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Alternatives Badge Tools: "SmartGroup" activity "…

- - - - 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?
        
        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.
        
        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
        
        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
  - - - 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.
      - 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. Sometimes a medication is recalled from the market entirely, or an organization stops offering a particular lab test. Rather than retiring such orders immediately, use alternatives to educate your providers that the drug or test is no longer available and present them with other options. After a while, retire those orders.
        
        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.
        
        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.
        
        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.
  - - - Exercise 3: Build an Alternative for a Preferred Procedure
        Imagine that a report at your organization shows a large number of orders for CT of the lumbar spine. In most cases, MRI is better for imaging patients with back pain. You might want to make use of an alternative to help providers choose the best option.
        Part 1: Build the Alternative
        
        Because you now have some experience building alternatives, the rest of this exercise is less guided. Use your initials as a prefix for any records you build. Build an “xyz CT Lumbar Spine Alternative” SmartGroup to include: Ambulatory order: MRI LUMBAR SPINE WO CONTRAST [IMG283]; configure the display name to say: “For back pain: MRI lumbar spine wo IV contrast”. Ambulatory order: MRI LUMBAR SPINE W WO CONTRAST [IMG287]; configure the display name to say: “For infection: MRI lumbar spine w and wo IV contrast”. Inpatient order: MRI LUMBAR SPINE WO CONTRAST [IMG283]; configure the display name to say: “For back pain: MRI lumbar spine wo IV contrast”. Inpatient order: MRI LUMBAR SPINE W WO CONTRAST [IMG287]; configure the display name to say: “For infection: MRI lumbar spine w and wo IV contrast”. HINT: You can include both inpatient and outpatient orders in the same SmartGroup; the alternative displays the correct orders based on user workflow. Create an “xyz CT Lumbar Spine Alternative” SmartText with this display text (HINT: You must enter a Context before you can add formatting, like bold font and tables.): A CT of lumbar spine is less effective than an MRI for purposes of evaluating back pain. Unless the reason for this procedure is listed on the table below, select MRI lumbar spine wo IV contrast. Add a table to your SmartText. Find the option to add a table here: Build the “xyz CT Lumbar Spine” Alternative (LMA) record. Remember it is for Procedures, not Medications. It should: Allow the clinician to continue with the original order. Require the clinician to give a reason to continue with the original order. Have a link called “Indications for low back pain imaging” to https://www.aafp.org/pubs/afp/issues/2002/0601/p2299.html Attach the alternative to the three Procedure (EAP) records that start with “XYZ CT LUMBAR SPINE…” (replacing XYZ with your initials). Path: Text >> Clinical Administration >> Procedures, Scheduling >> Procedures (EAP) HINT: This alternative should appear in BOTH inpatient and outpatient settings. In a Procedure record, both are set in the top half of the alternative Procedure screen. You should attach this alternative to three records: with contrast, without contrast, and with/without contrast. The alternative should appear no matter which of the three is initially ordered.
        
        Part 2: Add Reasons to Continue
        
        You want the following reasons available when a clinician chooses to continue with the original order (replacing XYZ with your initials): XYZ Original order clinically indicated XYZ Suggested alternative is contraindicated XYZ Patient refused Add these reasons to the Alt Procs – Continue Reason (Item EPT 20055) category list. HINT: To edit a category list, go to Hyperspace >> Search >> “Category List Maintenance” This list redirects to the Alt Meds – Continue Reason (Item EPT 20005) category list. This list is used to supply reasons for continuing past both procedure and medication alternatives. Remember to close Category List Maintenance when you are done editing the category list! This activity is needed by many people, but is locked while you have it open.
        
        HINT: If it does not appear, check that you have included Inpatient orders in your SmartGroup. Also, check that you have attached the alternative in the procedure record for the Inpatient context.
        
        Exercise 4: Build an Alternative for Admission Medication Reconciliation
        You have two Angiotensin Receptor Blockers (ARBs) on formulary: losartan and valsartan. Losartan is preferred, except for patients with congestive heart failure (CHF). In that case, valsartan should be ordered. Currently the system default alternative only suggests losartan and not valsartan. You'd like to give providers the option to select valsartan during admission medication reconciliation, as well.
        Part 1: See the System-Level Alternative in Action
        
        Log in to Hyperspace as RXPHARM / epic and open the Orders activity for Ross. Go to Admission >> Admission Orders >> Review Home Medications. Add a prior to admission medication from the Database: XYZ olmesartan (BENIcar) 5 MG tablet (replacing XYZ with your initials). Go to Reconcile Home Medications and try to order the XYZ olmesartan. An alternative appears! This is a dynamic alternative from System Definitions, which It automatically finds and suggests formulary medications when a non-formulary medication is ordered during admission medication reconciliation. You'll learn more about how this alternative is built and how it selects equivalent medications in a future lesson. What is the reason that losartan tablets are suggested? Hint: See the Reason for Match column. Losartan is appropriate for most patients, but valsartan should be available for patients with CHF. Cancel the alternative.
        
