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7 th Annual Pharmacy Informatics Conference Clinic Orders – Impact on Pharmacy Processes and 7 th Annual Pharmacy Informatics Conference Clinic Orders – Impact on Pharmacy Processes and Overview of the Controlled Implementation Effort Stephen Corma, RPh Pharmacist Consultant , Bar Code Resource Office of Informatics & Analytics April 3, 2014

Clinic Orders Ø Inpatient Medications for Outpatients (IMO) allowed providers to order inpatient medications Clinic Orders Ø Inpatient Medications for Outpatients (IMO) allowed providers to order inpatient medications for outpatients through CPRS Ø Supported pharmacy dispensing Ø Did not support medication administration through BCMA Ø Clinic Orders is the nationally supported solution allowing inpatient medications to be administered to outpatients using BCMA. VETERANS HEALTH ADMINISTRATION 1

Presentation Objectives: Following this presentation, attendees will: Ø Understand how IMO & clinic orders Presentation Objectives: Following this presentation, attendees will: Ø Understand how IMO & clinic orders differ Ø Outline Quick Order modifications required for successful implementation Ø Examine the Impact of clinic orders on pharmacy processes Ø Identify how to obtain additional implementation support VETERANS HEALTH ADMINISTRATION

IMO vs. Clinic Orders IMO Ø Provided the ability to order inpatient medications for IMO vs. Clinic Orders IMO Ø Provided the ability to order inpatient medications for outpatients Ø Was not designed to work with BCMA Ø Local workaround created to link IMO and BCMA together (pseudowards) VETERANS HEALTH ADMINISTRATION Clinic Orders Ø works directly in the clinic where the medication is ordered Ø Medications administered in clinics using BCMA are recorded in the same file as in the inpatient setting Ø Does not require the use of workarounds to link IMO and BCMA Ø A new view was added to BCMA and displays clinic orders separately 3

Clinic Order Pathway -ORDER DIALOGPSJ PAT OE Y PATIENT ADMITTED? IP MED (UD OR Clinic Order Pathway -ORDER DIALOGPSJ PAT OE Y PATIENT ADMITTED? IP MED (UD OR IV) N PAT LOCATION (FILE #44) ADMIN IP MEDS? ? Y Appointment D/T Today or Future? N N ONLY IV ORDERABLE ITEM SELECTABLE Y CLINIC ORDER! (UD OR IV) VETERANS HEALTH ADMINISTRATION -OPT IV/INFUSION- NOT A CLINIC ORDER! 4

What Clinic Orders is not… Ø Not mandated for use by any national office What Clinic Orders is not… Ø Not mandated for use by any national office or directive Ø Not the ultimate solution for documentation of medication administration in all settings Ø Not compatible with non-traditional workflows Ø Sites will need to evaluate their workflows to determine if a possible Clinic Order site can implement from a practical perspective, or can they modify their current workflow to accommodate clinic orders VETERANS HEALTH ADMINISTRATION 5

Traditional Inpatient Workflow VETERANS HEALTH ADMINISTRATION 6 Traditional Inpatient Workflow VETERANS HEALTH ADMINISTRATION 6

Examples of Non-Traditional Workflow Ø Any area where medications are ordered verbally and administered Examples of Non-Traditional Workflow Ø Any area where medications are ordered verbally and administered by the nurse at the bedside without pharmacy involvement Ø Procedural areas where the provider and nurse are at the patient’s bedside Ø Areas that work from ‘standing orders’ such as flu clinics NOTE: Future versions will work to provide a solution to using Clinic Orders in areas with a non-traditional workflow. VETERANS HEALTH ADMINISTRATION 7

Quick Order Modifications Ø Existing UD and IV quick orders (for IP MEDS) will Quick Order Modifications Ø Existing UD and IV quick orders (for IP MEDS) will function for clinic orders Ø You build a Clinic UD/IV order exactly the same way that an Inpatient UD/IV quick order is built-they are interchangeable Prerequisites: ü the patients can’t be admitted ü the patient location must be an authorized clinic ü the appointment date/time is either today, now or in the future VETERANS HEALTH ADMINISTRATION 8

