117 Pharmacy Reengineering FY07 Update

1. 117 Pharmacy Reengineering FY07 Update A Perfect World

2. 2 Faculty Mike Mims, Program Manager Pharmacy Reengineering (PRE) Cathryn Herren Analyst, PRE Lina Bertuzis Analyst, PRE

3. 3 PRE Background Many VHA technology problem areas and weaknesses identified Prior to 2001 First Consulting study Included patient safety issues SwRI awarded multi-year, fixed-price contract FY04 to develop new pharmacy system Period of performance ends September 2008

4. 4 PRE Proof of Concept Demo December 14, 2006 Purpose: Demonstrate viability of Pharmacy Enterprise Product System (PEPS) Successfully interoperated VistA pharmacy with COTS database (First DataBank-FDB) Demonstrated integration between PEPS and COTS PEPS and VistA Used reduced set of PEPS functionality PEPS test data Demonstrated integration between PEPS and COTS PEPS and VistA Used reduced set of PEPS functionality PEPS test data

5. 5 POC Summary Proof of Concept Demonstrated key functionality Identified major risks for production system Tested VistA - PRE info flow Validated & refined PEPS system requirements Provided environment to evaluate VistA integration strategy Allowed Level of Effort (LOE) estimate adjustment for production build

6. 6 POC Lessons Learned Proof of Concept showed Level of effort > originally thought Testing Activities require significant time/ resources HealtheVet (HeV) architecture not maturing as quickly as hoped Dramatic funding reductions = significant project delays Cost estimates to continue current pace w/ SwRI greatly exceed original expectations

7. 7 POC Testing Activities 2006 Testing Usability Functional Acceptance Test Code Evaluation 508 Compliance

8. 8 FY07 - Changing Environment Entire VA Environment changed New Organizational Structure Continuing Resolution No Approved Budget (80% of FY06 Budget) Unable to move forward with New Contract with SwRI Generated Re-planning effort

9. 9 PRE Versions PRE v0.5, v1.0 and Remaining Work V. 0.5 pre-release V. 0.5 Enhanced Order Checks V. 1.0 Pharmacy Enterprise Product System (PEPS) Beyond PRE V. 1.0

10. 10 Risks Production environment Support staff Legacy system enhancements Performance COTS drug database licenses COTS drug database Both versions of PRE share the following risks: Production environment Support staff Legacy system enhancements Performance COTS drug database licenses PRE V.1.0 has two additional risks: COTS drug databaseBoth versions of PRE share the following risks: Production environment Support staff Legacy system enhancements Performance COTS drug database licenses PRE V.1.0 has two additional risks: COTS drug database

11. 11 Dependencies Standards & Terminology Services (STS) SwRI CPRS COTS Drug Database Clinical Data Services (CDS) Cross-Application Integration Protocol (CAIP) Both versions share the following Dependencies: Standards & Terminology Services (STS) SwRI CPRS COTS Drug Database Clinical Data Services (CDS) CAIP PRE V.1.0 has two additional dependencies: Clinical Data Services (CDS) CAIPBoth versions share the following Dependencies: Standards & Terminology Services (STS) SwRI CPRS COTS Drug Database Clinical Data Services (CDS) CAIP PRE V.1.0 has two additional dependencies: Clinical Data Services (CDS) CAIP

12. 12 Beyond PRE v1.0 Working with Business Owners Organize Prioritize Sequencing must consider Patient safety issues Funding requirements Availability of common services Ability of other applications to implement

13. PRE V. 0.5 Pre-Release Cathryn Herren

14. 14 Background Information Current Order Checks to be enhanced Using First Data Bank (FDB) New Dosing Order Checks Using FDB National Drug File Connection to FDB GCNSEQNo in VA Product File

15. 15 Why A Pre-Release Data required for FDB dosing checks Not currently in VistA FDB medication route for dosing FDB drug unit for dosing Numeric dose and corresponding unit for Local Possible Dosages Needs checking in VistA Administration Schedule Frequency

16. Medication Route Mapping

17. 17 Standard Routes Created by Standards and Terminology Service (STS) Approved by Pharmacy Benefits Management (PBM) Mapped to FDB dose route table by STS To be exported as a Pharmacy Data Management (PDM) file STANDARD MEDICATION ROUTE file (#51.23)

18. 18 STANDARD MEDICATION ROUTE file (#51.23) No local editing allowed Future updates by STS via New Term Rapid Turnaround (NTRT)

19. 19 Mapping Local to Standard Medication Routes New field in MEDICATION ROUTES file (#51.2) Pointer to STANDARD MEDICATION ROUTES file (#51.23) Required only for Medication Routes marked for ALL PACKAGES In PACKAGE USE field (#3)

