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Troubleshooting Pharmacy Issues

Troubleshooting Pharmacy Issues. January 2012. Session Content . This presentation shows some common issues that may happen with EHR and Pharmacy. It is NOT a comprehensive list of potential issues.

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Troubleshooting Pharmacy Issues

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  1. Troubleshooting Pharmacy Issues January 2012

  2. Session Content • This presentation shows some common issues that may happen with EHR and Pharmacy. • It is NOT a comprehensive list of potential issues. • The solutions proposed represent the most common causes of the listed issues, and again, are NOT comprehensive. • This presentation is designed to develop basic troubleshooting skills for Pharmacy Informaticists.

  3. Issue: Inactivated Medication • When attempting to order a medication from the quick order menu the user receives a message stating that the item “has been inactivated and may not be ordered anymore.”

  4. Potential Solution: Inactivated Medication • Check both drug and orderable item for an inactive date • REMOVE inactive dates to make item active again—NEVER set a future date! • Check quick orders—if a new NDC was put in as a new drug instead of editing the existing entry, will need to change all the quick orders.

  5. Potential Solution: Inactivated Medication, continued Select Pharmacy Data Management Option: Drug Enter/Edit Select DRUG GENERIC NAME: FOSINOPRIL 10MG TAB (90'S) CV800 -24391 11-27-08 00781-5083-92 *************************************************************************** This entry is marked for the following PHARMACY packages: Outpatient GENERIC NAME: FOSINOPRIL 10MG TAB (90'S) Replace … INACTIVE DATE: NOV 27,2008// @ SURE YOU WANT TO DELETE? Y (Yes) … ** You are NOW in the ORDERABLE ITEM matching for the dispense drug. ** FOSINOPRIL 10MG TAB (90'S) is already matched to FOSINOPRIL TAB

  6. Potential Solution: Inactivated Medication, continued This Orderable Item has an Inactive Date. *** NOV 27, 2008 To modify the Orderable Item, use the 'Edit Orderable Item' option. Do you want to match to a different Orderable Item? NO// Select Pharmacy Data Management Option: ORDERABLE ITEM Management Edit Orderable Items Dispense Drug/Orderable Item Maintenance Orderable Item/Dosages Report Patient Instructions Report Select Orderable Item Management Option: EDit Orderable Items This option enables you to edit Orderable Item names, Formulary status, drug text, Inactive Dates, and Synonyms.

  7. Potential Solution: Inactivated Medication, continued Select PHARMACY ORDERABLE ITEM NAME: FOSIN 1 FOSINOPRIL TAB 11-27-08 2 FOSINOPRIL/HYDROCHLOROTHIAZIDE TAB 09-23-04 N/F CHOOSE 1-2: 1 FOSINOPRIL TAB 11-27-08 Orderable Item -> FOSINOPRIL Dosage Form -> TAB Dispense Drugs: --------------- FOSINOPRIL= 10MG TABS NOV 27, 2008 FOSINOPRIL= 20MG TABS NOV 27, 2008 FOSINOPRIL= 40MG TABS NOV 27, 2008 FOSINOPRIL 10MG TAB (90'S) FOSINOPRIL 20MG TAB (90'S) NOV 27, 2008 FOSINOPRIL 40MG TAB (90'S) NOV 27, 2008

  8. Potential Solution: Inactivated Medication, continued Are you sure you want to edit this Orderable Item? NO// YES Now editing Orderable Item: FOSINOPRIL TAB Orderable Item Name: FOSINOPRIL// This Orderable Item is Formulary. Select OI-DRUG TEXT ENTRY: INACTIVE DATE: NOV 27, 2008// @ Inactive Date deleted! DAY (nD) or DOSE (nL) LIMIT: MED ROUTE: SCHEDULE TYPE: SCHEDULE: DAILY// PATIENT INSTRUCTIONS: FOR KIDNEY PROTECTION AND BLOOD PRESSURE Replace There are inactive drugs, matched to this Pharmacy Orderable Item. Do you want to reactivate all Drugs/Additives/Solutions that are matched to this Orderable Item?: (Y/N/L): N// NO Select SYNONYM:

  9. Issue:No Doses in the Quick Order • User is attempting to order Losartan but discovers there are no available doses in the quick order. • Note that in addition to the empty dosage box, there is no indication of a tablet strength in the preview box.

