What’s a CROC? Rob Silverman Pharmacy Benefits Management Program Manager, Clinical Informatics

This is an Updated Version Rob sent an even newer copy dated October 11 th. Per Rob Please be advised that effective with patch PXRM*2*22, some of the screen captures have changed … the teratogenic meds project exposed a few issues with the enter/edit templates with regards to nationally released order checks.

Whoa… what did he say? No, I did not title this class ‘Whatta Crock!’ Hopefully you won’t think so either… 3

This is a Croc 4

This is not a Croc 5

These are Crocs 6

These are not Crocs 7

So What is a CROC? Clinical Reminder Order Check New feature introduced with CPRS version 28 and an associated Clinical Reminders Patch, PXRM*2*16 8

Disclaimer Although I have obtained permission, the term ‘CROC’ is not officially recognized as a name for the package, options or functionality discussed herein… 9

Objectives Now that we’ve moved to the more serious stuff, this session is designed so that attendees will be – Familiar with the functionality provided by Clinical Reminder Order Checks – Able to design a drug-specific order check, such as for drug-disease state interactions – Conversant in the terminology used with Clinical Reminder Order Checks 10

Clinical Reminder Order Checks This session is about a new feature introduced with CPRS version 28 (more specifically, Clinical Reminders patch PXRM*2*16) For the first time, you can set up OC’s (order checks) on your local VistA system using reminder options – OC’s – order checks, not oral contraceptives! – Some sites did work with IRM to update OC’s before this, through the Order Check Expert System. CROCs can be entirely managed through the reminders menu 11

New Option on the Reminders ‘Big’ Menu CF Reminder Computed Finding Management... RM Reminder Definition Management... SM Reminder Sponsor Management... TXM Reminder Taxonomy Management... TRM Reminder Term Management... LM Reminder Location List Management... RX Reminder Exchange RT Reminder Test OS Other Supporting Menus... INFO Reminder Information Only Menu... DM Reminder Dialog Management... CP CPRS Reminder Configuration... RP Reminder Reports... MST Reminders MST Synchronization Management... PL Reminder Patient List Menu... PAR Reminder Parameters... ROI Reminder Orderable Item Group Menu... XM Reminder Extract Menu... GEC GEC Referral Report Select Reminder Managers Menu Option: ROI Reminder Orderable Item Group Menu OE Add/Edit Reminder Orderable Item Group OI Reminder Orderable Item Inquiry OT Reminder Orderable Item Group Test Select Reminder Orderable Item Group Menu Option: 12

CAUTION! Do not use this feature frivolously! – HEAVY RESOURCE DRAIN In order to manage CPU impact, it is strongly recommended that you establish a governance process, such as using the P&T Committee, to review and approve drug-related CROCs… 13

Pharmacy-Related Uses of Clinical Reminder Order Checks Pharmacogenomics (e.g., G6PD deficiency) – San Diego & PBM project following April 2011 National Pharmacy Conference Drug-Disease State Alerts Drug-Specific Warnings Local Drug-Drug Interactions – Pharmacy Reengineering makes VistA file #56 (DRUG INTERACTION) obsolete Teratogenic Meds Order Checks – National “Interim” Solution 14

Where can one find a CROC? At the point of ORDER ACCEPTANCE Again at ORDER SIGNATURE The information IS passed to Pharmacy as part of the display of provider-seen order checks The information IS NOT presented during backdoor order entry, or as part of order finishing order checks. 15

What’s this? 16

ALERT FATIGUE! Always good to have a humor break… Military fatigues are good. Alert fatigue is not. If you create too many CROCs, they will become ‘white noise’ and be ignored by providers. Once again, USE THEM JUDICIOUSLY! 17

Terminology Time Before building a CROC, we need to have a common language and framework. ORDERABLE ITEM – The CPRS file (specifically #101.43) that lists things that can be ordered for a patient. Example, LISINOPRIL TAB ORDERABLE ITEM GROUP – A group of orderable items, defined either individually or by VA DRUG CLASS, used to identify WHAT will trigger the order check. 18