20. 20 Auto-population of new field Exact matches to Standard Medication Route Exact match to FDB route Mapped to Standard Medication Route for that entry Mapping Local to Standard Medication Routes

21. 21 Options for mapping Medication Route File Enter/Edit Map Local Medication Route to Standard Find Unmapped Local Medication Routes Mapping Local to Standard Medication Routes

22. 22 Medication Route File Enter/Edit Modified for mapping to standard medication route User to get warning if route not mapped when required

23. 23 Map Local Medication Route to Standard Option only for mapping to Standard Medication Route User selects route to map FDB route is displayed when mapping to Standard Displays mapping for a route already mapped Redisplays the mapping and FDB route after mapped to standard

24. 24 Map Local Medication Route to Standard

25. 25 Find Unmapped Local Medication Routes Loops through unmapped medication routes for mapping to Standard Medication Route System displays routes to user for mapping FDB route is displayed when mapping to Standard

26. 26 Find Unmapped Local Medication Routes Redisplays the mapping and FDB route after mapped to the standard If route not mapped, user is presented with next route requiring mapping User can enter ^ to exit the loop

27. 27 Find Unmapped Local Medication Routes

28. 28 Find Unmapped Local Medication Routes

29. 29 Dosage Form File Enter/Edit Modified to not allow entry of a new Medication Route

30. 30 Medication Routes Mapping Local to Standard Reports Medication Route Mapping Report Medication Route Mapping History Report

31. 31 Medication Route Mapping Report Displays all medication routes requiring mapping or just unmapped medication routes Displays medication routes alphabetically Displays Standard Medication route when mapped

32. 32 Medication Route Mapping Report Displays FDB route when mapped Displays Outpatient Expansion for the medication route

33. 33 Medication Route Mapping Report

34. 34 Medication Route Mapping Report

35. 35 Medication Route Mapping History Report Report of mapping changes between local medication routes and standard medication routes Display all medication routes or a single medication route User selects time range

36. 36 Medication Route Mapping History Report

37. 37 Medication Route Mapping History Report

38. Drug Units Mapping

39. 39 Drug Units Mapping New field to associate possible dosages to FDB drug unit for dosing

40. 40 Local Possible Dosages Two new fields added to DRUG file (#50) within the LOCAL POSSIBLE DOSAGES multiple (#904) UNITS � FDB drug units for dosing NUMERIC DOSE � a numeric representation of the dosage based on the unit defined

41. 41 Local Possible Dosages Population of two new fields Not required for supply items Not required for FDB topical dosage forms Software to auto populate, if possible

42. 42 Options for Population Enter/Edit Dosages Drug Enter/Edit Edit Local Possible Dosages Edit All Local Possible Dosages

43. 43 Enter/Edit Dosages Modified to allow editing of the two new fields User to get a warning if the DRUG file (#50) strength does not match the VA Product strength Redisplays data once entered

44. 44 Drug Enter/Edit Modified to allow editing of the two new fields User to get a warning if the DRUG file (#50) strength does not match the VA Product strength Redisplays data once entered

45. 45 To allow editing of the two new fields User selects drug System prompts for entry of two new fields Redisplays data once entered Edit Local Possible Dosages

46. 46 Edit All Local Possible Dosages Loops through local possible dosages eligible for dosage checks that do not have either the Numeric Dosage or Units entered System displays drug and local possible dosage requiring the needed fields System prompts for entry of two new fields

47. 47 Edit All Local Possible Dosages Redisplays data once entered If no data is entered, user is asked if they want to continue User can enter ^ to exit the loop

48. 48 Reports Strength Mismatch Report Review Dosages Report Local Possible Dosages Report

49. 49 Strength Mismatch Report Displays dosage information For entries in the DRUG file (#50) with local possible dosages whose strength is different than the strength of the VA Product match Displays strength of DRUG file (#50) entry and strength of VA Product match entry Displays VA Product match entry

50. 50 Strength Mismatch Report Select Pharmacy Data Management Option: ENhanced Order Checks Setup Menu � Select Enhanced Order Checks Setup Menu Option: STrength Mismatch Report � This report will print Dosage information for all entries in the DRUG (#50)File that have a different Strength than what is in the VA Product (#50.68)match. If these drugs have Local Possible Dosages, you need to be careful whensetting the new Units and Dosage field to be used for Dosage checks. This report can only identify Strength mismatches if the Drug has Possible Dosages, and the Strength has beenedited. This report cannot identify Strength mismatches where no Possible Dosageshave been created. � �� This report is designed for 132 column format! � DEVICE: HOME// <Enter> Mismatched Strength Report Outpatient Expansion PAGE: 1----------------------------------------------------------------------------------------- (156) GUAIFENSESIN 100MG/5ML SYRUP Inactive Date: Strength: 50 Units: Application Package: OX Possible Dosages: Dispense Units Per Dose: 1 Dose: 50MG/2.5ML Package: I Dispense Units Per Dose: 2 Dose: 100MG/5ML Package: I Local Possible Dosages: 1 TEASPOONFUL Numeric Dose: 100 Units: MG Package: O 2 TEASPOONFUL(S) Numeric Dose: 200 Units: MG Package: O Note: Strength 50 does not match NDF strength of 100. VA PRODUCT MATCH: GUAIFENESIN 100MG/5ML SYRUP.