        Part 2: Build the SmartGroup
        
        Log in to Hyperspace as RXADM / epic. Create a SmartGroup called “XYZ Valsartan Alternatives” (replacing XYZ with your initials). On the Configuration form add your XYZ VALSARTAN POTASSIUM 40 MG PO TABS as an Inpatient Order item. Add it four times with these details: 40 mg, Oral, Daily 80 mg, Oral, Daily 160 mg, Oral, Daily 320 mg, Oral, Daily On the left, go to General Info and select "Panel (requires contact to be released)". To allow clinicians to select an order from this SmartGroup, it must be a panel. Enter a display name of "For patients with CHF (valsartan)". Next go to Panel Info and enter a Panel Type of "Medication Panel". Notice there is now a field called Medication Replacements. You must select medication panel or mixed panel (if the alternatives include both medications and procedures). Be careful! Once selected it can't be changed, even if you create a new version. Enter all medications for which this alternative option should be suggested. In class, we'll just enter these three: XYZ OLMESARTAN MEDOXOMIL 5 MG PO TABS XYZ OLMESARTAN MEDOXOMIL 20 MG PO TABS XYZ OLMESARTAN MEDOXOMIL 40 MG PO TABS Release the SmartGroup and close it.
        
        Test Your Work: see CAM olmesartan (BENIcar) 5 MG tablet
        
        You have Ross' chart open in Hyperspace, and you should be looking at his admission orders. On Reconcile Home Medications, try to order the XYZ olmesartan. The dynamic alternative appears with losartan alternatives, and also your SmartGroup with the display name "For patients with CHF (valsartan)". Select the valsartan option and accept the alternative. Now your panel SmartGroup appears so the provider can select valsartan. The previous order appears at the top for reference. If the SmartGroup were not marked as a panel, this would not be possible. Only panel SmartGroups can display this way, as a panel in the Orders sidebar. Remove all orders and close the chart.
        
        CAM VALSARTAN ALTERNATIVES [188917]
    - - SmartText (ETX)
        
        SmartTexts allow for rich text: After setting the Functional Type to “MR Alternative,” you can use various fonts, colors, tables, bulleted lists, images, and other rich text.
        
        SmartLinks work in alternatives: You can use SmartLinks in the SmartText in an alternative.
        
        Test thoroughly: Check the appearance of the alternative at different screen resolutions and different size monitors.
        
        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.
        
        Help! My alternative is not appearing
        
        An alternative does not appear if: It is attached to the wrong context (OP, IP, or CAM). Use Alternatives? is not set to “Yes.” It is not attached to the ERX or EAP you ordered. (This is more likely to be the issue for IMS medications.) It is attached to an ERX with something in the Dispensable product field. Go to the dispensable product record and attach your alternative there (unless you want the alternative to only appear when the user orders the med with DAW selected by default. When the user selects a DAW medication, the alternative attached the brand ERX appears). It is attached to an ERX but only for a different hospital than the patient is admitted to. Has no SmartText, no Web Links, and no viable orders. Has no viable orders and you checked Hide when no alternatives are suggested. Alternatives can also be restricted by order class. The list of allowed classes for alternatives is found here: Clinical Administration > Management Option > System Definitions > Medication, Allergy, Imm > Order Validation > Alternative Medication Settings.
        
        Help! My alternative appears, but there are few or no alternative orders in it
        
        Check for viable orders, or orders that can appear in that context (IP, OP, or CAM), as well as the following: A SmartGroup must be attached to the alternative. The SmartGroup must be released (or released for testing if you have security to test SmartGroups). The SmartGroup must not be restricted (you’ll learn more about restrictors in the next chapter) The item in the SmartGroup must match the context (IP, OP, or CAM). If the SmartGroup contains only order panels, the workflow must support panels (see Using Alternatives to Suggest and Order Panel). In a non-discharge CAM context with a CAM preference list in place, the order must be in both the SmartGroup and the CAM preference list.
        
