Download Meditechnicalities

Meditechnicalities
The IN Group
MUSE International
May 30, 2012
Background
Every implementation gives additional insight
into technical issues that need to be addressed
to optimize the MEDITECH environment. This
session will focus on lessons learned in Magic,
CS and 6.0 installations of Pharmacy and
pharmacy related modules. It will include
discussion on how to add additional functionality
and improve patient safety with eMAR, POM,
and RXM . WE will also discuss recent and
upcoming enhancements
Pharmacy
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Multiple Sites/Facilites now or later
– Build for each site not .dft
Order From POM = Y
Additive = Y
– Items flagged as “Y” do not need to have an IV route associated in the
routes fo administration field. If something is always an additive
removing the IV routes will prevent a physician from changing the route
to IV on a MED type order.
IV Fluid = Y
Premix = Y
– Premix Piggyback Iv’s are problematic in that they need to be ordered in
mg or grams rather than volume (mls). Meditech discouraged the use
of a dummy carrier but could not provide a better solution.
IV Order Strings – where to build
– Intermittent IV’s (IV Type by SIG)
– Continuous IV’s (IV Type by Rate)
PHA Drug Dictionary
PHA Drug - Dispensing
PHA Drug – Ordering (INJ)
Order Strings – For Location
Pharamcy Location
Nomenclature Dictionary
Multiple codes per drug only one
in pharmacy – watch DR reports!
PHA Drug Ingredients
RxCUI is a multiple field for NPR
reports even though only one
populates
CS PHA 8496 (new)
When there are multiple routes defined on a drug, then the system defaults in a new
standard ".ROUTE" for these DM override orders.
The new .ROUTE is not allowed to be attached to a drug in the route lookup in the Drug
Dictionary.
The .ROUTE value is also unavailable in the Order Type Dictionary, Pharmacy Oncology - Drug Mapping Dictionary, Drug - Quick Add Non Formulary dictionary.
CS PHA 8496 introduced the ability to specify routes for IV orders.
In the releases without CS PHA 8496 this solution only applies to MED type orders.
Dispensing Machine orders that use an IV order type (created from drugs flagged as
IV Fluid) use the Route defined in the Order Type Dictionary.
The releases with CS PHA 8496 the orders look to the Drug Dictionary and set up
".ROUTE" for all orders.
In 6.x releases the .ROUTE is added to the Route of Admin Dictionary and you are able
to add eMAR Assessments to it.
PHA Rules
Start Date Check – Go-Live
You only need this once hopefully
Back Order Warning
Black Box Warning (w/link)
This medication contains a Black Box Warning,
please review additional information uses web
link
Dispense Check
Please enter a quantity to dispense”
Prompts user to dispense a quantity > 0 for PRN
orders
Dose per kg Comment
This will calculate and display
mg/kg DOSE for order
File Mg/Kg in comments
This will file the DOSE in mg/kg
in the label comments for the
order
Multiple Site INV Check
This will confirm the appropriate
inventory is associated with a given
order – Prevents Ordering at wrong
SITE hopefully
Duplicate Generic 2 hr check
This is a more “in your face” duplicate
generic check
Should also be built as POM Rule –
attached to specific medications
Duplicate Generic 12 hr Check
Duplicate Generic 24 hr Check
Order Set of Origin from POM
• A CDS attached in the Order Type
dictionary can allow the OE order set
name to be displayed in PHA under the
Queries tab, so the pharmacist will know
which set the order originated from
The setup and the attribute used are shown below:
eMAR / BMV
• Settings in Pharmacy Drug Dictionary
are global for ALL Sites/Locations of
Database
PCS Assessments
eMAR / BMV RULES
• Override setting for particular sites or location with the
use of RULES
• Replace common medication comments related to
administration with rules – i.e. do not exceed amount
of acetaminophen in 24 hours - use rules to total
acetaminophen content and display for user
administering medication when approaching do not
exceed amount – additional rule with BMV could
prevent administration if certain amounts exceeded.
• Prevent administration that could cause a potential
ADE.
Acetaminophen 24 hour rule
Displays cumulative
acetaminophen dose for past 24
hrs once past trigger value
Check Number of Doses and
Levels
This rule displays the number of
doses administered and
previous levels if done.