51. 51 Review Dosages Report Modified to display two new fields defined for Local Possible Dosages

52. 52 Review Dosages Report Dosage report for all drugs Outpatient Expansion ----------------------------------------------------------------------------------------- (699) GUAIFENESIN 100MG/5ML SYRUP Inactive Date: Strength: 100 Units: Application Package: OX Possible Dosages: Dispense Units Per Dose: 1 Dose: 100MG/5ML Package: I Dispense Units Per Dose: 2 Dose: 200MG/10ML Package: I Local Possible Dosages: 1 TEASPOONFUL Numeric Dose: 100 Units: MG Package: O 2 TEASPOONSUL(S) Numeric Dose: 200 Units: MG Package: O (2280) IBUPROFEN 300MG TAB *N/F* Inactive Date: Strength: 300 Units: MG Application Package: OX Possible Dosages: (None) Local Possible Dosages: 900MG Numeric Dose: 900 Units: MG Package: IO 1200MG Numeric Dose: 1200 Units: MG Package: IO (5249) IBUPROFEN 400MG (120'S) *N/F* Inactive Date: Strength: 400 Units: MG Application Package: OX Possible Dosages: Dispense Units Per Dose: 1 Dose: 400MG Package: IO 1 TABLET Dispense Units Per Dose: 2 Dose: 800MG Package: IO 2 TABLETS Local Possible Dosages: (None) (1676) TIMOLOL 0.25% OPTH SOLN (10ML) Inactive Date: Strength: Units: Application Package: OXU Possible Dosages: (None) Local Possible Dosages: 2 DROPS Numeric Dose: 2 Units: DROPS Package: IO End of Report

53. 53 Local Possible Dosages Report Displays drugs in the DRUG file (#50) with local possible dosages that have missing data in the numeric dose and units fields Excludes supplies and FDB topical dosage forms User can print all drugs or a specific alphabetic range of drugs

54. 54 Local Possible Dosages Report Displays local possible dosage information Displays strength of NDF match (if strength does not match DRUG file (#50) entry) Prints VA Product match when strength mismatch

55. 55 Local Possible Dosages Report �Local Possible Dosages Report for Drugs G through G PAGE: 1----------------------------------------------------------------------------------- (30) GELUSIL TABLES Inactive Date: Strength: Units: Local Possible Dosages: 1 TABLET Numeric Dose: Units: Package: I 2 TABLET(S) Numeric Dose: Units: Package: I (156) GUAIFENSESIN 100MG/5ML SYRUP Inactive Date: Strength: 50 Units: MG Application Package: OUX Local Possible Dosages: 1 TEASPOONFUL Numeric Dose: Units: Package: IO 2 TEASPOONFUL(S) Numeric Dose: Units: Package: IO Note: Strength 50 does not match NDF strength of 100. VA PRODUCT MATCH: GUAIFENESIN 100MG/5ML SYRUP

56. 56 Administration Schedule Frequency Administration Schedule File Report Displays Administration schedules (all or just those with no frequency defined) Standard administration times (ward specific administration times if defined) Outpatient Expansion Other Language Expansion Schedule Type Frequency (in Minutes)

57. 57 Administration Schedule Frequency User selects all administration schedules User selects all administration schedules

58. 58 Administration Schedule Frequency User selects administration schedules without a frequency defined User selects administration schedules without a frequency defined

59. 59 New Menu Enhanced Order Checks Setup Menu option

60. PRE V. 0.5 Enhanced Order Checks Lina Bertuzis

61. 61 Enhanced Order Checks Use FDB Drug Information Framework (DIF) APIs and database Enhance Existing Order Checks Drug-Drug Duplicate Drug Duplicate Class Add New Dosing Order Checks Max single & daily dose range General Dosing range information

62. 62 Enhanced Order Checks Incorporate Dosing Checks in Verification Process CPRS Order Checks added Order Check History New - Check Drug Interaction Option New Hidden Action � Order Check vs. Med Profile Consistent Pharmacy Order Check Display

63. 63 Enhanced Order Checks Plus� Hidden Action - Intervention Menu Identify Recently Discontinued/Expired Orders Identify D/C and Hold Action

64. 64 Order Checks � Data Flow When a HealtheVet VistA application (i.e. Outpatient Pharmacy) requests and order check to be performed, an XML message is sent from VistA to FDB via VistAlink. The PRE V. 0.5 application PEPS services will receive; validate the format and triage the request before sending on to FDB Drug Information Framework (DIF) which will perform the requested order check(s) and return the results. When a HealtheVet VistA application (i.e. Outpatient Pharmacy) requests and order check to be performed, an XML message is sent from VistA to FDB via VistAlink. The PRE V. 0.5 application PEPS services will receive; validate the format and triage the request before sending on to FDB Drug Information Framework (DIF) which will perform the requested order check(s) and return the results.

