Paperless Refill LCDR Robin A Bartlett Pharm D

Paperless Refill LCDR Robin A. Bartlett, Pharm. D Clinical Applications Coordinator Cherokee Indian Hospital

Objectives l l l How to activate paperless refill pharmacy site parameter option How to process pharmacy-only medication refills utilizing paperless refill How to process outpatient clinic-initiated paperless refill requests How to approach coding queue issues with paperless refill implementation How to reconcile missing purpose of visits associated with paperless refill

Work Flow Considerations l May need to change pharmacy refill policies facility-wide to ensure refills available to optimize paperless refill processing – Cherokee implemented for all new prescriptions: l 30 days supply with 11 refills with billable insurance and l 90 days supply with 3 refills for patients without insurance – EHR Med Quick Orders designed to reflect this policy Pharmacist data entry essential – may require work flow redesign to assign new technician duties l Check EHR pending order queue for clinic refill requests on regular basis l Pharmacy visits with unspecified diagnosis and missing POV may increase medical records coding queue error report volume l

Advantages l Eliminates need for paper documentation of pharmacy only or outpatient clinic-initiated refill visits (PCC or PCC+) l Automatically prompts pharmacist to select POV for each medication refill processed l Purpose of Visit (POV) options pull from patient-specific problem list l Automatically populates necessary EHR fields to complete pharmacy visit

Activating Paperless Refill l CORE l HEAL – Health systems… l IHSP – IHS Specific Pharmacy Site Parameters l IHS – IHS Pharmacy Site Parameters – Paperless refill option: “YES” – Pharmacy visit location: “Pharmacy”

Processing Refills Outpatient Pharmacy Manager – Select IHS Kernel Option: CORE – Select IHS Core Option: HEAL – Select Health Systems Option: PSM OR – Select IHS Kernel Option: (shift 6) ^PSM Outpatient Pharmacy Manager – (Your facility may have different acronym) Outpatient Pharmacy software - Version 7. 0 Division: CIHA 7247 You are logged on under the CIHA division. Number of Days For Chronic Med Profile: (1 -999): 90// Pre-Select PMI/Chronic Med Profile Device? (Y/N) ? No// (No) Select LABEL PRINTER: HOME// VT Right Margin: 80// OK to assume label alignment is correct? YES// Select Outpatient Pharmacy Manager Option: RX (Prescriptions) l

Processing Refills l Rx (Prescriptions…) – Patient Prescription Processing – Barcode Rx Menu. . . – Complete Orders from OERR – Discontinue Prescription(s) – Edit Prescriptions – List One Patient's Archived Rx's – Reprint an Outpatient Rx Label – View Prescriptions Select Rx (Prescriptions) Option: Patient Prescription Processing l Select PATIENT NAME: DEMO, GEORGE l

Patient Information DEMO, GEORGE <A> PID: 123 -12 -1234 (HRN: 9) Ht(cm): 152. 40 (04/11/2005) DOB: JAN 1, 1930 (77) Wt(kg): 72. 27 (03/29/2005) SEX: MALE Eligibility: CHS AND DIRECT vs. DIRECT ONLY vs. PENDING VERIFICATION Insurance Information: PRIVATE - RX PAID PRESCRIPTIONS - Grace Period: L. L. C - Grace Period: 3 KANAWHA-NON-BEN - Grace Period: 3 Disabilities: P. O. BOX 0000 CHEROKEE PHONE: NORTH CAROLINA 28719 Prescription Mail Delivery: Regular Mail Select Action: Next Screen// Allergies Verified: PEANUT OIL, BEE POLLEN, Adverse Reactions Pending Clinic Appointments: FEB 15, 2007@15: 30 WILDCATT-PEDIATRIC/WCC NEW-30 (24 days) EA Enter/Edit Allergy/ADR Data PU Patient Record Update DD Detailed Allergy/ADR List EX Exit Patient List Select Action: Quit//

Patient Medication Profile # RX # 1 2635654 2 2623397 3 2635647 4 2635648 5 2635649 6 2635650 7 2623398 8 2635651 9 2635652 10 2635653 ISSUE LAST REF DAY QTY ST DATE FILL REM SUP DRUG FERROUS SULFATE= 325 MG TAB 90 FOSINOPRIL= 40 MG TAB 30 GLYBURIDE= 5 MG TAB 360 HYDROCHLOROTHIAZIDE= 25 MG TAB 30 LEVOTHYROXINE= 0. 1 MG TAB 30 METFORMIN 500 MG *XR* TAB 120 METHOCARBAMOL 750 MG TAB 40 METOPROLOL= 50 MG TAB 60 PIOGLITAZONE= 30 MG TAB 30 SIMVASTATIN= 40 MG TAB 30 PU Patient Record Update PI Patient Information Select Action: Next Screen// ? ? NO New Order SO Select Order A 12 -22 A 11 -29 A 12 -22 A 01 -22 A 12 -22 A 11 -29 A 12 -22 11 30 11 -29 11 30 12 -22 3 90 12 -22 11 30 01 -22 11 30 12 -22 11 30 11 -29 1 10 12 -22 11 30 01 -22 10 30

