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wAM Fundamental Mistral v3 with hierachy, RXAMB100 Willow Ambulatory…
wAM Fundamental Mistral v3 with hierachy
Table of Contents
RXAMB100 Willow Ambulatory Fundamentals
Introduction
Document Details
How to Use This Training Companion
Training Companion Types
How to Practice Outside of Class
Download Course Materials
How to Request Access to Epic's Cert Environments
Access a Study Environment
Reviewing and Filling New Prescriptions
Introduction
Workflow for New Prescriptions
Process Steps
Workflow Diagram
Flags
Workflow Review
Finding and Reviewing New Orders
Work Queues
Initial Review Queue
Work Requests
Splitting Work Requests
Completing First Fill Review
Adjudication
Completing Clinical Review
Reviewing Medication Warnings
Reviewing the Patient's Chart
Contacting a Provider to Clarify an Order
Filling Some of a Patient's Scripts
Filling
Filling via Pill Counters
Filling Manually
Fill Labels
Completing the Fill
Verifying Fills
Dispensing Fills
Point of Sale (POS) Activity
Reviewing the Med Profile
Reviewing Prescription History
Workflow Variations
Exercise 1: Review and Fill as a Pharmacist
Reviewing the Chapter
Review Questions
Review Key
Study Checklist
Entering New Prescriptions
Introduction
Entering Paper Prescriptions
Entering a Simple Script
Finding Medications on a Preference List
Where Does the Medication Come From?
Where Do the NDCs Come From?
Why is This NDC Selected?
Entering a Script's Details
Adding to the Sig
Using Inline Prescription Entry
Prescription Entry Shortcuts
Entering a Free-Text Provider
Entering a Script That Will Not Be Filled Now
In-Class Exercise
Exercise 1: Entering Mixtures
Exercise 2: Entering Brand Name and Partially Filled
Key Takeaways
Translating Sigs
Reviewing the Chapter
Transferring Prescriptions
Refilling Prescriptions
Day 1 Lab
Registering New Patients
Managing Adjudication Issues
Clinician Interactions
Reporting
Day 2 Lab
Appendix A: Do This Next
Appendix B: Reviews
RXAMB100 Willow Ambulatory Fundamentals
1.1 Introduction
1.1.1 Document Details
1.1.1.1 Version: February 2026
1.1.1.2 Last Revised: March 27, 2026
1.1.1.3 Request project specification by: October 23, 2026
1.1.1.4 Submit project by: November 27, 2026
1.1.1.5 Request exam by: October 19, 2026
1.1.1.6 Next version materials available: October 26, 2026
1.1.2 How to Use This Training Companion
1.1.2.1 Use with other course materials
1.1.2.2 Check version and dates
1.1.2.3 Check All Training Companion Change Log for significant changes
1.1.2.4 New materials released regularly
1.1.3 View a Training Companion With and Without Answers
1.1.3.1 Use without answers for training
1.1.3.2 With answers version for reference only
1.1.3.3 Toggle in Galaxy menu
1.1.3.4 Download options from toolbar
1.1.4 How to Practice Outside of Class
1.1.4.1 Ensure using current version
1.1.4.2 Check for significant changes before use
1.1.4.3 Self-study requirements for proficient status
1.1.4.3.1 Review Epic's Training Guide - Epic Community Member
1.1.4.3.2 Watch EA002 Overview of Proficient Self-Study e-learning
1.1.4.3.3 Approved for direct Epic employees only
1.1.4.3.4 Not available for badges and some applications
1.1.5 Download Course Materials
1.1.5.1 Available on Galaxy
1.1.5.2 Available on Course Catalog
1.1.5.2.1 Use application/role filters
1.1.5.3 Available via EpicU
1.1.5.3.1 Training Home
1.1.5.3.2 Your In-Progress Certificates section
1.1.5.3.3 Expand sections for course materials
1.1.6 How to Request Access to Epic's Cert Environments
1.1.6.1 Purpose: Complete projects and study
1.1.6.2 Steps
1.1.6.2.1 Go to Training Home on UserWeb
1.1.6.2.2 Under Certificate Resources, select Cert Environment Request
1.1.6.2.3 View current environments
1.1.6.2.4 Request new Study and/or Project environments
1.1.6.2.5 Note: One environment per version
1.1.6.3 Access Epic Access
1.1.6.3.1 Most learners: access.epic.com
1.1.6.3.2 Europe/Middle East: EUaccess.epic.com
1.1.6.3.3 Wait 15 minutes for Europe/Middle East
1.1.6.4 Login
1.1.6.4.1 Same credentials as UserWeb
1.1.6.4.2 6-digit authentication code if prompted
1.1.6.5 Additional setup may be required
1.1.6.5.1 Confirm Citrix version with IT team
1.1.6.6 Check Your Setup option
1.1.6.7 Launch application via icons
1.1.6.7.1 Study icons for self-study
1.1.6.7.2 Project icons for projects
1.1.6.7.3 Virtual Training icons for virtual classes
1.1.6.7.4 Search for missing icons
1.1.6.7.5 Star icon to add to Home screen
1.1.6.8 Technical difficulties
1.1.6.8.1 See Galaxy article for file opening issues
1.1.6.8.2 Email
training@epic.com
for material/user issues
1.1.7 Access a Study Environment
1.1.7.1 Purpose: Complete exercises independently
1.1.7.2 Refresh schedule: Every Friday at 10:00 PM Central Time (or EU Central Time)
1.1.7.3 Access steps
1.1.7.3.1 Same as cert environments
1.1.7.3.2 Confirm Study icon contains version month
1.1.7.4 Login using training credentials
1.1.7.5 If work completed by another trainee, choose different classroom info sheet
1.1.8 Training Companion Types
1.1.8.1 Critical Box
1.1.8.1.1 Contains critical information
1.1.8.2 Example Box
1.1.8.2.1 Provides scenario for following content
1.1.8.3 Beyond the Basics Box
1.1.8.3.1 Additional helpful information
1.1.8.3.2 Not critical for course assessments
1.1.8.4 Write-It-Down Box
1.1.8.4.1 Write down information or answer questions
1.1.8.5 Foundation System FYI Box
1.1.8.5.1 How Foundation System handles workflow
1.1.8.5.2 Other Foundation considerations
1.1.8.6 SetUp Box
1.1.8.6.1 More information about system configuration
1.1.8.7 Real World Context Box
1.1.8.7.1 Clarifies industry-standard terminology or practice
1.1.8.8 Generative AI Box
1.1.8.8.1 More information about AI features, tools, and usage
Reviewing and Filling New Prescriptions
2.1 Introduction
2.1.1 Purpose: Learn pharmacy workflow
2.1.1.1 Reviewing prescriptions
2.1.1.2 Filling prescriptions
2.1.1.3 Dispensing fills
2.1.1.4 Transferring prescriptions
2.1.1.5 Managing adjudication issues
2.1.2 Learning expectations
2.1.2.1 Use tools and complete workflows with help
2.1.2.2 Not expected to complete every workflow from memory
2.1.3 Support contact
2.1.3.1 Email
WillowTrainingSubmission@Epic.com
2.1.3.2 Include: companion/chapter/page, environment, user ID, patient name/MRN, configuration, troubleshooting tried
2.2 Workflow for New Prescriptions
2.2.1 Key concept: Scripts vs fills
2.2.1.1 Scripts can have multiple fills (with refills) = The fill is what get verified and sold
2.2.1.2 Script gets reviewed
2.2.1.3 Fill gets verified and sold
2.2.1.4 Focus switches from script to fill when filling begins
2.2.2 Process steps
2.2.2.1 Script Received
2.2.2.1.1 Status: Pending Fill
2.2.2.1.2 Electronic script
2.2.2.1.2.1 From EpicCare or e-prescribing service
2.2.2.1.3 Paper script
2.2.2.1.3.1 Transcribe in Willow to receive
2.2.2.1.3.2 Saving transcription counts as First Fill Review
2.2.2.1.4 Prescription numbers assigned immediately
2.2.2.2 First Fill Review
2.2.2.2.1 Status: Pending Fill (no change)
2.2.2.2.2 Performed by: Usually technician
2.2.2.2.3 Actions
2.2.2.2.3.1 Check for missing information
2.2.2.2.3.2 Check for potential dispensing issues
2.2.2.2.3.3 Verify NDC is in stock
2.2.2.2.4 Completion
2.2.2.2.4.1 Automatically triggers Adjudication
2.2.2.2.5 NDC Definition
2.2.2.2.5.1 National Drug Code
2.2.2.2.5.2 Registered with FDA
2.2.2.2.5.3 Specific to manufacturer, medication, package size, package type
2.2.2.2.5.4 Example: 0378-7185-05 = Metformin 500 mg PO tablets, 500-count bottle by Mylan
2.2.2.2.5.5 Must be printed on bottle label
2.2.2.2.5.6 Must be sent on claim for adjudication
2.2.2.2.5.7 Different NDCs can have different costs
2.2.2.2.5.8 Changing NDC triggers automatic re-adjudication and label reprint
2.2.2.3 Adjudication
2.2.2.3.1 Status: Pending Fill (no change)
2.2.2.3.2 Process
2.2.2.3.2.1 Send claim to Pharmacy Benefits Manager (PBM)
2.2.2.3.2.2 Real-time processing
2.2.2.3.2.3 Determines patient co-pay
2.2.2.3.2.4 Determines covered amount
2.2.2.3.3 Outcomes
2.2.2.3.3.1 Success: Script and fill move to next stage
2.2.2.3.3.2 Failure: Charging Rejected flag added
2.2.2.3.4 Profit calculation
2.2.2.3.4.1 Profit = Acquisition cost - (Covered amount + Patient charge)
2.2.2.3.4.2 Can be hidden for users/groups
2.2.2.4 Clinical Review
2.2.2.4.1 Status: Ready to Fill
2.2.2.4.2 Performed by: Pharmacist only
2.2.2.4.3 Actions
2.2.2.4.3.1 Check sig (directions)
2.2.2.4.3.2 Check interactions
2.2.2.4.3.3 Check appropriateness
2.2.2.4.4 Requirements
2.2.2.4.4.1 Required once per script (not per fill)
2.2.2.4.5 Special functions
2.2.2.4.5.1 Changes trigger re-adjudication
2.2.2.4.5.2 Request Revision button
2.2.2.4.5.2.1 Sends script back to technicians
2.2.2.4.5.3 Discontinue button
2.2.2.4.5.3.1 Cancels fill
2.2.2.4.5.3.2 Discontinues prescription in EpicCare (not just pharmacy)
2.2.2.5 Print the Label
2.2.2.5.1 Status: Fill Initiated
2.2.2.5.2 Performed by: Usually technician
2.2.2.5.3 Actions
2.2.2.5.3.1 Print fill label from work queue
2.2.2.6 Complete the Fill
2.2.2.6.1 Status: Ready to Verify (after all fills in work request completed); If only one script is filled in a multiple scripts in a work request, then its status is "Filled" only untill ALL are filled, then status become "Ready to Verify"
2.2.2.6.2 Performed by: Usually technician
2.2.2.6.3 Actions
2.2.2.6.3.1 Count/measure medication
2.2.2.6.3.2 Barcode scanning workflow
2.2.2.6.3.2.1 Scan Rx # barcode
2.2.2.6.3.2.1.1 Opens Rx Management tab
2.2.2.6.3.2.1.2 Selects fill
2.2.2.6.3.2.2 Scan bulk package NDC barcode
2.2.2.6.3.2.2.1 Verifies NDC match
2.2.2.6.3.2.2.2 Status changes to Filled
2.2.2.6.3.2.2.3 On mismatch: Error message with options
2.2.2.6.3.2.2.3.1 Return to shelves for correct package
2.2.2.6.3.2.2.3.2 Change NDC (triggers re-adjudication and label reprint)
2.2.2.6.3.2.2.3.3 Must re-scan NDC after change
2.2.2.6.3.2.3 Prepare fill (outside Willow)
2.2.2.6.3.2.3.1 Count pills
2.2.2.6.3.2.3.2 Affix label to container
2.2.2.6.3.2.4 Repeat for each fill
2.2.2.6.3.3 Manual completion (without barcode)
2.2.2.6.3.3.1 Double-click patient from
Ready to Fill
queue
2.2.2.6.3.3.2 Manually select fill
2.2.2.6.3.3.3 Click Mark as Filled
2.2.2.6.3.3.4 Barcode Scanning Warning in production
2.2.2.6.3.3.4.1 Requires override reason
2.2.2.6.3.3.5 In training: Can select Don't Show Again for session
2.2.2.7 Verify the Fill
(Verify ALL fills is completed and go to WILL CALL queue
2.2.2.7.1 Status: Ready to Dispense (after all fills in work request verified); If only one med is verified in a fill that contain multiple meds within a work request then its status is "Verified" till ALL fills done then it changed to "Verified"