65. 65 Drug-Drug Interaction - FDB FDB Drug-Drug Interaction Module (DDIM) Supports drug products marketable in US Reports only most clinically significant interactions Evaluated at ingredient and route levels Four Severity levels classify drug interactions based on degree of patient risk do not incorporate level of documentation for an interaction

66. 66 Drug-Drug Interaction - FDB Severity Level 1 Contraindicated Drug Combination Severity Level 2 Severe Interaction Severity Level 3 Moderate Interaction Severity Level 9 Undetermined Severity- Alternative Therapy Interaction

67. 67 Drug-Drug Interaction - FDB Professional Interaction Monograph Monograph Title Severity Level Mechanism of action Clinical Effects Predisposing factors Patient Management Discussion References

68. 68 Drug-Drug Interaction - FDB Consumer Interaction Monograph Monograph Title Medical Warning How the Interaction Occurs What Might Happen References

69. 69 Drug-Drug Interaction - FDB Customization Severity level may be changed Clinical effect codes for the interaction may be changed Custom messages may be assigned to the interaction Custom interaction may be created

70. 70 Enhanced Drug-Drug Interaction Order Check - VistA Continue to use VistA severity levels Critical Significant Customize FDB severity level and add custom interactions at National Level No change to current user actions in VistA

71. 71 Enhanced Drug-Drug Interaction Order Check � VistA (continued) Provide new warning message Display VistA severity Short description of interaction�s clinical effects Provide optional display of detailed interaction monograph (professional)

72. 72 Enhanced Drug-Drug Interaction Local Order Check - Outpatient

73. 73 Enhanced Drug-Drug Interaction Remote Order Check - Outpatient

74. 74 Enhanced Drug-Drug Interaction IV Order Check - Inpatient

75. 75 Enhanced Drug-Drug Interaction

76. 76 Enhanced Drug-Drug Interaction (continued)

77. 77 Professional Drug Monograph

78. 78 Professional Drug Interaction Monograph (continued)

79. 79 Enhanced Drug-Drug Interaction � Pharmacy Data Management Modify Enter/Edit Local Drug Interaction option No changes to Drug Interaction file (#56) locally Request severity change @ National Request add of drug interaction @ National Provide option to check if FDB link is up Notification when FDB link is down Provide report on order checks that could not be performed and that corrective action can be taken.

80. 80 New Option Check Drug Interaction Allows user to check drug interactions between two or more drugs Provided on Outpatient Pharmacy & Inpatient Medication (UD & IV modules) menus Selection from DRUG file (#50)

81. 81 New Option Check Drug Interaction (continued) User will see the following information: Numbered list of interacting drug pairs VistA severity Short description of drug interaction Detailed professional monograph (optional) Consumer interaction monograph (optional)

82. 82 New Option Check Drug Interaction (continued)

83. 83 New Option Check Drug Interaction (continued)

84. 84 New Option Check Drug Interaction (continued)

85. 85 New Option Check Drug Interaction (continued)

86. 86 Duplicate Ingredient & Duplicate Therapy Check - FDB FDB Duplicate Therapy Module Duplicate Ingredient checking compares ingredients of the drugs Duplicate Therapy Class checking uses therapeutic drug classes developed specifically for duplicate therapy selection identifies drug groups involved and provides a duplicate therapy class name relative to the duplication