  10. Potential Solution:No Doses in the Quick Order • Providers can free text a dose into the dosage field in order to complete the medication quick order. • This will NOT work for e-Rx meds, and is a temporary solution ONLY • Note there is still no tablet strength indication in the preview box. • See next slide for more

  11. Issue: Local Possible Dosages are Confusing • Is it one puff of the 250/50mcg inhaler or one puff at the 500/50mcg inhaler? • Note: the orderable item is generic, “FLUTICASONE/SALMETEROL INHL, ORAL”

  12. Solution: Local Possible Dosages are Confusing • Separate out the orderable items, “FLUTICASONE 250MCG/SALMETEROL 50MCG INHL, ORAL

  13. Recommendation: Separate Descriptive Orderable Items • It is important to use separate descriptive orderable items that include strength as part of the orderable name in the following circumstances: • Drugs that have local possible dosages (combo drugs, topicals, ophthalmics, inhalers, etc.) • Drugs where the strength is expressed as a percentage (i.e IV solutions, topicals, etc) • IV Additives where there is more than one strength used at the facility (i.e. Cefazolin 1gm and Cefazolin 2gm) • Medications that may be dispensed from Omnicell/Pyxis when the pharmacy is not open.

  14. Issue: Standard Schedule NOT Available • Why is the Standard Schedule of “AC TID” not showing as an available option?

  15. Potential Solution Build the administration schedule into the Standard Schedule File located under Pharmacy Data Management (PDM): ********************************************************************** Select Pharmacy Data Management Option: STANdard Schedule Edit Select ADMINISTRATION SCHEDULE: AC TID Are you adding 'AC TID' as a new ADMINISTRATION SCHEDULE (the 82ND)? No// Y (Yes) NAME: AC TID// OUTPATIENT EXPANSION: 3 TIMES A DAY BEFORE MEALS OTHER LANGUAGE EXPANSION: TYPE OF SCHEDULE: CONTINUOUS// CONTINUOUS STANDARD ADMINISTRATION TIMES: 0730-1230-1730 FREQUENCY (IN MINUTES): 1440// Select WARD:

  16. Issue: Standard Schedule is NOW Available

  17. Issues: Unknown Quantity when Ordering Medication • Provider goes to “All Other Meds” to order a medication, but it not sure what to put for the QTY?

  18. Possible Solution: Add a “QTY Dispense Message” Enter your choice(s) separated by commas : O O - Outpatient ** You are NOW editing OUTPATIENT fields. ** AN Outpatient Pharmacy ITEM? Yes// Y (Yes) CORRESPONDING INPATIENT DRUG: MAXIMUM DOSE PER DAY: STANDARD SIG: AP TO FACE HS UD LOCAL NON-FORMULARY: NORMAL AMOUNT TO ORDER: SOURCE OF SUPPLY: 3// CURRENT INVENTORY: -10245.5// ACTION PROFILE MESSAGE (OP): MESSAGE: QUANTITY DISPENSE MESSAGE: 1 BOTTLE=60ML OP EXTERNAL DISPENSE:

  19. Possible Solution: Add a “QTY Dispense Message”

  20. Issue: “Pop-up” Fatigue • Providers can start to experience “Pop-up” Fatigue if too many pops occur while trying to order medications, labs, etc. • “Pop-ups” should be kept to a minimum and only used when absolutely necessary.

  21. Possible Solution: Use Drug Text to Minimize “Pop-ups” CMOP Mark/Unmark (Single drug) DOS Dosages ... DRED Drug Enter/Edit Drug Interaction Management ... Electrolyte File (IV) Lookup into Dispense Drug File Medication Instruction File Add/Edit Medication Route File Enter/Edit OIM Orderable Item Management ... Orderable Item Report Formulary Information Report Drug Text Enter/Edit Drug Text File Report Pharmacy System Parameters Edit Standard Schedule Edit Synonym Enter/Edit Controlled Substances/PKI Reports ...

  22. Possible Solution: Use Drug Text to Minimize “Pop-ups”

  23. Issue: Do we use quick order Inpatient Medications or Unit Dose • The pharmacist making the inpatient quick orders calls with the above question…what is the difference between these types of quick orders and which one should be used when?

  24. Potential Solution: Do we use quick order Inpatient Medications or Unit Dose • There is no functional difference between the two types • Sites may choose to use either type for all non-infusion quick orders • Sites may decide to locally determine which type should be used for which item • Would only be useful if using Quick Order Wizard or performing Fileman searches for specific types of quick orders

  25. Issue:The route of “IM” is not available • Provider wants to order a one-time dose of Ceftriaxone to be given “IM” but that route is not available

  26. Potential Solution:The route of “IM” is not available Solution: RPMS > PDM > Dosages > Dosage Form File Enter/Edit ************************************************** Select DOSAGE FORM NAME: INJ,SOLN 1 INJ,SOLN 2 INJ,SOLN,SA CHOOSE 1-2: 1 INJ,SOLN NAME: INJ,SOLN Select MED ROUTE FOR DOSAGE FORM: IV PIGGYBACK// INTRAMUSCULAR 1 INTRAMUSCULAR IM Are you adding 'INTRAMUSCULAR' as a new MED ROUTE FOR DOSAGE FORM (the 4TH for this DOSAGE FORM)? No// YES