2.2.2.7.2 Performed by: Pharmacist
2.2.2.7.3 Actions
2.2.2.7.3.1 Barcode scanning workflow
2.2.2.7.3.1.1 Scan fill label
2.2.2.7.3.1.1.1 Opens Rx Management for fill
2.2.2.7.3.1.2 Visually inspect product
2.2.2.7.3.1.2.1 Reference product image and description in Willow
2.2.2.7.3.1.3 Perform clinical review if needed
2.2.2.7.3.1.3.1 Changes may trigger label reprint and re-adjudication
2.2.2.7.3.1.4 Verification options
2.2.2.7.3.1.4.1 Scan ID badge to verify
2.2.2.7.3.1.4.1.1 Status changes to Verified
2.2.2.7.3.1.4.2 Or click Reject Fill
2.2.2.7.3.1.4.2.1 Status changes to
Fill Rejected
2.2.2.7.3.1.4.2.2 Returns to Ready to Fill queue
2.2.2.7.3.1.5 Repeat for each fill
2.2.2.7.3.2 After last fill verified
2.2.2.7.3.2.1 Patient chart closes
2.2.2.7.3.2.2 Return to Ready to Verify queue
2.2.2.7.3.2.3 All fills' statuses become Ready to Dispense
2.2.2.7.4 Manual verification (without barcode)
2.2.2.7.4.1 From Ready to Verify queue
2.2.2.7.4.2 Double-click patient to open Rx Management
2.2.2.7.4.3 Click fill to select
2.2.2.7.4.4 Click Fill verified checkbox
2.2.2.7.4.5 Click Accept to close chart
2.2.2.8 Dispense Fill to Patient
2.2.2.8.1 Status: Dispensed
2.2.2.8.2 Performed by: Cashier, tech, or pharmacist
2.2.2.8.3 Actions
2.2.2.8.3.1 Mail order/courier: Begin packaging and delivery
2.2.2.8.3.2 Pickup
2.2.2.8.3.2.1 If patient not arrived: Place in holding bin
2.2.2.8.3.2.2 If patient arrived: Process sale via POS
2.2.3 Workflow Diagram
2.2.3.1 Script Received
2.2.3.2 First Fill Review
2.2.3.3 Adjudication
2.2.3.4 Clinical Review
2.2.3.5 Filling
2.2.3.6 Fill Verify
2.2.3.7 Point of Sale
2.3 Flags
2.3.1 Purpose
2.3.1.1 Drive Willow Ambulatory workflows
2.3.1.2 Indicate next task that needs to be done
2.3.1.3 When removed, script/fill moves to next step
2.3.2 Types and behavior
2.3.2.1 Red Flags
2.3.2.1.1 Block immediately
2.3.2.1.2 Block fill or work request from advancing
2.3.2.1.3 Called blocking flags
2.3.2.1.4 Examples
2.3.2.1.4.1 First Fill Review = happened when a new rx is sent to Willow from EpicCare
2.3.2.1.4.2 Charging Rejected = when Adjudication failed after First Fill Review flag is removed
2.3.2.1.4.3 Needs Clinical Review = if technician removed First Fill Review instead of pharmacist
2.3.2.2 Blue Flags
2.3.2.2.1 May block dispensing or not block at all
2.3.2.2.2 If blocks at Ready to Dispense: Must be resolved before dispensing
2.3.2.2.3 If does not block: Can be resolved anytime, even after dispensing
2.3.2.2.4 Can be added early and remain through many steps
2.3.2.2.5 Examples
2.3.2.2.5.1 Blocks Dispensing: Consult Patient
2.3.2.2.5.2 Does Not Block: Patient Pay Amount Change
2.4 Workflow Review
2.4.1 Table: When step completed → Status updates to → Found in work queue
2.4.1.1 New Script Received → Pending Fill → Initial Review
2.4.1.2 First Fill Review → (no change) → n/a
2.4.1.3 Adjudication → (no change) →
2.4.1.4 Clinical Review → Ready to Fill → Clinical Review
2.4.1.5 Print the Label → Fill Initiated → Ready to Fill
2.4.1.6 Complete the Fill → Filled → n/a
2.4.1.7 Fill ALL Fills → Ready to Verify → Ready to Verify
2.4.1.8 Verify the Fill → Verified → n/a
2.4.1.9 Verify ALL Fills → Ready to Dispense → Will Call queue
2.4.1.10 Dispense the Fill → Dispensed → n/a
2.5 Finding and Reviewing New Orders
2.5.1 Role: Technician
2.5.2 Task: Review new prescriptions sent to pharmacy
2.5.3 Example: Start with First Fill Review for Jamal
2.6 Work Queues
2.6.1 Purpose: Show tasks needing completion
2.6.2 Location: Left column of pharmacy homepage
2.6.3 Characteristics
2.6.3.1 Configurable per user
2.6.3.2 Can differ for different user types
2.6.4 Customization
2.6.4.1 Drag and drop to change order
2.6.4.2 Right-click options
2.6.4.2.1 Control favorites
2.6.4.2.2 Set default queue on login
2.6.5 Initial Review Queue
2.6.5.1 Shows First Fill Review tasks
2.6.5.2 Columns
2.6.5.2.1 Priority
2.6.5.2.2 Delivery
2.6.5.2.3 Patient
2.6.5.2.4 MRN
2.6.5.2.5 DOB
2.6.5.2.6 Due
2.6.5.2.7 Reason (shows tasks and number of scripts)
2.6.5.3 Due time configuration
2.6.5.3.1 Set system-wide or per pharmacy
2.6.5.3.2 Configurable minutes for different situations
2.6.5.3.2.1 Waiting patients: 10 minutes
2.6.5.3.2.2 Discharge scripts: 45 minutes
2.6.5.3.3 Removed from queue if >4 hours overdue (e.g. due to PA required etc.)
2.7 Reviewing Scripts
2.7.1 Action: Double-click patient row to open chart
2.7.2 Example: Jamal's chart review questions
2.7.2.1 How old is Jamal?
2.7.2.2 How many refills was atorvastatin written for?
2.7.2.3 What is cash price of lisinopril?
2.8 Marking a Patient as Arrived
2.8.1 Location: Flagged Prescriptions tab
2.8.2 Steps
2.8.2.1 Click pencil icon next to Delivery info
2.8.2.2 Select Waiting status
2.8.2.2.1 Makes patient a waiter
2.8.2.2.2 Prioritizes patient in work queues
2.8.2.2.3 Appears in Waiting Patients at top of queues
2.8.2.3 Add Comment
2.8.2.3.1 Example: Needs to catch bus in 15 minutes
2.8.2.3.2 Called Work Request Comments
2.8.2.3.3 Appear in work queues
2.8.2.3.4 Removed when work request complete (after dispensing)
2.9 Work Requests
2.9.1 Purpose
2.9.1.1 Group patient's prescriptions together
2.9.1.2 Virtual representation of physical basket process
2.9.2 Characteristics
2.9.2.1 Multiple scripts for same patient
2.9.2.2 Same work request if received at same time
2.9.2.3 Includes due time and delivery method
2.9.3 Workflow behavior
2.9.3.1 Fills typically advance together
2.9.3.2 Blocking flags affect entire work request;
None of the fills in a work request can advance past "pending fill" if any of these have any of these flags
