July 2012

Pharmacy Data ManagementAssociated Files

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Course Objectives• Examine the need for complete and accurate support files in an

information system. Determine the benefits from efficient functioning and the risks associated with errors. Defend the notion that time spent configuring the drug file properly will save time and effort in other uses of the medical information system.

• Explain national standards as they relate to medications and drug files: consider ISMP recommendations for Sound Alike/Look Alike medications and abbreviations forbidden by national standards bodies such as The Joint Commission or ISMP and recommend an implementation plan.

• Recognize how an order is constructed in the system (schedule, dosage form, etc.) and the interrelationship between supporting files. Defend the reasons for the way inpatient and outpatient pharmacy quick orders are built and used.

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Menu Options Dosages ...Drug Enter/EditDrug Interaction Management ...Electrolyte File (IV)Lookup into Dispense Drug FileMedication Instruction File Add/EditMedication Route File Enter/EditOrderable Item Management ...Orderable Item ReportFormulary Information ReportDrug Text Enter/EditDrug Text File ReportPharmacy System Parameters EditStandard Schedule EditSynonym Enter/Edit Controlled Substances/PKI Reports…

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Dosages File

• The following options are available: • Auto Create Dosages• Dosage Form File Enter/Edit• Enter/Edit Dosages• Most Common Dosages Report• Noun/Dosage Form Report• Review Dosages Report

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Dosage Form File Enter/Edit

• Need to go to Dosages Menu to find it• Edits here affect every drug with that dosage

form!• Can associate one or more routes• Can change the verb• Must remove the prepositions• Can edit the nouns

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Dosage Form File, cont.NAME: TAB Comes from matching; do not editSelect MED ROUTE FOR DOSAGE FORM: ORAL// Can have more than oneVERB: TAKE// This will be on the label, so should be patient friendlyOTHER LANGUAGE VERB: Leave Blank!PREPOSITION: Leave Blank!OTHER LANGUAGE PREPOSITION: Leave Blank!Select NOUN: TABLET(S)// Can have more than one, will have doses of 1 and 2 of most noun(s) here createdNOUN: TABLET(S)//OTHER LANGUAGE NOUN: Leave Blank!PACKAGE: Both// Usually bothSelect NOUN:CONJUNCTION: Not usually used, but might be for topicals that have a %strength

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Dosage Form File, cont.NAME: INHL,ORALSelect MED ROUTE FOR DOSAGE FORM: ORAL//VERB: INHALE// OTHER LANGUAGE VERB:PREPOSITION:OTHER LANGUAGE PREPOSITION:Select NOUN: PUFF(S)// NOUN: PUFF(S)// OTHER LANGUAGE NOUN: PACKAGE: Both//Select NOUN:CONJUNCTION:

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Dosage Form File, cont.NAME: OPHTHALMIC,CRCSelect MED ROUTE FOR DOSAGE FORM: IN BOTH EYES//VERB: PLACE//OTHER LANGUAGE VERB:PREPOSITION:OTHER LANGUAGE PREPOSITION:Select NOUN:CONJUNCTION:

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Dosages

• Enter/Edit Dosages• Possible Dosages

• Single entity tablets & capsules, and some other single entity agents

• Auto Creation • Creates 1 and 2 (units)• May have to edit if 2 is inappropriate or add more dosages

• Can add/edit• Enter Package use Inpatient and/or Outpatient (if allowed)

• Local Possible Dosages• All other drugs ie creams, susp, MDIs• Add/edit individual (local) dosages

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Adding New Dosages• Dosages are onlyfor Single Entity tablets and capsules• PDM > Dosages > Dosages Enter/EditSelect Drug: HALOPERIDOL 10MG TAB CN709 Strength from National Drug File match => 10 MG

Strength currently in the Drug File => 10 MGEdit Strength? N//Rarely edit the strength here! Some apparent utility with very select IV push drugs when used with automated systems such as Pyxis – but may change with BCMA.Strength => 10 Unit => MGSelect DISPENSE UNITS PER DOSE: ??