        Help! My alternative doesn’t appear from an Order Set
        
        An Order Set can suppress alternatives. On the Settings form of the Order Set, when Suppress the following warnings within the SmartSet includes “Alternative Order” no alternatives appear for orders placed from that Order Set.
        
        Help! The “Reason to continue with original order” field does not appear, ever
        
        If the category list for this field is empty, then the Reason to continue with original order field does not appear on any alternatives, even if it is required. Add reasons to the category list for item EPT 20005.
        
        Help! My alternative won’t appear when I try to reorder an inpatient order
        
        For one-time orders that have been completed, or orders that have reached their specified end-time, clinicians have the option to “reorder” that medication or procedure. For alternatives to appear for inpatient reorders, item LSD 4173 must be set to 1 (Reorder IP medications) and/or 2 (Reorder IP procedure)
        
        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. For example, Procedure A has an alternative attached that includes Procedure B as the alternative order. Procedure B also has an alternative attached that includes Procedure C. If you order Procedure A you will see an alternative. If you order Procedure B you will see an alternative. However, if you order Procedure A and select Procedure B from within the alternative, you get Procedure B and do not see its alternative. In other words, only the first alternative appears.
- - - - via 1. TEXT linking CER rule, 2. OPAs = Criteria + Smartset Base
        Restricting Alternatives by Age The alternative should not appear for patients who are under 1 year of age.To restrict this alternative, you can use either a rule or a OPA
        Restricting via a CER Rule https://d.pr/i/vj0wVC
        
        Attaching Rules and Alternatives to Medications = https://d.pr/i/f6jyTH ; Rules can only limit alternatives for inpatient medication orders. They cannot limit alternatives for outpatient medications, that is where OPA can be used for CAMs that needed a restriction.
        
        Restricting via a OPA https://d.pr/i/aXUu7e
        You can only use rules to restrict alternatives for inpatient and clinic administered medication orders. If an alternative is intended for outpatient medication orders, you cannot use a rule. You also cannot use rules to restrict procedures. In these cases, you should use OPAs.
        
        To prevent an Alternative from appearing for patients of a given age range in any context, you add two OPA records as shown below. Each of these two serve a different purpose.
        -- The Criteria OPA contains the age range of the patients for whom this SmartGroup SHOULD appear.
        -- The SmartSet Base OPA links the Criteria OPA record to the SmartGroup.
        Then, you configure the alternative to only appear if the SmartGroup appears.
        
        1. Creating Criteria OPA Records
        
        e.g https://d.pr/i/PImD1z; In a Criteria OPA, you can add one or more criteria to evaluate patient data. If you add more than one criteria, the system applies “and” logic between them
        
        If you add both an age restriction and a medication restriction in one Criteria record, clinicians would only see the SmartGroup for patients who are both in the age range and had an order for that medication.
        2. Creating SmartSet Base https://d.pr/i/0uXoFV OPA Records In the Foundation System, SmartSet Base records start with “SB.” The Record Type is “SmartSet Base,” NOT “Base.” pdf https://d.pr/i/Zt7qyv
        
        You use the Logic field when you have more than one Linked Criteria. It tells the system how linked records relate to each other. The SmartSet Base's Logic field supports "AND", "OR", and "NOT" logic
        
        On the Triggers form, always include Triggers of both “Inpatient” and “Outpatient.” These are the only two triggers used for Alternatives. The others are used only for restricting SmartSets or SmartGroups.
        
        If you don’t include one of these two triggers, the SmartGroup does not appear in that context – not now, not ever, never. On the other hand, if your SmartGroup is only used for inpatient orders, it doesn’t hurt to include the Outpatient triggering action. So, always include both
        
        3. Attaching SmartSet Base OPA Records to SmartGroups e.g https://d.pr/i/BL53oF
        
        In the SmartGroup, on the Criteria form, enter the SmartSet Base OPA in the Restrictions field.If you attach multiple SmartSet Base OPAs here, the SmartGroup is restricted if the criteria in any of the SmartSet Base OPAs are met.
        -- For example, you want to show an alternative for patients with orders for prednisone or psoriasis on the problem list. You list “SB Prednisone” and “SB Psoriasis” in the Restrictions field.
        Yes, you could have done this with a single “SB Prednisone or Psoriasis,” but separate SmartSet Base OPAs are more likely to be reused elsewhere.
        