2.9.3.2.1 First Fill Review
2.9.3.2.2 Needs Clinical Review
2.9.3.2.3 Charging Rejected
2.9.3.3 All fills must be Filled before any can be Verified
2.9.3.4 All fills must be Verified before any can be Dispensed
2.9.3.5 Pending Refill Approval blocks individual fill only
2.9.4 Views
2.9.4.1 Flagged Prescriptions view
2.9.4.1.1 Easy to resolve flags
2.9.4.1.2 Accessed from work queue
2.9.4.1.3 Cannot split work requests
2.9.4.1.4 Cannot manage multiple work requests
2.9.4.2 Front Counter view
2.9.4.2.1 Manage anything for patient
2.9.4.2.2 Accessed from Open Patient button or Front Counter activity
2.9.4.2.3 Harder to resolve flags
2.9.4.2.4 Can split work requests
2.9.4.2.5 Can manage multiple work requests
2.9.5 Splitting Work Requests
2.9.5.1 Required when: One script has blocking flag but others don't
2.9.5.2 Required when: Patient needs some scripts now, others later
2.9.5.3 Cannot be done from Flagged Prescriptions view
2.9.5.4 Must use Front Counter view
2.9.5.5 Steps
2.9.5.5.1 From Work Queue: Single-click to select patient
2.9.5.5.2 Click Open Patient (opens Front Counter view)
2.9.5.5.3 At bottom: Work Requests section
2.9.5.5.4 Click Move Fills
2.9.5.5.5 Select fills to move
2.9.5.5.6 Create new work request (with or without original info)
2.9.5.5.6.1 Original info copied by default
2.9.5.5.6.2 Click down arrow for blank work request
2.9.5.5.7 Accept changes
2.9.5.6 Example: Jamal's atorvastatin now, lisinopril tomorrow
2.10 Flags and Work Requests
2.10.1 Flags can block individual fills
2.10.2 Flags can block other fills in same work request
2.10.3 Example: Both of Jamal's fills have First Fill Review flags
2.10.3.1 Must review both scripts before either can be filled
2.11 Completing First Fill Review
2.11.1 Performed by: Technician or pharmacist
2.11.2 Purpose: Confirm script has no obvious errors or missing information
2.11.3 Provider Prescribed section
2.11.3.1 Read-only until pencil icon clicked
2.11.3.2 Edits typically for correcting mistakes
2.11.3.2.1 Example: Typos in patient instructions
2.11.4 Rx origin
2.11.4.1 Electronic: From EpicCare, Surescripts, or other interface
2.11.5 Comment fields
2.11.5.1 Provider comments
2.11.5.1.1 Entered by ordering provider
2.11.5.1.2 Appear for all fills
2.11.5.1.3 Easily seen by provider
2.11.5.1.4 Used for special requests
e.g. particular type of package (largest size) or a dye-free product
2.11.5.2 Pharmacy prescription-level comments
2.11.5.2.1 Appear for ALL fills for pharmacy staff
2.11.5.2.2 Used for special requests heard by pharmacy
2.11.5.3 Work Request comment
2.11.5.3.1 Only persists for current fill
2.11.5.3.2 Highly visible to pharmacy staff
2.11.5.3.3 Appears in Work Queue
2.11.6 Action: Click Review to mark as reviewed
2.11.7 Example: Jamal's atorvastatin (Lipitor)
2.11.7.1 Review details
2.11.7.1.1 When was fill requested?
2.11.7.1.2 What is frequency?
2.11.7.1.3 How to edit sig
2.11.7.1.4 Which NDC will be used?
2.11.7.1.5 What language is Translated sig?
2.11.7.1.6 What coverage will be used?
2.11.8 Adjudication trigger
2.11.8.1 Automatically sends claim to PBM when Review clicked
2.11.8.2 Payment Summary window appears
2.11.8.2.1 Shows insurance coverage amount
2.11.8.2.2 Shows patient payment amount
2.11.8.2.3 Shows profit amount
2.12 Adjudication
2.12.1 Purpose
2.12.1.1 Pharmacy wants to know it will get paid
2.12.1.2 Need to know patient co-pay
2.12.2 Process
2.12.2.1 Click Review for insured fill
2.12.2.2 System submits claim to Pharmacy Benefits Manager (PBM)
2.12.2.3 Real-time adjudication
2.12.2.4 Success or failure message within seconds
2.12.3 Outcomes
2.12.3.1 Success: Script and fill advance to next stage
2.12.3.2 Failure: Charging Rejected flag added to fill
2.12.4 Payment Summary
2.12.4.1 Insurance coverage amount
2.12.4.2 Patient charge amount
2.12.4.3 Profit amount
2.12.4.4 Can be hidden for users/groups
2.13 Completing Clinical Review
2.13.1 Performed by: Pharmacist only
2.13.2 Purpose: Check prescription for errors, appropriateness, safety issues
2.13.3 View: Same as First Fill Review
2.13.4 Key considerations
2.13.4.1 Adjudication already completed
2.13.4.2 Changes to medication/dispense amount/NDC trigger re-adjudication when Review clicked
2.13.5 Special buttons
2.13.5.1 Request Revision
2.13.5.1.1 Sends script back to technicians for corrections
2.13.5.2 Discontinue
2.13.5.2.1 Cancels fill
2.13.5.2.2 Discontinues prescription in EpicCare
2.13.6 Example: Jamal's atorvastatin
2.13.6.1 Click Review to complete clinical review
2.13.7 Example: Jamal's lisinopril
2.13.7.1 Medication Warning appears when attempting to review
2.13.7.2 Action: Do NOT mark as clinically reviewed
2.13.7.3 Action: Click Cancel to close warning window
2.13.7.4 Research needed before proceeding
2.14 Reviewing Medication Warnings
2.14.1 Trigger: When pharmacist clicks Review
2.14.2 Types
2.14.2.1 Drug-Allergy
2.14.2.2 Drug-Drug
2.14.2.3 Over or Under Dosing
2.14.2.4 Duplicate Therapy
2.14.2.5 Age/gender precautions
2.14.2.6 Pregnancy/lactation precautions
2.14.3 Source: Third-party medication data vendor
2.14.4 Configuration: Filters determine which warnings appear
2.14.5 Beyond the Basics: Evaluating Sex and Gender
2.14.5.1 Filtering and rule-based evaluations leverage Epic's default sex logic
2.14.5.2 Default sex logic examines clinical and demographic data
2.14.5.3 Stops at first indication patient is not cisgender
2.14.5.4 If no indication of transgender/intersex/nonbinary: Applies sex-based logic
2.14.5.5 Purpose: Hide sex-specific tools and warnings to reduce alert fatigue
2.14.5.6 Ensures all needed clinical tools available
2.14.5.7 More info: Sex, Gender, and Names Setup and Support Guide on Galaxy
2.14.5.7.1 Understand System's Sex-Based Filtering
2.14.5.7.2 Build Rules that Filter by Sex or Gender
2.14.5.7.3 Understand When OB/GYN Tools Are Available
2.15 Reviewing the Patient's Chart
2.15.1 Purpose: Access more patient information
2.15.2 Methods
2.15.2.1 Visit Summary
2.15.2.1.1 Most relevant information
2.15.2.1.2 Links to more information
2.15.2.2 SnapShot tab
2.15.2.2.1 Recent patient encounters
2.15.2.3 Chart Review
2.15.2.3.1 Comprehensive medical history
2.15.2.3.2 All encounters
2.15.3 Reordered prescriptions: Visible in Provider Prescribed section
2.16 Contacting a Provider to Clarify an Order
2.16.1 Provider contact information
2.16.1.1 Access: Click provider name
2.16.2 Secure Chat
2.16.2.1 Fastest method for internal providers
2.16.2.2 Automatically attached to patient chart when opened from chart
2.16.2.3 Example: Message to Marty Seeger, MD about lisinopril
2.16.3 Consult Physician flag
2.16.3.1 Add if provider not immediately available
2.16.3.2 Helps find script when provider calls back
2.17 Filling Some of a Patient's Scripts
2.17.1 Scenario: Patient needs some scripts now, others later
2.17.2 Example: Jamal needs atorvastatin now, will return for lisinopril
2.17.3 Requirement: Split into separate work requests
2.17.4 Process
2.17.4.1 Cannot split from Flagged Prescriptions view
2.17.4.2 Must use Front Counter view
2.17.4.3 Move lisinopril to new work request
2.17.4.4 Indicate fill Ready tomorrow at 11:00 am
2.17.4.5 Add comment: Reached out to Dr. Seeger for clarification
2.17.4.6 Confirm only one script needs Clinical Review
2.17.4.7 After clarification received: Merge work requests back together
2.18 Filling
2.18.1 Trigger: After all review and adjudication complete for work request
2.18.1.1 After all blocking flags removed
2.18.2 Methods
2.18.2.1 Filling via Pill Counters
2.18.2.1.1 Automated Prescription Filling System (APFS)
2.18.2.1.2 Used by larger, busier pharmacies
2.18.2.1.3 Used for high-volume medications
2.18.2.1.4 Workflow
2.18.2.1.4.1 Willow checks if medication loaded in pill counter
2.18.2.1.4.2 If loaded: Automatically tries to fill from pill counter
2.18.2.1.4.3 Interface message sent to pill counter
2.18.2.1.4.4 Pill counter takes over filling process
2.18.2.1.5 Labeling
2.18.2.1.5.1 Pill counters label their fills
2.18.2.1.5.2 No need to print label from Willow
2.18.2.1.6 Workflow variability
2.18.2.1.6.1 Depends on pill counter make/model
2.18.2.1.6.2 Depends on local regulations
2.18.2.2 Filling Manually
2.18.2.2.1 Willow prints fill label
2.18.2.2.2 Label used to complete, verify, and sell fill
2.18.2.2.3 Printing options
2.18.2.2.3.1 Immediate Printing
2.18.2.2.3.1.1 Labels print automatically
2.18.2.2.3.1.2 Technicians watch printer
2.18.2.2.3.1.3 Common for waiting patients, off-shifts, small pharmacies
2.18.2.2.3.2 Ready to Fill Queue
2.18.2.2.3.2.1 Fills appear with
Ready to Fill
status
2.18.2.2.3.2.2 Technician selects work request (usually due soonest)
2.18.2.2.3.2.3 Double-click to print fill labels
2.19 Fill Labels
2.19.1 Print location: Nearest workstation
2.19.2 Status change: Fill Initiated
2.19.3 Foundation System label sections
2.19.3.1 Bottle label
2.19.3.2 Warning labels
2.19.3.3 Image Description
2.19.3.4 Script label
2.19.3.5 Patient instructions
2.19.3.6 Flags
2.19.3.7 Fill log label
2.19.3.8 Fill priority
2.19.3.9 Delivery label
2.19.3.10 Counseling label
2.19.3.11 Partial fill label
2.19.3.12 Preparation instructions
2.19.3.13 Receipt
2.19.4 Customization
2.19.4.1 Foundation System contains all sections
2.19.4.2 Organizations customize by picking/arranging desired sections
2.20 Completing the Fill
2.20.1 Barcode-enabled workflow
2.20.1.1 Step 1: Get NDCs from shelves
2.20.1.1.1 Ensure workstation shows Ready to Fill queue or patient chart
2.20.1.2 Step 2: Scan fill label barcode
2.20.1.2.1 Opens Rx Management tab
2.20.1.2.2 Selects scanned fill
2.20.1.3 Step 3: Scan manufacturer package barcode
2.20.1.3.1 System checks NDC match
2.20.1.3.2 If match: Status changes to Filled
2.20.1.3.3 On mismatch: Error message
2.20.1.3.3.1 Options
2.20.1.3.3.1.1 Return to shelves for correct package
2.20.1.3.3.1.2 Click icon to
change
NDC
2.20.1.3.3.1.2.1 Triggers automatic re-adjudication
2.20.1.3.3.1.2.2 Triggers fill label reprint
= NDC is linked to the Fill label
2.20.1.3.3.1.2.3 Must scan NDC again to complete
2.20.1.4 Step 4: Prepare fill (outside Willow)
2.20.1.4.1 Count pills
2.20.1.4.2 Affix label to container
2.20.1.5 Step 5: Repeat steps 2-4 for each fill
2.20.1.6 After last fill in work request
2.20.1.6.1 Status changes to Ready to Verify
2.20.1.6.2 Patient chart closes
2.20.2 Manual completion (without barcode)
2.20.2.1 Double-click patient from Ready to Fill queue
2.20.2.2 Manually select fill in patient chart
2.20.2.3 Click Mark as Filled
2.20.2.4 Barcode Scanning Warning
2.20.2.4.1 In production: Requires override reason
2.20.2.4.2 In training: Can select Don't Show Again for session
2.21 Verifying Fills = within RX Management
2.21.1 Requirement: Each fill must be checked by pharmacist
2.21.2 Purpose
2.21.2.1 Ensure fill accuracy
2.21.2.2 Verify right product
2.21.2.3 Double-check dispense amount for controlled substances
2.21.2.4 Review script
2.21.3 Typical setup
2.21.3.1 Verification station focuses on verification
2.21.3.2 Works from Ready to Verify work queue
2.21.4 Barcode-enabled workflow
2.21.4.1 Step 1: Pick basket and scan fill label
2.21.4.1.1 Rx Management for fill appears
2.21.4.2 Step 2: Visually inspect product
2.21.4.2.1 Reference product image and description in Willow
2.21.4.3 Step 3: Perform clinical review if needed
2.21.4.3.1 Changes may trigger label reprint and re-adjudication
2.21.4.4 Step 4: Verification options
2.21.4.4.1 Scan ID badge to verify
2.21.4.4.1.1 Status changes to Verified
2.21.4.4.2 Or click Reject Fill
2.21.4.4.2.1 Status changes to Fill Rejected
2.21.4.4.2.2 Returns to Ready to Fill queue
2.21.4.5 Step 5: Repeat steps 1-4 for each fill
2.21.4.6 After last fill verified
2.21.4.6.1 Patient chart closes
2.21.4.6.2 Return to Ready to Verify queue
2.21.4.6.3 All fills' statuses become Ready to Dispense
2.21.5 Manual verification (without barcode)
2.21.5.1 From Ready to Verify queue
2.21.5.2 Double-click patient to open
Rx Management
2.21.5.3 Click fill to select
2.21.5.4 Click Fill verified checkbox
2.21.5.5 Click Accept to close chart
2.21.6 Training resource
2.21.6.1 Verify Fills [RXAMB002] on welearning.epic.com
2.22 Bagging Fills
2.22.1 Purpose: Move fills to patient package
2.22.2 Trigger: When verification complete
2.22.3 Printed items
2.22.3.1 Bag label
2.22.3.2 Monograph (typically)
2.22.3.3 Med Guide (typically)
2.22.3.4 Can print with fill label instead
2.23 Dispensing Fills
2.23.1 Trigger: After all fills in work request verified
2.23.2 Status: Ready to Dispense
2.23.3 Methods
2.23.3.1 Mail order or courier
2.23.3.1.1 Packaging and delivery process begins
2.23.3.2 Pickup
2.23.3.2.1 If patient not arrived: Place in holding bin
2.23.3.2.2 If patient arrived: Process sale via POS
2.23.4 Point of Sale (POS) Activity
2.23.4.1 Purpose
2.23.4.1.1 Sell prescriptions
2.23.4.1.2 Record patient counseling
2.23.4.2 Features (since May 2019)
2.23.4.2.1 Sell non-prescription merchandise
2.23.4.3 Features (since August 2021)
2.23.4.3.1 Dispense prescriptions for multiple patients in one transaction
2.23.4.4 Benefits of integrated POS
2.23.4.4.1 Access to patient prescription history
2.23.4.4.2 Access to medication list
2.23.4.4.3 Access to other medical information
2.23.4.4.4 Last-minute safety reminders
2.23.4.4.4.1 Newer interactions
2.23.4.4.4.2 NDC substitutions
2.23.4.4.5 Up-to-date billing information
2.23.4.4.5.1 Co-pay changes
2.23.4.5 Pseudoephedrine Sales (since May 2024)
2.23.4.5.1 Query and report to National Precursor Log Exchange (NPLEx)
2.23.4.5.2 Real-time results
2.23.4.5.3 Automatically requires patient ID collection
2.23.5 Example: Jamal's prescriptions
2.23.5.1 Role: Tech at pickup window
2.23.5.2 Steps
2.23.5.2.1 Log in as technician to EMC South Pharmacy
2.23.5.2.2 Click Point of Sale activity under Epic button
2.23.5.2.3 Add Patient: Select Jamal from Recent Patients tab
2.23.5.2.4 Enter postal code: 53593
2.23.5.2.5 Select Jamal's atorvastatin and lisinopril
2.23.5.2.6 Add non-prescription item
2.23.5.2.6.1 Find Merchandise field in bottom left
2.23.5.2.6.2 Search for lint roller
2.23.5.2.6.3 Add to sale items
2.23.5.2.7 Patient requests pharmacist consultation
2.23.5.2.7.1 Call pharmacist over
2.23.5.2.7.2 Click Start Counseling
2.23.5.2.7.2.1 Counseling resources appear under prescription
2.23.5.2.7.2.1.1 Med guides
2.23.5.2.7.2.1.2 Monographs
2.23.5.2.7.2.2 Counseling Comments for documentation
2.23.5.2.7.3 Click Complete Counseling
2.23.5.2.7.3.1 Enter pharmacist User ID and password
2.23.5.2.7.3.2 User Authentication allows counseling without logout/login
2.23.5.2.8 Payment
2.23.5.2.8.1 Jamal pays with cash: $30.00
2.23.5.2.8.2 Under Payments: Tender $30.00 cash payment
2.23.5.2.8.3 Click Complete Sale
2.23.5.2.8.3.1 Cash drawer opens
2.23.5.2.9 Close any open patient charts
2.24 Reviewing the Med Profile
2.24.1 Purpose: Review script history and details
2.24.2 Access: From Front Counter
2.24.3 Three views
2.24.3.1 Recent Rx profile
2.24.3.1.1 Everything due or in progress
2.24.3.1.2 All other active scripts owned by Willow Ambulatory pharmacy
2.24.3.2 Entire Rx profile
2.24.3.2.1 Everything that could have been filled in pharmacy
2.24.3.2.2 Includes discontinued and transferred scripts
2.24.3.3 Medical record
2.24.3.3.1 All scripts recorded in system
2.24.3.3.2 Includes scripts ordered in Epic and sent to outside pharmacies
2.24.4 Usage: Hold mouse over information for more details
2.24.5 Example: Pharmacy manager checking who worked with Jamal
2.24.5.1 Open Jamal's chart
2.24.5.2 Check Med Profile
2.24.5.3 View atorvastatin and lisinopril received today
2.25 Reviewing
Prescription History
2.25.1 Purpose: Zoom in on script details
2.25.2 Access: Double-click script in Med Profile
2.25.3 Views
2.25.3.1 Report view (top)
2.25.3.1.1 View information
2.25.3.2 Prescription Event Details (bottom)
2.25.3.2.1 Take action
2.25.4 Information levels
2.25.4.1 Script level
2.25.4.2 Fill level
2.25.4.3 Adjudication level
2.25.5 Order Audit Trail
2.25.5.1 Shows all changes to order over time
2.25.6 Example questions for Jamal's atorvastatin
2.25.6.1 Who prescribed?
2.25.6.2 What did patient pay?
2.25.6.3 Who did first fill review?
2.25.6.4 At what time did filling begin?
2.25.6.5 Did tech barcode scan when marking fill complete?
2.25.6.6 At what time was fill sold?
2.25.6.7 Who sold the fill?
2.25.6.8 Were changes made to script by pharmacy?
2.25.6.9 What printed for this fill today?
2.25.6.10 What printed when order entered?
2.25.6.11 Did patient's MRN print on bottle label?
2.25.6.12 What to click to cancel fill and return to inventory?
2.25.7 Hint: Click today's dispense date under Dispense History
2.26 Workflow Variations
2.26.1 Organizational configuration choices
2.26.1.1 Require clinical review before filling?
2.26.1.2 Queue fill labels to be printed on demand?
2.26.1.3 Sell fills in Epic's POS or non-Epic POS system?
2.26.2 User-specific workflow changes
2.26.2.1 Pharmacist completes first fill review
2.26.2.1.1 System counts as First Fill Review AND Clinical Review
2.26.2.1.2 No Needs Clinical Review flag added
2.26.2.1.3 Fill can advance to Ready to Fill (if no other blockers)
2.26.2.2 Pharmacist completes filling process
2.26.2.2.1 System marks as Filled AND Verified
2.26.2.2.2 Fill advances to Verified or Ready to Dispense
2.27 Exercise 1: Review and Fill as a Pharmacist
2.27.1 Steps
2.27.1.1 Log in as pharmacist to EMC Prescription South Pharmacy
2.27.1.2 Find Claire patient in Initial Review queue
2.27.1.3 Double-click to open chart in Flagged Prescriptions view
2.27.1.4 Click Review
2.27.1.4.1 First Fill Review flag resolved
2.27.1.4.2 Adjudication successful
2.27.1.4.3 Next step: Clinical Review (if pharmacist) or Needs Clinical Review flag (if tech)
2.27.1.5 Close Payment Summary window
2.27.1.6 Open Claire's chart from Front Counter button
2.27.1.7 Find Lexapro prescription at top of Med Profile
2.27.1.7.1 Status: Ready to Fill
2.27.1.7.2 Expected: Yes, because pharmacist completed First Fill Review
2.27.1.7.3 Skipped step: Clinical Review (pharmacist review counts as both)
2.27.1.8 Based on status: Find in Ready to Fill queue
2.27.1.9 Close Claire's chart
2.27.1.10 Open Ready to Fill Queue
2.27.1.11 Double-click to open Claire's chart
2.27.1.12 Click on Lexapro fill in work request
2.27.1.12.1 Fill and Verify button appears
2.27.1.12.2 Different from technician view (tech sees Mark as Filled)
2.27.1.13 Fill and Verify Claire's Lexapro
2.27.1.14 Jump to POS via cash register icon next to Claire's photo
2.27.1.15 Enter postal code: 53703
2.27.1.16 Select Lexapro
2.27.1.16.1 Counseling links appear immediately
2.27.1.16.1.1 Available automatically for pharmacist in POS
2.27.1.16.1.2 Tech must click Start Counseling first
2.27.1.17 Click Complete Counseling
2.27.1.17.1 No user authentication required (pharmacist is current user)
2.27.1.18 Document payment: $10.00 cash
2.27.1.19 Complete Sale
2.27.1.20 Click Done
2.28 Reviewing the Chapter (pg. 49)
2.28.1 Review Questions
2.28.1.1 If fill has status of Pending Fill, what needs to happen next?
2.28.1.2 For pharmacy, can have pharmacists review clinical details before filling or during verification. What are advantages/disadvantages of each?
2.28.1.3 A script has been reviewed by pharmacist. All blocking flags resolved but status still Pending Fill. Why?
2.28.1.4 Where can you put comment so it appears in work queues?
2.28.1.5 What always happens after first fill review for patient with insurance?
2.28.1.6 A fill's status is Filled. What next workflow step to advance? (Choose one: A. Mark fill as complete, B. Mark other fills in work request as complete, C. Verify fill, D. Verify other fills in work request)
2.28.2 Review Key
2.28.2.1 If fill has status of Pending Fill, what needs to happen next?
2.28.2.1.1 All blocking flags need resolved for all fills in work request
2.28.2.1.2 Includes: First Fill Review, Needs Clinical Review, Charging Rejected, others
2.28.2.2 Pharmacist review timing advantages/disadvantages
2.28.2.2.1 Before filling
2.28.2.2.1.1 Advantage: Fewer returns and wasted products
2.28.2.2.2 During verification
2.28.2.2.2.1 Advantage: Pharmacist interacts with script only once, increasing efficiency
2.28.2.3 Script reviewed by pharmacist, all blocking flags resolved, status still Pending Fill. Why?
2.28.2.3.1 Script in work request with other scripts not ready
2.28.2.3.2 If any script has First Fill Review, Needs Clinical Review, Charging Rejected, or other blocking flag, all scripts must wait
