1. January 2012 RPMS/EHR Case Scenario

2. Course Objectives Compare and contrast how healthcare organizations can utilize safety strategies and reduce the risk of medication and other errors by implementing technology at different points along the medication use process. Analyze medication and other patient-related information captured in patient care information systems. Examine the risk of medication and other errors and consequences in patient safety for improperly configured systems. Delineate the process of provider order entry and order completion by pharmacy and explain the pharmacist’s role. Appraise the need for standardization throughout the clinical information technology system, including use of a standardized menu structure. Integrate the potential impact of the Institute of Medicine (IOM) recommendations, available medication management technologies and patient safety into the practice of Pharmacy Informatics.

3. Do something we know Go into RPMS Outpatient Pharmacy Roll & Scroll (R&S) and enter this order on your patient: Adult: Amoxicillin 500mg #30 1 capsule three times a day for 10 days No refill Child: Amoxicillin 250mg/5ml 150ml 5ml po tid x 10 d No Refill What do we put in the Nature of Order field?

4. Completing the order: print/hold/suspend Label Printer: NULL DEVICE LABEL: QUEUE/CHANGE PRINTER/HOLD/SUSPEND/LABEL or '^' to bypass Q// ?? Enter 'Q' to queue labels to print Enter 'H' to hold label until Rx can be filled Enter 'P' for Rx profile Enter 'S' to suspend labels to print later Enter 'L' to print labels without queuing Enter '^' to bypass label functions. LABEL: QUEUE/CHANGE PRINTER/HOLD/SUSPEND/LABEL or '^' to bypass Q// UEUE LABEL(S) QUEUED TO PRINT

5. Do something we might know Log into EHR GUI Pick your patient and create a visit Order a medication using the quick order menu Order another medication. This time use the “All Other Medications” option Go back to RPMS Outpatient R&S and finish one of the orders by picking your patient Finish the other order using the menu option: Complete Orders from OERR (Queue)

6. Complete Orders from OERR Select Rx (Prescriptions) Option: COMplete Orders from OERR Select By: (PA/RT/PR/CL/E): PATIENT// ?? Enter 'PA' to process orders by patients 'RT' to process orders by route (mail/window) 'PR' to process orders by priority 'CL' to process orders by clinic or 'E' or '^' to exit Select By: (PA/RT/PR/CL/E): PATIENT// ?? Enter 'A' to process all patient orders 'S' to process orders for a patient or 'E' or '^' to exit Select Patient: DEMO,PATIENT TABITHA F 06-03-1993 XXX-XX-9925 WW 169797 Do you want to see Medication Profile? Yes// *PATIENT PROFILE DISPLAYS  PENDING MED ORDERS DISPLAY Choose the order (S then # or just #) (then the following choices appear) BY Bypass DC Discontinue ED Edit FN Finish Are you sure you want to Accept this Order? NO// Y YES Do you want to enter a Progress Note? No// NO Notice: when going by route, priority, or clinic RPMS may take you into another patient. If you want to quit, enter EX EA Enter/Edit Allergy/ADR Data PU Patient Record Update DD Detailed Allergy/ADR List EX Exit Patient List

7. Points to Consider How is “finishing” orders from OERR different from pharmacist entry into R&S? Which would be less error-prone? How is “Complete Orders from OERR” different from going patient by patient? How would it change your pharmacy flow? If you have EHR, how do you know if orders are waiting? Which method of EHR order entry was easier? Why? How could “All Other Medications” result in more work for the pharmacy? Who should build the quick orders?

