Alternatives Badge (Tips and Troubleshotting
Pg. 2-28 upward
Tips and Troubleshotting
Pg. 2-28 upward
- Help! My Alternative is not appearing
- Help! My Alternative appears, but there are few or no alternative orders in it
- Help! My Alternative doesn’t appear from an Order Set
- Help! The “Reason to continue with original order” field does not appear, ever
- Help! My Alternative won’t appear when I try to reorder an inpatient order
- Help! If a clinician selects one of the alternatives within an Alternative, then I want another Alternative to appear, and then another!
-- Let’s not get too fancy here; the beauty of Alternatives is their simplicity. There is
no way to “chain” a series of Alternatives.
Alternative, then I want another Alternative to appear, and then
3. Alternative (LMA)
- An Alternative can contain multiple SmartGroups
-- If you add more than one SmartGroup for the same context (e.g. both include Outpatient orders), the orders from the SmartGroups appear as one cohesive list of orders, respecting the order they are listed in the SmartGroup and the order the SmartGroups are listed in the Alternative. This can be a nice tool when a group of orders might be used as a “building block” that can be added to more than one Alternative. This technique can also be used to suggest different alternatives (see the next chapter) based on patient criteria.
- You can let some users always continue with original orders
-- A profile setting allows the ability to continue with the original order regardless of the setting in the Alternative. This might be a good option for pharmacists or administrators. For steps, go to Galaxy and read the Allow Some Clinicians to Continue with Original Order When Alternative is Required section of the Alternatives Setup and Support Guide.
- Restricting Alternatives by outpatient formulary
-- For an ERX record, you can limit outpatient alternatives to only fire if the patient is covered by a specific formulary. This is based on the patient’s insurance, not the hospital/clinic’s inpatient formulary. For example, an Alternative attached to entacapone (COMTAN) might fire only if the patient has a formulary that does not include entacapone. This isn’t used very often, because it requires manually creating and maintaining Formulary (EFY) records for each payor/plan combination.
2. SmartText (ETX)
- SmartTexts allow for rich text
- Smartlinks work in alternatives
- Test appearance in different monitors, etc.
1. Smartgroup (OSQ)
- Alternative orders appear in the order you list them Selecting an order by default in the OSQ (i.e. the check box in front of “IP Order”) has no effect in the Alternative.
- Defaults set in the SmartGroup override ERX, EAP, and ORD
• For Alternatives appearing for newly placed orders, the detail comes from ERX or EAP if not specified in the SmartGroup.
• For Alternatives appearing for reordered medications, the detail comes from the original order (ORD) if not specified in the SmartGroup.
-- Therefore, for Alternatives for home medication reconciliation, it might make more sense to NOT put details in the SmartGroup so that the details come from the existing prescription. For Alternatives for therapeutic interchange, details in the SmartGroup might be more helpful.
- Alternatives only respect the Configuration form
-- The General Info or Panel Info form of the SmartGroup record do not apply in Alternatives.
- Using Alternatives to suggest an Order Panel
-- To display an Order Panel within an Alternative, the Order Panel record must be added to a SmartGroup and the SmartGroup must be attached to the Alternative. Panels records attached directly to Alternative records are NOT treated as panels.
-- You can use an Alternative to suggest an Order Panel in some workflows, but not all. Suggested order panels DO NOT display in Alternatives that pop up:
• During medication reconciliation.
• Upon ordering.
-- Alternatives cannot suggest procedures for medications or vice versa. A medication Alternative can suggest only medications or panels containing only medications. A procedure Alternative can suggest only procedures or panels containing only procedures. When adding a Panel to a SmartGroup, select Ambulatory Order or Inpatient Order as usual, and enter the name of the Order Panel.
Alternatives for Meds
Alternatives can appear in all order entry activities, including Order Entry, Manage Orders, orders navigator sections, and medication reconciliation navigator sections
Look up in galaxy: "Alternatives Setup and Support Guide"
3 Steps to build an alternatives
- Design the Alternative by asking: • Which orders should trigger it? • What message should appear to the user? • What links should appear? • Which alternative orders should be suggested? • Can users continue with the original order? 2. Build a SmartGroup. • Include all alternative orders. • Set default values (such as dose, route, and frequency) in the orders. • Write a display name for each order.
- Build a SmartText.
- Build the Alternative record. • Attach the SmartGroup. • Attach the SmartText. • Include links.