2.28.2.4 Where to put comment to appear in work queues?
2.28.2.4.1 Work request comment
2.28.2.5 What always happens after first fill review for insured patient?
2.28.2.5.1 Claim sent for adjudication
2.28.2.6 Fill's status is Filled. Next workflow step?
2.28.2.6.1 B. Mark the other fills in the work request as complete
2.28.2.6.2 Filled status means fill already marked complete
2.28.2.6.3 Other scripts in work request not yet completed
2.28.2.6.4 After all fills filled: Status changes to Ready to Verify
2.29 Study Checklist
2.29.1 Key Terms
2.29.1.1 Work queue
2.29.1.2 Flagged Prescription view
2.29.1.3 Work request
2.29.1.4 Blocking flag
2.29.1.5 First Fill Review
2.29.1.6 Adjudication
2.29.1.7 Clinical Review
2.29.1.8 Front Counter view
2.29.1.9 Ready to Fill queue
2.29.1.10 NDC
2.29.1.11 Status
2.29.1.12 POS
2.29.1.13 Fill
2.29.2 Tasks
2.29.2.1 Review a script or fill
2.29.2.2 Move scripts between work requests
2.29.2.3 Add a comment that appears in work queue
2.29.2.4 Add a flag to a fill
2.29.2.5 Initiate a fill
2.29.2.6 Document completing a fill
2.29.2.7 Verify a fill
2.29.2.8 Dispense a fill using POS activity
2.29.2.9 Navigate to Prescription History
2.29.2.10 Identify information on patient's Med Profile
2.29.2.11 Fill just some scripts in work request
2.29.3 Concepts
2.29.3.1 Difference between Flagged Prescription and Front Counter views
2.29.3.2 How work request affects movement of individual fills
2.29.3.3 Difference between different types of comments and where they appear
2.29.3.4 Reason Willow uses flags
2.29.3.5 Flags can block either fill or work request
2.29.3.6 Effects a flag has on fill and work request
2.29.3.7 Options for when flag blocks
2.29.3.8 How color of flag can indicate blocking behavior
2.29.3.9 How blocking behavior affects review and filling workflows
2.29.3.10 Different statuses a script goes through and what each means
2.29.3.11 Given work request, identify key information about each fill
2.29.3.12 Given in-progress work request, predict status after task completed
2.29.3.13 Given Med Profile, determine what happening with each prescription
Entering New Prescriptions
3.1 Introduction
3.1.1 Most prescriptions arrive electronically
3.1.2 Paper prescriptions still necessary
3.1.2.1 When other clinics not live on Epic
3.1.2.2 When patients arrive with outside provider prescription
3.1.3 Primary workspace: EMC Prescription North Pharmacy
3.1.3.1 POS turned OFF
3.1.3.2 Fills move from Verified directly to Dispensed
3.1.3.3 Skips Ready to Dispense status
3.1.4 By the End of This Lesson
3.1.4.1 Enter new prescriptions into Willow Ambulatory
3.1.4.2 Use inline prescription entry
3.1.4.3 Enter prescriptions for mixtures
3.1.4.4 Enter prescriptions with non-English sigs
3.2 Entering Paper Prescriptions
3.2.1 Access
3.2.1.1 Front Counter window
3.2.1.2 Pharmacists default to Medication Profile
3.2.1.3 Rx Management tab for prescription entry
3.2.2 Work Requests section at bottom
3.2.3 Customer is waiting checkbox
3.2.3.1 Starts counting wait time
3.2.4 Example: Sherlock arrives with paper scripts
3.3 Entering a Simple Script
3.3.1 Location: Rx Management tab
3.3.2 New Rx field
3.3.3 Search for medication (full or partial name or synonym)
3.3.4 Example: metoprolol tartrate (Lopressor) tablets
3.4 Finding Medications on a Preference List
3.4.1 Two lists available
3.4.1.1 Preference list
3.4.1.1.1 Medications available in your pharmacy
3.4.1.2 All medications
3.4.1.2.1 Every medication in database
3.4.1.2.2 In US: All FDA approved medications
3.4.2 Example: Choose metoprolol tartrate (Lopressor) tablet 50 mg
3.5 Where Does the Medication Come From?
3.5.1 Source: Medications (ERX) master file
3.5.1.1 Master file in Epic database
3.5.1.2 Contains medication records
3.5.2 Simple ERX records
3.5.2.1 Specific combination of drug, strength, form
3.5.2.2 Example: metoprolol 25mg, 50mg, 100mg, extended release, combination drugs
3.5.3 Third-party vendors (import most ERX records)
3.5.3.1 Medi-Span (and Medi-Span GDD in Singapore)
3.5.3.2 FDB (First Databank)
3.5.3.3 Multilex (from FDB-Europe, UK)
3.5.3.4 G-Standaard (Netherlands)
3.5.4 ERX record information (from vendor)
3.5.4.1 Industry-standard clinical information
3.5.4.1.1 Pharmaceutical classes
3.5.4.1.2 Therapeutic classes
3.5.4.2 DEA schedule
3.5.4.3 Product index
3.5.4.3.1 Equates different but equivalent medication records
3.5.4.3.2 Example: ASPIRIN 325 MG PO TABS = ASPIRIN 500 MG PO TABS (different strength)
3.5.4.4 Links to medication warnings
3.5.4.4.1 Drug-drug interactions
3.5.4.4.2 Duplicate therapy warnings
3.6 Where Do the NDCs Come From?
3.6.1 Source: NDC master file in Epic
3.6.1.1 Record for every NDC available
3.6.2 Inactive NDCs
3.6.2.1 Marked by third-party vendors when manufacturer stops production
3.6.2.2 Epic maintains records for inactive NDCs
3.6.2.3 Purpose: In case pharmacy still has stock
3.7 Why is This NDC Selected?
3.7.1 Pharmacy configuration
3.7.1.1 Each pharmacy maintains list of stocked NDCs
3.7.1.2 Each pharmacy maintains preferred NDC for each ERX
3.7.2 Selection process
3.7.2.1 When medication selected for script
3.7.2.2 Willow fills in preferred NDC for that ERX in that pharmacy
3.7.3 Storage: Medication List (EFY) master file
3.7.3.1 Must be updated when pharmacy changes stocked NDCs
3.8 Entering a Script's Details
3.8.1 Navigation
3.8.1.1 Tab key to move between fields
3.8.1.2 Alt key navigation
3.8.1.2.1 Alt + underlined letter for field name
3.8.1.2.2 Example: Alt+E for Dispense field
3.8.1.2.3 Sig field: Alt+U
3.8.2 Example: Sherlock's metoprolol script
3.8.2.1 Medication: metoprolol tartrate tablets 50 mg
3.8.2.2 Route: oral
3.8.2.3 Frequency: 2 times daily (choose first option)
3.8.2.4 Dispense: 60 tablets
3.8.2.5 Refills: 11
3.8.2.6 Prescription date: today
3.8.2.7 Provider: Marty Seeger, MD
3.8.2.8 Origin: Written
3.8.3 Sig building
3.8.3.1 Automatically composed from dose, route, frequency
3.9 Adding to the Sig
3.9.1 Composed sig
3.9.1.1 Built automatically from structured fields
3.9.2 Free-text sig
3.9.2.1 Edit composed sig directly
3.9.2.2 Warning: If dose/route/frequency changed after free-text edit, sig turns yellow
3.9.2.3 Purpose: Warn that dose/route/frequency no longer matches sig
3.9.3 Adding text AFTER composed sig
3.9.3.1 Does NOT activate yellow warning
3.9.3.2 System can update composed sig while keeping additional text
3.9.4 Revert option
3.9.4.1 Click composed sig icon to revert to original composed sig
3.9.5 Example: Add "Take with food" to metoprolol
3.10 Using Inline Prescription Entry
3.10.1 Purpose: Quickly enter prescriptions
3.10.2 Format
3.10.2.1 Medication name first
3.10.2.2 Additional instructions last
3.10.2.3 Order of other fields doesn't matter
3.10.3 Example: Sherlock's hydrocortisone cream
3.10.3.1 Inline entry: hydro 2.5 cream bid d30g r0 wt owrit [Apply to left arm
3.10.3.2 Interpretation
3.10.3.2.1 hydro 2.5 cream = hydrocortisone cream 2.5%
3.10.3.2.2 bid = 2 times daily
3.10.3.2.3 d30g = dispense 30 grams
3.10.3.2.4 r0 = 0 refills
3.10.3.2.5 wt = written today
3.10.3.2.6 owrit = origin written
3.10.3.2.7 [Apply to left arm = instructions
3.10.4 Prescription entry shortcuts
3.10.4.1 Common Latin abbreviations
3.10.4.1.1 PO: per os (oral route)
3.10.4.1.2 PRN: pro re nata (as needed)
3.10.4.1.3 Q4H: quaque 4 horam (every 4 hours)
3.10.4.1.4 Q6H: every 6 hours
3.10.4.1.5 Q12H: every 12 hours
3.10.4.1.6 BID: bis in die (twice per day)
3.10.4.1.7 TID: ter in die (three times per day)
3.10.4.1.8 QID: quater in die (four times daily)
3.10.4.2 Forbidden abbreviations
3.10.4.2.1 QD: every day
3.10.4.2.2 Q1D: every 1 day
3.10.4.2.3 Reason: Can be misread
3.10.4.2.4 ISMP recommendation: Spell out all frequencies
3.10.4.3 Epic behavior
3.10.4.3.1 Spells out frequencies in sig
3.10.4.3.2 Allows Latin abbreviations during entry
3.10.4.4 Standard frequency tip
3.10.4.4.1 Use period before frequency name for standard version
3.10.4.4.2 Example: .bid for scheduled 2 times daily
3.10.5 Shortcuts used in example
3.10.5.1 2 times daily: .bid
3.10.5.2 End after 10 days: x10days
3.10.5.3 Days supply of 10 days: ds10
3.10.6 Shortcut help
3.10.6.1 Click question mark button to far right of New Rx field
3.11 Entering a Free-Text Provider
3.11.1 When needed: Provider not in system
3.11.2 Method: Click Other
3.11.3 Enter free-text provider name
3.11.4 Note: Automatically uses first script's provider for subsequent scripts in SAME work request
3.12 Entering a Script That Will Not Be Filled Now = PROFILE ONLY
3.12.1 Method: Do NOT click Accept
3.12.2 Simply start entering next script in New Rx field
3.13 In-Class Exercise
3.13.1 Exercise 1: Entering Mixtures
3.13.1.1 Part 1: Enter a Mixture ERX
3.13.1.2 Part 2: Entering a Mixture on the Fly
3.13.1.3 Part 3: Explore the Effects of Ingredient Types
3.13.1.4 Document Your Findings
3.13.2 Exercise 2: Entering Brand Name and Partially Filled
3.13.2.1 Part 1: Enter a Brand Name Prescription
3.13.2.2 Part 2: Indicate a Partial Fill
3.13.2.3 Part 3: Completing a Partial Fill
3.13.2.4 Document Your Findings
3.13.3 If You Have Time: More Prescription Entry Practice
3.13.3.1 Enter Scripts as Technician
3.13.3.2 Review Scripts and Print Labels as Pharmacist
3.13.3.3 If You Still Have Time: Complete Fill Verification
3.13.3.4 If You STILL Have Time: Do the Completion Fill
In-Class Exercise
Exercise 1: Entering Mixtures
Compound or mixture definition
Combination of more than one medication
Often oral liquids, eye drops, ear drops, topicals
Two entry methods
Prebuilt template: mixture ERX
Represents commonly prescribed compound
Administrators list ingredients and relationships
Can be ordered from EpicCare
Administrators control ingredient/proportion changes
Create mixture on the fly
Using simple ERX records
Part 1: Enter a Mixture ERX
Scenario: Sherlock's ciprofloxacin prescription
Ciprofloxacin 50 mg/mL suspension 500 mg twice daily
Dispense 100 mL
Written by Marty Seeger
Not commercially available as oral solution
Steps
Search and select medication
Enter prescription details
Check Transfer
Confirm with source pharmacy
Enter dispensing history
Key observations
NDC in Pharmacy to Dispense section blank
No single NDC for mixture
Ingredients have the NDCs
Edit Mixture button
Would be Create Mixture for simple ERX
Click Edit Mixture to confirm NDCs and recipe
Number of ingredients
Each ingredient is simple ERX record
Recipe amounts visible
Administrators control ingredient/proportion changes
Part 2: Entering a Mixture on the Fly
Scenario: Sherlock's tacrolimus order
Tacrolimus 1mg/2mLs in simple syrup-Ora Plus 5 mg
Oral twice daily
Dispense 60 mL
0 refills
Written today by Marty Seeger
Mixture made by mixing tacrolimus capsules into equal parts simple syrup and ora-plus
Steps
Search for tacrolimus
No ERX records represent oral solution
Administrators haven't built mixture ERX
Choose tacrolimus (Prograf) capsule 5 mg
Click Create Mixture
Select Ingredient to Add
Type: Base
Ingredient: Simple Syrup
Edit Mixture window
Add Ingredient: Base of Ora-Plus PO Liqd
Change recipe to: 30 mg tacrolimus, 30 mL Simple Syrup, 30 mL Ora-Plus
Close Edit Mixture
Enter Dose: 5 mg
Warning appears at top of Provider Prescribed box
Sig not clear for liquid mixture
Need mL not mg
Edit Mixture: indicate tacrolimus is Dosed ingredient
Close Edit Mixture
Sig changes
Warning disappears
Add details: Written t, Frequency .bid, Dispense 60 mL, Refills 0, Origin Written
Part 3: Explore the Effects of Ingredient Types
Record mixture name: tacrolimus 1 mg/2 mL in simple syrup oral solution-Ora-Plus liquid
Open Edit Mixture
Unselect Ora-Plus
Add Ingredient: Ora-Plus as Type of Additives
Enter recipe amount: 30 mL for Ora-Plus additive
Compare new name with original
System composes mixture names based on ingredient types
Incorrect ingredient type = misleading/incomplete mixture name
Uncheck Ora-Plus additive, check Ora-Plus base
Verify name: tacrolimus 1 mg/2 mL in simple syrup oral solution-Ora-Plus liquid
Close Edit Mixture
Document Your Findings
Button to see NDCs: Edit Mixture
When entering oral solution mixture, sig reads "Take 120 mg by mouth..." - forgot to check dosed ingredient button
Mixture name impacted by incorrect ingredient type
Exercise 2: Entering Brand Name and Partially Filled
Part 1: Enter a Brand Name Prescription
Scenario: Sherlock's Synthroid prescription
Synthroid tablets 50 mcg oral daily
Dispense 30 tablets
1 refill
Marty Seeger MD indicated must take Synthroid, not levothyroxine
Steps
Search: Synth 50
System selects generic
Medication and NDC fields show levothyroxine 50 MCG tablet
Need brand
Select Advanced view above Provider Prescribed
Check Brand necessary
Select SYNTHROID 50 MCG PO TABS from dropdown
NDC now shows Synthroid (brand)
Enter details
Written: t
Dose: 50 mcg
Route: Oral
Frequency: daily
Dispense: 30 tablets
Refills: 1
Origin: written
Authorized: Marty Seeger
Enter DAW reason: Prescriber Requested
Key points
DAW = Dispense As Written
Brand name appears in Medication and NDC fields
Part 2: Indicate a Partial Fill
Scenario: Synthroid inventory low
Patient returns for remaining 25 tablets later
Steps
Under Pharmacy to Dispense: select Partial Fill
Enter Dispense: 5 tablet
Advanced View must be selected
Partial fill icon appears next to Synthroid
Click Accept and Stay
Accept without hard copy scan, override warnings
Hydrocortisone and sertraline not on Payment Summary
Profiled, not being filled
Record: Total Covered, Patient Charge
Click OK on Payment Summary
Print labels: check Initiate Fill for each non-Profiled script, click Accept and Stay
Override warnings for training
Highlight each prescription, click Fill and Verify
Pharmacist completes fill, verification happens simultaneously
Go to Med Profile
Key observations
Hydrocortisone: Rx # assigned even though Profile-only
Synthroid status: Pending Fill
But Synthroid was dispensed
Double click Synthroid to open Prescription History
Review Dispense History section
When partial fill sold, system automatically creates "completion fill"
Reminds users to finish after more inventory received
Back on Med Profile: half-tablet icon clarifies completion fill
Fills Rem, Fill Qty Rem, Fill Qty Used columns
Quantities calculated as if completion fill already happened
Accept to close chart
Reopen chart from Front Counter
Find Sherlock in recent patients
Check new work request (Pending Fill)
Synthroid has half-tablet icon and Completion Fill Hold flag
Completion Fill Hold flag reminds about outstanding fill
Completion fills found in Waiting for Stock Queue
Close chart
Part 3: Completing a Partial Fill
Scenario: Synthroid shipment received
Ready to process completion fill
Steps
Open Waiting for Stock queue
Find Sherlock (don't open yet)
Completion Fill due date
Double click to open Sherlock
Release Fill for Synthroid
Amount charged: $0.00
Compare with Part 2 amount
Patient charged for all 30 tablets up front, even though only received 5
In partial fill process, adjudication can happen at partial or completion fill
Dispense amount on claim is for full dispense amount
Most organizations charge up front when partial fill adjudicated
Few payers support both
Click OK on Payment Summary
Which queue now? Ready to Fill
Print label, mark filled, verify, dispense completion fill
Key points
Willow Inventory streamlines process
When stock documented as received, system automatically changes completion fills from pending to ready
Eliminates manual steps
Log out
Document Your Findings
True/False: Profile only medications assigned Rx #
True: still owned by pharmacy, assigned prescription numbers
Med Profile icon in Next Fill column: completion fill
True/False: Medication name displays brand when brand selected
False: Willow displays generic even if brand typed or selected
To switch to brand: Advanced view + Brand necessary
If You Have Time: More Prescription Entry Practice
Enter Scripts as the Technician
Steps
Log in as technician to EMC Prescription North
Use Front Counter to find Sherlock, go to Rx Management
Enter: lipitor 20 40mg po .daily x365day d60tab r11 pwhitecoat ow wt
Medication field: brand (Lipitor) or generic (atorvastatin)?
Indicate patient wants brand name
Confirm brand name appears in Medication and NDC
Shouldn't 40mg dose use 40mg tablets?
Select 40mg tablets
System adjusts sig
Click pencil icon to edit
Re-enter dispense amount and refills
Adjust for new strength
Enter second script: Pegasys 180mcg weekly d3mL r0 ow wt
Only one choice on preference list
System automatically selected and applied inline details
Route field default: Subcutaneous (only allowed route)
Provider field auto-filled from prior script
Don't have enough Pegasys for complete fill
Dispense partial fill: 1 mL vial
Enter third script: anthralin daily d50g r0 ds45 ow wt [Wash off after 20 minutes.
Click pencil icon to edit Medication
Other choices? No
Why? List filtered to generic medications in pharmacy
Select Brands checkbox to see available brands
KEEP anthralin 1% cream
Scripts entered and complete
Prescription numbers assigned yet? No
When assigned? After accepting transcriptions
Click Accept and Stay
Click OK to close Payment Summary
Scripts ready to be filled? No
Still need clinical review
Three prescriptions have Clinical Review Needed blocking flags
Prescription numbers now assigned
Log out
Review Scripts and Print Labels as the Pharmacist
Steps
Log in as pharmacist to EMC Prescription North
From Clinical Review queue, open Sherlock, review each script, override warnings
After reviewing last script, chart closes, return to Clinical Review queue
Sherlock gone (no scripts require Clinical Review)
Which queue now? Ready to Fill
Initiate fills for Sherlock
Message: fill initiated, labels printing
View Med Profile
Status: Fill Initiated for anthralin, Lipitor, Pegasus
Double click anthralin to see Prescription History
Expand Prescription Event Details
Fill label printed
Close Prescription History
If You Still Have Time: Complete Fill Verification
Steps
Fill and Verify all scripts
Back to Med Profile
Status of anthralin and Lipitor?
Status of Pegasus? Why? Completion fill to do
Double-click Pegasus to open Prescription History
First Fill (Partial) and First Fill (Completion)
Status of Partial fill? Completion fill?
After both fills dispensed, total quantity?
When was patient charged?
Close Prescription History
Back on Med Profile: Fills Remaining for Pegasus = 0
Counting pending completion fill
Shows how many fills will remain once pending completion fill dispensed
Close record, return to home screen
If You STILL Have Time: Do the Completion Fill
Scenario: Few days later, more Pegasus received, Sherlock returned
Steps
From Waiting for Stock queue, open Sherlock's chart
Review details, everything looks good
Release completion fill
Is Sherlock charged for completion fill?
Status of Pegasus script now?
Initiate, Fill, Verify completion fill
Go to Med Profile
Status column for Pegasus: Dispensed
Done with Sherlock's prescriptions
Key Takeaways
Entering Mixtures
Two ways: prebuilt mixture ERX or on the fly
Mixture ERX built by administrators
Lists ingredients (simple ERX records) and relationships
Can be ordered by MDs/RNs in EpicCare
Administrators control whether ingredients/proportions can be changed
Create mixture on the fly
Using simple ERX records
If mixture has dose
Must indicate which ingredient the dose applies to by checking Dosed ingredient
Be careful to select correct type for each ingredient
If wrong type, prescription name could be misleading
Entering Brand Name Scripts
System automatically chooses generic products
To use brand: check Brand Necessary in Advanced View
Medication and NDC fields only display brand name records
Order name here and on bottle label shows brand name
Fill in DAW reason to tell insurance company why brand is necessary
Dispensing a Partial Fill
Partial fill: initial dispense of few days' supply
Completion fill: remaining amount
To mark a fill as partial
Advanced view > Partial fill > enter dispense amount
Adjudication can happen at partial fill, completion fill, or both
After partial fill dispensed, system
automatically
creates completion fill
Reviewing the Med Profile
Partially filled scripts appear unusually
Completion Fill Hold flag reminds pharmacy users about outstanding fill
Completion fills can be found in Waiting for Stock work queue
Completing the Partial Fill
Completion Fill Hold flag
Completion fills in Waiting for Stock queue
When stock received: open completion fill and click Release Fill to start moving through process
Translating Sigs
Willow can generate patient sigs in alternate languages
For common, predictable sigs
Requires translation table configured
Translation table: list of predictable patient sigs in English + translations for each language
Foundation System provides translations for
Spanish, French, Chinese, German, Vietnamese, Arabic, Russian, Hmong, Korean
Community Library: search for "prescription translation table import"
If patient's primary language is represented on translation table
Willow attempts to translate sigs for that patient
Process
System first composes patient sig in your system's primary language
Checks translation table to see if that sig is represented
If it is, and there's a translation for patient's language, translation appears in Translated sig field
Sherlock scenario: wants Synthroid details in Spanish
Change Sherlock's preferred Language to Spanish on Patient tab
From Med Profile, highlight Synthroid and click Fill
Open Rx Management
Under Pharmacy to Dispense section, click Automatic translation available (click to use)
Translated sig appears
Free-text instructions
Unlikely to be translated automatically
If you add free-text instructions to primary-language sig
Translated sig will turn yellow to notify you translation must be updated
System translates sig as a whole, not sentence-by-sentence
If system can't find translation for entire sig, it won't attempt to translate any of it
Probably will not automatically translate sigs in these cases
You add free-text instructions via inline prescription details
You receive electronic prescription from EpicCare with free-text instructions
When clicking translated sig, options appear
Edit Translation
Translate free-text instructions yourself and manually add to translated sig
Keep Current Translation
Keep both sigs as is
Only include free-text instructions in English sig
Clear Translation
Delete translated sig
Give patient English sig only
Sherlock scenario: free-text important, don't know Spanish, daughter can help
Click Translated sig
Click Keep Current Translation button
Click Accept
Print label for this script
Both sigs appear on fill label
Translated sig appears first
Original (non-translated) sig appears under it
Fill and Verify Sherlock's Synthroid
Reviewing the Chapter
Review Questions
Why do we get almost all simple ERX records from third party data vendors?
When users enter mixtures on the fly, what can go wrong?
When you don't have enough of a medication in stock you might do a partial fill, followed by a completion fill a few days later. When does the system send claims for the fills?
True or False: If Epic can't find an exact match for a sig in the translation table, the Translated sig will be blank.
A script is entered with a dose of 0.5 mg/kg. The English sig is "Take 1.3 mL (13 mg) by mouth in the morning." This sig does not automatically translate into the patient's preferred language. This is because Epic does not have a translation for
__
. (Choose only one.)
A. Take 1.3 mL (13 mg)
B. by mouth
C. in the morning.
D. Take 1.3 mL (13 mg) by mouth in the morning.
Review Key
Why do we get almost all simple ERX records from third party data vendors?
Third party vendors provide data difficult to collect yourself
Classifications
Controlled status
Relationships between medications
Medication warnings
When users enter mixtures on the fly, what can go wrong?
System allows user to enter any ingredients in any quantities
Type
of each ingredient and whether it is the
Dosed
Ingredient affects the name and calculated concentration
System does NOT stop user from entering any of this information incorrectly
When does the system send claims for partial/completion fills?
In training system: one claim for entire filled quantity at point of partial fill
Can change system to send claim at point of completion fill
True or False: If Epic can't find exact match for sig in translation table, Translated sig will be blank.
True. Only sigs for which
exact
match found in translation table will be translated.
Why doesn't the sig translate?
Answer: D. Sig translation requires entire entered sig to match string in sig translation table. It does not translate sig piece-by-piece.
