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TT-RX100 Fundamentals L1 Entering Orders L2 Supporting Nurses L3…

- - - - Both types of administration instructions are prominently displayed on the MAR. Note to Pharmacy is visible from the MAR, but users must “drill down” to see it.
  - - - The vendor provides information about all of the medication products and packages currently being manufactured. Each ERX record created by the thirdparty data load has information including (but not limited to): • Industry-standard clinical information such as the pharmaceutical and therapeutic classes • The medication’s DEA schedule (which indicates whether it’s a controlled substance and the level of abuse potential) • A generic product index that is used to equate different but equivalent medication records to each other (for example, the product index tells the system that ASPIRIN 325 MG PO TABS is just a different strength of ASPIRIN 500 MG PO TABS) • Links to medication and allergen warnings that can appear to ordering providers and pharmacists (such as drug-drug interaction and duplicate therapy warnings) The Medications (ERX) database also contains records for: • Commercially available compounds, e.g. guaifenesin-codeine 100-10 mg/5 mL liquid which has 100 mg of guaifenesin and 10 mg of codeine in every 5 mL of liquid • Mixtures, which are prepared specifically for each patient, combining multiple simple ERXs • Orderables, which map to more specific dispensable products.
      - Preference List vs. Database : The Preference List tab for pharmacists includes every medication that is available in the pharmacy. However, the Database tab includes every ERX record, procedure record, and panel - over 70,000 records!
        
        The Database tab is available for pharmacists and administrative users; physicians and nurses typically don’t have access to it for “during visit” inpatient orders.
    - - There is a single ERX record in your system for HYDROCORTISONE 1 % EX CREA, regardless of the number of hospitals you have at your organization. When a physician in Hospital A orders this medication, it will have the same default dose, route, and frequency that it has when a pharmacist orders it in Hospital B.
    - - EFQ: Frequency (EFQ) records are global. If you configure “2 Times Daily” to have standard due times at 0900 and 1800, those will be the due times in every hospital in your organization. You can override due times for specific frequencies on a unit-by-unit basis, but doing so can require a lot of work (both up front and to maintain). Also, if a patient is transferred between units, any orders that “follow” won’t be rescheduled. Epic recommends standardizing your due times across your sites prior to implementation
      - Interval (i.e start with "EVERY") = Every 12 hours, etc...
  - - - The packages with check marks are the ones stocked in the dispensing pharmacy. https://d.pr/i/slsEjt
      - Because NDCs are required by payors and CMS, and because they can have such a large impact on how medications are dispensed and charged for, an order can’t be verified without a package. If a pharmacist enters an order without a package, the order will not autoverify. https://d.pr/i/Mq3VwD
    - - If you create custom NDC records for products that you repackage, you will need to configure items in the NDC record such as the package size, units, and the original NDC used to create the package (which contains the information that should be sent to billing)
    - - How it works: https://d.pr/i/hUuIg5; https://d.pr/i/nOs5F4
        
        How Intelligent Package Selection Works The way the system picks a package (NDC) record for liquids is called Intelligent Package Selection (IPS). IPS tries to pick a package based on: • The administer amount (volume) of each dose • The packages available in dispense locations that serve the patient When possible, IPS chooses a package that matches the volume needed for each dose. If an exact match is not possible, your organization can configure how Epic chooses the package. You can configure it to do any of the following: • Look to another dispense location for an exact match • Dispense multiple smaller packages • Dispense the next largest package (and have nurses use only part of it) • Dispense from the largest package available (which usually means pharmacy will draw up a custom syringe)
  - - - Epic uses Intelligent Medication Selection (IMS) to minimize the amount of product-based ordering users need to do. When ordering a solid-form medication (tablets, capsules, suppositories, etc.) with a single active ingredient and multiple strengths, you don’t need to pick the strength when searching for the product.
      -  How IMS for Solids Works The ADS cabinet serving Seamus’s unit is stocked with 5 mg tablets and 2.5 mg tablets, but not 10 mg tablets. For a 12.5 mg dose, IMS chose to dispense 2 x 5 mg tablets + 1 x 2.5 mg tablet from the ADS, rather than dispensing 1 x 10 mg + 1 x 2.5 mg from central pharmacy. Intelligent Medication Selection tries to find a combination of strengths for a single ingredient solid that allows for the: • Closest dispense location • Smallest number of different strengths in a dose • Smallest total number of tablets, capsules or suppositories in a dose Also: • Dispense locations can be configured to allow or not allow nurses to split tablets. • Combinations that require more than a certain number of tablets in a dose will always dispense from the central pharmacy. When a patient transfers to another unit, the system reevaluates the dispense logic for any IMS orders. It also adjusts the product(s) being used based on what’s available in the dispense locations serving the patient’s new room and bed.
        