More terminology ORDER CHECK RULE – Used to define WHO (i.e., which patients) to which the order check will apply – Can be based on REMINDER TERMS or REMINDER DEFINITIONS – Can have more than one rule for a given OI group REMINDER DEFINITION – When the ‘who’ part is more complex, you define whether the reminder should be TRUE or FALSE to identify a patient that will trigger the order check 19

Text, text, more text ORDER CHECK TEXT – Think of this as the primary message of the order check (WHY WHAT) REMINDER DEFINITION TEXT – Think of this as a description of why the patient’s record triggered the order check (WHY WHO) COMBO – You can even display BOTH with the order check if you use a reminder definition to define the ‘who’ 20

Design and Build (A) Side A – On what ORDERABLE ITEMS will the order check apply? – Not limited to medications – Not even limited to one clinical domain – Item by item … or by drug class – OI GROUPS are EXCHANGEABLE via VistA Reminder Exchange 21

Design and Build (B) Side B – To which patients will it apply? Reminder TERM or DEFINITION – Based on level of complexity – Evaluation as either TRUE or FALSE Examples – TERMS with Computed Findings such as VA-AGE or locally written Creatinine Clearance – DEFINITION to identify female patients of childbearing age with no evidence of medical inability to conceive 22

Flags 23

Flags for CROCs ACTIVE FLAG: YES or NO TESTING FLAG: YES or NO (applies to the order check setup and CPRS user) ACTIVE=YES & TESTING=YES  IN TEST ACTIVE=YES & TESTING=NO  IN LIVE/PRODUCTION ACTIVE=NO & TESTING=ANYTHING  INACTIVE 24

Other Considerations Clinical Danger Level – LOW/MODERATE or HIGH Who are your TESTERS? CPRS Order Check Parameter National Repository for Pharmacy Related CROCs 25

Before CROCs 26

With CROCs 27

Scenario Design an Order Check for dabigatran (Pradaxa®) to remind providers about dose reduction when creatinine clearance is less than 30 mL/min – Today’s example will use serum creatinine values greater than 2 mg/dL to focus more on the order check than on the lab result Note: Screen captures in these slides show only the relevant fields 28

Roadmap Reminder Term (Patients with Cr > 2 mg/dL) Orderable Item Group Although the introduction showed the components in the opposite direction, you have to build the ‘referenced’ pieces first, and then put them in as pointers second… 29

Reminder Term Select Reminder Term Management Option: TE Add/Edit Reminder Term Select Reminder Term: ZZ CREATININE > 2 (TERM) Are you adding 'ZZ CREATININE > 2 (TERM)' as a new REMINDER TERM (the 1215TH)? No// Y (Yes) REMINDER TERM CLASS: L LOCAL NAME: ZZ CREATININE > 2 (TERM) Replace CLASS: LOCAL// Reminder Term has no findings! Select Finding: LT. CREATININE Are you adding ' CREATININE' as a new FINDINGS (the 1ST for this REMINDER TERM)? No// Y (Yes) Editing Finding Number: 1 FINDING ITEM: CREATININE// CONDITION: I V>2 30

Orderable Item Group The OI Group is the heart of the Order Check Select Reminder Managers Menu Option: ROI Reminder Orderable Item Group Menu Select Reminder Orderable Item Group Menu Option: OE Add/Edit Reminder Orderable Item Group Select Reminder Orderable Item Group by: (N/D/O/R/T/Q): N// ORDERABLE ITEM GROUP NAME Select Reminder Order Check Rule: DABIGATRAN Are you adding 'DABIGATRAN' as a new REMINDER ORDERABLE ITEM GROUP (the 3RD)? No// Y (Yes) GROUP NAME: DABIGATRAN// CLASS: L LOCAL SPONSOR: REVIEW DATE: DESCRIPTION: No existing text Edit? NO// Select DRUG CLASS: Select ORDERABLE ITEM: DABIGATRAN CAP,ORAL Are you adding 'DABIGATRAN CAP,ORAL ' as a new ORDERABLE ITEM LIST (the 1ST for this REMINDER ORDERABLE ITEM GROUP)? No// Y (Yes) Select ORDERABLE ITEM: 31

Order Check Rule Each RULE exists as a part of the OI Group That allows you to set up multiple rules that apply to the same list of drugs 32