Additional Options Select Action: Next Screen// ? ? The following actions are also available: RP Reprint (OP) DN Down a Line RN Renew (OP) RD Re Display Screen DC Discontinue (OP) PT Print List RL Release (OP) PS Print Screen RF Refill (OP) > Shift View to Right PP Pull Rx (OP) < Shift View to Left IP Inpat. Profile (OP) SL Search List OTH Other OP Actions QU Quit Enter RETURN to continue or '^' to exit: Select Action: Next Screen// RF LS Last Screen FS First Screen GO Go to Page + Next Screen - Previous Screen ADPL Auto Display(on/off) UP Up a Line

Refill Processing Select Action: Next Screen// RF RF Barcode Refill? NO// Select Orders by number: (1 -13): 10 FILL DATE: (12/22/2006 - 1/22/2007): TODAY// (JAN 22, 2007) MAIL/WINDOW: WINDOW// WINDOW METHOD OF PICK-UP: CLERK: RAB// RAB EXPIRES: (1/22/2007 - 12/31/2699): T+6 M// (JUL 21, 2007) BILL STATUS: AUTO BILL// AUTO BILL WANT TO ADD/EDIT INSURER INFO// Now refilling Rx# 2635653 Drug: SIMVASTATIN= 40 MG TAB *** NO RESULTS FOR ALT/SGPT SINCE 01 -22 -06***(LAB) Qty: 30 Sig: TAKE ONE TABLET BY MOUTH EVERY EVENING TO LOWER CHOLESTEROL

Pharmacy Only POVs Is this a Pharmacy Only Visit (Paperless refill)? ? Yes// Historical POVs: 1) 427. 31 Atrial Fibrillation 2) 989. 81 Toxic Effect of Asbestos 3) 401. 9 hypertension 4) 250. 0 diabetes 5) 272. 4 Hyperlipidemia Please select the appropriate Problem List diagnosis for the drug prescribed. : (1 -5): ^ (Use shift 6 (up-hat) if there are no POV present to match diagnosis) Active Problem list: 1) 427. 31 Atrial Fibrillation 2) 989. 81 Toxic Effect of Asbestos 3). 9999 hypertension 4). 9999 diabetes 5) 272. 4 Hyperlipidemia 6) 314. 01 ADHD 7) 304. 00 NO NARCOTICS PER PAIN GROUP 8). 9999 no opiods!!! 9) 381. 4 otitis media 10) 493. 90 asthma Please select the appropriate Problem List diagnosis for the drug prescribed. : (1 -10): 5 or ^ (Use shift 6 (up-hat) if there are no POV present to match diagnosis)

Diagnosis Narrative l l Please enter a narrative describing the diagnosis. Diagnosis Narrative: – ^ (DO NOT Shift 6 (up-hat) – Leads to missing POV or narrative uncoded – – – diagnosis. 9999 – coding will send back Type narrative for preexisting condition (i. e. Hyperlipidemia) – Coding can replace. 9999 uncoded diagnosis code with appropriate ICD-9 code Do not “GUESS” with non-obvious medications (i. e. amitriptyline – sleep disorder, neuropathic pain, depression, etc. ) Unless you “KNOW” that the patient has this diagnosis, you should NOT choose a common use [May be adding diagnosis to patient’s historical POV list that patient doesn’t actually exhibit (i. e. fosinopril – hypertension vs. microalbuminuria)] Refer back to patient’s Problem list and Historical POVs in EHR to choose an appropriate diagnosis If appropriate diagnosis NOT present, choose a previously entered diagnosis for this refill (i. e. fosinopril – diabetes) Designated refill POV does NOT associate specifically with med refilled

Paper vs. Paperless Refill Documentation l Think about how you would have documented refill via Pharmacy Only Visit on paper – PCC form – PCC plus form Same basic concepts with paperless refill system l Specific diagnosis NOT needed for each medication diagnosis when not present in patient’s active problem list or historical POVs l

Routing Slip l Patient Registration Requested Refills

Routing Slip l Clinic EHR, Paperless Refill, Automated Refill Line Refill Requests

Clinic Refill Processing Rx (Prescriptions…) – – – – Patient Prescription Processing Barcode Rx Menu. . . Complete Orders from OERR Discontinue Prescription(s) Edit Prescriptions List One Patient's Archived Rx's Reprint an Outpatient Rx Label View Prescriptions Select Rx (Prescriptions) Option: Complete Orders from OERR

Clinic Requested Refills Select Rx (Prescriptions) Option: Complete Orders from OERR Select By: (PA/RT/PR/CL/E): PATIENT// All Patients or Single Patient: (A/S/E): SINGLE// Select Patient: ? ? Please enter a minimum of two (2) characters. Enter Patient's name whose med orders are to be completed. DEMO, GEORGE Select Patient:

EHR Pharmacy Orders

Pending EHR Refill Orders ----------------------PENDING---------------------15 FERROUS SULFATE= 325 MG TAB Refill Request Rx #: 2635654 Select Action: Quit// 15 Processing Refill Request for Rx 2635654 FILL DATE: (12/22/2006 - 1/22/2007): TODAY// (JAN 22, 2007) MAIL/WINDOW: WINDOW// WINDOW METHOD OF PICK-UP: Now refilling Rx# 2635654 Drug: FERROUS SULFATE= 325 MG TAB Qty: 90 Sig: TAKE ONE TABLET BY MOUTH THREE TIMES A DAY WITH FOOD FOR IRON REPLACEMENT; MAY COLOR STOOLS BLACK Is this a Pharmacy Only Visit (Paperless refill)? ? Yes// NO # RX # 2 2635654 DRUG ISSUE LAST REF DAY QTY ST DATE FILL REM SUP FERROUS SULFATE= 325 MG TAB 90 A 12 -22 01 -22 10 30

Pharmacy Statistics

Rx Refills

Pharmacy Only Visits

Coding Queue Issues l Primary vs. Secondary Diagnosis – – Medication diagnosis = primary POV Issue of repeat prescriptions = secondary POV Automatic priority setting with Paperless Refill Pharmacy Only – Non-billable visit Uncoded Diagnosis (0. 9999) l Missing Purpose of Visits l Multiple visits or locations with same visit date l – clinic + pharmacy or 2 pharmacy visits l Primary Provider Errors – technician vs. pharmacist l Lock-out 30 days after visit

Error Reports HEAL Health Systems. . . PCC MGR Patient Care Component. . . PCC Manager Menu. . . PCC Patient Care Data Entry Menu. . . DEU Data Entry Utilities. . . SUP Data Entry SUPERVISORY Options and Utilities. . . VRR Visit Review Report. . .

Error Reports ZERO PPPV MRG TXER INP ALL ECD CINC DTCR V 12 Visits with a Zero Dependent Entry Count Visits with No Primary Provider and/or POV Multiple Visits on one day - Potential Merges Data Transmission Transaction Errors Inpatient Visit Review All of the Above Visit Error Code Description Menu. . . Scheduling Check-In Created Visits Not Yet Coded DTC Visits with No Billing Link Visits at 12: 00 with No Billing Link

Error Tracking

RX Errors

Organizing Error Reports l Separate by each pharmacist l Patient chart number l Patient name l Date of Service

Coding Queue Reports HEAL Health Systems. . . PCC MGR Patient Care Component. . . PCC Manager Menu. . . PCC Patient Care Data Entry Menu. . . ENT Enter/Modify/Append PCC Data. . . EHRC EHR/PCC Coding Audit Menu. . . EHRD EHR/PCC Coding Audit for Visits in Date Range

Coding Queue Reports You should limit your date range to no more than 7 days. Viewing more than 7 days worth of visits may take a while to process. Enter Beginning Visit Date: 1/1/07 (JAN 01, 2007) Enter Ending Visit Date: 1/7/07 (JAN 07, 2007) Enter a code indicating what LOCATIONS/FACILITIES are of interest: A// Enter a code indicating what CLINICS (IHS clinic code) are of interest: A// Enter a code indicating what HOSPITAL LOCATIONS are of interest: A// Enter a code indicating which providers are of interest: A// Select visits based on chart deficiency reason: D/ Do you wish to continue? Y//

Visit Sort Options Select one of the following: N Patient Name H HRN D Date of Visit T Terminal Digit of HRN S Service Category L Location of Encounter C Clinic O Hospital Location P Primary Provider A Chart Audit Status R Chart Deficiency Reason (Last one entered) I Has Medicare/Medicaid or PI How would you like the list of visits sorted: H// D

Coding Queue Actions # VISIT DATE PATIENT NAME HRN FAC D N M A G Display Visit Note Display Modify Visit Append to Visit Merge S R C H O HOSP LOC CL INS PRIM PROV STATU Status Update Resort List Chart Audit History Health Summary One Patient's Visits X B F E T Visit Delete B Merge 2 Diff Dates F Move V File E Move V File 2 Dates Change Date/Time

Pharmacy POV Reconciliation l Missing POV Error Report – Each pharmacist should reconcile their own missing purpose of visits l Missing pharmacy POV report multi-factorial – Paperless Refill – Outside provider new prescription – Release returned to stock medications – Release from hold medications – Outlying clinics

POV Reconciliation Selecting appropriate EHR Visit (date ranges) l EHR Medication Management Tab l – Look at issue and last refill dates for desired date – May need to double click on each medication that has previous issue date and scroll to refill dates to find Clinical Reports Tab – Pharmacy – All Outpatient Meds l Problem List/POV Tab l – Select corresponding diagnosis from historical POV or problem list and designate new vs. refill l Working with locked-out visits

QUESTIONS ?