Study Checklist
Define
Preference list
All medications
ERX
Master file
NDC
Inline prescription entry
Free-text provider
Profile only
Compound
Mixture ERX
Mixture on the fly
Dosed ingredient
Perform
Enter a new prescription
Use inline prescription entry
Enter a mixture on the fly
Indicate a script should use the brand product
Partially fill a script
Find and start a completion fill
Identify partial fills, completion fills on the Med profile
Understand
Where you select an ERX during prescription entry
What information is defined by an ERX record
Where most ERX records come from
What information third-party medication data vendors provide
How a pharmacy's Medication List affects prescription entry
Which ERX records appear as options under the Medication field in Rx Management
When mixture templates are useful
When mixtures on the fly are useful
How the type selected for an ingredient affects the name of a mixture
How automatic sig translation works, and when it doesn't work
3.14 Key Takeaways
3.14.1 Entering Mixtures
3.14.2 Entering Brand Name Scripts
3.14.3 Dispensing a Partial Fill
3.14.4 Reviewing the Med Profile
3.14.5 Completing the Partial Fill
3.15 Translating Sigs
3.16 Reviewing the Chapter
Transferring Prescriptions
4.1 Transferring prescriptions between pharmacies
4.2 Transferring prescriptions within the same pharmacy
4.3 Transferring prescriptions to external pharmacies
4.4 Transferring prescriptions from external pharmacies
Transferring Prescriptions
Introduction
Prescriptions owned by receiving pharmacy
Transfer required to fill another pharmacy's script
Same-organization pharmacies can fill each other's scripts
Transfer reasons
Patient on vacation
Patient moving to town
Transfer process
Patient request initiates transfer
Pharmacist contacts owning pharmacy
Owning pharmacy provides script information
Information entered into Willow Ambulatory
Ownership transferred
Transfer communication
Pharmacist-to-pharmacist phone call typically required
Electronic transfers possible
Configure Pharmacies to Support Electronic Prescription Transfers
Relative Date Conventions
t indicates today's date
t+1 indicates tomorrow
t-1 indicates yesterday
w indicates week
m indicates month
y indicates year
n indicates right now
n+30 indicates thirty minutes from now
Lesson Objectives
Transfer in prescription from external pharmacy
Transfer out prescription to external pharmacy
Fill on behalf of another pharmacy
In-Class Exercise
Exercise 1: Transferring Scripts In
Scenario
Jamison transferring three prescriptions from old pharmacy
Prescription Entry Steps
Log in to Willow Ambulatory as pharmacist
Use Front Counter to open patient chart
Go to Rx Management
Search and select medication
Enter prescription details
Rx name, strength, form
Written date
Sig
Dose entry in scientific units
Frequency
Dispense quantity
Refills
Rx origin
Authorized by provider
DEA number
Check Transfer
Confirm with source pharmacy
Transfer from pharmacy name, address, phone
Rx number
DEA number
Authorized by pharmacist
Enter dispensing history
First disp. date
Last disp. date
Fills remaining
Existing Medication Orders
Script already in system from EpicCare
Most information auto-filled
Confirm with source pharmacy
Rx number
Authorized by pharmacist
First disp. date
Last disp. date
Fills remaining
Fill on Behalf Option
Script owned by another Willow pharmacy
Can fill
without
transferring
Ownership does not change
Prescription number
unchanged
Filling pharmacy indicated on label and in fill history
Med Profile
Recent Rx profile view shows
fillable
scripts
Includes scripts owned by other Willow pharmacies
Adjudication and Verification
Accept and Stay to adjudicate fills
Payment Summary window shows adjudication status
Mark transferred scripts as reviewed
Print labels for all fills
Fill and Verify each fill
PDMP Reviewed for controlled substances
Close patient chart
Exercise 2: Transferring Scripts Out
Scenario
Jacob from External Outpatient Pharmacy calls
Jamison wants to transfer all prescriptions
Multi-select Prescriptions
Use Shift key for range selection
Use Ctrl key for individual selection
Transfer Limitations
Transfer button disabled for some scripts
Hover over Transfer button to see reason
Transfer button used for both in and out
System determines type from owning pharmacy
Inhaler owned by South pharmacy
Can only transfer in, not out
Transfer Process
Select scripts to transfer
Enter Transfer to pharmacy
Enter Authorized by pharmacist
Transfer cannot be completed for controlled substances
Controlled substances cannot be transferred again
System-level rule prevents transfer
Cancel transfer for restricted scripts
Transfer non-controlled scripts
Provide information to receiving pharmacy
Pharmacy's DEA number
Pharmacy's phone number and address
Rx number
Number of fills remaining
Quantity remaining
Date last filled
Confirm transfer completion = Look on the Med Profile to the Owning PHarmacy column
Verify script now owned by External Outpatient Pharmacy
Key Takeaways
Transferring Scripts In
Three main scenarios
Script not in Epic system at all = NO WAM
Script in system but dispensing history not = NOT OWNED BY YOUR PHARMACY
Both script and dispensing history in system
Script in system if
Originally entered by provider into EpicCare
Entered by pharmacist into Willow Ambulatory
Dispensing history in system if
Script currently owned by pharmacy in organization using Willow Ambulatory
New prescription number assigned after transfer
Filling on Behalf Of Another Pharmacy
Can transfer between
two Willow Ambulatory pharmacies
Can fill on behalf if local regulations allow
When filling on behalf
Ownership does not change
Prescription number does not change
Pharmacist-to-pharmacist phone call NOT needed
Filling pharmacy indicated on label and in fill history
Transferring Scripts Out
Select multiple scripts using Shift or Ctrl key
Transfer button on Med Profile for both in and out
If disabled, hover to see reason
Transfer out limitations
Must be owned by logged-in pharmacy
Must have refills remaining
If controlled and to non-integrated pharmacy, cannot have been transferred before
Controlled Substance Schedules
C-I
No accepted medical use
Only illegal drugs
No standard ERX records
C-II
High abuse potential
Examples: morphine, oxycodone
Cannot be transferred
Cannot have refills
C-III
Moderate dependence
Examples: ketamine, pentobarbital
Can be transferred only
once
between
non-integrated pharmacies
C-IV
Limited dependence
Examples: Ativan, Ambien
Can be transferred only
once
between
non-integrated pharmacies
C-V
Limited abuse potential
Examples: cough syrups with codeine
Can be transferred only
once
between
non-integrated pharmacies
Non-controlled medications
Can be transferred unlimited times
Reviewing the Chapter
Review Questions
Name 2 things required when transferring a prescription into your pharmacy
What is the difference between transferring in vs filling on behalf
What are the advantages of filling on behalf
In what situation can't you fill on behalf
Reasons cannot transfer zolpidem (C-IV) script
A. Last filled as partial fill
B. Received as hard copy
C. Transferred in from another pharmacy
D. No refills remain
Review Key
Prescription's clinical information, pharmacy name, pharmacist, prescription number, written date, fills remaining
Transfer in: take ownership, new Rx #. Fill on behalf: remains owned by original, keeps original Rx #
No patient confusion from number change, eliminates phone call, fewer clicks
Cannot fill on behalf of pharmacies outside system or not using Willow Ambulatory; some states/organizations don't allow
C and D
Study Checklist
Define
Transfer
Fill on behalf of
Perform
Transfer a script in
Transfer a script out
Process a fill on behalf of another pharmacy
Understand
How system knows whether to transfer in or out when Transfer is clicked
Advantages of filling on behalf of another pharmacy
Limitations of filling on behalf of another pharmacy
Effects of filling on behalf of another pharmacy
Why a script might already be in your system
Why the fill history might already be in your system
Refilling Prescriptions
5.1 Refilling prescriptions process
5.2 Refilling prescriptions with changes
5.3 Refilling prescriptions with no changes
5.4 Refilling prescriptions with partial fills
Continue
Refilling Prescriptions
Introduction
Refill Request Methods
In person
MyChart (web or app)
IVR (computerized phone system)
No Refills Remaining
Send Refill Authorization Request (RAR) to provider
In-Class Exercise
Exercise 1: Refilling a MyChart Request
Part 1: Requesting Refills (Patient: Caesar)
Log in to MyChart
View Medications
Shows active and recently ended prescriptions
Atorvastatin not requestable (not owned by pharmacy)
Request Alphagan and lisinopril refills
Alphagan: 0 refills remaining
lisinopril: has refills remaining
Add comment to lisinopril: "last label was smeared"
Pickup: EMC North in 2 days at 3:00 PM
Payment: Pay later
Submit request
Routing Logic
Alphagan → MD's office (new prescription needed)
lisinopril → Pharmacy (has refills)
Part 2: Processing the Refill Request (Technician)
Find Caesar in Ready to Fill queue
Initiate filling
Ready date/time: from patient's MyChart entry
Patient comments visible: smeared label concern
Work request: 2 fills
Alphagan: Waiting For Approval
lisinopril: Ready to Fill
Mark lisinopril as filled
Part 3: Approving the RAR (Nurse: OPRN1## in Hyperspace)
Open In Basket → Rx Request
Find Caesar's request
Sign All to approve
Order Mode: Per protocol: no cosign required
Assign Provider: Marty Seeger
Part 4: Processing Approved Refill (Pharmacist)
Find Alphagan in Clinical Review queue
Complete Clinical Review
Initiate fill from Ready to Fill queue
Fill and Verify Alphagan
Fill and Verify lisinopril
Accept and Stay
Both scripts status: Dispensed
Part 5: Finalizing the Sale
Create new work request
Open Caesar's Med Profile
Fill probenecid
Warning: "dispense quantity is short" (ignore for training)
Initiate fill
Fill and Verify
Close chart
Exercise 2: Refilling a Verbal Request (Patient: Cleopatra)
Open Cleopatra's chart
Check Fills Remaining
Attempt to fill tretinoin and Ambien
Routing
Ambien → Johnny Smith
RAR prints for fax (non-EpicCare provider)
tretinoin → EMC IM NURSES
RAR sent to In Basket (EpicCare pool)
Reason: electronic vs non-electronic routing capability
Fax Ambien RAR to Dr. Johnny Smith
Receive new Ambien prescription via fax
Click Pending Refill Approval flag for zolpidem CR
Enter Origin: Fax
Select NDC
Approve Request (override warnings)
Ambien status: Ready to Dispense
Initiate Ambien fill
Fill and Verify Ambien (PDMP reviewed)
Why not Dispensed: tretinoin flag blocks work request selling
Move Ambien to another work request
Check Med Profile
Document Your Findings
Notifications: sent when fill reaches Ready to Dispense
MyChart Med Profile: active and recently ended scripts only
Refill Requests: only for prescriptions owned by pharmacy in healthcare system
RARs: created when 0 refills remain, sent to provider/pool
RAR Routing
Printed/FAX: non-EpicCare, non-Surescripts providers
Electronic: EpicCare (In Basket) or Surescripts providers
If You Have Time: Refilling from a Call Center
Log in as pharmacist to EMC Rx Call Center
Open Caesar's chart from Front Counter
Fill button inactive: missing Dispense at location
Set Dispense at: EMC South - For WAM only
Request Alphagan fill
Acknowledge RAR required
Deliver by mail to Home address
If You Have Time: Enrolling in Med Sync, Auto Refill, Auto Request
Log in as pharmacist to EMC Prescription North
Open Caesar's chart → Med Profile → Refill Management
Enroll in Med Sync: every 30 days (next: t+30)
Select medications: probenecid, lisinopril
Enroll in Auto Refill
All 3 scripts show Auto Refill icon
Select Auto Req for probenecid
All 3 scripts show Auto Req icon
Auto refill delivery: Pickup
Dispense pharmacy: EMC Prescription Pharmacy North
Confirm icons by patient photo
Med Profile shows Auto Refill indicators
Key Takeaways
MyChart Notifications
Sent when Work Request status =
Ready to Dispense
MyChart Med Profile
Shows active and recently ended scripts within 30 days (FS)
Discontinued prescriptions do NOT appear = if more than 30 days
Recommend: disallow refill requests for externally owned scripts
Routing Refill Authorization Requests (RARs)
Trigger: script has 0 refills remaining
Recipient: based on encounter department setup (PCP, prescriber, or staff)
Sending Method
EpicCare providers: In Basket
Surescripts providers: Surescripts
Non-EpicCare: printed form for fax
"Pending Refill" Approval flag
Assigned to RARs sent to In Basket, faxed, or via Surescripts
Removed when processed in EpicCare
Beyond the Basics: Converting Prescriptions
Convert active prescriptions with refills from old system
Determine if duplicate of physician-entered script
Source of duplicates during conversion
Scripts ordered in org and filled elsewhere
Scripts ordered and filled in org
Scripts filled in org but ordered elsewhere
Conversion Tools
HL7 & Coverage Conversion utility
XML import
Reviewing the Chapter
Study Checklist
Key Terms: MyChart, IVR, Refill request, RAR, In Basket
Tasks: request refill from MyChart, process refill request, approve RAR, process verbal refill
Concepts: MyChart visibility, refill request routing, RAR sending method, pending refill flags
Day 1 Lab
Introduction
Purpose: less-guided review of day's material
Scenario: EMC Prescription South pharmacy
First floor of outpatient clinic
Processes prescriptions from clinic depts and outside prescriptions
Multiple pharmacists and technicians per shift
Pharmacy Stations
Drop-off counter: technicians
Clinical review: pharmacists
Filling station: technicians
Fill verification: pharmacists
Pick-up counter: pharmacists and techs
Learning Objective: apply entering, reviewing, filling, verifying prescriptions
Technician at the Drop-Off Window (Patient: Hugo)
Log in as technician to EMC Prescription South
Use Front Counter to find Hugo
Clear "Pharmacy patients only" if needed
Make Hugo a waiter
Add work request comment: "call cell when fills ready"
Enter four new prescriptions by Sam Stethoscope
esomeprazole (NexIUM) DR capsule 20 mg oral BID dispense 60 capsules 1 refill
levocetirizine (Xyzal) tablet 5 mg oral nightly dispense 30 tablets 11 refills
methotrexate tablet 2.5 mg - Dose of 7.5 mg oral weekly dispense 12 tablets 5 refills
buPROPion (Wellbutrin XL) 24 hr tablet 150 mg oral daily with breakfast dispense 30 tablets 11 refills
Check Spanish translation for each sig
Translated successfully: levocetirizine, bupropion
Translation failed: esomeprazole, methotrexate
Reason: exact English sig not found in Spanish translation table
Search for "metho tab"
Preference list: NO methotrexate 7.5 mg tablets
All medications: 7.5 mg tablet exists
Interpretation: 7.5 mg tablet not stocked in this pharmacy
Cancel methotrexate search
Delete "metho tab" from search field
Apply Hugo's coverage to all four fills
Accept and Stay
Result: one work request with four fills
Status: In Review
Fill labels printed? No (scripts still in review)
Record esomeprazole Rx#
Log out
Pharmacist doing Clinical Review
Log in as pharmacist to EMC Prescription South
Find Hugo's new prescriptions in Clinical Review queue
Check details
Esomeprazole: maximum suggested daily dose
Levocetirizine: cash-paying patient cost
Methotrexate: days supplying
Indicate all four scripts look fine as written
Log out
Technician Filling Scripts (First Instance)
Log in as technician to EMC South
Find Hugo's scripts in Ready to Fill queue
Fill each script as written, except levocetirizine
Update levocetirizine fill
NDC: 42291-386-90 (Avkare 90-each box)
Reason: build team hasn't updated stock list
Mark levocetirizine as filled
Accept and Stay
Why re-adjudicates: swapped NDCs, needs to "re-bill"
Why label reprints: NDC printed on label, new label needed
Why click Mark as Filled again: chance to barcode scan new label
Check status: all fills say "Ready to Verify"
Meaning: all fills filled, work request sent to Ready to Verify queue
Close Hugo's chart
Notice smeared label on esomeprazole
Can read Rx# but not patient instructions
Use Prescription History to look up esomeprazole
Hint: use Rx# from earlier
Reprint smeared fill label
Hint: expand Prescription Event Details
Close Prescription History
Affix new label to esomeprazole container
Place fills on verifying pharmacist's desk
Log out
Pharmacist Verifying Fills (First Instance)
Log in as pharmacist to EMC South
Open Ready to Verify queue
Double click Hugo's row to open chart
Notice esomeprazole bottle feels off
Check: only 30 capsules in bottle (should be 60)
Other three fills are correct
Verify other three fills
Set basket on stack for technician to re-count esomeprazole
Reject esomeprazole fill
Enter reason and comment
Work request status for esomeprazole: Fill Rejected
Verify rest of Hugo's filled prescriptions
Why verified fills not Ready to Dispense: all fills in work request must be verified before any can be dispensed
Log out
Technician Filling Scripts (Second Instance - After Rejection)
Log in as technician to EMC Prescription South
Find rejected fill for Hugo in Ready to Fill queue
Find rejected reason and comment: under Pharmacy to Dispense
Go to pharmacist station
Find basket of Hugo's fills
Correct esomeprazole fill
Give basket back to pharmacist
Complete the fill
Log out
Pharmacist Verifying and Dispensing Fills
Log in as pharmacist to EMC South
Open Hugo from Front Counter
Verify Hugo's esomeprazole fill
Check work request comment: "call cell when ready"
Call Hugo on his cell
Sell medications to Hugo personally (to ensure counseling)
Open Point of Sale activity
Enter postal code: 53719
Add all four scripts to sale
Add Visine to sale
Mark counseling provided to Hugo
Process cash payment
Complete sale
Send Hugo on his way
Day 1 Lab
6.1 Practical exercises and scenarios
Registering New Patients
7.1 Registering new patients process
7.2 Entering patient information
7.3 Verifying patient information
7.4 Saving patient information
Registering New Patients
Introduction
Registering patients correctly creates patient records as needed
Ensures positive patient identification and proper billing reimbursement
Willow Ambulatory integrated with other Epic applications
Many patients already have records
Saves pharmacy staff time
Less registration needed
Must be careful not to create duplicate records
Duplicate records cause lots of confusion
Lesson Objectives
Create new patient records
Add and update insurance information
Mark collection of signed documents
Document a patient's allergies
Identify Willow-specific and shared information
Use a workers' comp account
Enter a script when matching a competitor's price
Registering New Patients
Scenario: Watson new to organization, no patient record
Hands driver's license for initial demographics
Prefers to be called Watsy
Creating New Patient Records
New patient records created at
Front Counter > New Patient
Search for patient before creating new record to avoid duplicates
Log in as pharmacist in EMC North
Go to Front Counter, click New Patient
Click SSN magnifying glass, choose Standard Unknown SSN
Click Watson's name in Storyboard to open Patient Information
Add Preferred name of Watsy, Accept
Name updates in Storyboard
Hover over name shows legal name
Adding Patient Information
Staff from stand-alone pharmacy systems: what they write in Epic may be seen by many other roles
Pharmacy notes
Only visible for Willow Ambulatory users
Shared notes
Appear in many places throughout Epic applications
FYIs
Discrete way to record information
Can trigger pop-up warnings
May or may not appear to users outside pharmacy
Scenario: Watson has service dog Sammy
Wants everyone to know to ask before petting
Where to enter: Shared notes
Add Shared note: "Service dog is Sammy. Please ask before petting."
Watson's medication preference
Can't stand cherry flavored meds
Wants banana flavor whenever possible
Add Pharmacy note mentioning preference
Appears in Storyboard
Address information
Home and Temporary Addresses used by other Epic applications
Willow Ambulatory uses
Prescription Address
Default address selected in Willow Ambulatory
Changing Home or Temporary addresses in WAM changes it throughout organization
Prescription address only seen by WAM users
February 2026 version: search for addresses as they type
Adding addresses
Click Update to add new Home address: 42 Wallaroo Way
Type "53717" in city/zip, tab to fill rest
Click Accept to close
Documents
Click Add in Documents section to add/upload documents
Example: HIPAA Notice, Child Resistant Cap Waiver
Other document types can be added based on needs
Cancel without adding document
Adding Coverages
Personal coverage definition
Insurance or prescription benefit plan specific to individual patient
Can be manually added, edited, or ended by pharmacy users
Used to adjudicate prescription claims
Determines how much patient or insurance will pay
Can verify eligibility and add new coverages as needed
Watson's insurance card scenario
Under Personal Coverages, Add Watson's prescription coverage
Outpatient pharmacy workflows
Rely on BIN (Bank Identification Number) and PCN (Processor Control Number)
Embedded in payer data
Used during adjudication to route claims accurately
Steps
Search for Watson's coverage in Payer field using PCN on his card
Manually fill in Subscriber ID and Person information
Pharmacy staff familiar with insurance card information needed for successful adjudication
Use Filing order to indicate this as Watson's Primary coverage
Coverage comments
Payer Comments, Plan Comments, Coverage Entry Instructions
Help with registration and resolving adjudication problems
Coverage Comments
Specific to patient's coverage
Help users select right coverage for a fill
Accept to save and add coverage
Trainer demo: Enter Plan comments, see them appear for all patients with that plan
Designating Filing Order & No Matching Plan
If no matching plan in Epic, two options
Option 1: Notify build team, wait to add coverage until plan built
Option 2: Add coverage as generic "other" payer and plan as placeholder
Manually add information needed for adjudication
For BIN: need to add BIN override field under Additional claim defaults
Watson's discount card: HappyRx – Discount Card
Subscriber ID: 487019023
Group ID: 785311
RXBIN: 092018
RXPCN: 55667788
Discount cards added as personal coverages in Willow Ambulatory
Industry Context: Discount cards used in many scenarios
Manufacturers offer to reduce copay
Others used in place of insurance to lower cash price
Often one card per patient with subscriber ID
Steps
Add Personal Coverage to start entering details
Search by BIN for this coverage
Coverage not built out by administrator
Need placeholder coverage and override
Clear Payer field, search "Rx Help Card"
Fill in rest of fields based on Watsy's HappyRx Discount Card
BIN number not editable, but needed for adjudication
Watson only wants to use coupon card for his glimepiride
Where to make note: Coverage comments (specific to Watson)
Under Additional claim defaults, search for BIN
Select Field 101-A1 BIN Number
Type 092018 (card's BIN) in NCPDP Override pop-up, click OK
When adjudicating using this coverage, Epic will send value listed in BIN Number override to PBM
Give discount card a Filing order of Don't file automatically
Making this "Secondary Coverage" would pull in by default with primary coverage
"Don't file automatically" allows users to manually decide when to add coupon card
Compare coverage to screenshot, click Accept when done
Querying for Coverages
Click Eligibility to add patient's coverages with few clicks
Queries PBMs for any coverages associated with patient
Any coverages returned can be added without further data entry
Especially useful for Medicare Part D patients
Eligibility query NOT set up to work in certification environments
Adding a Workers' Comp Account
Watson has workers' comp account
Injured on job one week ago at Spike's Delight Hedgehog Salon
Account: RX WORKERS COMP
Subscriber ID: 123456789
Under Additional Accounts/Coverages, Add worker's comp account for Watson
Documenting Allergies
To allow system to check for drug-allergy interactions, need accurate allergy list
To edit allergies: go to Allergies/Contraindications tab
Allergy list shared among all Epic applications
If confirm list is correct: click Mark Allergies As Reviewed
Watson's allergies
Latex allergy
Very mild, sometimes results in rash upon exposure
Add Agent of Latex, Reaction of Rash, Type of Allergy, Accept
Click Mark Allergies As Reviewed
Reconciling Patient Entered Allergies
Patients can update allergies in MyChart
Patient entered allergy appears as
unreconciled
allergy
Appears in patient storyboard with warning icon
Not used in drug interaction checking until reconciled
Can be added by provider by clicking Approve Change... and filling in remaining details
Selecting Coverages
Using a Workers' Comp Account
Watson asks to fill three paper scripts
First script: duloxetine, covered by workers' comp account
To use workers' comp account in prescription entry
Complete medication details
Select hammer icon in billing section
In Rx Management, enter script: dulox 60 60mg po .daily d30cap r11 wt ow pseeg
Hover to discover: hammer icon adds worker's comp account, add it for duloxetine
Selected workers' comp account WILL default in for refills as long as still valid
Adding a Secondary Coverage
If patient has multiple personal coverages, can be applied to same script
Both must be 3rd-party (not internal) coverages
Watson's second script: glimepiride 4mg daily
Suggests discount card will further decrease copay
Enter script: glime 4 4mg po .daily d30tab r11 wt ow
Green plus icon allows adding additional coverage
Add Watson's discount card as secondary personal coverage
Once set for a script, secondary coverage applies to that script and all its refills
Unless it is a shared coverage
If want secondary coverage to always default for new scripts = Patient's level coverage on Patient Tab
Mark as primary and secondary on Patient tab > Personal Coverages > Edit...