Choose from: 1 10 IO 2 20 IO

Automatically created when drug was matched to the NDF. Does not mean they make sense so review (e.g., 1600 mg of ibuprofen)

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Adding New Dosages (cont.)Select DISPENSE UNITS PER DOSE: 3Are you adding '3' as a new POSSIBLE DOSAGES (the 3RD for this DRUG)? No//YEnter an 'I' for Inpatient, 'O' for Outpatient, 'IO' for both.PACKAGE: IOStrength => 10 Unit => MG

• Don’t add LPDs to get more choices for single entity tablets & capsules• Won’t be selectable (even though you will be able to add them)

• Dosages can not be imprecise i.e. 1-2 tablets (LPDs can)• Don’t use a leading zero for fractions of a dispense unit

• i.e. ½ tablet would be .5 NOT 0.5

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Deleting Inappropriate Dosages

The system automatically generates 1 and 2 on single entity solid oral dosage forms. Sometimes 2 is inappropriate.

PDM > Dosages > Dosages Enter/EditSelect Drug: 1457 NITROGLYCERIN 0.4MG TAB,S.L CV250

Strength from National Drug File match=> 0.4 MG

Strength currently in the Drug File => 0.4 MG

Edit Strength? N// Strength => 0.4 Unit => MG

Select DISPENSE UNITS PER DOSE: ?? Choose from: 1 0.4 IO 2 0.8 IO Select DISPENSE UNITS PER DOSE: 2 DISPENSE UNITS PER DOSE: 2// @ SURE YOU WANT TO DELETE THE ENTIRE '2' DISPENSE UNITS

PER DOSE? Y

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Deleting Inappropriate DosagesSelect DISPENSE UNITS PER DOSE:PACKAGE: IO

Strength => 0.4 Unit => MGEnter/Edit Local Possible Dosages? N //Select Drug:

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Adding Local Possible Dosages• For all other Drugs LPDs apply

• **Even if they have dosages associated with them

• PDM > Dosages > Dosages Enter/Edit• Enter past the Dosages section if it appears• Add any LPDs you will want to use in the Sigs• Include

• Article if needed (A, THE)• Quantity (1, 2 etc.)• Noun (TABLET, CAPSULE, SUPPOSITORY, ML)• What you type is what you get – Abbreviations do NOT expand MG do NOT

calculate• Avoid “Teaspoonful”, “Tablespoonful”, etc., (Use “ML”)

• Evidence suggests this leads to medication errors

• Delete Superfluous LPDs• 2 suppositories etc.

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Adding LPDsPDM > Dosages > Dosages Enter/EditSelect Drug: 2432 ACETAMINOPHEN/BUTALBITAL/CAFFEINE TAB CN103 Can select specific Drugs with the IEN (# column from the NSYN report)

This entry is marked for the following PHARMACY packages:

Outpatient

Select LOCAL POSSIBLE DOSAGE: ? Answer with LOCAL POSSIBLE DOSAGE

Choose from:1 CAPSULE IO2 CAPSULES IO

You may enter a new LOCAL POSSIBLE DOSAGE, if you wish (1-60 characters in length) Include number, noun, and article (if needed)

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Adding LPDsSelect LOCAL POSSIBLE DOSAGE: 1-2 CAPSULES Are you adding '1-2 CAPSULES' as a new LOCAL POSSIBLE DOSAGE (the 3RD for this DRUG)? No// YLOCAL POSSIBLE DOSAGE: 1-2 CAPSULES//PACKAGE: IO

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Deleting LPDsPDM > Dosages > Enter/Edit DosagesSelect Drug: 1595 BISACODYL 10MG SUPP,RTL Strength from National Drug File match=> 10 MGStrength currently in the Drug File => 10 MGEdit Strength? N//

Strength => 10 Unit => MGSelect DISPENSE UNITS PER DOSE: ??

Choose from:1 10 IO2 20 IO

Select DISPENSE UNITS PER DOSE: Select LOCAL POSSIBLE DOSAGE: ?

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Deleting LPDsAnswer with LOCAL POSSIBLE DOSAGE Choose from:

1 Suppository IO 2 Suppositories IO

LOCAL POSSIBLE DOSAGE : 2// @ SURE YOU WANT TO DELETE THE ENTIRE '2 SUPPOSITORIES‘ AS A LOCAL POSSIBLE DOSAGE? YSelect DISPENSE UNITS PER DOSE:PACKAGE: IOStrength => 0.4 Unit => MGEnter/Edit Local Possible Dosages? N //Select Drug: Ready to edit next Drug

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Look Up into Dispense Drug File

• Snapshot of medication information• Cost• Synonyms• NDC• Dosages• VA Drug Class Code

Can be of use for non-pharmacy staff to look up meds (billing)

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Medication Instruction

Select MEDICATION INSTRUCTION NAME: ??Choose from:(M) (MUST SEE PROVIDER FOR MORE REFILLS)A/A **AVOID ALCOHOL**AH **AVOID ALCOHOL**AOOH AT ONSET OF HEADACHEDD **DOSE DECREASED** Generally for patient instructionsDIN **DOSE INCREASED** Not for schedules (BID, Q12H, etc.).