8. Copy to New, Renew, Refill These functions are available in RPMS pharmacy and in EHR GUI In Prescription Processing, after selecting an order, the following actions are available DC Discontinue PR Partial RL Release ED Edit RF (Refill) RN Renew The following actions are also available: (Secondary Menu) AL Activity Logs (OP) OTH Other OP Actions GO Go to Page VF Verify (OP) DIN Drug Restr/Guide (OP)LS Last Screen CO Copy (OP) + Next Screen PS Print Screen RP Reprint (OP) - Previous Screen PT Print List HD Hold (OP) < Shift View to Left QU Quit UH Unhold (OP) > Shift View to Right RD Re Display Screen PI Patient Information ADPL Auto Display(On/Off) SL Search List PP Pull Rx (OP) DN Down a Line UP Up a Line IP Inpat. Profile (OP) FS First Screen

9. Renew vs. Copy to New Both create a new prescription from an old one Renew has functional differences between EHR and RPMS use Renew in RPMS PharmacyRenew in EHRCopy to New Carries all elements to new RX including provider Carries all elements but providerOffers all elements for transfer to new RX Doesn’t allow editing of QTYCan only edit number of refills, pick up location, and chronic flag Allows full editing of the new RX (except Drug name) Adds an alpha character to RX #Allows a new RX #Allows a new RX Former RX is used in calculating Suspense fill date Former RX is discontinued and days supply information not considered for suspense fill date on the new RX

10. Refill Is simply a request to pharmacy to process an existing refill on an existing prescription Can be done through RPMS and EHR Refills are not “orders” and do not print in the pharmacy with other orders (if using printing) Pharmacies in facilities using refills through EHR should use the “Complete Orders from OERR” menu in the pharmacy package and monitor their Queue so they don’t miss these

11. Purpose of Visit One item required for a complete visit is a Purpose of Visit (POV). For pharmacy only visits (refills, pharmacy managed clinics, refill extensions, etc.), this POV may not be automatically added. Pharmacists will need to add the POV to the visit in the EHR

12. Purpose of Visit It is VERY important that pharmacists select as a purpose of visit a diagnosis code that has already been applied to the patient by the medical provider. Selecting a purpose of visit that has not previously been applied to the patient may constitute “diagnosing” a patient, which most pharmacists are not allowed to do. Utilize the Historical POV section whenever possible.

13. Practice: Purpose of Visit In the EHR, select your patient and a visit Find the POV section (on the training database, this will be the “POV” tab) Find the section with Past Diagnoses. For refills, find the date of the original prescription. Select the appropriate diagnosis. For new prescriptions from outside providers, if the diagnosis is not on the prescription, contact the prescriber.

14. Notes Notes may or may not be required, depending on the site. However, it is good practice to write a note whenever there is information that should be communicated to other persons who may be taking care of the patient. Note templates can assist users in documenting the appropriate information in a more standard method.

15. Practice: Write a note In EHR, pick your patient and visit if not already selected Find the “Notes” tab Click on “New Note” in lower left corner In the next dialog box, type “pharmacy” to look for a note title If desired, click on the “templates” button in the lower left and select an appropriate template Press the “Awaiting Signature” button ( )

16. Inpatient: Not Much Different Still use same functions in EHR, only use inpatient menus on order menus and inpatient note templates R&S menu is Unit Dose (or IV menu, but can access IVs from the UD menu) No Refill option

17. Go to EHR Hands on exercise: Inpatient Medications Pick a patient who is in inpatient (Use the “wards” list in the patient selection box) Go to Inpatient Medication menu and order a medication for your patient Finish orders in UD (or IV) package Use the non-verified/pending orders queue Document Medication Reconciliation Write a note

18. Inpatient Discharge Scenario Write Discharge Orders in outpatient medications menu Finish discharge meds through Pharmacy 7.0 (Outpatient Pharmacy) Discharge Process (abbreviated) - Enter Discharge Orders in EHR - Medication Reconciliation - Pharmacy processes orders - Patient counseling - Patient leaves hospital - Discharge patient Home (or equivalent)

19. Go To EHR Document medication dispensing to patient (in EHR note, or with education code(s), etc.) Document Medication Reconciliation (education code M-MR)

20. Points to Consider How are patients admitted to inpatient (through ADT)? How do delayed orders fit in? How will pharmacy know there are new orders? How will Pharmacy know there are discontinued orders? What is the best process for Medication Reconciliation at your site? How are discharge medications processed?

21. Questions?