        4. Hiding Alternatives with No Valid Orders
        To hide an alternative when a OPA causes its SmartGroup to disappear, you must open the Alternative (LMA) record and select Hide Alternative when no Alternatives are suggested.
      - Restricting Alternatives by Provider and Encounter Type and Location = "Smartset Base" record only needed In some cases a Criteria OPA record is NOT necessary. https://d.pr/i/xsAx8j
        **Including or excluding a Location in a SmartSet Base OPA is subtly different from what you saw in the previous lesson: attaching a medication alternative to an ERX for just one hospital. There are three differences:
        
        You cannot attach a procedure alternative to an EAP for just one hospital.
        
        You cannot attach an outpatient alternative to an ERX for just one clinic.
        
        Attaching a medication alternative to an ERX for just one hospital causes the alternative to appear for only inpatient orders in that hospital. Discharge orders are unaffected. Including just one hospital via a SmartSet Base OPA allows the alternative to appear for discharge orders in that hospital.
        
        When you enter multiple criteria in one table, you must be very careful how you enter this information. If you enter multiple criteria in one row, then Epic applies “AND” logic between them; those criteria work together to identify a smaller set of situations to include or exclude. If you want the system to read the criteria as “OR” logic, put the criteria on different rows. https://d.pr/i/5W9V7M
        
        Build a More Complex Alternative
        Exercise 5: Build an Alternative for ARBs
        Part 1: Plan your Build :check: table = https://d.pr/i/qCgWiE ; Diagram = https://d.pr/i/tEt2dr
        
        Right now, you only want to configure your records for inpatient use. But in the future you might use the same records, with a little modification, for outpatient use too. In order to be most efficient in the long term, should you use OPAs or rules restrict your alternatives? OPAs are more flexible.
        
        Part 2: Edit the SmartText
        
        Log in to your Hyperspace Project environment as: RXADM/epicA SmartText named “XYZ ARB ALTERNATIVE” (replacing XYZ with your initials) was created for you by Training Magic. Open that record now!Confirm that the SmartText matches the screenshot at the beginning of this exercise.Hint: To change the cell colors, select the cells you want, right click and choose Cell color…Save and close.
        
        Part 3: Create a Criteria OPA
        
        Create a Criteria OPA named "XYZ CL HAS CHF" (replacing XYZ with your initials).Hint: If you still have the Decision Support Editors workspace open, click Criteria to create a new record.Remember to release it.Add criteria for Diagnoses and include the Diagnosis Grouper EDG CONCEPT HX CONGESTIVE HEART FAILURE [100040].Save your record.
        
        Part 4: Create a “Has CHF, Not a Pharmacist” SmartSet Base OPA
        
        Create a SmartSet Base OPA named “XYZ SB HAS CHF, NOT PHARMD” (replacing XYZ with your initials).Hint: If you still have the Decision Support Editors workspace open, create a SmartSet Base record using the "Other CDS" tab (not the OPA or Criteria tab). Remember to release it.Link it to your “XYZ CL HAS CHF” Criteria OPA.Make it NOT appear for the provider types of “Pharmacist.”Enter the correct triggers.Save your record.
        
        Part 5: Create a “No CHF, Not a Pharmacist” SmartSet Base OPA
        
        Create a SmartSet Base OPA named “XYZ SB NO CHF, NOT PHARMD” (replacing XYZ with your initials).Remember to release it.Link it to your “XYZ CL HAS CHF” Criteria OPA. In the Logic field, type “NOT 1”.In the previous SmartSet Base record, you wanted it to include patients with CHF.In this SmartSet Base, you want it to exclude those patients. The SmartGroup containing losartan should appear for patients without CHF.Rather than creating a second Criteria OPA called “CL WITHOUT CHF,” you are reusing the “CL CHF” Criteria and reversing the logic by placing “NOT” in front of it.In other words, “NOT including CHF” is the same as “NO CHF.”Make it NOT appear for the provider types of “Pharmacist.”Enter the correct triggers.Save your record.
        
        Part 6: Create a Losartan SmartGroup
        
        Create a SmartGroup called “XYZ Losartan Alternatives” (replacing XYZ with your initials).Hint: If you still have the Decision Support Editors workspace open, click SmartGroup Editors to create a new record.Add the correct value in the Restrictions field.Hint: On the Criteria formRemember: Losartan should be the suggested ARB for most patients (those without CHF).On the Configuration form add your XYZ LOSARTAN POTASSIUM 25 MG PO TABS as an Inpatient Order item. Add it three times.Make it match the top screenshot at the beginning of this section.Release your record.
        