Black Box Warning (eMAR)
PCS
• IV Flow sheet
– Use rules to monitor and notify pharmacy when new
IV bag is needed.
• Surveillance - Trigger Clinical Notifications – send to
Nursing status Board
PCS – Surveillance
(Sepsis)
If 2 or more of section A
marked……message sent to nursing
(Risk of SIRS)
If 2 or more section A and 1 (except
“None”) from section C then nursing and
pharmacy get message
Severe Sepsis Screening.
POM Order Sets
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Create Style Guide – consistency from set to set is important.
– Headers / Order of Sections / Order of items within sections
– Medications – grouped by drug class or not – alphabetical or importance
• Pain scales – separate sections for each?, be consistent
• IV Solutions – 0 ml/hr plus POM RULE to force change
• Pom Display Names
All order sets should be restricted to appropriate OE site – failure to restrict
may effect the filing time for modifications to the set.
Use Taper to DC orders in hours rather than days
Use of Protocol Tables
Dosing Sets precautions
Multi-facility Systems should consider separate Order Sets for each facility.
MIS and Pharmacy Dictionary settings drive functionality
POM Rules
Interaction Conflict Group
Default POM Order Type
Protocol Tables
Dosing Sets
Overriding the Default IV Type
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To control the Order Type for IV’s with Additives when entered via OE sets.
Example of NS 250 mL with an additive such as KCL. Additive could be in Primary or
Intermittent IV.
When an OE set for an IV is built with these items the order type will default to IVPB,
from the CDP setting.
To change the order type to a continuous IV type (CONTIV) the order in the set can
be modified.
On the General Information tab, change the procedure to <MED> and enter the same
additive as a Medication and the enter the same dose .
Go to the Pha IV tab and enter the IV fluid of NS5. (A lookup here will show what IV
fluids have been defined in the Drug Dictionary under the IV Fluid Strings tab.)
You now have access to the Med Order Type tab and can enter the CONTIV order
type.
Go back to the General Information screen and change the Procedure back to <IV>.
Check for Allergy Rule
Please update patient's allergy
before proceeding
Check IV Rate not 0 ml/hr
All maintenance fluids on Orders
sets set to 0 m/hr – required
physician to change from 0
before filing
Black Box Warning –POM
POM Order Check for
Appropriate Route
Drug specific – not to allow
certain IV routes – can also be
controlled by additive = “Y”
Medication Location Restriction
Utilizes Drug CDS to control
where medication can be
ordered
Check Duplicate PRN Reason
Doesn't account for free text,
etc. But in theory is good
Pediatric Specific
Required PT Weight
Hard Stop – weight required for
PEDS
Created Override for certain
meds
Rounding Warning (Dosing Set)
Warning to remove “rounding”
feature of Dosing Set for
patients < 5 Kg
< 13YO – Dose as Adult
6.x Changes
CS PHA 9808:Attach a CDS-type Protocol to
Medication Orders
• With this enhancement, Pharmacy is able
to display a CDS type protocol on an order
ordered from Order Management (OM).
FOC OM 5132 - Ability to View Order/Amb Order Option
Details Prior to Selection
• Allow for a complete detailed view of an
order/ambulatory order option without
selecting the option.
• This view will be accessible by clicking on
the Detail cell for any Orders/Amb Orders
options displaying on a selection table.
FOC OM 3425:
Enhancements to Amb Orders / Convert / Reconcile
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This DTS introduces a small portion of Development Design Project 12803
which supports several access and user interface
(UI) changes to the Reconcile and Convert screens. Specifically, the
following changes were made with this DTS:
1. OM Access Dictionary - Lookup options for Reconcile were changed from
Yes/No to Edit/View/No.
2. OM Access Dictionary - Lookup options for Convert were changed from Yes/No
to Edit/No**
3. OM Reconcile - A View version of the Reconcile screen was created.
4. Ambulatory Medications - The ability to enter PRN Reason directly from Manage
Amb Order List screen (and other related Amb med screens) was added.