        If single ingredient solid, then it tries to find:
        
        Closest dispense location (configurable limits)
        
        Smallest strengths
        
        Smallest number of tablets/caps/suppositories
    - - Clinical Context… “IVPB” stands for intravenous piggy back. These are small IV bags (or syringes) containing a medication diluted in a solution like D5W or NS. The term comes from the fact that they "piggy back" on the same IV line as a continuous maintenance IV. They usually infuse over a period of time, like 30 or 60 minutes, rather than running continuously.
      -  How IMS for IVs Works IMS for solid medications works more-or-less automatically and requires relatively little configuration. By contrast, IMS for IVs requires a considerable amount of work to implement. Your project team needs to:
        Configuring IMS for IVs is a significant part of your install but makes life much easier for your end users. You’ll learn more about configuring IMS for IVs in future classes.
        
        Configure all the simple Medication (ERX) records for your premixes and ingredients.
        
        Configure mixture Medication (ERX) records for each way you might prepare and compound doses for patients.
        
        Configure an orderable Medication (ERX) record for each IV drug that is dispensed in different ways.
        
        Map the orderable to each dispensable, providing logic for when each dispensable should be used.
- - - - Unverified Orders: Medication orders that are signed appear on the MAR; they will have a red stop sign icon and no dispense location until they are verified.
        
        No dispense location has been assigned to the medications; dispensing begins when a medication is verified.
        
        Nurses receive a warning if they try to administer a medication that is not yet verified.
- - - - Order Sets are organized into groups of orders called SmartGroups. When you open an Order Set, some SmartGroups are required and others are not. SmartGroups can be expanded or collapsed by default. Some SmartGroups contain orders for medications, and others contain other kinds of orders. The organization of and orders contained in SmartGroups, along with their preselected details and defaults, are choices made by administrators. It is important for Willow Project Team members to understand how Order Sets are used by physicians because they are responsible for creating SmartGroups that contain medication orders. https://d.pr/i/EW2pCr
    - - Medication Warnings: appear inline or upon signing
    - - Customizing Preference List: https://d.pr/i/t5fuFy
        https://d.pr/i/u8g4vz
      - Facility List Tab of Doc and RN = https://d.pr/i/JhpKA6
        If an order is not found on their Preference List tab, clinicians can expand their search to the Facility List. It is the largest search physicians and nurses can access during order entry. The Facility List includes: • All procedure, or non-medication, orders (labs, imaging, diet, nursing) available in the patient’s hospital • All medications on the hospital’s formulary
      - Once physicians or nurses find an order, they have most of the same fields and options in the Order Composer as pharmacists. The only difference is that pharmacists have the Dispense section at the bottom of the Order Composer. When you are validating and configuring your Medication (ERX) records, remember that you should be planning for CPOE. Think about how each order will appear to a physician or nurse, not just about how it appears to a pharmacist. :check:
      - Entering a Non-formulary Inpatient Order = search of "HELP" in the Additional Admission Orders and Order Sets field
- - - - The Rx Surgical Orders Requiring Advanced Preparation is created from a template, Rx Advanced Prep. As of Epic’s 2015 version, this template can be modified to search appointment or hospital visit encounter types (not just surgeries). This allows pharmacists to find treatment and therapy plans, particularly useful to meet the needs of oncology patients and their infusion appointments.
      - There are situations where you need to prepare doses of medications for patients who aren't admitted or arrived yet. These orders have been Signed and Held, but not released. This is common for situations like scheduled surgeries and infusion clinic appointments. An unreleased order doesn’t appear in the patient’s chart, nor does it get sent to pharmacy for verification or dispensing. Signed and Held orders are released after the patient arrives, often causing a rush in the pharmacy to prepare these medications each morning. To avoid this, pharmacists can use a Reporting Workbench report to find, verify and print labels for the orders so they can be prepared in advance
    - - From the list of results, select the order(s) you want to verify (you can select multiple orders for a single patient) and click Verify Orders. The patient’s chart opens to the Verify Orders activity. Verifying an order causes labels to print for the medication, so preparation can begin. Upon admission, the nurse will release any signed and held orders for the patient. Orders that were verified using this report and are not modified by the physician before they are released will not appear in the Verify Queue again.