        Part 7: Update Your Valsartan SmartGroup
        
        In the previous lesson, you created a SmartGroup for valsartan, and caused it to appear in the dynamic alternative. Now you'll update it to work with your more complex alternative. Open your SmartGroup called “XYZ Valsartan Alternatives”. Create a new contact (aka version). Add the correct value in the Restrictions field.Remember: Valsartan should be suggested for patients who have CHF.On the Panel Info form, remove all medications in the Medication Replacements field (this should include your three XYZ OLMESARTAN records). Confirm that it matches the bottom screenshot at the beginning of this section.Release your record.
        
        Part 8: Create a Losartan Alternative
        
        Create an Alternative called “XYZ ALTERNATIVES FOR LOSARTAN” (replacing XYZ with your initials).Hint: If you still have the Decision Support Editors workspace open, click Alternatives to create a new record.Add your XYZ ARB Alternative SmartText.Add the correct SmartGroup.Hint: this alternative should appear for patients with CHF, and should suggest valsartan.Add a hyperlink to match the alternative screen at the beginning of this section. (The link can go to any web page you like.)Don’t allow users to continue with their original selection.Hide the alternative when the SmartGroup is restricted.Save your record.
        
        Part 9: Create a Valsartan Alternative
        
        Create an Alternative called “XYZ ALTERNATIVES FOR VALSARTAN” (replacing XYZ with your initials).Configure it like the losartan alternative, but make sure you add the correct SmartGroup.Hint: This alternative should appear for patients without CHF and should suggest losartan.Hint: Hide this alternative when losartan should not be suggested.Save your record.
        
        Part 10: Create an Olmesartan Alternative
        
        Create an Alternative called “XYZ ALTERNATIVES FOR OTHER ARBS” (replacing XYZ with your initials).Configure it like the losartan alternative, but this time add both ARB SmartGroups.Hint: This alternative should suggest valsartan if the patient has CHF, and suggest losartan if the patient does not have CHF.Hint: this alternative shouldn't appear for pharmacists. Save your record and close the workspace.
        
        Part 11: Attach the Alternatives
        
        Attach the correct alternatives to ALL your xyz losartan, xyz valsartan, and xyz olmesartan ERX records.Remember to attach them as the Inpatient Alternatives (not Outpatient).Attach them as default alternatives (i.e. don’t restrict them to a specific hospital).Remember to set Use Alternatives? to “Yes” for Inpatient.If needed: There shouldn't be any Foundation System alternatives attached, but remove any that you find.
        
        What can an alternative do that a OPA cannot?
        Alternatives can restrict users from proceeding with the original order. Alternatives allow users to remove the current order during medication reconciliation. OPAs can allow users to remove the current order, but not during medication reconciliation.
        
        You want to set up a piece of decision support that suggests ordering the Consult to Pharmacy EAP whenever a physician tries to order any warfarin tablet ERX. Why must you use a OPA for this instead of an alternative? **Alternatives cannot suggest a Procedure (EAP) when a Medication (ERX) is ordered. OPAs can do this.
        
        You have an alternative with a SmartSet Base OPA attached to the SmartGroup. You want the alternative to appear only to Nurses in the Park Place Hospital. How can you do this? (Choose ALL that apply.)A. In the SmartSet Base OPA Encounter Limitation Inclusion table, list nurses in the provider type.B. Add Park Place Hospital in the Encounter Limitation Inclusion table on a different row as the nurse provider type.C. Attach the alternative to the ERX for just the Park Place Hospital.D. Check Hide when no Alternatives are suggested in the alternative record
        -- Answer: A, C, and D. A is correct, and B is incorrect because it says to list Park Place Hospital in a DIFFERENT row. If you included this in the SAME row, B would be correct and C would be unnecessary! Be sure to hide when no alternatives are suggested, so that it doesn't display to users with no options.
        
        You have a medication alternative that should only appear in inpatient encounters when a patient has a diagnosis of pneumonia. Should you use OPAs or a rule to restrict the alternative?Use a rule. Rules can be used for inpatient medication alternatives and they are simpler to set up than OPAs because they involve fewer records.
- - - - Exercise 2: Matching on a Pharmaceutical Subclass
        Kristi is also taking entacapone (Comtan) tablet 200 mg at home. You don’t have this medication on formulary, but you do have tolcapone (a similar medication).
        