87. 87 Drugs assigned to one or more classes classification category = MOA (e.g. Beta-Adrenergic Receptor Blockers, ACE inhibitors) classification category = Therapeutic Indication (e.g. Anticonvulsants, Antimalarials) Each Duplicate Therapy Class is assigned a duplication allowance Customization Change duplication allowance for therapy class Duplicate Ingredient & Duplicate Therapy Check � FDB (continued) Each Duplicate Therapy Class is assigned a duplication allowance. The duplication allowance specifies the maximum number of duplicate therapy matches that can occur with a class without creating a warning. Example follows: Example 1: Drug: Chloroquine Phosphate Duplicate Therapy Class: Antimalarials Duplication Allowance: 0 Number of duplications present? 1 Exceeds Allowance? Yes For the example above, the duplication allowance is zero. If more than one drug in the Antimalarial class is prescribed, a match occurs and a warning should be generated. Example 2: Drug 1: Lovastatin Drug 2: Atorvastatin Duplicate Therapy Classes: Antihyperlipidemics; HMG-CoA Reductase Inhibitors Duplication Allowance: Antihyperlipidemics = 1 ; HMG- CoA Reductase Inhibitors = 0 Number of duplications present: 1 for both Exceeds allowance: No for Antihyperlipidemics & Yes for HMG � CoA Reductase Inhibitors In the example above, 2 duplicate therapy matches occurs. For the Antihyperlipidemic match, the warning is suppressed because the duplication allowance for this class is one and therefore allowed. The other match would exceed the allowance of zero and generate a warning message.Each Duplicate Therapy Class is assigned a duplication allowance. The duplication allowance specifies the maximum number of duplicate therapy matches that can occur with a class without creating a warning. Example follows: Example 1: Drug: Chloroquine Phosphate Duplicate Therapy Class: Antimalarials Duplication Allowance: 0 Number of duplications present? 1 Exceeds Allowance? Yes For the example above, the duplication allowance is zero. If more than one drug in the Antimalarial class is prescribed, a match occurs and a warning should be generated. Example 2: Drug 1: Lovastatin Drug 2: Atorvastatin Duplicate Therapy Classes: Antihyperlipidemics; HMG-CoA Reductase Inhibitors Duplication Allowance: Antihyperlipidemics = 1 ; HMG- CoA Reductase Inhibitors = 0 Number of duplications present: 1 for both Exceeds allowance: No for Antihyperlipidemics & Yes for HMG � CoA Reductase Inhibitors In the example above, 2 duplicate therapy matches occurs. For the Antihyperlipidemic match, the warning is suppressed because the duplication allowance for this class is one and therefore allowed. The other match would exceed the allowance of zero and generate a warning message.

88. 88 Enhanced Duplicate Drug & Duplicate Class Checks - VistA VistA changes: Use FDB Enhanced Therapeutic Classification instead of VA drug class (order checks only) Outpatient Pharmacy Application left current VistA duplicate drug check added FDB duplicate ingredient check replaced VistA class check with FDB duplicate therapy check combined duplicate ingredient & therapy warnings no change in user actions to be taken

89. 89 Local Duplicate Drug - Outpatient

90. 90 Local Therapeutic Duplication - Outpatient

91. 91 Local and Remote Therapeutic Duplication - Outpatient

92. 92 Local/Remote Therapeutic & Ingredient Duplication - Outpatient

93. 93 Enhanced Duplicate Ingredient & Duplicate Therapy Checks - VistA VistA changes (continued): Inpatient Medications Application replaced duplicate drug with FDB duplicate ingredient replaced duplicate class with FDB duplicate therapy combined duplicate ingredient & therapy warnings no change in user actions to be taken

94. 94 Local Therapeutic Duplication Inpatient

95. 95 Local/Remote Outpatient Orders Therapeutic Duplication - Inpatient

96. 96 Local Therapeutic and Ingredient Duplication - Inpatient

97. 97 Local Therapeutic and Ingredient Duplication � Inpatient (continued)

98. 98 Therapeutic and/or Ingredient Duplication - Inpatient

99. 99 Dosage Checks - FDB Maximum Single Dose Check Daily Dosage Range Check General dosing range � Common Indicator

100. 100 Dosing Checks � FDB (continued) Information required by FDB: Patient parameters passed to API Age (in days) - required Weight (in Kg) � only req�d for certain drug/age combos Body Surface Area (BSA in m2) using DuBois formula � only req�d for certain drug/age combos

101. 101 Order information passed to API: Drug � GCNSEQNO map to FDB Single Dose Amount � Number or decimal value Dose Unit - FDB Dose Unit (from VistA Drug unit map) Dose Route � FDB Dose Route (from VistA Med Route map) Dosing Checks � FDB (continued)

102. 102 Order information passed to API Dose Type � Maintenance, Single Dose, etc Dose Rate � DAY, HOUR, MINUTE Frequency - # of Administrations per Day; derived from VistA schedule Duration - # of days dosing regimen administered Duration Rate � DAY, HOUR, MINUTE Common dose indication � when general dosing required. Dosing Checks � FDB (continued)

103. 103 FDB Dosing Checks screen out Topicals Medical Supplies Dosing Checks � FDB (continued)

104. 104 Dosage Checks - VistA VistA Changes Outpatient Pharmacy application For simple orders Dosing checks performed after conjunction prompt For complex orders Business rules defined for type of check(s) performed per dosing sequence Dosing checks performed after conjunction prompt

105. 105 Dosage Checks - VistA (continued) User must log intervention to continue Screened out supply items Dosing Check unable to be performed against vendor database User informed Reason for failure provided