Sending Test Claims
Patients want to know payment amount before handing prescription or agreeing to buy OTC
To run test claim: enter script, click Test Billing
If patient decides to take script elsewhere or put OTC back: remove script
Won't be saved on Med Profile or owned by pharmacy
Watson price conscious, wants to know out-of-pocket for glimepiride
Doesn't want to pay more than $5
Make sure glimepiride selected in work request
Click Test Billing at TOP right above Pharmacy to Dispense = Top = Test ONE script
To run for multiple scripts: click Test Billing at bottom of work request = Bottom = Test MULTIPLE scripts
Matching a Competitor's Price
Pharmacy staff might be allowed to match competitor's prices
Watson's final script: amoxicillin capsules 250 mg Q6H for 10 days
Saw advertised at Sgt. Pepper's Pharmacy across town for $4, less than copay
If can match price, he'll pay cash
To match price: select price match coverage (shared/global coverage)
Can be used for any patient
Enter script: amox 250 cap 250mg po .q6h x10days wt ow
Add pharmacy's RX PRICE MATCH shared coverage
Match $4 price with Override reason of "Price match"
Click Accept and Stay to start processing three scripts
Print labels, fill, verify, dispense all three fills
Shared coverages do NOT default in for refills
Unlike workers' comp accounts
Example: enter script, select Price Match shared coverage
Next refill won't have it selected automatically
Exception: fill script twice in same day
Shared coverage does default from prior fill
System assumes patient would ask for same price match same day
Reviewing the Chapter
Review Questions
You create a new patient record and enter her coverage. Later, a technician opens her patient record and doesn't see the coverage you entered. Why might this be?
What three pieces of information on the front counter tab of a patient chart are seen only in Willow Ambulatory?
What are the two processes for dealing with plans that don't exist in Epic?
Which of the following would cause the biggest problem if not done correctly?
A. Adding a worker's comp account
B. Creating a patient record
C. Entering a personal/family coverage
D. Updating the address
You know that a plan requires you to retain the leading zeros on the member number. Where can you add this information so that your coworkers are reminded to enter member numbers correctly in the future?
You enter a script and adjudicate the script to a workers' comp account. Which account defaults on the next fill of the script?
You enter a script with a primary coverage of a personal/family account and a coverage of "Price match." Which account(s) default on the next fill of the script?
Review Key
Duplicate patient record created. Coverage entered on one record, technician looking at other.
Default address, prescription address, pharmacy notes
Enter help desk ticket and wait for plan creation, OR use Rx Help plan to record coverage
B. Creating a patient record
Introduces duplicate record possibility
Leads to conflicting information and appearance of missing information
Can lead to poor clinical decision making
Coverage Entry Instruction (admin) or Plan Comment (user)
Workers' comp account defaults as primary coverage for subsequent fills
Only personal/family account defaults. Price match would need to be reselected.
Study Checklist
Define
Pharmacy Notes
Shared Notes
FYI
Payer
Plan
Coverage
Payer Comments
Plan Comments
Coverage Comments
Eligibility query
Additional Accounts/Coverages
Secondary coverage
Shared coverage
Perform
Identify whether patient already has record in Epic
Create new patient record
Add coverage that does NOT have matching plan in Epic
Add worker's comp coverage
Select secondary coverage
Match competitor's price
Understand
Why creating new patients in Epic is less common and more dangerous than stand-alone systems
Difference between Pharmacy notes, FYIs, Shared notes and who can see each
Information in Willow Ambulatory that does NOT appear in other Epic applications
Differences between various comment fields on Coverage Information window
Options for users when encounter plan that does not exist in Epic
How patient-entered allergies affect drug interaction checking
That personal and workers' comp coverages carry forward to subsequent fills of a script
That secondary coverages for one script are not added automatically to other scripts
That shared coverages do not carry forward to subsequent fills of a script
That after sending test claim, you can remove script so it doesn't show in patient's history
Managing Adjudication Issues
8.1 Managing adjudication issues process
8.2 Resolving adjudication issues
8.3 Documenting adjudication issues
Managing Adjudication Issues
Introduction
Adjudication isn't always straightforward
Sometimes get rejection and need to know where to make changes
Lesson Objectives
Update a coverage to resolve an adjudication error
Correct patient information to resolve an adjudication error
Override a claim value to resolve an adjudication error
Respond to DUR errors
Dispense a vacation supply
Fixing Adjudication Errors
Claims can be rejected for many different reasons
Claim contains
Patient information: name and date of birth
Coverage information: member number and person code
Prescription information: NDC and cash price
If any information incorrect or inconsistent with PBM's records, claim can be rejected
Bonny scenario: new paper script for verapamil
Steps
Log in as pharmacist to EMC Prescription North
Open Bonny patient from Front Counter
Enter script: verap 100 100mg po nightly d30cap r11 ow wt pseeg
Accept and Stay to adjudicate
Payment Summary shows Failure: Charging Rejected for coverage AETNA/RX GOLD
Missing or Invalid Person Code
When claim rejected
Click Bill to see details of the claim
Click Resolve Charging Flags to work on issue now
Click OK to leave the issue for later or for someone else
Updating Coverage Information
To fix coverage information: click pencil icon next to coverage
Fix any incorrect information and click Accept
To re-adjudicate: click Recalculate Charges
Bonny's scenario: Person code should be 02, not 01
Steps
Click pencil icon next to Bonny's coverage
Update Person code to 02 and Accept
Recalculate Charges to re-adjudicate
Updating Patient Information
When claim rejected, error could be in
Your records
The PBM's records
If your records are wrong: correct them
Example: click patient's demographics on Storyboard to correct DOB
If PBM's records are wrong: do NOT change your records
Bonny's DOB matches Epic, so records are correct
Deferring Adjudication
Charging flags are blocking flags
For some patients, might want to start filling script before charging error is resolved
Bonny scenario: long time patient, just switched insurance, causing problems
While Bonny contacts insurance company, want to start filling script
To start filling a script: click Defer Adjudication
Charging Rejected flag (red, blocks fills) replaced with Adjudication Required flag (blue, does not block fill)
Steps
Click OK to close Payment Summary window
Red flag (Charging Rejected) blocks work request
Click Defer Adjudication
Enter Follow-up date of "t" for today
Add Comment: Bonny is reaching out to her insurance company
Click Accept
Flag turns into blue flag (Adjudication Required)
Print labels for her script
Do NOT verify the fill
Close Bonny's chart
Overriding Information at th
e Coverage Level
Can override what is sent on claim to match PBM's records
Done by attaching override fields to patient's coverage or prescription/fill
Only patient can fix errors in PBM's records
Patient must contact payer and follow payer's process
Pharmacies need faster way to make adjudication succeed
To attach override field to patient's coverage
Open Coverage Information window
Add field and value to send on every claim with this coverage
Bonny scenario: PBM thinks she was born 5/9/1938
Steps
From Charging queue, find and open Bonny's charging flag
Click pencil icon next to Bonny's coverage
Add field of "DOB"
Override 304-C4 Date of Birth field with "5/9/1938"
Click Accept
If override added after rejection on fill
Select fill in Rx Management or Flagged Prescriptions
Change edited coverage to something else (such as Cash)
Reselect edited coverage
Recalculate Charges to apply override fields
Steps
From dropdown, change coverage to cash, then back to Aetna/RXGOLD
Date of Birth override appears
Click Recalculate Charges to re-adjudicate
Overriding Information a
t the Prescription/Fill Level
Previous example: override fields attached to coverage apply to every script and fill using that coverage
Attach override fields at prescription/fill level to affect just one prescription or fill
Whether it affects all fills or just one
depends
on what you override
Bonny's verapamil fails adjudication again with DUR error
Drug-drug interaction between verapamil and digoxin
Call Bonny's physician and confirm interaction is not a concern
DUR (Drug Utilization Review) errors
Checks to ensure drugs are dispensed appropriately
Many types: refill too soon, drug-allergy interactions
Receive "Reason for Service Code" that gives more details
Pharmacy staff generally know how to resolve from experience and training
Steps
Click Resolve Charging Flags
DUR Reject Error is prescription/fill issue, not coverage issue
In Overrides on bottom half of DUR Reject screen, search for field 439-E4
Override DUR errors
Recalculate Charges
Fill and Verify to get verapamil to Dispensed
Close Bonny's chart
Dispensing a Vacation Supply
When patient goes on extended vacation, might need refill sooner than normal and/or extra supply
Bonny scenario: returns, requests refill on verapamil, visiting niece for couple months
Can change amount being dispensed for particular fill in Pharmacy to Dispense section
Steps
Reopen Bonny from Front Counter
Initiate another Fill of verapamil, switch to Rx Management
In Pharmacy to Dispense section, change Dispense amount from 30 to 75 capsules
When attempt to adjudicate fill too early or with different amount than prescribed
, expect rejection
To help adjudication succeed: use override field to add Submission Clarification Code of "Vacation Supply"
In Flagged Prescription view, override field appeared below coverage
In Front Counter view, those fields are hidden
Steps
Click Advanced view (above Provider Prescribed) and scroll down to see coverage section
Previous coverage-level and prescription/fill-level overrides have carried forward
In Add field, search for "Submission Clarification Code" (or enter 420-DK)
Enter override of "Vacation Supply" to fill and attempt to adjudicate
Fill Request Validation warning appears (Willow: refill too soon)
Click Yes
Initiate, fill, verify verapamil
Reviewing Quantity Remaining on the Med Profile
On Med Profile, "Fills Rem" calculated from "Quantity Remaining"
Does not always need to be whole number
Before fill: Bonny had 330 capsules remaining
Dispensing 75 capsules
After fill: 255 capsules remaining
255 divided by 30 capsules per fill = 8.5 fills
Fills Remaining column shows "8+"
Steps
Open Bonny's Med Profile
Close chart and wish Bonny "bon voyage"
Bonny returns few months later, asks for refill of verapamil and has new prescription for teriparatide
Open Bonny and Initiate refill of verapamil
Go to Rx Management, change dispense amount back to 30 capsules
Check Advanced View to view overrides
Date of Birth and DUR overrides still there
Submission Clarification Code is gone
Submission Clarification Code typically only needed for one fill
Will not carry over to future refills
Administrators can control which overrides should not carry over
Handling Prior Authorizations & Postponing Adjudications
Bonny's teriparatide: cash price is high
Some medications require prior authorization by insurance company before they agree to pay
Workflow for prior authorization (paper/fax/telephone prescriptions)
Patient presents the prescription
Pharmacy enters it and sends claim for adjudication
PBM rejects claim and indicates prior authorization required
Pharmacy notifies physician's office that prior authorization required
Sometimes by printing forms and faxing to physician's office
Physician's office works with patient's insurance company to get prior authorization
If authorized, physician's office notifies pharmacy
Pharmacy attempts to adjudicate claim again
If insurance company sends prior authorization number to physician's office
Physician passes it to pharmacy
If provided, prior authorization number should be added as override field on claim
This workflow often takes few days and is largely outside pharmacy's control
Epic can improve workflow with Electronic Prior Authorization (ePA)
Interface with ePA vendor like SureScripts or CoverMyMeds
Users at organizations using ePA can initiate prior authorization requests from
Payment Summary window by clicking Request
For more information: galaxy.epic.com search for "Electronic Prior Authorization"
Steps
Attempt to adjudicate fills
Prior Authorization Required for coverage AETNA/RX GOLD
Print and fax Claim Rejection Report
Resolve Charging Flags
Move Fills
When cannot resolve flag quickly
Let pharmacy staff know why flag remains unresolved
If in same work request as other scripts, consider moving to new work request so it doesn't hold up others
Delete Ready at date and time so it doesn't appear overdue in work queue
Bonny's teriparatide requires prior authorization
Tell Bonny will call when ready
Send physician paperwork necessary for prior authorization
She asks for verapamil now, you agree
Steps
Move Fills and put teriparatide in its own work request
Add comment: following up on PA paperwork
Remove Ready at date so it does not appear as overdue today
Accept
Initiate, fill, verify Bonny's verapamil
Close Bonny's chart
Resolving a Postponed Charging Flag
Few days later, Bonny's physician's office calls with prior authorization number: 101979
Open Bonny's teriparatide from Charging queue
Need to add override to provide PBM with prior authorization number
Should override be applied to coverage or prescription/fill? Prescription/fill
Steps
Add field 462-EV as prescription/fill-level override
Enter prior authorization number 101979
Recalculate Charges to resolve charging flag
Initiate, fill, verify Bonny's teriparatide
Hint: Find it in Ready to Fill queue
Exercise: Adjudicating Alicia
Alicia just started using healthcare organization
After office visit with Dr. Seeger, has new scripts for lisinopril and Sprintec
Also has hard copy script for tacrolimus from transplant specialist Yuri Nalysis
Wants all 3 scripts filled
Steps
Sign in as pharmacist into EMC North
Open Initial Review work queue, find Alicia, double-click to open chart
First fill is for lisinopril, everything looks good, mark as reviewed
Date of Birth issue
Ask Alicia what her DOB is, matches what we have
Call PBM, they have "5/17/1991" in records
Need to override DOB at coverage level
Click Resolve Charging Flags
Click pencil next to Alicia's coverage, override DOB with 5/17/1991
Switch to cash and back to Alicia's Rx Training/RX ADJUDICATION... coverage
Recalculate Charges, problem solved, click OK
Check Alicia's Sprintec, mark as reviewed
Click Benefit outweighs risk for any med warnings
Another adjudication error: Refill Too Soon, wait 15 days
Talk with Alicia, has enough to get through until next refill
Proceed with other fills
Enter Alicia's hard copy script
Find and open her from Front Counter
In Med Profile, select
Medical record
Can see Alicia self-reported tacrolimus
Double-click tacrolimus: taking it for Renal Transplant Status
Hint: Indications of Use
Close and go to Rx Management
Enter: tacro 5 5mg po .bid d60cap r11 ds30 ow wt-14 pNalysis
See "existing order", but that's just Alicia's self-report
Click Create New Rx
Need to enter Yuri Nalysis as free-text Other provider
Enter name, click Accept
Accept and Stay, select Benefit outweighs risk for med warnings
Another adjudication failure: missing diagnosis code
Click OK
Use SnapShot to review key patient demographic and clinical information
Problem List card
Current medications list
Can click most SnapShot headers to jump into particular activity
Go to SnapShot at top of Alicia's chart
What diagnosis code should we use? Z94.0
Back in Rx Management, click on tacrolimus Charging Rejected flag
Need to add override
Should apply at prescription level (diagnosis only applies to tacrolimus)
In override code field, search for "diag"
Select either result
Override field 492-WE with value "ICD-10"
Override field 424-DO with "Z94.0"
Recalculate charges
Issue now: PA
Call Prior Auth team, they have PA # ready: 04221975
Click Resolve Charging Flags
Add prescription level override of 462-EV
Prior Authorization Number: 04221975
Recalculate Charges
Adjudicates successfully, click OK
Sprintec will give problems
What should we do? Move Sprintec into new work request
Why? Otherwise won't be able to dispense lisinopril and tacrolimus
Click Move Fills, get Sprintec into its own work request
Add Ready at date of t+15 at 10a
Click Accept
Initiate, fill, verify Alicia's lisinopril and tacrolimus
Accept to close Alicia's chart
Reviewing the Chapter
Review Questions
You fill a script. The claim is rejected because patient's name is different in your system and PBM. What should you do?
When you add a billing override to a fill, will it appear on subsequent refills of that scripts?
A. Yes
B. No
C. Maybe
A patient arrives with new script for lisinopril 20 mg tablets, 20 mg daily, 30 tablets, 11 refills. They want 3 month's supply, so you sell them 90 tablets. How do you indicate vacation supply to avoid PBM rejection?