        Go to Review Home Medications. You should be logged in to Hyperspace as FAMMD/epic with Kristi's admission open. Admission >> Admission Orders >> Review Home Medications In Add Prior to Admission Med, look up and add “entacapone (Comtan) 200 mg tablet” (not an “XYZ” record). The order composer opens with 200 mg already selected as the dose. Click Accept. Go to 2. Reconcile Orders. Order the entacapone. You see an alternative. What’s the reason the suggested alternatives were picked? Answer: "Antiparkinson COMT Inhibitor" This time, the dynamic alternative is suggesting an entirely different medication. There are NO strengths or forms of entacapone on formulary, so instead the system suggests the formulary medications that are part of the same pharmaceutical subclass, Antiparkinson COMT inhibitors. Select the “TOLCAPONE 100 MG PO TABS” option. Note that the Dose and Frequency fields are blank, but the route is filled in, just like the AMOXICLLIN 125 MG PO CHEW above. Close the order composer and clear the Order button.
        
        Medispan Specifics If your medication data vendor is Medispan, there is one particular exception to be aware of. Before considering the subclass, the system determines the value in the Pharm Class field (ERX item 110). If the pharm class listed is between 93 and 100, the system will NOT select alternatives based on subclass and indication. Why? Medispan has made this recommendation because values 93-100 include classes such as diagnostic products, medical devices, and miscellaneous. Rather than suggest alternatives that would be inaccurate, no alternatives will be offered.
        
        How Epic Populates Dose, Route, and Frequency
        As you saw in the preceding exercises, the dynamic alternative automatically copies some of a home med’s details into the selected alternative – whatever details are safe to carry over. It does not apply any defaults from the ERX record. When you selected the: AMOXICILLIN 200 MG/5 ML PO SUSR, the dose, route, and frequency all copied over from the home medication. AMOXICLLIN 125 MG PO CHEW, only the route copied forward. The dose and frequency had to be filled in.
        
        Here’s how the dynamic alternative logic works:
        -- If the ERX has the same drug, route, and form (based on 3rd party data, for example, PO SUSR), the dose, route, and frequency all carry over.
        -- If the ERX has the same route, but a different form or drug (for example, PO SUSR and PO CHEW), only the route carries over.
        -- If the ERX has a different route (for example, PO SUSR and IJ SOLR) nothing carries over.
        
        When a detail does not carry over from the home medication, the fields are blanked out and required. The system does not apply any defaults from the selected ERX record. This prevents users from assuming that the system made an appropriate conversion from the home medication to the inpatient order.
        The Alternative Build Audit Utility
        
        While this behavior is often appropriate, it does lead to more clicks for providers. There are some situations where a slight change could remedy the issue. Use the Alternative Build Audit utility to find situations where the system will not be able to carry over details from the original order. Then review to find situations where you might want to update your build to address it. Path in text: Clinical Administration >> Management Options (System Definitions, Profiles, Utilities, etc.) >> Other System Modules >> Willow >> Inpatient >> Build Audit Utilities >> Alternatives Go to Galaxy and read this section of the Alternatives Setup and Support Guide: Allow Order Details to be Carried Over When Reordering.
        
        Preventing Erroneous Non-Formulary Warnings
        Inpatient IMS for Solids
        For Inpatient ordering, Intelligent Medication Selection (IMS) for Solids streamlines the ordering process by automatically selecting products for providers. They simply pick the drug, dose, and frequency and sign the order. During admission medication reconciliation, IMS for Solids works for reordered home medications in the same way as it does new inpatient orders.
        When a Dynamic Alternative Appears for IMS Solids
        
        If a medication has been configured to use IMS, and any strength of the medication is on your formulary, dynamic alternatives do NOT appear. If none of the strengths are on your formulary, dynamic alternatives DO appear. Example A patient was taking 10 mg of Crestor daily at home. The nurse documents the home medication. The provider reorders the Crestor. None of the strengths of Crestor are on your formulary. A dynamic alternative appears. OK, so I can put one strength of a formulary IMS med on my formulary and be fine? No. Try this:
        
        Exercise 3: What the Pharmacist Sees
        When pharmacists verify new inpatient medication orders, they see a warning if the medication is not formulary. Epic determines the formulary status of reordered home meds before IMS picks the ERXs to dispense. Therefore, when IMS changes a non-formulary home med to a formulary product, pharmacists see an erroneous non-formulary warning.
        
        Part 1: Check the Formulary
        --Log in to Hyperspace as RXADM/epic. From Rx Admin, select Medication List Admin and open your “XYZ Dynamic Alt Formulary.” Confirm that the following strengths of atorvastatin are on the formulary: atorvastatin 10 mg PO tabs atorvastatin 20 mg PO tabs atorvastatin 40 mg PO tabs Confirm that the 80 mg tablets of atorvastatin are NOT on the formulary. Close your med list.
        
