E-Prescribing Drug File Optimization Overview

1. E-Prescribing Drug File Optimization Overview

2. E-Prescribing Drug Name • Dispense Drug Name transmits to the outside/community pharmacy • Sites need to setup standard drug file names. • All sites should avoid special characters (a list will be provided) in drug file names. ! ” # $ % & ’ ( ) * + , - . / : ; = ? @ [ \ ] ^ _ ’ { | } ~ Generic Name + Dose + Dosage Form

3. E-Prescribing Drug Name Cont… Which Drug Name is Appropriate?

4. E-Prescribing Drug Name Cont… • It is important to check for any existing entries first BEFORE entering a new entry. • Re-activating and updating the existing entry is usually preferred over simply adding more and more entries. • Entries can NOT be deleted from the drug file, but can be inactivated. • NEVER change one drug to another drug when updating your drug file dispense names.

5. Drug Number DRUG NUMBER: 86030 • This number is automatically assigned by the system (fileman) when entering a new drug for the first time. • Among other things, it is needed for Pyxis/Omnicell Interface setup. • Will be included in E-Rx drug reports to quickly identify drugs that need modifications

6. E-PrescribingDrug VA Classification • The VA Classification field controls the EHR medication order checks. • Includes order checks for allergies & drug-drug interactions. • Automatically assigned when matched to the NDF • Those that don’t auto-populate will need to be manually entered until drug is entered into NDF AM110 PENICILLIN-G RELATED PENICILLINS AM115 CEPHALOSPORIN 1ST GENERATION AM300 AMINOGLYCOSIDES BL110 ANTICOAGULANTS CN100 ANALGESICS CN101 OPIOID ANALGESICS CN400 ANTICONVULSANTS CN600 ANTIDEPRESSANTS CN601 TRICYCLIC ANTIDEPRESSANTS CN700 ANTIPSYCHOTICS CN800 CNS STIMULANTS CV100 BETA BLOCKERS/RELATED CV150 ALPHA BLOCKERS/RELATED CV200 CALCIUM CHANNEL BLOCKERS CV701 THIAZIDES/RELATED DIURETICS CV800 ACE INHIBITORS

7. E-PrescribingDEA, Special HDLG 0 MANUFACTURED IN PHARMACY 1 SCHEDULE 1 ITEM 2 SCHEDULE 2 ITEM Will NOT be refillable 3 SCHEDULE 3 ITEM 4 SCHEDULE 4 ITEM 5 SCHEDULE 5 ITEM 6 LEGEND ITEM i.e. a prescription ONLY item 9 OVER-THE-COUNTER L DEPRESSANTS AND STIMULANTS A NARCOTICS AND ALCOHOLS P DATED DRUGS I INVESTIGATIONAL DRUGS M BULK COMPOUND ITEMS C CONTROLLED SUBSTANCES - NON NARCOTIC R RESTRICTED ITEMS S SUPPLY ITEMS B ALLOW REFILL (SCH. 3, 4, 5 NARCOTICS ONLY) W NOT RENEWABLE F NON REFILLABLE • It is VERY important to have the correct codes in this field. • Wrong codes can create invalid prescriptions, affect billing (POS), and impact e-prescribing in the future. • Remember that the report logic for Meaningful Use (MU) will also use this field to EXCLUDE control substances from the final number of prescriptions used to calculate the electronic order entry requirement of 40%. • You can use combinations of codes in order to complete this requirement or you can use a single entry to complete it. • Some fields Impact EHR and the functionality of renewing/refilling

8. POP Quiz - Question Complete Order Units for following Drugs:

9. POP Quiz - Answer Complete Order Units for following Drugs:

10. LOCAL NON-FORMULARY & FORMULARY ALTERNATIVE • Used to designate a drug as non-formulary at the local site. • If utilized, pop-ups will display to provider within EHR. • It is recommended if you mark an entry as non-formulary, then also add an entry under formulary alternative.