Quick Order Modifications (Considerations) Ø Evaluate each clinic area to understand the current medication Quick Order Modifications (Considerations) Ø Evaluate each clinic area to understand the current medication ordering process Ø Determine what modifications may be required to implement Clinic Orders in that area Ø Coordinate with the Clinical Applications Coordinator for changes to existing Quick Order dialogues Ø Changes can include linking the medications quick orders to the updated Clinic order medication order screen Ø Create new medication orders if orders are currently done via a nursing text order, administered in clinic (with or without status of “done”) VETERANS HEALTH ADMINISTRATION 9

Quick Order Modifications (Considerations) Important Notes: Ø A Quick Order type of “Clinic Order” Quick Order Modifications (Considerations) Important Notes: Ø A Quick Order type of “Clinic Order” does not yet exist Ø The CPRS development team is currently working on creating one, along with a tool that can be used to convert existing UD & IV Quick Orders types to a clinic order type Ø Nursing text and Pharmacy orders created as “administered in clinic” (with or without status of done) will have to be manually converted Ø A method to identify nursing text orders and “administered in clinic” orders is also being considered VETERANS HEALTH ADMINISTRATION 10

Impacts to Pharmacy Work Flow 1) Clinic Orders must be entered through CPRS Ø Impacts to Pharmacy Work Flow 1) Clinic Orders must be entered through CPRS Ø Pharmacy cannot enter clinic medications through “Back Door” Pharmacy Ø Pharmacy cannot edit the location chosen by provider during finishing/verification Ø Some sites still use alternative processes for order entry other than CPOE (paper orders, printed consults, printed progress notes, etc. that print in Pharmacy for “Back Door entry”) VETERANS HEALTH ADMINISTRATION 11

Impacts to Pharmacy Work Flow Process needs to be evaluated and modified as needed: Impacts to Pharmacy Work Flow Process needs to be evaluated and modified as needed: Ø Ø Ø Pharmacists would have to enter orders directly into CPRS and be given necessary keys & options to do so Conversion to Quick Orders for providers is another option Use of COTS software (example – Vista Chemotherapy Manager for Oncology clinic) VETERANS HEALTH ADMINISTRATION 12

Impacts to Pharmacy Work Flow 2) Clinic orders currently cannot be entered on an Impacts to Pharmacy Work Flow 2) Clinic orders currently cannot be entered on an admitted patient Ø CPRS v 30 b will introduce a new order dialog for CLINIC ORDERS that will allow the ordering of CLINIC orders on admitted patients Ø The release date for CPRS v 30 b has yet to be determined Ø Education to providers is key as CPRS does not “block” them from entering a clinic order on an inpatient Ø A warning is presented to the provider on the chosen location, but that may not be sufficient to prevent errors without proper training VETERANS HEALTH ADMINISTRATION 13

Impacts to Pharmacy Work Flow 3) The Clinic must be set to allow Clinic Impacts to Pharmacy Work Flow 3) The Clinic must be set to allow Clinic Orders (IMO) Ø A Clinic Order is a unit dose or IV order entered into a clinic that has been configured to allow clinic medications Ø The way you set up IMO is the same way you set up Clinic Orders Ø Consideration: should orders be allowed to survive through an admission/Parameters to control this are in the clinic definition file 53. 46. In most cases, the answer is “no”, but there may be exceptions – ED, Dialysis, Oncology VETERANS HEALTH ADMINISTRATION 14

Impacts to Pharmacy Work flow 4) Finishing/verification of Clinic Orders Ø Staffing: Who will Impacts to Pharmacy Work flow 4) Finishing/verification of Clinic Orders Ø Staffing: Who will finish/verify Clinic Orders? Ø Where will missing dose requests & pre-exchange reports print? Same printer as inpatient or separate printer in different location? Ø Do you have dedicated (separate) staff for inpatient & outpatient Pharmacies or does staff rotate through all areas? Ø Are pharmacists who will be assigned to finish/verify the orders competent or require additional training on UD & IV orders? Ø Can the Pharmacists assigned to Clinic Orders handle the additional workload or do resources need to be realigned? VETERANS HEALTH ADMINISTRATION 15