        Part 2: Order Home Meds
        -- Log in to Hyperspace as RXPHARM/epic. Click Orders in the top left corner, and search for your Kristi patient. Go to Admission >> Admission Orders >> Review Home Medications for your Kristi patient. Add a home medication of “atorvastatin (LIPITOR) tablet 80 mg.” Go to 2. Reconcile Orders and click Order for the atorvastatin. Ignore any warnings/OPAs about pharmacogenetics. Why don’t you see a dynamic alternative? The dynamic alternative did not appear because at least one strength of atorvastatin is on your formulary. Click Sign & Verify. Select and Order mode Sam Stethoscope as the provider. Override any warnings you see. In Verify Orders: Is the order flagged as non-formulary? (Look at the top left corner of the Verify activity, under the name of the order.) Which product will be dispensed? Is it on your formulary? The 40 mg tabs will be dispensed. They are in stock and on formulary. But the order is flagged as “non-formulary” because the 80 mg tablets (the product you technically selected when entering the order) are not on your formulary. Reject this order (hint: click next to Verify) Leave Kristi's chart open.
        
        Part 3: Fix the Problem
        
        Logged in to Hyperspace as RXADM/epic, add the atorvastatin 80 mg tablets to your formulary: If the formulary is not open, Rx Admin >> Medication List Admin >> XYZ DYNAMIC ALT FORMULARY. Click Edit. Then click Add. Add the medication ATORVASTATIN CALCIUM 80 MG PO TABS. Click Accept and then Close. Return to Hyperspace (logged in as RXPHARM/epic) and Kristi's admission. Go to the Admission activity >> Admission Orders >> Review Home Medications. Add a new home medication for “atorvastatin (LIPITOR) tablet 80 mg”. When prompted, choose Add Duplicate. Go to 2. Reconcile Home Medications. Click Order next to the new atorvastatin order. Click Sign & Verify. Override any warnings. In Verify Orders: Is the order flagged as non-formulary? Nope! The system is still dispensing 2 x 40 mg tablets because of IMS, but the erroneous non-formulary warning is gone! Hooray! Close Kristi's chart.
        
        To prevent erroneous non-formulary warnings, put all available stren
        
        Building Alternatives for Common Non-Formularies
        Epic recommends manually creating alternatives for the 100 or so most frequently ordered non-formulary medications. This allows you to show a SmartText, web link, and dose suggestions specific to those medications. It also allows you to control which medications are suggested as alternatives.
        These manually created alternatives appear instead of the dynamic alternative. The dynamic alternative still appears for the ~15,000 less-common non-formulary medications.
        Exercise 4: Ordering a Common Non-Formulary
        
        Part 1: Check the Formulary In Hyperspace (logged in as RXADM/epic), open the XYZ DYNAMIC ALT FORMULARY med list. Hint: Rx Admin >> Medication List Admin. Confirm that there ARE entries for losartan tablets. Confirm that there are NO entries for valsartan. This means that ordering valsartan during med rec could trigger the dynamic alternative. But you also attached an alternative to valsartan in the prior lesson. Which one will appear? Let’s find out! Keep the formulary open.
        
        Part 2: Order Home Meds Log in to Hyperspace as TRN081/train (Sam Stethoscope, an inpatient physician). Click the Epic button and search for "Encounter". Open your Kristi Xyz patient's admission and find the Unit Navigators activity (it may be under the More Activities drop down arrow). On the Admission tab, select Admission Orders. Go to Review Home Medications for your Kristi patient. Add a new patient-reported medication for your XYZ valsartan (Diovan) tablet 80 mg from Database Lookup. Go to 2. Reconcile Home Medications. Order your valsartan. You see YOUR alternative, not the dynamic alternative. Click Cancel for your alternative. On the Storyboard, click “No active principal problem” to open the Problem List. Add a new problem of “congestive heart failure.” (You may need to click to edit and add this.) Go back to 2. Reconcile Home Meds. Order your valsartan. What happens? No alternative appears. Remove the order. Keep Kristi's chart open.
        
        If the ordered ERX is linked to a specific alternative for the patient’s hospital, the dynamic alternative does NOT appear. This is true even if the linked alternative does not actually appear due to restrictions!
        