11. Synonym • Remember there are multiple Synonym Fields in Drug File • Under drug Enter/Edit this particular “Synonym” field is for pharmacist and only seen when entering prescriptions via RPMS. • Not useful for provider order entry of medications via EHR. TRADE NAME • Brand Name; multiple entries if necessary QUICK CODE • for pharmacy personnel use DRUG ACCOUNTABILITY • VA Function CONTROLLED SUBSTANCES • VA Function

12. Drug Message • Multiple “Message” prompts in drug file. • Information entered here will display to the pharmacist when entering a prescription via RPMS. • It will display to the Provider as a “pop-up” in EHR too! • It is a Free Text field. • Be aware of “Pop-Up Fatigue.”

13. Inactive Date • Multiple “Inactive” Fields in Drug File. • If no longer using an item, then enter a past date in this field to inactive the entry (i.e. T-1). • If this field is blank then it means the entry is ACTIVE. • NDF Updates can sometimes inactivate an active drug. • To re-activate a drug use the “@” symbol. • NEVER put future inactive dates in this field. • Reminder, drug entries are not deleted but rather inactivated. • NOTE: we will be using the Inactive Date Field in our drug file reports

14. E-PrescribingOrder Unit Fields

15. E-PrescribingDispense Unit NCPDP Code • National Council for Prescription Drug Programs (NCPDP) • Provides a standard for the exchange between prescribers, pharmacies, intermediaries, payers. • E-Prescribing requirement for new prescription Request, change of new prescription, cancel of prescription, refill/renewals request/response or resupply in long term care. • E-prescribing; It will generally be the same as what is entered for the Dispense Unit field. 12 Packet 00 Not Specified AR Suppository AV Capsule BG Bag BO Bottle BX Box CH Container CQ Cartridge EA Each F2 International Unit FG TransdermalPatch FO Fluid Ounce GR Gram IH Inhaler KT Kit LT Liter ME Milligram ML Milliliter PH Pack PT Pint SZ Syringe TB Tube U2 Tablet UM Million Units UN Unit UU Lozenge VI Vial X4 Drop Y2 Tablespoon Y3 Teaspoon Y7 Gum ZZ Mutually Defined

16. POP Quiz - Question Complete Order Units for following Drugs:

17. POP Quiz - Answer Complete Order Units for following Drugs:

18. E-PrescribingNational Drug Code (NDC) • 5-4-2 Format Only for proper functioning with POS & NDF Matching. • It may be necessary to use leading zero’s to get the correct format. • For sites that don’t have a pharmacy, you will still need to populate the NDC field. • To acquire an NDC you can search the FDA NDC file search: http://www.accessdata.fda.gov/scripts/cder/ndc/queryndctn.cfmthis site will also display common quantities so you can complete the order unit, dispense unit, and dispense units per order unit. • Search the internet for those that are not on the FDA site. 00006-0713-68

19. Price Fields

20. E-PrescribingNational Drug File Matching • You MUST match to the NDF to obtain VA Drug Class. • This will allow allergy checking and Drug/Drug interactions to operate correctly. • Without this code your providers will NOT get the appropriate order checks, which can ultimately result in adverse patient outcomes. • NOTE: The attempt to match is based off the NDC code(s), then the Generic Name. • Make sure the drug, dosage form, package size, and package type are accurate

21. E-PrescribingDosages • There are 2 types of dosages that a drug can be assigned. • Possible dosages are normally assigned automatically when you match the drug to the NDF. • There are some drugs that will not automatically receive a possible dose when matched and in those cases we will optimize the local possible dosage field. • Best practice supports possible dosages over local possible dosages HOWEVER we have already indicated that not all drugs will have possible dosing.

22. E-PrescribingDosages Cont… • When possible dosages are auto-created, the system automatically creates entries for 1 x strength of the dispense unit and 2 x strength of dispense unit. • Keep in mind that this is automatically done for you AND you should always confirm that the dose automatically assigned is therapeutically and clinically appropriate. • If the dose is inappropriate it can be removed by using the @ sign. • If the drug has additional dosing options (1/2 tab, 3 tabs, etc) the package owner may create those in order to optimize dosing options for the provider during CPOE.