Impacts to Pharmacy Work Flow 5) Workload Determinations Ø There is not a standard Impacts to Pharmacy Work Flow 5) Workload Determinations Ø There is not a standard mechanism for obtaining the number of medication orders written in a particular clinic due to the variety of ways those orders can be entered Ø One solution - estimate workload by obtaining the number of medications dispensed from an Automated Dispensing Cabinet (Pyxis, Omnicell) in an area to get the number of medications dispensed from a particular cabinet per day Ø If your facility does not have an Automated Dispensing Cabinet (ADC), a representative sample of progress notes that contained medication administrations could be obtained and manually counted as an estimate VETERANS HEALTH ADMINISTRATION 16

Impacts to Pharmacy Work Flow 6) Automated Dispensing Cabinets (Pyxis/Omnicell) Are automated dispensing cabinets Impacts to Pharmacy Work Flow 6) Automated Dispensing Cabinets (Pyxis/Omnicell) Are automated dispensing cabinets stocked with all the meds the clinic needs? What is your process for supplying meds not normally stocked? How do you handle meds in short supply, on recall, or out of stock? Is there a master list or a direct lookup of drugs available for each of the automated dispensing cabinets readily available to Pharmacists as a reference? Ø Are drugs stocked in cabinets marked as ward stock in drug file? ( option located under menus for auto replenishment) Ø Ø VETERANS HEALTH ADMINISTRATION 17

Impacts to Pharmacy Work Flow 7) Policies & Procedures Ø What will constitute early Impacts to Pharmacy Work Flow 7) Policies & Procedures Ø What will constitute early or late administrations? Ø How long will the medication stay active? Ø Typically, administration frequencies for outpatient areas will be “now” or “once”. Explore other situations that may be specific for a particular area such as monthly or day-of-week schedules may be appropriate Ø Will there be a need to create additional clinic specific frequencies? If yes, what will those be? VETERANS HEALTH ADMINISTRATION 18

What is the ‘Controlled Implementation’? Ø The Bar Code Resource Office will be responsible What is the ‘Controlled Implementation’? Ø The Bar Code Resource Office will be responsible for providing implementation support to the facilities Ø Since BCRO staff were not directly involved in the testing and implementation of the patches, it is important for BCRO to work with the sites to see “firsthand” the steps and processes needed to get Clinic Orders up and running at a facility Ø The technical documentation released with the software does not address pitfalls and problems sites may run into during implementation Ø The team goal is to identify these pitfalls and problems, document them, and publish them as “Lessons Learned” that other sites can be aware of prior to their implementations VETERANS HEALTH ADMINISTRATION 19

Controlled Implementation Status VETERANS HEALTH ADMINISTRATION 20 Controlled Implementation Status VETERANS HEALTH ADMINISTRATION 20

Additional Implementation Support BCRO has created a Share. Point site to house implementation documents Additional Implementation Support BCRO has created a Share. Point site to house implementation documents and lessons learned to support future implementations, and authored the “Operational Guidelines for Successful Implementation of Clinic Orders”. Education regarding all features of IMR 5 and IMR 6 has been presented on monthly Bar Code Medication Administration National Calls. Additional information should be obtained from your local BCMA Coordinator. General information is available from the BCRO Website http: //vaww. va. gov/barcode/ BCRO Clinic Orders Share. Point https: //vaww. portal 2. va. gov/sites/bcro/Bar. Code/Pages/BCMA%20 Clinic%20 Orde rs. aspx VETERANS HEALTH ADMINISTRATION 21

Additional Implementation Support VA Documentation library, which can be found at http: //www. va. Additional Implementation Support VA Documentation library, which can be found at http: //www. va. gov/vdl/application. asp? appid=84 Pharmacist training for completion of UD and IV orders can be found at the PBM education site on Moodle: http: //vapharmacytraining. remote-learner. net/login/index. php How do I get more help if needed? If the issue is a purely technical issue (installation problems, error messages, etc. ), you should enter a Remedy ticket (or have your local IT support person enter it for you if you do not have access to Remedy). For any other issues, send a message to the Bar Code Resource Office (BCRO) and our office will review the issue and provide further assistance. VETERANS HEALTH ADMINISTRATION 22

Questions? VETERANS HEALTH ADMINISTRATION 23 Questions? VETERANS HEALTH ADMINISTRATION 23