106. 106 VistA changes: Inpatient Medications application Dosing checks after administration times prompt Business rules defined for type of check(s) performed for order types Dosage Checks - VistA (continued)

107. 107 User must log intervention to continue Screened out supply items Dosing Check unable to be performed against vendor database User informed Reason for failure provided Dosage Checks - VistA (continued)

108. 108 Dosage Checks - VistA (continued)

109. 109 Dosing ChecksPharmacy Data Management Pharmacy Data Management Add entries in APSP Intervention Type file (#9009032.3) Exceeds Max Single Dose Exceeds Daily Dose Range Exceeds Max Single Dose & Daily Dose Range

110. 110 Outpatient Pharmacy Verification Options � Dosing Checks Verification Options modified to incorporate dosing checks Same business rules as critical drug interaction Dosing warning displayed, no action required Non-verified status assigned to order Warning displayed on Rx label

111. 111 Verification OptionsDosing Checks Update Options Pharmacy Prescription Processing Complete Orders from OERR Rx Verification by Clerk Process Drug/Drug Interactions (renamed Process Order Checks) List Non-Verified Scripts

112. 112 Verification OptionsDosing Checks (continued)

113. 113 Verification OptionsDosing Checks (continued)

114. 114 Verification OptionsDosing Checks (continued)

115. 115 Verification OptionsDosing Checks (continued)

116. 116 Verification OptionsDosing Checks (continued)

117. 117 CPRS Order Checks Added CPRS Checks included in Pharmacy Checks (backdoor) Aminoglycoside Ordered Dangerous Meds for Pt over 64 Glucophage- Lab Results

118. 118 Order Check History Order check details stored Types of order checks included Clozapine order checks CPRS order checks (front door generated) Pharmacy order checks (backdoor generated) Viewable through Activity log (OP & IP)

119. 119 Order Check History Details Date/Time Order Check Name Severity (drug-drug interactions) Interacting Rx #� (OP orders) Interacting Drug(s) Dosage (if complex order) Warning message (text) Override Reason Override Provider Pharmacy Intervention IEN Pharmacy Intervention Recommendation

120. 120 Order Check History Details

121. 121 Order Checks Against Patient Active Medication Profile A new ListMan hidden action - Medication profile screen User can perform order checks for one or more drugs against a patient�s active medication profile (IP & OP) Drug selection from DRUG file #50

122. 122 Order checks performed Drug-Drug Duplicate Ingredient Duplicate Therapy Allergy/Adverse drug reaction (ADR) - against VistA database Users can select order statuses to check against Order Checks Against Patient Active Medication Profile (continued)

123. 123 Optional detailed drug interaction monograph (consumer and professional) For Inpatient Profile output - A list of drugs (from the outpatient profile) common to both inpatient & outpatient profiles Order Checks Against Patient Active Medication Profile (continued)

124. 124 Order Checks Against Patient Active Medication Profile (continued)

125. 125 Order Checks Against Patient Active Medication Profile (continued)

126. 126 Order Checks Against Patient Active Medication Profile (continued)

127. 127 Order Checks Against Patient Active Medication Profile (continued)

128. 128 Order Checks Against Patient Active Medication Profile (continued)

129. 129 Pharmacy Order Check Display Order Make display order consistent between Outpatient and Inpatient When finishing pending orders Entering new orders via backdoor Allow user action after display - Inpatient Minimize performance issues Decrease Number of Warning Displays

130. 130 Enhance Allergy/ADR Order Check Display Display the same order check information for Outpatient Pharmacy and Inpatient Medication applications Combine Local and Remote Allergy/ADR warnings

131. 131 Enhance Allergy/ADR Order Check Display (continued)

132. 132 Pharmacy Order Check Display Order Outpatient Pharmacy Allergy/ADR (local and remote combined) CPRS order checks (new) Local Critical and Significant drug interactions Remote Drug Interactions Local & Remote Duplicate Therapy/Duplicate Ingredient or Drug Dosing Checks

133. 133 Inpatient Medications Allergy/ADR (local and remote combined) CPRS order checks (new) Local Critical and Significant drug interactions Outpatient Medication Orders (local and remote) �Drug Interactions Duplicate Therapy - Local Inpatient, Outpatient Local & Remote Duplicate Therapy/Duplicate � Local Inpatient, Outpatient Local & Remote Dosing Checks Pharmacy Order Check Display Order (continued)

134. 134 Intervention Hidden Action Provide Intervention Menu Hidden Action to Delete an intervention Edit an intervention Enter an intervention Print an intervention View an intervention

135. 135 Intervention Hidden Action (continued) Place on Outpatient and Inpatient ListMan screens Patient Information Medication Profile Detailed Order

136. 136 Discontinued/Expired Medication Orders Identify Recently Discontinued/Expired Orders on Medication Profile Outpatient Pharmacy Displayed via reverse video Inpatient Medications Listed under New profile sub header