23. E-PrescribingDosages Cont… • For drugs that are not automatically assigned a possible dosage you will need to manually create FREE TEXT dosages using Local Possible Dosage option. • Drugs that you will typically need to create local possible dosage include: combination products, ophthalmic products, topical, inhalers, etc. • When creating a local possible dosage keep in mind that they need to “speak” to the patient. • You will also need to be consistent with expanding numeric values in local possible dosage. • Remember best practice supports use of possible dosages over local possible dosages in most cases.

24. E-PrescribingDosages Cont… • Best practice indicates that range dosing should be avoided to prevent drug errors. • For E-Prescribing to be successful every drug should have an assigned dose. Drugs with no dose result in the provider free texting the entry which can increase the risk of transmission failure.

25. E-PrescribingDosages Cont… 1 UNIT DOSE: 10MG PKG: IO 2 UNIT DOSE: 20MG PKG: IO 300 ML150 ML 1 TEASPOONFUL 2 TEASPOONFULS ENTIRE CONTENTS OF BOTTLE Possible Dosages Local Possible Dosages

26. E-PrescribingApplication Packages • The letters that are available depend on the keys you hold. • Marking a drug “O” authorizes it to be ordered in an Outpatient (aka Ambulatory Setting) and it will be processed through the Outpatient Pharmacy Drug File • Marking a drug “U” authorizes the drug to be ordered on the inpatient ward and is processed through the Unit Dose package • Marking a drug “I” authorizes it for IV drugs and allows for processing in the IV package • Marking a drug “X” allows you to order it as a NON-VA Medication MARK THIS DRUG AND EDIT IT FOR: O - Outpatient U - Unit Dose I - IV C - Controlled Substances X - Non-VA Med A - ALL

27. QUANTITY DISPENSE MESSAGE: • Can enter package size to assist providers when entering QTY in EHR • Examples : inhaler=6.7gm bottle = 3.5ml tube = 3gm

28. E-PrescribingORDERABLE ITEMS • The choice defaults to the first part of the generic name which is usually what you want. • If the default does not meet your needs or you are separating Orderable Items for select drugs you can use the “^” sign to create a new Orderable Item Name. • Most tablets and capsules will share orderable items however there will be times when you will need to separate a dispense drug into its own orderable item and then specify within the OI name dose to guide the providers when ordering. • We will be discussing special circumstances later in this course to review drugs that will require a separate OI to minimize failed prescription transmissions when using E-Prescribing. Matching ENALAPRIL 10MG TAB to ENALAPRIL TAB

29. Pharmacy Orderable Item Overview Cont…

30. Pharmacy Orderable Item Overview PATIENT STATUS: OUTPATIENT// DRUG: LISINOPRIL 30MG TAB CV800 00310-0133-10 ...OK? Yes// (Yes) VERB: TAKE Available Dosage(s) 1. 30MG 2. 60MG Select from list of Available Dosages, Enter Free Text Dose or Enter a Question Mark (?) to view list: • Dispense Drug • Used by Pharmacist when entering new orders via RPMS • Dispense drug is detailed in nature • Pharmacy does NOT use Orderable Items when entering orders Pharmacist order entry

31. Pharmacy Orderable Item Overview Cont… • Orderable items: • Used by the provider during CPOE • Generally generic in nature and contain Generic Drug Name and Dosage Form • Dispense Drug does NOT appear in order dialog Provider order entry

32. Issues Related to Orderable Items • Free texting doses for Orderable Items: • Tied to drugs with “no” assigned doses • Tied to drugs with defined local possible dosages • Tied to drugs with defined possible dosages • Copy to New Order • Original order contained free text dosages • Original order was a combination drug • Dispense drugs attached to wrong orderable items • Solution vs Suspension • Cream vs Ointment • Immediate Release (IR) vs Sustained Release (SR)

33. Provider free texted dosage in EHR causing a “disconnect” when it crosses to pharmacy for processing Since the provider free texted dosage Pharmacy will be forced to select the dispense drug before they can finish the order

34. Provider free texted dosage in EHR causing a “disconnect” when it crosses to pharmacy for processing Since the provider free texted dosage Pharmacy will be forced to select the dispense drug before they can finish the order

35. “Problematic” Orderable Items • Drugs requiring Local Possible Dosages • Combination Products • Topical Medications • Ophthalmic Medications • Inhalers • Drugs where strength is expressed in percent • Topical Medications • Ophthalmic Medications • IV Additives where you carry more than one strength

36. “Problematic” Orderable Items Cont… • Pyxis, Omincell, PickPoint or Telepharmacy medications • Prevent existing prescriptions from being discontinued when the medication order from EHR is finished • Additional options to prevent these drugs from being renewed, refilled, and ordered through the all other medications menu • Mark Omnicell/Pyxisdrugs with DEA Special HDLG: • non-renewable • non-refillable prescriptions • Restrict the orderable item so that it can only be ordered by providers as a quick order.