** The remaining portion of Development Design Project 12803 will
introduce a View option for Convert**
FOC OM 5119: CPOE Streamlining - Red Edit Button
and Keyboard Shortcuts
Enhancement
• A change has been made to replace all
instances of the old Blue Edit Required
icon in OM have been replaced with the
new Red Edit Required icon.
FOC OM 5082 - Reflex Set Dictionary: Arrange Screen
Functionality
• This enhancement will allow Reminders to
be added to Reflex Sets as well as provide
the ability for the full use of the Arrange
screen in the Reflex Set Dictionary.
FOC OM 5302 - 6.x OM:
Allow for Weight Based IV Fluid Calculation
• This introduces the ability to calculate a total IV
fluid Volume based on a patients weight using
the dose calculator.
• The dose calculator will now be available in the
lookup of the IV Fluid field. The information used
to calculate the dose will be displayed on the
details screen.
• This also introduces the dose calculator for fluids
in dose sets.
Other Vendor Order Sets
• Other Vendor Sets should not be imported
if they contain “blanks” due to unmapped
items
• Systematic versioning should be included
in the mnemonic (External ID) so importing
new versions will not over-write previous
versions
• Suggest – save a set immediately once
imported
OE Reflex Dictionary
• Reflex Orders are your Friend
• Use reflex Orders to Order secondary
orders that support other processes, i.e.:
– Saline Flush reflexed from IV start order
– Patch Removal Order reflexed from Patch
Order
– Respiratory Treatment from Medication
– Radiology Prep from Exam Order
EDM
• Facilitating Look-up of Medications
• Use fo Favorite Order Sets to enhance
Order Set Menu
• Separate Site ?? (will this work?)
• Verified Orders
• Pyxis Settings – to Profile or not to Profile
• Rules
Ordered from ED comment
Adds “Ordered for ED Only” to
label comments
OTO – ONE (SCH) Check
Makes sure OTO orders are not
ordered with a schedule of SCH
(they don’t DC)
Warning for Patients if
Drug Class + Wt + LOC
Specific for ped patients for
specific drug types in specific
location of ED
Dose Restriction Rule
Uses Drug CDS top control
partial doses of oral forms
Restrict to Specialist MD
Designed to limit ordering of
medication to specific physicians
Metformin Rule
MU Rule per medical staff,
modification of Creatinine
Clearance Rule
RESIII#"2,"^TMIII,
[f z.cc.calc](SRCRI,PTURN,MED)^CALCRESI,
[f z.cc.calc](SRCRII,PTURN,MED)^CALRESII,
[f z.cc.calc](SRCRIII,PTURN,MED)^CALRESIII,
CALCRESI|0^CRCLI,
CALCRESII|0^CRCLII,
CALRESIII|0^CRCLIII,
IF{((SEX="M")&(SRCRI>1.4))!((SEX="F")&(SRCRI>1.3)) 1;""}^OK,
IF{OK [ord pom]("IN.MET",1);1};
Message:
Metformin is contraindicated in this patient based on the patient's serum creatinine of [f SRCRI]
Previous CrCls: [f CRCLI] on [f DTI] @ [f TMI]
[f CRCLII] on [f DTII] @ [f TMII]
[f CRCLIII] on [[f DTIII] @ [f TMIII]
Orders Restricted to Paper
Temporary limitation of POM to
adults
Ped IV Rate Calculation
Uses a formula based on patient
weight to calculate rate – this
was also for ED
RXM / AOM
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Identification of linked medications
Continuation of Certain Medications
Transfer Routine
Rules
AOM/RXM Drugs Dictionary
AOM/RXM STRINGS
ADD STRINGS FOR OTHER
STRENGTHS ??
AOM/RXM DRUG LINK
Med Rec Check
Works in Theory – but not used
Additional rule should be developed
to ensure continuation of specific
meds i.e. Beta Blockers
Transfer Routine
• Be very careful
• Should be completed immediately
• Physician understanding of functionality
critical to satisfaction
Questions & Discussion
• Contact information:
 Bruce Matthias
[email protected]
 Penny Hilton
[email protected]
 Steve Botwinski
[email protected]
 Jose Castro
[email protected]
Presentation available at:
www.theingroup.com