After dispensing 3-month supply from previous question, how many fills remain according to Med Profile in Willow?
Review Key
If patient's name incorrect in your system: fix it using pencil icon next to name
If patient's name correct in your system: have patient contact payer to fix their name. In meantime, add override field to coverage with incorrect name, so sending name PBM expects. Need to toggle coverage before resubmitting claim.
C. It depends on the NCPDP field. Some fields set in system definitions to only apply to one fill. Others carry forward to subsequent refills.
Click Advanced view, add override field of Submission Clarification Code [420-DK] and value of "Vacation Supply"
9 refills remain. Sold initial 30 tablet fill plus two refills.
Study Checklist
Define
Test claim
Adjudication
Claim
NCPDP
PBM
Override fields
Prior authorization
Perform
Identify why a claim is rejected
Update a coverage with correct information
Fill a script even though adjudication failed
Add an override field to a patient's coverage
Identify and override DUR errors
Communicate adjudication solutions to other pharmacy staff in Willow Ambulatory
Add a submission clarification code to a script
Understand
What happens when you defer adjudication
When you should or should not update patient information in Willow
When you should add override fields to a coverage
That override fields attached to a coverage apply to every fill associated with that coverage
When and where you should override to get successful adjudication
That some, but not all, override fields attached to a script carry forward to subsequent fills of that script
Where other pharmacy staff see that a charging flag has been postponed
Clinician Interactions
9.1 Clinician interactions process
9.2 Communicating with clinicians
9.3 Documenting clinician interactions
Clinician Interactions
Introduction
Epic is an integrated system
Doctors, nurses, and pharmacists share same medication profile and patient charts
Important to understand how users affect each other
Lesson Objectives
Understand how providers manage prescriptions in a clinic visit
Understand how providers reconcile medications during admissions
Understand how provider actions affect the pharmacy
Receive and fix new prescriptions in the pharmacy
Manage the shared medication profile
How Information is Shared across Epic
Users can log in to different places to access applications
Hyperspace
Epic's front-end user interface for most applications
Examples: Resolute Professional Billing, EpicCare Ambulatory, Willow Inpatient
Users: physicians, schedulers, billers
Willow Ambulatory
Epic's front-end user interface specifically for outpatient pharmacy
Users: pharmacists, pharmacy technicians
Chronicles
Epic's database management system ("the database")
All data accessed in Hyperspace and Willow Ambulatory lives in Chronicles
When user logs in and opens patient chart, Hyperspace or Willow Ambulatory requests data from Chronicles
When user documents in patient chart, they are saving data to Chronicles
Understanding How Providers Manage Medications
Before the Office Visit
Clyde scenario: at clinic for appointment, stops at ground-level retail pharmacy
Requests refills of simvastatin and albuterol inhaler
Steps
Log into Willow Ambulatory as pharmacist (EMC Prescription North)
Open Clyde's chart and refill simvastatin and Proventil inhaler
Print labels for these two fills but do NOT mark them as filled
Accept to close Clyde's chart
Opening a New Encounter
Provider normally finds patients on schedule
In training and testing, can create encounters on the fly
Steps
Log into Hyperspace as Pat, physician (md1## / train)
Accept default login department
Ctrl+Space to search "encounter"
Open Encounter - Patient Care
Search for Clyde patient and click Accept
Create Encounter with Type of Office Visit, click Accept
Adjusting Prescriptions
To manage prescriptions: go to This Visit tab, find Medication Management section
Open dropdown for medication, click pencil icon to adjust dose, route, frequency, or other details
For solid medications: product should match dose if possible
Physician can click View Available Strengths and choose best product
Similar to Willow Inpatient but not same
For Inpatient orders: Intelligent Medication Selection automatically selects appropriate product
For Ambulatory orders: product selection is manual
Adjust the Dose of a Prescription
Clyde scenario: simvastatin 10 mg oral daily, physician finds 10 mg dose not effective, increase to 20 mg
Physician should change product to match new dose but forgets
Steps
Open to This Visit tab
Find Medication Management card, click simvastatin, click pencil icon
Benefit outweighs risk and Accept Pharmacogenomic OPA
Change Dose to 20 mg
Do NOT change strength of product
Make order Nightly, click Accept
Sign prescription now by clicking Sign Orders in lower right corner
Accept in Pharmacy Search window and Accept in Select Pharmacies windows (do not select pharmacy)
Override and Accept any warnings
Order printed as hard/paper copy (pop-up in upper right corner)
Go to Chart Review, Meds tab
How many rows appear for simvastatin? Two
Why is one crossed out? Provider used pencil icon to change prescription, EpicCare discontinued original and replaced with new
Reorder Medications
Physician can add refills by opening dropdown for medication and clicking Reorder
When reordering, system discontinues old script and creates new script
Sig can be
Based on discrete dose, route, and frequency
Free-text
Combination of discrete and free-text
Clyde scenario: nystatin-triamcinolone ointment, infection hasn't cleared up
Steps
Back on This Visit tab, click reorder icon for nystatin-triamcinolone
Clyde used up last tube quickly, wants pharmacy to dispense big tube
Open order composer for nystatin-triamcinolone (click box in bottom right corner)
For bulk products: dispense units usually limited to g or mL (not tube or inhaler)
EpicCare displays common sizes from currently available NDCs
Common sizes do NOT reflect what pharmacy has in stock
Add Note to Pharmacy: "Please dispense the largest package available"
Where will users in Willow Ambulatory see this note? Provider Prescribed, in Notes to Pharmacy
Accept to close order
Clyde needs additional refills for rescue inhaler
Reorder Clyde's albuterol inhaler with both PRN reasons and 11 refills
Hint: Click lightning bolt, open order, Edit Sig
Do NOT sign orders yet
Entering New Prescriptions
When provider searches for new scripts, Epic presents three lists of medications
Preference List: common meds for specialty, same medication can be added multiple times with different default sigs
Facility List: meds supported in this facility
Database Lookup: all medications on market
Once select medication from list, can adjust details using order composer
Physician prescribes amoxicillin capsules for ear infection
Click Add Order at bottom left, add "Amox 500 cap TID 10"
Ignore Allergy warning for now
Clyde having trouble sleeping, physician orders sleep medication
Search for "Ambien CR 6.25"
Choose Pharmacies
Pharmacy must be chosen to send prescription electronically, otherwise prints
Three types of pharmacies in Epic
External: pharmacy outside healthcare system
Internal: pharmacy inside healthcare system
NOT
using Willow Ambulatory
Integrated: pharmacy inside healthcare system
IS
using Willow Ambulatory
Clyde scenario: pick up three prescriptions at EMC Prescription Pharmacy North, one at External Outpatient Pharmacy
Steps
Click Select a pharmacy under list of queued orders (bottom right)
Search Name for EMC Prescription Pharmacy North, select Send to multiple pharmacies
Click Add Pharmacy, search for External Outpatient Pharmacy, select Mail Order option, click Accept
Send nystatin-triamcinolone to External Outpatient Pharmacy
Send albuterol, amoxicillin, zolpidem to EMC Prescription Pharmacy North
Click Accept in Select Pharmacies window
Sign Orders (bottom right)
Review Medication Warnings
Medication warnings can appear for
Drug-drug
Drug-allergy
Dose
Duplicate therapy
Other types of interactions
Warnings based on
Patient's med profile
Allergies
Age
Sex assigned at birth
Lab results
Pregnancy and lactation statuses
Some warnings very important, others rare and minor
Control which type and severity of warnings appear for each group of users
Clyde allergic to penicillin, mild itching
Amoxicillin is type of penicillin, drug-allergy warning appears
Physician decides to override because Clyde taken amoxicillin before without reactions
Steps
Use Benefit outweighs risk to override med warnings
For more info: CLN2220 - Medication Warnings badge on galaxy.epic.com
Printing the After Visit Summary
When patient sees physician, receive After Visit Summary (AVS)
AVS is summary of visit
Includes
List of prescriptions patient should take
What has changed about those prescriptions
Where those prescriptions were sent
Find AVS preview in lower right by Sign button
Steps
Use carrot next to PRINT AVS to open AVS Preview and Options window
Which prescriptions printed? simvastatin and zolpidem
What changed for Clyde's albuterol? the "reasons to take this"
Log out of Hyperspace
Exercise: Review Provider-Entered Orders
Part 1: Finish Processing Clyde's In-Progress Fills
Pharmacist working in EMC Prescription Pharmacy North
Basket on verify station with two scripts for Clyde: simvastatin and albuterol inhaler
Use SecondClyde patient (identical to Clyde)
Steps
Log in to Willow Ambulatory as pharmacist (EMC North)
Open SecondClyde patient
Select Proventil in work request
Fill and Verify disabled because script discontinued
At top of script can continue filling because:
Replaced by new prescription with same drug, dose, route, frequency
Pharmacist can continue filling (technician cannot) = b/c RPh can enter order and tech can't (similar concept)
Click Continue Filling
What is different between new prescription and fill in progress?
Ordering provider, PRN reason(s), dispense amount, number of refills can be different
Differences don't prevent filling discontinued script
Continue filling only applies to REFILLS (b/c more info is needed for FIRST FILL)
To continue filling FIRST FILL, even if reordered with same drug, dose, route, frequency, additional requirements needed:
DAW status
PRN reasons
Click Continue Fill In Progress
Fill and Verify enabled
What happened to new albuterol prescription with 11 refills?
Normally new prescription sent to pharmacy would go to first fill review
But didn't happen in this case
Go to Med Profile tab
What is status of new albuterol script? How many fills remaining?
Old albuterol prescription could continue to be filled
New prescription for albuterol automatically marked Profile only (Profile only meds don't go through any filling steps, just only go to "Clinical Review"
System didn't initiate first fill for it
In work request at bottom, select simvastatin
Look at top of Provider Prescribed
Can you continue filling this discontinued script? Why not?
Click Details for specifics
Cancel fill for simvastatin, indicate physician requested change
For albuterol click Fill and Verify
Close chart
Part 2: Review SecondClyde's New Prescriptions
SecondClyde finished office visit with physician
Physician entered new prescriptions:
Simvastatin 10 mg tablets, dose of 20 mg (modified from old 10 mg prescription; signed before picking pharmacy)
Nystatin-triamcinolone ointment (reordered from old script, typo in patient instructions and note to pharmacy; sent to external pharmacy)
Albuterol inhaler (reordered from script just verified in Part 1; sent to this pharmacy)
Amoxicillin 500 mg capsules (new order, sent to this pharmacy)
Zolpidem 6.25 mg CR tablets (new order, sent to this pharmacy; controlled substance)
New scripts entered in EpicCare need to be reviewed
Usually appear in Initial Review work queue
Steps
Logged into WAM as pharmacist
Go to Initial Review work queue
Open SecondClyde patient
Mark amoxicillin as reviewed
Review allergy and agree with physician
Click Benefit outweighs risk
Only reviewed one script, but sent more than 1 script to this pharmacy
Go to Clinical Review work queue, double-click SecondClyde
Profiled albuterol is here
Why Profiled? See Profiled reason under Pharmacy to Dispense
Mark albuterol as reviewed
Profile-only meds don't go through filling steps, just go to Clinical Review
Reviewed two of SecondClyde's new scripts
What about zolpidem, simvastatin, nystatin-triamcinolone? Why didn't have to review them?
Go to Part 3 to learn why
Part 3: Fill SecondClyde's New Prescriptions
Based on work queues, done with SecondClyde's orders
Original albuterol prescription ready to dispense
SecondClyde shows up at front counter with paper scripts: simvastatin and zolpidem
Says doctor reordered nystatin-triamcinolone
Why didn't see these earlier?
In real world: add scripts to existing work request with SecondClyde's albuterol
But in training environment: no POS system, Ready to Dispense orders automatically become Dispensed
Will add simvastatin and zolpidem to amoxicillin work request
Steps
Go to Front Counter, open SecondClyde's chart
SecondClyde handed paper scripts: simvastatin and zolpidem
Why paper scripts for these orders but not nystatin-triamcinolone?
Why don't see zolpidem CR, simvastatin 20 mg tablets, nystatin-triamcinolone?
Paper script for zolpidem: controlled substance, org doesn't e-prescribe controlled substances
Paper script for simvastatin: provider did not choose pharmacy to e-prescribe to
Nystatin-triamcinolone: sent to different pharmacy electronically, so no paper script, not processing it
Select
Medical record
Which pharmacy owns nystatin-triamcinolone script? Look under Owning Pharmacy column
What will have to do if SecondClyde wants you to fill it?
Transfer
Select nystatin-triamcinolone order (new one, NOT discontinued), click Transfer
Pretend called External Outpatient Pharmacy, got necessary information
Make up Rx number and who spoke with
Check sig is free of grammatical errors
Scroll down to bottom of Provider Prescribed section
Enter "2" in fills remaining
Enter "t" for today in First disp. and Last disp.
Where do you see comment about using largest package available? Notes to Pharmacy
Select largest NDC available
Warning at top of Pharmacy to Dispense: dispensing more than physician prescribed
Physician specifically asked to dispense largest package, so edit prescribed dispense amount
Back on LEFT side, change Dispense and Total quantity remaining to "60" g
Override or accept warnings
Back on NDC field, re-select largest NDC available
System tried to use same NDC patient received last time for consistency
Indicate 10 day supply
That takes care of nystatin-triamcinolone
What about other two scripts? Go back to Med Profile
Which pharmacy owns simvastatin and zolpidem scripts? None (no owning pharmacy)
SecondClyde got hard copies, could take to any pharmacy
Why hard copy for simvastatin? Physician did not pick pharmacy to e-prescribe to
Physician did send zolpidem to this pharmacy
What's special about zolpidem that caused it to print as hard copy? Controlled substance
Select zolpidem, click Hard Copy to indicate received hard copy
What if not already on Med Profile? When patient hands paper script, probably start entering it
Go to Rx Management
Search for "simvastatin 10", select Zocor option
When enter new script, Willow checks Medical Record for active prescriptions for same drug
If match exists, displayed
Click Receive Hard Copy
Physician neglected to change strength from 10 mg to 20 mg tablets
Use pencil next to Medication
Patient sig updates to match: "Take 1 tablet..."
Click Accept and Stay, override warnings
Initiate Fills for all four scripts
Notice for simvastatin and nystatin-triamcinolone how View Changes (under Provider Prescribed) appears
Mark them as filled and verified, marking PDMP as Reviewed
In live system, PDMP integration allows review of controlled substance prescriptions via Review PDMP report
Not configured in training environment, report is blank
Part 4: See the Impact in EpicCare
Steps
Log in to Hyperspace as physician, accept default login department
Open SecondClyde's Office Visit
Search for encounter
Compare medications and orders physician sees in Medication Management with pharmacist perspective
What does MD see? Changes pharmacist made updated existing orders, no new orders created
Go to Chart Review, Meds tab
Active simvastatin order: one 20 mg tablet, not two 10 mg tablets
Nystatin-triamcinolone: applied to right leg, not keg, dispensing 60 g
Double-click to see
Part 5: Document Your Findings
When a provider uses Change or Reorder buttons in EpicCare
What happens to original order? Discontinued
What does system create? New prescription
In what circumstances can you fill a prescription that has been :check: discontinued?
Can continue filling if in process of being filled
Reordered with same drug, dose, route, frequency
Not the first fill
Have security to continue filling
Why would new prescription received in Willow from EpicCare be marked Profile only?
New script automatically marked Profile only when reordered from script that can continue to be filled
What are three things provider might do to cause new prescription entered in EpicCare
NOT
to appear on Recent pharmacy profile in Willow?
Not select pharmacy to send script to
Select different pharmacy to send script to
Prescribe controlled substance when e-prescribing controlled substances not supported
How would patient know where to get medication if provider chooses external pharmacy?
AVS shows patient which pharmacy script was sent to
To fill at different pharmacy: script has to be transferred
What are two ways to process order entered in EpicCare but for which patient presents hard copy?
Find on med profile or search for drug on Rx Management
Next step: click Receive Hard Copy
You modify detail (product, patient sig, or dispense amount about prescription in Willow
True/False: original order is discontinued and replaced with new order. False
True/False: change you make is visible to providers in EpicCare. True
If modify details of prescription in Willow, what might patient have that could be confusing and out-of-date?
Printed AVS is now out-of-date
Key Takeaways
Continue Filling Reordered Prescriptions
In most cases, discontinued scripts cannot be filled
Pharmacist (not tech) can allow discontinued script to be FILLED if
Fill has status of Fill Initiated, Filled, Ready to Verify, Verified, or Ready to Dispense PRIOR to script being discontinued
Script has been filled before and was reordered with same drug, dose, route, frequency
Note: prescriptions not filled before have additional requirements including DAW status
When this happens, new (replacement) prescription automatically marked Profile only to avoid duplicate fills
Profile-only scripts don't go through filling steps, just go to Clinical Review
Why Doesn't a Script Appear in
First Fill Review
?