        When Non-Specific Med Alternatives Appear
        Normally, a non-specific medication alternative appears instead of the dynamic alternative because it is linked to the ordered ERX. However, the dynamic alternative appears instead of the non-specific med alternative if BOTH of the following are true:
        
        None of the ERXs suggested by the non-specific med alternative are on the formulary or facility preference list, AND
        
        The dynamic alternative can find alternative formulary ERXs to suggest.
        
        Exercise 5: Non-Specific ERX Alternative versus Dynamic Alternatives
        Kristi tells you that she is currently taking two daily drugs: Nexium pills and irbesartan pills. However, she has no clue what dose or strength was prescribed for either med. You want to order these for the admission.
        
        Part 1: Check the Formulary In Hyperspace (logged in as RXADM/epic), look at the XYZ DYNAMIC ALT FORMULARY med list. Hint: Rx Admin >> Medication List Admin. Confirm that there are NO entries for esomepraxole magnesium (brand name: Nexium). Confirm that there are NO entries for irbesartan. However, there ARE entries for losartan. Close the formulary.
        
        Part 1: Document Home Meds Return to Hyperspace (logged in as TRN081/train) and go to Review Home Medications for your Kristi patient. Add “NEXIUM PO” [60249] as a home med from Database Lookup. Enter a dose of “1 tablet” and a frequency of “Daily.” Also add “IRBESARTAN PO” [56567] as a home med from Database Lookup. Enter a dose of “1 tablet” and a frequency of “Daily.”
        
        Part 2: Reorder Home Meds Select 2. Reconcile Home Medications. Order the irbesartan. Even though you tried to order a non-specific medication the dynamic alternative appears because: None of the irbesartan strengths or forms listed in the non-specific medication alternative are on the formulary or facility preference list AND The dynamic alternative finds an appropriate alternative on formulary. Cancel the order. Order the Esomeprazole Magnesium (NEXIUM PO). The non-specific medication alternative appears because the dynamic alternative failed to find an appropriate alternative. There is nothing on formulary in Nexium’s pharmaceutical subclass. Cancel the order and close Kristi’s chart.
  - - - :check: Troubleshooting Dynamic Alternatives
        It can be difficult to determine why certain medications are or are not suggested as alternatives. The Dynamic Alternative Trace Utility shows you how the alternative suggestions are determined.
        Path: Text >> Clinical Administration >> Management Options >> Other System Modules >> Willow >> Inpatient >> Troubleshooting >> Dynamic Alternative Trace Utility
        
        Reviewing the Chapter
        
        A patient reported taking Flonase nasal spray with two sprays in each nostril two times a day, but isn’t sure what strength he was prescribed. The nurse recorded the home medication as “GENTAMICIN SULFATE OP” 2 applications Q6H in each nostril. Upon admission, in the Reconcile Home Medications section, you click Order. The following window appears: Why did this alternative appear? (Select only one.) The dynamic alternative found alternative medications on the formulary in the same pharmaceutical subclass. There was an ERX specific alternative attached to the GENTAMICIN SULFATE OP you selected. The GENTAMICIN SULFATE OP you selected was a non-specific medication without a strength or dose.
        
        **Answer: A. The dynamic alternative found alternative medications in the same pharmaceutical subclass. Also, none of the options listed in the non-specific medication alternative are on the formulary or the facility preference list. The non-specific medication alternative would have appeared if it contained formulary options, but it did not.
        **
        
        An IMS enabled medication is ordered during med rec but not all of the available strengths are on the formulary. The strength that the patient was taking at home is not on formulary. True or False: This causes the system to fire the dynamic alternative. Answer: False. The order does not display the dynamic alternative because at least one strength is on formulary. It WILL be flagged as non-formulary in Verify Orders because the strength that the patient was taking at home is not on formulary. This is why all strengths of IMS medications should be put on the formulary.
        
        Answer: False. The order does not display the dynamic alternative because at least one strength is on formulary.
        It WILL be flagged as non-formulary in Verify Orders because the strength that the patient was taking at home is not on formulary. This is why all strengths of IMS medications should be put on the formulary.
        
        Your organization is composed of 10 hospitals. Two of your hospitals’ formularies are consistently 6 months to a year out of date. For these two, you want their central pharmacies’ medication lists to trigger the dynamic alternative.
        For the other 8 hospitals you want the formulary to trigger the dynamic alternative.
        True or False: You can configure the system to use the formulary for some hospitals and the central pharmacy medication list for others.
        Answer: False. The type of list you designate for dynamic alternatives applies globally to your organization. You cannot choose which list on a hospital-to-hospital basis.