137. 137 Provide parameters to define �recently discontinued/expired� timeframe Outpatient Pharmacy Outpatient Site Parameter (7- 45 day range; If no value assigned, system assumes 7 days) Use Site Parameter Enter/Edit option Discontinued/Expired Medication Orders (continued)

138. 138 Inpatient Medications System Parameters (1-120 hour range, If no value assigned, system assumes 24 hours) Use Systems Parameter Edit option Ward Parameters (1-120 hour range; no default; takes precedence over system parameter value) Use Inpatient Ward Parameters Edit option Discontinued/Expired Medication Orders (continued)

139. 139 Discontinued/Held Medication Orders Quick identification of action by which orders were discontinued/held Display new code on medication profile No change in order status

140. 140 Discontinued/Held Medication Orders (continued) Outpatient Discontinue Type Codes DF � Discontinued due to edit by provider through CPRS DE � Discontinued due to edit via backdoor Pharmacy DP � Discontinued by provider through CPRS DC � Discontinued via backdoor Pharmacy DD � Discontinued due to death DA � Auto discontinued due to admission

141. 141 Discontinued/Held Medication Orders (continued) Inpatient Discontinue Type Codes DF � Discontinued due to edit by a provider through CPRS DE � Discontinued due to edit via backdoor Pharmacy DP � Discontinued by provider through CPRS D � Discontinued via backdoor Pharmacy DD � Auto discontinued due to death DA � Auto discontinued due to patient movements

142. 142 Discontinued/Held Medication Orders � Hold Action Hold Action Type Codes (Outpatient & Inpatient) HP � Placed on hold by provider through CPRS H � Placed on hold via backdoor Pharmacy

143. 143 Outpatient Medication Profile

144. 144 Inpatient Medication Short Profile

145. 145 Inpatient Medication Long Profile

146. PRE V. 1.0 Pharmacy Enterprise Product System (PEPS) Cathryn Herren

147. 147 PRE 1.0 Focus

148. 148 General Information Replacement for National Drug File (NDF) and Pharmacy Data Management (PDM) applications Involves integration with COTS Involves integration with VistA PEPS = Pharmacy Enterprise Product System COTS = Commercial Off the Shelf productPEPS = Pharmacy Enterprise Product System COTS = Commercial Off the Shelf product

149. 149 PEPS Roles PEPS National Manager Manages PEPS items at an enterprise level Reviews new item requests Reviews new COTS items Determines state of VA Data Fields PEPS Local Manager Manages PEPS items at a local level Requests new item additions Determines values of VA Data Fields for local use

150. 150 PEPS Functionality

151. 151 Add New Item Search PEPS Local and National Enter using existing item as template Local and National Enter without using existing item as template Local and National

152. 152 Add New Item (continued) Mark Item for local use (Local) Product entered into Local Drug file (#50) Orderable Item Auto Created Vista Notification to requestor and locally created mail group Request sent to National PEPS Manager (Local) Ability to Lock down VA Data Fields (National)

153. 153 Review Requests at National List of pending requests ready for review Makes data edits as needed Ability to lock down VA Data Fields Second Review prior to approval

154. 154 Review Approved by National National and local NDF updated PDM files updated if marked for local use Auto Match to NDF Orderable Item Auto Created (if changed) VistA Notification of NDF and PDM update sent to local

155. 155 Review Rejected by National National NDF & Local NDFs NOT updated IF product had been marked for local use at requesting facility Unmarked for local use in PEPS Inactivated in Drug File #50 VistA Notification of PDM update sent to local Includes orders containing the product

156. 156 Manage Items at Local Mark for Local Use Edit VA Data Fields Product entered into Local Drug file (#50) Orderable Item Auto Created Vista Notification to requestor and locally created mail group

157. 157 Manage Item at Local (continued) Edit VA Data Fields For items previously marked for local use Unmark for Local Use Item inactivated in Local Drug File #50 Vista Notification to requestor and locally created mail group

158. 158 Manage Items at National Edit VA Data Fields Ability to Lock Down VA Data Fields Ability to have second review National NDF and Local NDFs updated once approved by second review PDM files updated locally if marked for local use VistA Notification of NDF and PDM update sent to local

159. 159 National Review of COTS Update List of COTS Items Pending Review Makes VA specific data edits as needed Ability to lock down VA Data Fields Second Review prior to approval National NDF and Local NDFs updated once approved by second review VistA Notification of NDF update sent to local

160. 160 VA Data Fields - PEPS Data fields stored in PEPS, but not in VistA Data pulled from PEPS for use in VistA Pharmacy applications Outpatient Pharmacy Inpatient Medications Automatic Replenishment/Ward Stock BCMA

