP suspense until corrected or
  pulled early. Send reject message only once.

38
Support for Enrollment Vista Changes (EVC)

• PSO7225
• New Environmental Indicator prompt for Shipboard
  Hazard and Defense Was treatment related to
  PROJ 112/Shad?
• Change prompt Is this Rx for treatment of
  Environmental Contaminants exposure? to Was
  treatment related to service in SW Asia?

39
Support for CPRS GUI v27 (Outpatient Pharmacy)

• PSO7225
• New sorting sequences for patient medication
  profile
• Pharmacist comments to CPRS when Rx is put on
  hold, DCd, or returned to stock (instead of per
  pharmacy request)
• If pending renewal DCd, check for an active Rx
  for same drug. If so, prompt There is an active
  Rx for this pending order, Discontinue both
  (Y/N)
• Change message Unable to locate order to
  Invalid Pharmacy order number if provider DCs
  from Orders Tab
• Add flagging for Outpatient Pharmacy pending
  orders

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Inpatient Medications

• Jamie Crumley
• Inpatient Medications Developer

41
GUI v27 Inpatient Changes

• Picture is worth a thousand words
• Most significant changes are in the IV ordering
  dialog

42
Continuous
43
Intermittent
44
Order Dialog
45
Inpatient Medications Project Initiatives

• WDDE
• IMR Phase III
• IMR Phase IV
• Clozapine for Inpatients

46
Project Disclaimer

• These are the items that were on the list when
  the presentation went to press.
• Prioritization and budgeting can change the list.
• Requirements gathering is under-way.

47
Interface Components

• ADT Interface (already exists)
• Admission
• Discharge
• Transfer
• Inpatient Medications Orders
• Order by order
• Upload a patients profile

48
Interface Components (cont.)

• Inventory Transactions
• Stock loading/unloading
• Dispense activities
• Waste, return, destroy
• Formulary updates
• As they occur
• Upload the entire formulary

49
Reports

• New menu option Maintenance Reports in
  Controlled Substances
• Automation Cabinet Reconciliation Report
• Unaccounted Wastage Report
• Delayed Wastage Report
• Vault Reconciliation Report
• Invoice Reconciliation Report
• Dispensing/Receiving Report (Modified)

50
IMR Phase III and IV

• Order check display information
• Add prompt for Pharmacy
• Send Provider and Pharmacist override comments to
  BCMA
• Order Validation
• Order should display properly in BCMA
• Schedules
• Drug file

51
Clozapine Enhancements

• Order checks
• Stop date calculations
• Renewal/edit restrictions
• Monthly roll-up

52
Inpatient MedicationsPatient Safety Issues

• Behavior of same stop date on all orders.
• Special Instructions/Other Print Info
• IV Pre-Mix Order Checks

53
PSI-06-043

• Problem with behavior of the WALL
• Several expiring orders were renewed
• New order created
• Pharmacy finished the new order first

54
PSI-03-041

• Expand Special Instructions and Other Print Info
  to unlimited
• Matches CPRS
• Label Print
• BCMA Changes required

55
PSI-06-012

• No order checks on IV Premix
• Challenging due to no method to identify
  significance of the solution

56
BCMA

• Jesse Staab
• BCMA Delphi Developer

57
BCMA Project Status

• BCMA CCOW (PSB313)
• BCMA MSF (Mng. Scanning Failures)
• BCMA 508 (BCMA 508 Compliance)
• BCMA IHS (Param. of BCMA PT ID)
• BCMA HSCIII (Reports 1 / Coversheet 2)
• BCMA HSC IV (Reports 2 w/Misc)

58
BCMA - CCOW

• Patch PSB3.013
• Released on 08/17/06
• Joined CPRS and other VistA applications in
  implementing patient context management
• PSI-06-145 which resulted in the decision to
  disable CCOW

59
BCMA - 508

• Patch PSB3.010
• Released 01/30/07
• Role-Based 508 evaluation of BCMA to ensure 508
  compliance where appropriate without impacting
  existing features.

60
BCMA - MSF

• Intended to help nurses report problems and aid
  facilities in resolving those problems
• Captures information about failures from the user
• Creates reports to help identify system issues
• Sends notifications of problems so that they can
  be resolved in a timely manner
• 4 Change requests submitted after last year, CCB
  approved 3, SRS updated and sent to unions for
  review
• See TSPR for the project reactivation date

61
BCMA - IHS

• 1st collaborative effort involving a GUI
  following the HSDD development lifecycle
• Intended to provide Indian Health Service (IHS)
  with functionality required use BCMA
• Uses IHS patient identifier for scanning and
  reporting
• Records Pain Scores and retrieve Vitals data
  from VMeasures
• Invisible to VA users
• See TSPR for project reactivation date

62
BCMA HSC III

• PSB3.032
• New and modified reports
• Coversheet reports
• IV Bag status
• Med Therapy (no administration needed)
• Reports can be queued via GUI
• Reports can be directly printed without preview
• Inactive wards are now filtered out by default
• Reports can be printed by specific patients on a
  ward
• Coversheet changes
• New icons (flag / stat / no action IV)
• Reorder columns, added order start date
• Tools Menu

63
BCMA HSC III PSI Related Modifications

• PSI-06-019 Patch order is discontinued or
  expired
• PSI-06-056 Preventing extra PRN doses
• PSI-06-014 Display full med route on VDL
• PSI-06-029 Missed Med Report timeout
• PSI-06-160 Limitation of row height on the VDL
  not being able to display all additives
  and solutions

64
BCMA HSC IIIMedication Therapy Report
65
BCMA HSC IIIMedication Therapy Report
66
BCMA HSC IIIIV bag status report
67
BCMA HSC IIIMedication Overview Report
68
BCMA HSC IIIOther Enhancements
69
BCMA HSC IIICover Sheet Enhancements

• Flagged order
• Stat order
• IV with no action taken

70
BCMA HSC III PSI-06-019
71
BCMA HSC III PSI-06-056
72
BCMA HSC III PSI-06-014 PSI-06-160
73
Clinic Orders

• Expands IMO functionality
• Not just for medications
• Enabling BCMA for Clinic Orders
• User interface changes to cleanly display and
  administer all orders
• Report changes to accurately identify and report
  administration information
• No-count wards not required

74
Double-Scan Issue

• BCMA Double-Scan new service request
• http//vista.med.va.gov/pas/ViewTrackingRecord.asp
  ?RequestID20070205
• Patient Safety Alert AL07-09

75
BCMA HSC IV

• Reports Re-Design 2
• Query Builder (custom reporting tool to select
  and sort data to print)
• Export feature to allow data to be exported from
  BCMA into various formats.
• Cover Sheet Enhancements
• Displaying the patient photograph to provide a
  form of secondary form of identification (note
  Imaging pre-req)
• Displaying patient DNR
• Displaying override comments

76
Questions?