Select RULE NAME: DABIGATRAN AND RENAL FUNCTION Are you adding 'DABIGATRAN AND RENAL FUNCTION' as a new RULE NAME (the 1ST for this REMINDER ORDERABLE ITEM GROUP)? No// Y (Yes) DISPLAY NAME: Dabigatran and Renal Function ACTIVE FLAG: Y YES TESTING FLAG: Y YES SEVERITY: M MEDIUM RULE DESCRIPTION: No existing text Edit? NO// REMINDER TERM: ZZ CREATININE > 2 (TERM) LOCAL...OK? Yes// (Yes) TERM EVALUATION STATUS: TRUE TRUE ORDER CHECK TEXT: No existing text Edit? NO// YES ==[ WRAP ]==[ INSERT ]========== =========[ H=Help ]==== The dose of dabigatran should be reduced to 75mg PO BID when the patient's creatinine clearance is estimated to be less than 30 mL/min. ====== 33

New Option on the Reminders ‘Big’ Menu CF Reminder Computed Finding Management... RM Reminder Definition Management... SM Reminder Sponsor Management... TXM Reminder Taxonomy Management... TRM Reminder Term Management... LM Reminder Location List Management... RX Reminder Exchange RT Reminder Test OS Other Supporting Menus... INFO Reminder Information Only Menu... DM Reminder Dialog Management... CP CPRS Reminder Configuration... RP Reminder Reports... MST Reminders MST Synchronization Management... PL Reminder Patient List Menu... PAR Reminder Parameters... ROI Reminder Orderable Item Group Menu... XM Reminder Extract Menu... GEC GEC Referral Report Select Reminder Managers Menu Option: ROI Reminder Orderable Item Group Menu OE Add/Edit Reminder Orderable Item Group OI Reminder Orderable Item Inquiry OT Reminder Orderable Item Group Test Select Reminder Orderable Item Group Menu Option: 34

Reminder Definition ‘Usage’ Field Select Reminder Definition Management Option: RE Add/Edit Reminder Definition Select section to edit: G General USAGE: O// ?? The Usage field describes how the reminder definition will be used. This field must contain C if the reminder is to be selected in CPRS. The L or the O values will override all other values. For example, if L and C are defined in the usage field, the Reminder will not show on the cover sheet in CPRS, because L is in the Usage field. This is free text field and can contain any combination of the following codes: Code Usage C CPRS L Reminder Patient List O Reminder Order Checks P Patient R Reminder Reports X Reminder Extracts * All of the above, except L, and O. 35

User Level Order Check Parameters 36 This screen is accessed in CPRS > Tools Menu > Options

Results! Caution – control codes are not allowed in the OC display title 37

Demonstration

Questions? Contact Information Office

Backup Slides 40

New Orderable Items Subj: Orderable Item Updates [# ] 4 lines From: Clinical Reminders Support In 'PXRM (Clinical Reminders)' basket. Page DEXTROMETHORPHAN/GUAIFENESIN TAB,SA was added it is used in the following Orderable Item Groups None Enter message action (in PXRM (Clinical Reminders) basket): Ignore// Take Home Message: You will get updates, but have to use the information to maintain the order checks. 41

Alternative Selection of OI Groups Select Reminder Orderable Item Group Menu Option: OI Reminder Orderable Item Inquiry Select Reminder Orderable Item Group by one of the following: N: ORDERABLE ITEM GROUP NAME D: DRUG CLASS O: ORDERABLE ITEM R: REMINDER DEFINITION T: REMINDER TERM Q: QUIT Select Reminder Orderable Item Group by: (N/D/O/R/T/Q): N// 42

Evaluating Reminder Terms If you are basing an order check on the case of a lab test that is LESS than a specified value, remember that a canceled test has a numeric value of 0 (zero) – To avoid this, you can use CONDITIONS in your term setup: I V>0&(V<100) When evaluating for a REMINDER TERM=FALSE, this could be true for both patients that don’t meet the criteria and patients that did not have the indicated test/treatment – Example: TERM for Creatinine > 3 = FALSE could be a lab result of 2.5 or no lab result at all!