161. 161 Lab Results/Vital Measurements Display Define for a specific product in the EPL Lab test, specimen, functional area Vital measurement, functional area Information displayed in Outpatient Pharmacy Inpatient Medications BCMA

162. 162 An indicator �!� in reverse video is shown on the medication profile and detailed order display No indicator if order status is �expired� or �discontinued�

163. 163 Where Lab results/vital measurements are displayed based on functional area defined: Order Entry Finishing a Pending order Medication Administration (BCMA) Information displayed before order checks performed 

164. 164 Three new hidden actions LAB Lab Results VIT Vital Measurements LV Latest Lab/Vital All hidden actions available from medication profile & detailed order screens

165. 165 Parameters provided to set a default System/Ward level for Inpatient Medications System/Outpatient Site level for Outpatient Pharmacy Occurrence Limit (LAB & VIT) Time limit (LAB & VIT)

166. 166 Do Not MailOutpatient Pharmacy Currently user can indicate that Patient�s meds cannot be mailed Added functionality Identify products in EPL that cannot be mailed Pharmacy Orderable Items for a patient that cannot be mailed (VistA) Patient for which Controlled Subs cannot be mailed (VistA)

167. 167 If patient/drug marked �Do Not Mail� Mail routing defaults to �Window� User cannot edit routing �Patient or drug for patient is DO NOT MAIL� displayed During various order entry process (finishing, editing, renewing, etc) On detailed display of order Do Not MailOutpatient Pharmacy (continued)

168. 168 Dispense Limit (Qty)Outpatient Pharmacy Maximum quantity to dispense (number) for a specific time period (days) defined in EPL for a product Used to calculate default quantity for an order if value defined in EPL < result using schedule & days supply values If user enters a quantity exceeding this value warning message is displayed Override reason required Override reason stored with each Rx fill

169. 169 Dispense Limit (Days Supply) Outpatient Pharmacy Maximum days supply limit for product identified in the EPL Maximum upper limit for a drug = 90 days Maximum upper limit for a supply = 365 days Default upper limit for a CS = 30 days

170. 170 Limit Days Supply (new field) Created in Rx Patient Status file #53 Data type � set of codes (Y/N) Export with value of �Yes� for AUTH ABS +96 AUTH ABS -96 EMPLOYEE Rx Patient Status Enter/Edit (new option) Created to maintain all fields in Rx Patient Status file #53 Dispense Limit (Days Supply) Outpatient Pharmacy

171. 171 During order entry, the days supply default will be� Days supply defined for Rx Patient Status (order) if Limit Days Supply field is set to Yes Dispense limit (days supply) if defined in EPL for the product when Limit Days Supply field is set to �No� or null Days supply defined for Rx Patient Status (order) if dispense limit (days supply) IS NOT defined in the EPL for the product Dispense Limit (Days Supply) Outpatient Pharmacy

172. 172 Product Storage Requirements Product Identified in EPL Protect from light Inpatient Medications IV label Requiring refrigeration Inpatient Medications Unit Dose Pick List & Updated Pick List Pre-exchange Unit Report Automatic Replenishment/Ward Stock (AR/WS) Pick List

173. 173 Patient Specific Labels Product Identified in EPL Inpatient Medications Pre-exchange Unit Report Extra Units Dispensed BCMA Missing Dose e-mail and printed copy

174. 174 New BCMA Functionality Provides a means to quickly identify Controlled Substances Drugs that require a witness (2nd signature) and capture the 2nd signature High-Risk drugs that require follow-up and document the follow-up action Display Lab and Vital information based on the drug being administered Create/modify BCMA reports to support this functionality While some of the requirements shown are long standing BCMA requests, the implementation of PEPS allows BCMA to move forward with their implementation in a meaningful way. An example of this is the display of Labs and Vitals information. As many of you know the PRN dialog boxes in BCMA already display vitals information. But, since there was no way to determine what vital sign should be displayed for a specific drug... BCMA implemented a generic display of the �Big 5� Now with the implementation of PEPS specific information can be displayed with a specific order based on the relationship of the Lab or Vital to the drug. While some of the requirements shown are long standing BCMA requests, the implementation of PEPS allows BCMA to move forward with their implementation in a meaningful way. An example of this is the display of Labs and Vitals information. As many of you know the PRN dialog boxes in BCMA already display vitals information. But, since there was no way to determine what vital sign should be displayed for a specific drug... BCMA implemented a generic display of the �Big 5� Now with the implementation of PEPS specific information can be displayed with a specific order based on the relationship of the Lab or Vital to the drug.

175. 175 BCMA - Visual Queues �Provide a means to quickly identify�... Three new icons have been added to BCMA to quickly relay information related to a specific administration or order: Controlled Substance Drug that requires a Witness (2nd signature) High-Risk drug requiring a Follow-Up

176. 176 Questions?