No Pharmacy Chosen
If physician does not select pharmacy, system doesn't know where prescriptions should go
Therefore, they get printed
Because Epic integrated, they still appear on
Med Profile but without owning pharmacy
Controlled Substance Prescribed
In many systems, prescriptions for controlled substances always get printed
Appear on Med Profile
without
owning pharmacy
Patient could take paper scripts anywhere
It is possible for prescriptions for controlled substances to be sent electronically
As of November 2022, Willow Ambulatory supports automatically creating scheduled fills for e-prescribed controlled substances based on earliest fill date
External Pharmacy Chosen
Scripts sent elsewhere are presumed to be filled there
If patient arrives asking for fills, transfer scripts into pharmacy
If external pharmacy never received prescription, patient might have hard copy
In that case, fill using Hard Copy button rather than Transfer
Fixing Errors in Prescriptions
Pharmacy staff can fix errors on scripts in Willow Ambulatory
This does NOT discontinue and reorder script
Original prescription is modified
Only one prescription appears in Med Profile
If clinical details need to be modified, pharmacist should contact ordering physician to get script re-written
One Med Profile
Within organization, patient has only one Med Profile in Epic
Appears in Willow Ambulatory and Hyperspace
Changes made to prescriptions in one place are seen in other places
Reconciling Medications
Trainer demo section
Medication reconciliation usually involves many changes to Med Profile that affect outpatient pharmacy
Medication reconciliation occurs during inpatient admissions and outpatient visits
In both cases, providers interview patient, reviewing and updating current Med Profile
During admission, providers can order home medications for hospitalization
Upon discharge, providers decide which inpatient orders should be prescribed and which home medications should be resumed
To review patient's home medications during admission as physician
In Hyperspace, go to Patient Lists activity
In upper right, search for patient in Search All Admitted Patients field
Double click row to open chart
Go to Admission tab
Find Admission Orders section
Go to Review Home Medications tab
Updating Home Medications
At beginning of visit or admission, list of home medications reviewed and updated for accuracy
Antony scenario: amLODIPine makes him tired, usually takes every other day, took it yesterday
Steps
Indicate that Antony took amLODIPine yesterday
Click on amLODIPine sig to expand order composer
Update Frequency to Every other day
Antony says he took both tablets of topiramate today
Steps
Document his last dose of both topiramates
Removing Home Medications
One reason: after enter incorrect patient reported home medication
Another error: duplicate prescriptions
When provider clicks Discontinue or Remove for prescription, prescription is discontinued
Antony scenario: hasn't used fluticasone inhaler for months, friend posted online that fluticasone causes ear enlargement, no intention of using again
Steps
Record that Antony's last dose of fluticasone was more than month ago
Click red x to discontinue fluticasone
Review warning that appears
In this situation many providers would choose to cancel to prevent medication from being discontinued
Others would choose to discontinue to clean up Prior to Admission Med list
Will discontinue now to see downstream pharmacy effects
Discontinue fluticasone with Reason of non-compliance, Accept
Note: patient has one med profile across all Epic
If prescription owned by Willow pharmacy, users who start to discontinue see warning
If prescription discontinued during medication reconciliation, discontinued on Willow Ambulatory Med Profile
Managing Home Medications for an Admission
Steps
Go to Reconcile Orders tab of Admit Orders activity
Physician decides to continue Antony's amLODIPine as he has been taking it
As admitting physician, will let PCP decide if script needs to change after discharge
Steps
Order amLODIPine and Order as Reported
If internal provider made change or ordered additional medication at discharge, users in Willow Ambulatory would see
Modifying Home Medications
Some prescriptions written in way that one script equals two inpatient orders or two scripts can be consolidated into one inpatient order
Prescriptions for tapers or alternating doses often single outpatient script
Sig may be "Take 20 mg for 3 days, then 10 mg for 3 days" or "Take 25 mg every morning and 50 mg every night"
In hospital, these scripts need to become multiple orders because no place for multiple doses on one inpatient order
Prescriptions for combinations of strengths often multiple outpatient scripts
Provider writes one script for 25 mg daily and another for 100 mg daily for total dose of 125 mg
In hospital, can be single inpatient order
System automatically picks strengths necessary to make ordered dose: Intelligent Medication Selection (IMS)
When script doesn't work in hospital, provider has to manually adjust inpatient order
Potential for mistakes in inpatient orders and outpatient scripts after discharge
Antony scenario: combine topiramate scripts into single order for admission
Steps
Order first topiramate
Click on order name (blue) to open order composer, change dose to 125 mg daily
Don't Order second topiramate
View Unsigned Orders in bottom right, click Sign Orders
Reconciling Discharge Medications
When patient discharged, providers decide what meds patient should take at home
Path: Discharge > Discharge Orders > Review Medications for Discharge
Steps
Open Discharge tab, select Discharge Orders
Hospitalist discharging Antony wants home medications continued/resumed once discharged
Will leave decision of how Antony should take amLODIPine to prescriber
Actions taken during Discharge Medication Reconciliation may affect pharmacy
If home medication continued/resumed upon discharge, pharmacists using Willow do
NOT
notice any change to med profile or see new script to review
Patient just resumes taking existing fill
If home medications stopped upon discharge, pharmacy staff see discontinued on med profile
New orders appear in work queues for review
Steps
Click arrow for Antony's amLODIPine, select Defer to Prescriber
Click arrow for both prescriptions for topiramate
Under New Inpatient Orders, remove Discharge patient order
Sign orders
If internal provider made change or ordered additional medication at discharge, users in Willow Ambulatory would see
Managing the Med Profile after Discharge
Steps
Log in to Willow as Pharmacist in EMC Prescription North
Open Antony's chart from Front Counter, look at
Recent Rx Profile
Fluticasone is discontinued
Original amLODIPine and topiramate prescriptions remain
Switch to Medical Record, select Hospital checkbox
Can see Antony's hospital medications
What is frequency of Hospital medication order for amLODIPine? Why? Every other day
Changed by MD during Home Med Rec, then reconciled as Order as reported for inpatient stay
Why only one Hospital medication order for topiramate? Doctor combined Antony's 2 outpatient topiramate medications into 1 hospital medication order
Reactivating Discontinued Prescriptions
Several months later Antony asks for fill of fluticasone, but it was discontinued during admission
Think back to Antony's Admission Med Rec: reason fluticasone was removed/discontinued? Non-compliance
Pharmacy staff can reactivate discontinued prescriptions if
User has security to do so
Discontinue reason is allowed for reactivation
Non-compliance is good example of reason that would allow reactivation
Steps
Call ordering physician Walt Whitecoat, decide it's in Antony's best interest to have rescue inhaler
Reactivate Antony's fluticasone prescription with Reason of Confirmed with physician
Accept and find fluticasone on Med Profile
All prescription details have been reactivated, including refills
Where could find more detail about Antony's medication history, inpatient stay, other encounter information?
Prescription History, SnapShot, Chart Review
Continue Filling vs. Reactivate
People often confuse Continue Filling and Reactivate
Both are Willow Ambulatory-specific functions
Both involve discontinued prescriptions
Differences
Continue Filling
Only allowed for reordered scripts
Only applies when reordered script has been previously filled and has same drug, dose, route, frequency
Only allowed for pharmacists
Only applies if fill has been initiated but not yet sold at time reorder happens
Only applies to current fill - no future fills allowed
Original script remains discontinued - replaced by new script
Reactivate
Only allowed when discontinue reason is approved for reactivation
No other script involved
Special security required
Can reactivate any time after discontinue and before expiration date of script
After reactivation, script can be filled many times until no refills remain
Script is reactivated, acts like it was never discontinued
Diagram: Reactivate Discontinued vs Continue Filling Reordered
For more on medication reconciliation, search Galaxy
Learning Homes
What are Learning Homes?
Learning Homes are Radar dashboards
Give users access to customized, role-specific quick start guides, tip sheets, other training materials directly in Hyperspace
Distributing training materials electronically saves money on printing
Users always have access to latest information
From Learning Home, users can see updates about system changes, read short efficiency tips, open quick start guides without leaving Hyperspace
Utilizing Learning Homes
Accessing a Learning Home
Available to end users anywhere within Hyperspace
Opens as separate window, allowing to remain in current workspace while looking up information
Three ways to access
Press F1 on keyboard
Click question icon in upper right-hand corner of most activities
Search for "help" or "learning home" using Epic menu or Chart Search
End users working from laptop may need to press Fn + F1
For Mac keyboard conversions, reference Keyboard Conversions for Mac
Opening a Quick Start Guide
When users click quick start guide title, guide opens as PDF in separate window
First page is table of contents
Users can click section titles to jump to that topic
Communicating about Learning Homes
If principal trainer: notify users about Learning Homes as part of end user training
If not yet gone live: include information as part of standard Go-Live training
Principal trainers for each application should encourage end users to utilize Learning Home when have questions
If already gone live: remind users during upgrade training
Email or demonstration at department meetings can help users understand how to use tool
Tip sheet handed out at training session can help them remember
Learning Home training included in Training Wheels lesson plans
Part of users' pre-live training for customers using Epic's End User Training Services
Additional Resources
Learning Home Strategy Handbook
Radar Setup and Support Guide
Introduction to F1 Help Learning Homes [TED271]
Edit Learning Home Content [TED272]
Create a New Learning Home [TED273]
Available on Galaxy and E-Learning videos
Reviewing the Chapter
Review Questions
A physician enters prescriptions for a patient in EpicCare, but they do not appear in Willow Ambulatory. Why might this happen?
If a physician removes a home medication when a patient is admitted, what happens in Willow Ambulatory?
If a physician prescribes an inpatient order upon discharge and stops the existing home medication, what happens in Willow Ambulatory?
Review Key
Physician did not choose pharmacy, did not choose pharmacy in which working, prescription is for controlled substance
Prescription appears as discontinued on med profile
Prescribed inpatient medication goes to Initial Review queue to be filled, existing home medication is discontinued
Study Checklist
Define
Change prescription
Reorder prescription
Profiled prescription
Medication reconciliation (Med rec)
Reactivate
Continue filling
Perform
Fill prescriptions not sent to a pharmacy
Fill prescriptions sent to a different pharmacy
Fill prescriptions for controlled substances
Document that paper script has been received in Willow Ambulatory
Fill a reordered medication
Modify prescriptions
For home medication reordered for admission, continue correct order upon discharge
Reactivate a discontinued prescription
Understand
Where order placed in EpicCare Ambulatory will go after signed
Why prescription prescribed in EpicCare might not cross to Willow Ambulatory
Why prescriptions might need to be discontinued or modified
Effects on other users when prescriptions discontinued or modified in Willow Ambulatory
In what circumstances pharmacy can continue filling discontinued prescription
Why inpatient order might be two outpatient prescriptions and vice versa
Effect of deleting or removing medication from home medications list
Why pharmacy would reactivate discontinued prescription
Which scripts system allows pharmacy to reactivate
Difference between continue filling and reactivating
Reporting
10.1 Reporting process
10.2 Generating reports
10.3 Reviewing reports
Reporting
Introduction
Pharmacy managers want to pull information out of Epic to make pharmacy more efficient and effective
Epic provides variety of data visualizations and data sources for reporting
Suite of reporting options named Cogito
Three Cogito reporting tools: Radar Dashboards, Reporting Workbench, SlicerDicer
For overview: "Visualize Your Data with Cogito" in Galaxy
Lesson Objectives
Find and navigate Radar Dashboards
Use My Analytics to run favorite reports
Edit and save the settings of an existing report
Create a new report from a template
Use SlicerDicer to visualize data
Willow Ambulatory and Hyperspace
Most other users (clinical and non-clinical) use Hyperspace client to access applications
Willow Ambulatory users typically do not access Hyperspace for workflows
Pharmacy managers and directors might use Hyperspace reporting tools to inform pharmacy decision making
Reporting Workbench
Reviewing Pharmacy Metrics
Find My Dashboards in Willow Ambulatory at Epic > My Dashboards
From My Dashboards click name in upper left to open additional dashboards from reporting catalog
Search "outpatient pharmacy" to find dashboards created specifically for Willow Ambulatory users
Outpatient Pharmacy Administrator dashboard
Outpatient Pharmacy Director dashboard
Steps
Log in to Willow Ambulatory as administrator (adm1## / train) into EMC Prescription North
Find the My Dashboards icon
Click Outpatient Pharmacy Administrator dashboard
Search for and open Outpatient Pharmacy Director dashboard
What are average wait times and gross margin?
Click dashboard name and search for "outpatient pharmacy"
Reporting catalog includes many content types: dashboards (blue), Reporting Workbench Reports (purple), components (bar graph)
Hover over dashboard, then hover over Reporting Workbench Report
Dashboards can be run in Willow Ambulatory
Reporting Workbench reports cannot be run in Willow Ambulatory
Log out
Running Reporting Workbench Reports
Reporting catalog available in Willow Ambulatory and Hyperspace
Reporting Workbench reports can ONLY be RUN in Hyperspace
To find new report to run: search in Analytics Catalog
Reports designed for Willow Ambulatory start with
"rxamb"
Steps
Log in to Hyperspace as administrator into any department
Search for Analytics Catalog
Search for "RxAmb"
This prefix shows Foundation System's outpatient pharmacy RW Reports
Hover over RxAmb Free-text Providers report, click star icon to make it a favorite
Click play to run report
Which free-text providers are listed?
Report Options
Click on options [+] in top right corner
Options include saving results, showing column definitions, opening template editor
Workbench report results do not update in real time
Results are
static
Report needs to be rerun to include newly added free-text providers
Results available for limited period to ensure reports are rerun to reflect up-to-date data
If more time needed: users can save or export results
Favorited reports, recent results, saved results can all be viewed in My Reports
Steps
Search for My Analytics
Shows saved SlicerDicer sessions, Reporting Workbench Favorites, Recent and Saved Results
See RxAmb Free-text providers report in both Favorites and Recent Results
Modifying Existing Reports
Can change what report searches for and format of results
To edit report: right-click and choose Edit
Edit option available from My Reports, reporting catalog, or Library activity
Steps
Still on My Analytics dashboard, under Favorites, click on Viewed for RxAmb Free-text Providers report and then Edit
Make sure in Reporting Workbench Tagged Content and Favorites, not Recent and Saved Results
Saving Modified Reports
When modify report, can:
Run once and discard changes: click Run then Don't Save
Save and run anytime: make changes then click Save As
Steps
Click Save As and name new report trn1## Free-text Providers (2 weeks)
Modifying Date Criteria
Criteria tab displays search options available for report
When entering date for report to save: ALWAYS use relative dates
Example: enter "t-1" instead of yesterday's date
Relative dates shift as current date changes
If enter specific date, report will always use that date
Depending on data set size, might not be able to run reports for date ranges > 2-3 weeks
Steps
Expand Date Range to last two weeks
Modifying the Display Columns
Control what information appears on report
On Display tab can add, remove, reorganize columns
Steps
Open Display tab
Move NPI to far right side, remove Provider Fax Number
Selected columns listed in order they will appear from left to right
Use right/left arrows to add/remove columns
Modifying Who Can See a Report
On General tab, choose to save report as public or private
Public report: available to anyone with security to see corresponding report template
Private report: accessed and run only by person who saved it
Only administrators can save public reports
Some end-users can save private reports, others cannot
Steps
On General tab, make sure report is Private
Save and Run report
Creating New Reports
Can create new reports from scratch
Every report created from template
Template controls options available for report
Each template provides different set of items to search for
Several templates available for Willow Ambulatory
Templates found in reporting catalog
Steps
Go to Analytics Catalog, find Prescription Adjudications template (purple cog with hammer)
Click template to create new report
On General tab, make it public, call it trn1## adjudication errors (1 week)
Selecting Criteria
On Criteria tab, search for criteria
After adding criteria, enter values looking for
Logic
In some templates, can specify logic within and among report criteria
And, Or, custom logic allow determining whether all, one, or some criteria must be met
Steps
On Criteria tab, configure report to show only charging failures in EMC Prescription Pharmacy North or South in last week
Pay attention to logic
Save and Run report
Report Sharing
On General tab, options for report sharing
When first user runs report, all other sharing users see results in Recent Results section of My Reports
Improves performance by reducing number of times report needs to run
To share results: report must be saved as PUBLIC, report template must be configured to allow sharing
SlicerDicer
Epic's primary self-service reporting tool
Using SlicerDicer, report consumers empowered to explore data and quickly generate sophisticated visualizations
When using SlicerDicer, keep in mind:
Can only pull information from existing Data Models
Epic has released many Data Models, organization can curate own
Data is at least a day old
Reporting Workbench more appropriate if need real-time data
SlicerDicer Vocabulary
Data Model: set of data sorted with
pre-built filters
Session: report in Data Model
saved
by user
Population: base (initial cohort) refined using criteria
Criterion: filter that refines
population
to only desired records
Slice: filter that
divides population into groups
that can be viewed and
compared
Measure: filter that
determines what function aggregates data, can be thought of as y-axis on graph
SlicerDicer Filters serve multiple purposes, stored in
FDS
master file
Often referred to simply as "filters"
In SlicerDicer, filter does more than refine data
Represents single data point that can be used in various ways
Running a Report in SlicerDicer
Organization wants ordering providers to send prescriptions to pharmacies electronically
Goal of 75% ePrescribing across all Departments
Responsible for creating report that meaningfully visualizes this data
Steps
Return to Analytics Catalog
In Content Type, filter to just SlicerDicer
Search for "Outpatient Prescriptions"
No play button for SlicerDicer sessions
Run Outpatient Prescriptions data model by clicking on it
Click through SlicerDicer tutorial or click outside to dismiss
Use Dates card to set date range of last 2 years
Add Measure for "Percentage with Origin Code"
On right sidebar, choose Origin Code of "Electronic" for Measure
Slice by "Department"
Enter "15" in box under Slice by Department, then Grab Top 15
Can remove "None of the above" by clicking trash can icon
Under Measure, click Percentage with Origin Code: Electronic measure and Add Goal of "75"
Under Visual Options, switch to Graph Type of Horizontal Bar Graph
Save As (top right) session with name "trn1## ePrescribing by Department"
Scroll down to Save to Group, create new group called "trn1## SlicerDicer"
Click Create Session to save session
Reviewing the Chapter
Review Questions
If pharmacist wants to see report not in favorites, where can she find it?
You make copy of public report, want to try out ideas, should copy be public or private?
You would like real-time report of today's adjudication failures, Reporting Workbench or SlicerDicer better?
Pharmacy manager wants report on outpatient opioid prescriptions, analyze trends, identify non-compliant orders, explore dispensing history by department, Reporting Workbench or SlicerDicer better?
Review Key
In Report Catalog, Library, or Analytics Catalog assuming user has access
Should make it private report so only you can see and run it
Reporting Workbench, reflects failures in real time, SlicerDicer data is at least a day old
SlicerDicer, for analyzing trends over time, can Slice by department to investigate dispense history
Note: Foundation System has pre-built Data Model called "Opioid Outpatient Prescriptions"
Study Checklist
Define
Reporting Catalog
Dashboard
Reporting Workbench
My Reports
Library
Criteria
Relative dates
Public report
Private report
Template
SlicerDicer
Population
Measure
Slice
Perform
Select Dashboard to view
Save results
Mark report as favorite
Create modified version of report for future use
Make new public or private report from template
Understand
Difference between public and private report
Why report might not appear for user
Difference between saving results, marking report as favorite, making private report
Why relative dates important for saved reports
How "Valid until" time affects results
Difference between SlicerDicer and Reporting Workbench
Day 2 Lab
11.1 Practical exercises and scenarios
Appendix A: Do This Next
12.1 Next steps and additional resources
Appendix B: Reviews
13.1 Review questions and answers