Those go in standard schedulesFALL FOR ALLERGIESFAN FOR ANXIETYFAR FOR ARTHRITISFAS FOR ASTHMAFAX FOR ANXIETYFBC FOR BIRTH CONTROL

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Medication Instruction (cont.)FBP FOR HIGH BLOOD PRESSUREFBR FOR BREATHINGFCA FOR CALCIUMFCH FOR CHOLESTEROL CONTROLFCIRC FOR CIRCULATION

NAME: FFL// The abbreviation you will useSYNONYM: If you want more than one abbreviationEXPANSION: FOR FLUID// How it will look on labels and reportsPLURAL: Not usually usedINTENDED USE: OUTPATIENT ONLY// Inpatient, Outpatient, or bothFREQUENCY (IN MINUTES): No longer needed

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Medication Instruction (cont.)

NAME: AH//SYNONYM:EXPANSION: **AVOID ALCOHOL**//PLURAL:INTENDED USE: OUTPATIENT ONLY//FREQUENCY (IN MINUTES):

NAME: WF//SYNONYM: WFM//EXPANSION: WITH FOOD OR MILK//PLURAL:INTENDED USE: IN & OUTPATIENT//FREQUENCY (IN MINUTES):

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Medication Instruction File

• Enter or Edit common instructions• PM = Evening• AM = Morning• AP = Apply

Used in the EDIT ORDERABLE ITEMS option

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Medication RoutesSelect MEDICATION ROUTES NAME: ?? Choose from: BLOOD TEST BUCCAL BUCC BUCCAL DENTAL INFILTRATION BUCCDENTIF BUCCAL ORAL BUCCORAL BUCCAL SUBLINGUAL BUCCSL BY MOUTH BYMO CATHETER CAUDAL BLOCK CAUD CAUDAL EPIDURAL CAUDED CAUDAL EPIDURAL MISCELLANEOUS CAUDED MISC CAUDAL SUBCUTANEOUS INFILTRATI CAUDSC IF CHEW CHEW

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Medication Routes, cont. DEEP IM DENTAL DENT DENTAL INFILTRATION DENTIF DENTAL INTRAMUSCULAR DENTALIM DENTAL ORAL DENTORAL DENTAL ORAL TOPICAL DENTORALTOP DENTAL SUBCUTANEOUS DENTSCNAME: ORAL// Full nameABBREVIATION: PO// Abbreviation used in prescriptionsPACKAGE USE: ALL PACKAGES//

”National Drug File Only” will hide it from use locallyOUTPATIENT EXPANSION: BY MOUTH//

Include preposition, will show on labelOTHER LANGUAGE EXPANSION: Leave Blank!

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Medication Routes, cont.IV FLAG: mark “yes” if will process in the IV Package in RPMS

NAME: TOPICAL//ABBREVIATION: TOP//PACKAGE USE: ALL PACKAGES//OUTPATIENT EXPANSION: TO AFFECTED AREA//OTHER LANGUAGE EXPANSION:IV FLAG:

NAME: OPHTHALMIC//ABBREVIATION: OPH//PACKAGE USE: ALL PACKAGES//OUTPATIENT EXPANSION: INTO AFFECTED EYE(S) ReplaceOTHER LANGUAGE EXPANSION:IV FLAG:

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Medication Route File

• Enter or Edit common routes:• Ophthalmic = In Affected Eyes• Topical = To Affected Area

• The most common route (just one) can be added under “Edit Orderable Items.”

• Routes can be tied to Dosage Forms:• So that only certain ones show in the EHR for a given

Dosage Form (so providers can’t choose “IV” for an oral tablet, for example).

• This can be helpful, but editing can also have unintended consequences.

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Orderable Item Management

• Edit or Enter several pertinent fields:• Drug Text Entry for provider viewing if desired• Med Route• Schedule Type:• Can cause problems. Best to leave blank, especially for

drugs used in inpatient.