37. Combination Products AFTER: Orderable Item -> FLUTICASONE/SALMETEROL 100/50 Dosage Form -> INHL,ORAL Dispense Drugs: --------------- FLUTIC./SALMETEROL 100MCG/50 DISKUS BEFORE: Orderable Item -> FLUTICASONE/SALMETEROL Dosage Form -> INHL,ORAL Dispense Drugs: --------------- FLUTIC./SALMETEROL 100MCG/50 DISKUS FLUTIC./SALMETEROL 250MCG/50 DISKUS FLUTIC./SALMETEROL 500MCG/50 DISKUS AFTER: Orderable Item -> FLUTICASONE/SALMETEROL 250/50 Dosage Form -> INHL,ORAL Dispense Drugs: --------------- FLUTIC./SALMETEROL 250MCG/50 DISKUS AFTER: Orderable Item -> FLUTICASONE/SALMETEROL 500/50 Dosage Form -> INHL,ORAL Dispense Drugs: --------------- FLUTIC./SALMETEROL 500MCG/50 DISKUS

38. Medications with Strength Expressed in Percentage AFTER: Orderable Item -> ALBUTEROL 0.083% (PRE-MIX) Dosage Form -> SOLN,INHL Dispense Drugs: --------------- ALBUTEROL 0.083% 2.5MG/3ML INH SOLUTION AFTER: Orderable Item -> ALBUTEROL 0.5% Dosage Form -> SOLN,INHL Dispense Drugs: --------------- • ALBUTEROL 0.5% 5MG/ML INH SOLN BEFORE: • Orderable Item -> ALBUTEROL • Dosage Form -> SOLN,INHL Dispense Drugs: --------------- • ALBUTEROL 0.083% 2.5MG/3ML INH SOLUTION • ALBUTEROL 0.5% 5MG/ML INH SOLN

39. IV Additives with Multiple Strengths AFTER: Orderable Item -> CEFAZOLIN 1GM Dosage Form -> INJ Dispense Drugs: --------------- CEFAZOLIN 1GM VIAL (INJ) CEFAZOLIN (ANCEF) (A) AFTER: Orderable Item -> CEFAZOLIN 500MG Dosage Form -> INJ Dispense Drugs: --------------- • CEFAZOLIN 500MG VIAL (INJ) CEFAZOLIN (ANCEF) (A) BEFORE: Orderable Item -> CEFAZOLIN Dosage Form -> INJ Dispense Drugs: --------------- CEFAZOLIN 500MG VIAL (INJ) • CEFAZOLIN 1GM VIAL (INJ) • CEFAZOLIN (ANCEF) (A) • CEFAZOLIN (ANCEF) (A)

40. Pyxis/Omnicell Example Orderable Item -> LISINOPRIL Dosage Form -> TAB Dispense Drugs: --------------- LISINOPRIL 10MG TAB LISINOPRIL 10MG TAB U/D LISINOPRIL 20MG TAB LISINOPRIL 10MG TAB (PYXIS) LISINOPRIL 20MG TAB (PYXIS) Orderable Item -> LISINOPRIL (PYXIS) Dosage Form -> TAB Dispense Drugs: --------------- LISINOPRIL 10MG TAB (PYXIS) LISINOPRIL 20MG TAB (PYXIS) Example A Example B

41. PickPoint Example Orderable Item -> LISINOPRIL Dosage Form -> TAB Dispense Drugs: --------------- LISINOPRIL 10MG TAB LISINOPRIL 10MG TAB U/D LISINOPRIL 20MG TAB LISINOPRIL 10MG TAB (PP) LISINOPRIL 20MG TAB (PP) Orderable Item -> LISINOPRIL (PP) Dosage Form -> TAB Dispense Drugs: --------------- LISINOPRIL 10MG TAB (PP) LISINOPRIL 20MG TAB (PP) Example A Example B