- Attach the Alternative to the medication (ERX) or procedure (EAP) records that should trigger it. -->Via TEXT
2. Build an Alternative for Discharge Med Rec (Some inpatient medications should not be prescribed at discharge.)
1 Build an Alternative for a Medication Shortage
- Create the Smartgroup
- □ 1. Log in to Hyperspace as RXADM/epic. (Remember to use your Project environment!) □ 2. Use Chart Search (Press Ctrl + Space bar or click in the field in the upper right corner under the Log Out button) to search for “SmartGroup.” □ 3. Create a new SmartGroup (OSQ) called “<your initials> Tamiflu Capsules.” □ 4. Select the Configuration form on the left and click Add Item. □ 5. Select an Item type of “Inpatient Order.” □ 6. In the Order field, search for TAMIFLU 30 MG PO CAPS  and Accept. □ 7. Enter a Display Name of “Children 1 to 12 years, up to 15 kg”. • This field is case sensitive. □ 8. Select a Dose of 30 mg, a Route of oral, and a Frequency of daily. □ 9. Repeat those steps to add the following medications and details:
- □ 11. Click Release and close this record.
- Create the SmartText
- □ 1. Create a new SmartText called “<your initials> Tamiflu Restrictions.” □ 2. On the Restrictions tab, give it a Functional Type of “MR Alternatives”. □ 3. On the General tab, the text should read:
- □ 4. Select the Released box at the bottom of the screen. □ 5. Save and close your record.
- Create Alternative record
□ 1. Create a new Alternative (LMA) called “<your initials> Tamiflu Suspension.” □ 2. In the Record type field, enter “Medication.” □ 3. Click Accept. □ 4. In the SmartText field, enter “<your initials> Tamiflu Restrictions.” □ 5. Select Allow continuation with original selection (clinicians should be able to continue for children less than one year). No other check boxes should be selected. □ 6. Enter: Weblink Display Text Weblink URL Tamiflu dosing information http://www.tamiflu.com/tamiflu-for-children □ 7. In the Alternative Order SmartGroup enter “<your initials> Tamiflu Capsules.” □ 8. Save and close your Alternative record.
- Link alternative to the triggering medication
- □ 2. Go to: Clinical Administration > Meds, Allergens, Imm, etc. > Medications (ERX). □ 3. At the Medication prompt, look up <YOUR INITIALS> TAMIFLU 6 MG/ML PO SUSR. □ 4. Use Home F9 to go to the Outpatient Alternatives screen. □ 5. Arrow down to the BOTTOM half of the screen, under the heading of Inpatient Alternatives. Configure the settings as follows:
- System looks at ERX or EAP record to see if an
Alternative (LMA) should appear
- Foundation system has very few LMA b/c it tailors to specific organization
Options within an alternative with layout features
• Top left: Information for the clinician. Text comes from a SmartText (ETX).
• Top right: Links to more information, either from the internet or internal files.
• Bottom: Recommended alternatives. These options come from a SmartGroup (OSQ).
• Follow up choices: In each Alternative, you can choose to:
o Prevent the user from continuing with the original order.
o Require (or recommend) a reason when continuing with the original order.
Why alternatives useful?
- Preferred orders: suggest less expensive and/or more effective meds and procedures
- Temporarily unavailable orders: e.g. drug shortage and deactivate when no longer needed and switch back on when needed instead of remove them from every order sets...
- Permanently unavailable orders: opportunity to educate regarding med/lab test that are no longer available and offer alternatives, then retire these after provided education
- Medication reconciliation: Clinicians can use "Database lookup" to add any meds to the patient's home med list, which they can then order non-form home meds for the admission.
Why not use BPAs?
BPAs are extremely flexible and can do most of what Alternatives do, but Alternatives:
• take less time to build
• are easier to build correctly
• can prevent continuing with the original order
• work during medication reconciliation (BPAs can trigger during med rec, but can’t actually replace orders)
• link the alternative order to the original order in a reordering situation
Plus, automatic Alternatives for admission med rec can be turned on very quickly, something that would be prohibitively difficult with BPAs.
Use inpatient Alternatives to:
• Redirect from a home medication to a medication approved for use.
• Redirect to an IMS orderable, which allows Willow to select the appropriate dispensable product based on what’s available.
• Redirect to equivalent products. For example, a prescription for a daily amlodipine-atorvastatin (CADUET) tablet could be replaced in the hospital by one amlodipine tablet and one atorvastatin tablet.