• Schedule• Patient Instructions• Synonym (for EHR med ordering selection)

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Edit Orderable ItemsPDM > Orderable Item Management > Edit Orderable ItemsSelect PHARMACY ORDERABLE ITEM NAME: IBUPROFEN Orderable Item -> IBUPROFENDosage Form -> TABList all Drugs/Additives/Solutions tied to this Orderable Item? YES//

Lists all of the Drug File Entries that are linked to this OIDispense Drugs:---------------IBUPROFEN 200MG TABIBUPROFEN 400MG TABIBUPROFEN 600MG TABIBUPROFEN 800MG TAB

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Edit Orderable Items (cont.)Are you sure you want to edit this Orderable Item? NO// YESNow editing Orderable Item:IBUPROFEN TABOrderable Item Name: IBUPROFEN// Could change the OI name (for typos)

This Orderable Item is Formulary.This Orderable Item is marked as a Non-VA Med.

Select OI-DRUG TEXT ENTRY:Can associate drug text (dosing tables etc.) with an OI.Displays in EHR for providers to review.

INACTIVE DATE:DAY (nD) or DOSE (nL) LIMIT:

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Edit Orderable Items (cont.)MED ROUTE: If blank will default to ORAL (can’t put ORAL in here) All non-orals must have a route entered here.SCHEDULE TYPE: Leave Schedule type blank for Outpatient. SCHEDULE: Q6H//PATIENT INSTRUCTIONS: WF FPA//Select SYNONYM: ?? Choose from: ADVIL MOTRINYou may enter a new SYNONYM, if you wishSelect SYNONYM: Can have as many as you want- Usually all Trade Names.

Some sites use classes for some drugs i.e. OCP or STATINS.

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Drug Text Enter/Edit

• Enter Text that can be viewed.• Enter for viewing under Orderable Item Edit• Can enter multiple texts under Orderable Item• Providers can view on EHR med order entry• Pharmacist can view on rpms med order entry• Drug Texts longer than one line are viewed under heading

“Restriction/Guidelines”• Can cut and paste dosing tables if they are in text format• Recommended over using Drug Message• Details are in the “Drug Text creation editing and usage”

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Standard ScheduleSelect Pharmacy Data Management Option: standard Schedule

EditSelect ADMINISTRATION SCHEDULE: ??Choose from:(5) TIMES/DAY 0700-1000-1300-1600-19003PM 1500AC 0700-1100-1600AC BID 0700-1630AC TID 0700-1130-1630AC&HS 0630-1130-1630-2100ACCU-CHEK AC&HS 0630-0632-1130-1131-1630-1631-2100-2101BB 0700BDABID 1000-2200BID (DIURETIC) 0700-1500BID (HYPOGLYCEMIC) 0700-1500BID (INSULIN) 0700-0701-0702-1630-1631-1632

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Standard Schedule (cont.)BIWBL 1100BS 1630DAILY 1000NAME: TID// The “shortcut” abbreviationOUTPATIENT EXPANSION: THREE TIMES A DAY// How it looks in the RxOTHER LANGUAGE EXPANSION: Leave Blank!TYPE OF SCHEDULE: CONTINUOUS// Cont, day of week, or one-timeSTANDARD ADMINISTRATION TIMES: 1000-1500-2200//

Not needed if not inpatient at your facilityFREQUENCY (IN MINUTES): 480//

Minutes between doses, calculated as if split evenly through a 24 hour day

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Standard Schedule (cont.)Select WARD:

Not needed if not inpatient at your facilityNAME: WEDNESDAY//OUTPATIENT EXPANSION: EVERY WEDNESDAY//OTHER LANGUAGE EXPANSION:TYPE OF SCHEDULE: DAY OF THE WEEK//STANDARD ADMINISTRATION TIMES: 1000//Select WARD:

NAME: ONCE//OUTPATIENT EXPANSION: ONCE//OTHER LANGUAGE EXPANSION:TYPE OF SCHEDULE: ONE-TIME//

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Standard Schedule Edit

• Inpatient and Outpatient dosing schedule:• Sets administration times for standard schedules,

e.g., Daily=0900.• Inpatient schedules should match facility

administration policy.• Obsolete schedules should be deleted.• Used in the EDIT ORDERABLE ITEMS option.

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Putting it all together

• With drug file entry, creates a prescription and (if using) a label

• So…where are the nouns, verbs, and routes seen?