42. Telepharmacy Example Orderable Item -> LISINOPRIL Dosage Form -> TAB Dispense Drugs: --------------- LISINOPRIL 10MG TAB LISINOPRIL 10MG TAB U/D LISINOPRIL 20MG TAB LISINOPRIL 10MG TAB (TPH) LISINOPRIL 20MG TAB (TPH) Orderable Item -> LISINOPRIL (TPH) Dosage Form -> TAB Dispense Drugs: --------------- LISINOPRIL 10MG TAB (TPH) LISINOPRIL 20MG TAB (TPH) Example A Example B

43. Orderable Item Optimization • Optimize dosages • Assign dosages to ALL drugs • Maximize possible dosages • Assign possible dosages to all drugs that will allow • Minimize local possible dosing • Run Orderable Item Dosages Report • Review Orderable Item Name • Review Dosages assigned dispense drugs • Review that “correct” dispense drug has been attached • Follow recommendations to separate “problematic” Orderable Items

44. Would you Recommend a Separate Descriptive Orderable Items? Example A Example B

45. Would you Recommend a Separate Descriptive Orderable Items? ALBUTEROL SOLN,INHL Outpatient Dosages: 3ML/2.5MG ALBUTEROL 0.083% 2.5MG/3ML INH SOLUTION 0.25ML/1.25MG ALBUTEROL 0.5% 5MG/ML INH SOLN 0.5ML/2.5MG ALBUTEROL 0.5% 5MG/ML INH SOLN 1ML/5MG ALBUTEROL 0.5% 5MG/ML INH SOLN ALPRAZOLAM TAB Outpatient Dosages: 0.25MG (.5 TABLET) ALPRAZOLAM 0.5MG TABLET 0.5MG (1 TABLET) ALPRAZOLAM 0.5MG TABLET 1MG (1 TABLET) ALPRAZOLAM 1MG TABLET 2MG (1 TABLET) ALPRAZOLAM 2 MG TABLET 4MG (2 TABLETS) ALPRAZOLAM 2 MG TABLET Example A Example B

46. Which “one” Would you Recommend a Separate Descriptive Orderable Items? Example A Example B

47. Would you Recommend a Separate Descriptive Orderable Items? PREDNISOLONE SUSP,OPH Outpatient Dosages: 1 DROP PREDNISOLONE ACET (FORTE) 1% OPHTH SUSP 1 DROP PRED MILD 0.12% OPTH SUSP 10ML 2 DROPS PRED MILD 0.12% OPTH SUSP 10ML 1 DROP PRED MILD 0.12% OPTH SUSP 5ML 2 DROPS PRED MILD 0.12% OPTH SUSP 5ML BUPRENORPHINE/NALOXONE TAB,SUBLINGUAL Outpatient Dosages: 1 TABLET BUPRENORPHINE 2MG/NALOXONE 0.5MG TABLET 2 TABLETS BUPRENORPHINE 2MG/NALOXONE 0.5MG TABLET 1 TABLET BUPRENORPHINE 8MG/NALOXONE 2MG TABLET 2 TABLETS BUPRENORPHINE 8MG/NALOXONE 2MG TABLET Example A: Example B:

48. Would you Recommend a Separate Descriptive Orderable Items? Example A Example B

49. Would you Recommend a Separate Descriptive Orderable Items? BETAMETHASONE CREAM,TOP Outpatient Dosages: CREAM THINLY BETAMETHASONE DIPR 0.05% CRM (15) CREAM THINLY BETAMETHASONE DIPR 0.05% CRM (45) CLONIDINE PATCH Outpatient Dosages: 1 PATCH CLONIDINE TTS 1 PATCH 1 PATCH CLONIDINE TTS 2 PATCH 1 PATCH CLONIDINE TTS 3 PATCH Example A: Example B:

50. Would you Recommend a Separate Descriptive Orderable Items? Example A Example B