Alternatives and ACR Appropriateness Criteria The Alternatives functionality doesn’t incorporate the ACR Appropriateness Criteria. Epic does support interfacing with Medicalis and ACR Select to provide active decision support based on these criteria. This requires licensing with one of these two vendors and additional configuration. The Alternative above represents a less robust (but perhaps simpler and less expensive) decision support option.
For more information about incorporating ACR Appropriateness Criteria, see the Imaging Decision Support Setup and Support Guide in Galaxy.
1 Overview of Clinical Decision Support
NOTE: Ensure clinician Buy-in!!!
- Improve adherence to protocol
- Reduce errors
Considerations for implementation
- Determine which tools to use to meet objective
- Scope of implementation
- Who in charge of implementation
- Which members to involve in CDS
Determine the needs
- What guidelines to follow (e.g HEDIS, Core Measures, Leap Frogs) Will we continue to follow these in Epic
- What Key Indicators: (i.e. diabetes, stroke) are we tracking? Will we contininue to track these in Epic
- How many and which types of alerts are appropriate at go-live? phased roll-out, or all at once?
3. Analysis: Determine effectiveness prior and post go-live:
- Executive/steering committee: 1. Initial analysis 2. Define scope and goals>>>then Decision Support Group ->leverage Foundation system content->Build out decision support (map out on paper first)->Test and train end-users (keep simplicity and clarity) (best tool is useless without training)->Review outcomes w/reports (share stat, benefits, and success)->determine fixes and optimization (from feedback) and back to build out decision support
2. Determine which tool to use
- pg. 0-8 for key differences: know how to build
and maintain and thier limitations of these CDS tools
1. Prioritization and Goals
- What specific goals or metric we hope to achieve: e.g. higher percentage of geriatric 65yo pts receiving annual flu shot, or better controlled A1C results of diabetic patients.
Clinical Decision Support Tools:
- Best Practice Advisories (BPA): based on patient's data and criteria to trigger BPA-> e.g. CVA pts trigger the need of Antiplatelet if none on pt's med list
-- based on criteria: order, diagnoses, age, flowsheet data,current med, history
-- Embed in inbasket, or new window (recommend for high priority)
-- Based on two types: Criteria (medications, order questions, diagnoses, chief complaints, surgical history, allergies, and smartdata) and Base (defines who sees BPA, clinical text, suggestions, importance level, historical results, external links, facility-level restrictions, reoccurrence)
-- Base link to criteria and define logic:
- Medication warning includes: Allergy warning, Drug-Drug interaction warnings, and Dosing warning
-- appear in order lookup, verification, and MAR
-- provided by 3rd party vendor
-- Actions user can take: Remove, D/C, or Override warning with reason
-- when suppressed, will only for that particular user and not others
-- Admin can determine which warnings to show for different group of user by "Filter" OUT or "Suppress" warning (will not appear anywhere in hyperspace)
- Admin can configure: Which warnings are filtered or suppressed, Importance levels, Override buttons, In which order they appear in the med warning window
- Health Maintenance Advisories (HMA) (Preventive Health tool): trigger reminder to order labs and immunizations
-- Seen in patient's chart (Mychart), encounter, patient's header
-- advisory can be overriden when no longer relevant
-- Can access within patient's chart or w/in encounter
-- HMA is not designed to disrupt user workflow
- Alternatives: provides reason why med cannot be ordered and what alternative is available to order.
-- appear anywhere user entering orders
-- Either proceed or select alternatives
-- Alternative has SmartText (displays explanation to end user), Web pages or Shared Documentation (Supports the use of the alternative), SmartGroup (suggest the more appropriate order)
CDS applied in a Context:
-- Think about user and involve user
- What is the objective?
- What are the steps?
- Can it be improved
"What is it for me?"-- If negative outcome: talk to expert and
analyze why is it not working
- Right information
- Right person
- Right intervention format: Preference list, Active advisory, Passive advisory, Questionaire, Order panel, Documentation template, Patient header
- Right channel: ususally the EHR, smartphone, and Mychart, and other devices, don't blinded by another method
-- Don't forget to eval the scenario for best tool. One tool works best for previous may not work for the next scenario
-- If user also complied with a goal, DON'T Intrude the user workflow
- Right time in the workflow
Build tool to satisfy Meaningful Use requirement X, but can cause alert fatigue