  27. Potential Solution:The route of “IM” is NOW available

  28. Issue: Unable to Transfer from Inpatient to Outpatient

  29. Potential Solution: Unable to Transfer from Inpatient to Outpatient One Orderable Item is required for both the Bulk Outpatient Dispense Drug and the Unit Dose Inpatient Dispense Drug **************************************************** Orderable Item -> CITALOPRAM Dosage Form -> TAB Dispense Drugs: --------------- CITALOPRAM 40MG TAB CITALOPRAM 20MG TAB CITALOPRAM 20MG U/D TAB CITALOPRAM 10MG TAB

  30. Issue: Transfer to Outpatient Dialog Setting Defaults • Why are the fields “Pick Up” and “Refills” not filled in?

  31. Issue: No Dispense Drug Selected • Pharmacy has received a notice that they need to process an order for Lisinopril. • As they begin to process they notice a message in the drug field: No Dispense Drug Selected Pending OP Orders (ROUTINE) Jan 25, 2012 14:06:59 Page: 1 of 3 DEMO,ALLERGY CHARLES <A> PID: XXX-XX-5701 (HRN: 104836) Ht(cm): 170.18 (08/04/2011) DOB: NOV 2,1969 (42) Wt(kg): 76.05 (09/28/2003) + *(1) Orderable Item: LISINOPRIL TAB (2) Drug: No Dispense Drug Selected Verb: TAKE (3) *Dosage: 1 TABLET *Route: ORAL *Schedule: QDAY (4) Pat Instruct: FOR HIGH BLOOD PRESSURE Provider Comments: Instructions: TAKE 1 TABLET PO QDAY SIG: TAKE 1 TABLET BY MOUTH EVERY DAY FOR HIGH BLOOD PRESSURE (5) Patient Status: OUTPATIENT (6) Issue Date: JAN 25,2012 (7) Fill Date: JAN 25,2012 (8) Days Supply: 30 (9) QTY ( ): 30 Provider ordered 3 refills + Enter ?? for more actions BY Bypass DC Discontinue ED Edit FN Finish Select Item(s): Next Screen//

  32. Potential Solution:No Dispense Drug Selected • Check drug entry for correct doses (PDMDosagesEnter/edit dosages) • Check for both Possible Doses and Local Possible Doses: • setting both works in Pharmacy package but NOT in EHR • EHR will only see local doses if they are set • EHR will show possible doses if no local doses set • Check quick order: (BEHORDMNUQOC) • Matched to old agent? • Dose not selected from list?

  33. Local doses were set: • Select Dosages Option: enter/Edit Dosages • Select Drug: LISINOPRIL 10MG TAB CV800 00006-0952-58 • This entry is marked for the following PHARMACY packages: • Outpatient • Non-VA Med • LISINOPRIL 10MG TAB Inactive Date: • This drug has no Local Possible Dosages, do you want to create them? Y// Y YES • Setting Local Possible Dosages.. • Press Return to continue: • Strength: Unit: • Select LOCAL POSSIBLE DOSAGE: ? • Answer with LOCAL POSSIBLE DOSAGE • Choose from: • 1 TABLET IO • 2 TABLETS IO

  34. Possible Doses were set: • Select Drug: IBUPROFEN 400MG TAB MS102 N/F • This entry is marked for the following PHARMACY packages: • Outpatient • IBUPROFEN 400MG TAB *N/F* Inactive Date: • Strength from National Drug File match => 400 MG • Strength currently in the Drug File => 400 MG • Edit Strength? N// O • Strength => 400 Unit => MG • Select DISPENSE UNITS PER DOSE: ? • Answer with POSSIBLE DOSAGES DISPENSE UNITS PER DOSE • Choose from: • 1 400 IO • 2 800 IO • You may enter a new POSSIBLE DOSAGES, if you wish • Type a Number between 0 and 99999999, 4 Decimal Digits • Select DISPENSE UNITS PER DOSE:

  35. A Local dose in addition to Possible doses (must remove local possible dose): • Enter/Edit Local Possible Dosages? N// YES • Strength: 400 Unit: MG • Select LOCAL POSSIBLE DOSAGE: ? • Answer with LOCAL POSSIBLE DOSAGE: • 1-2 TABLETS IO • You may enter a new LOCAL POSSIBLE DOSAGE, if you wish • Answer must be 1-60 characters in length. • Select LOCAL POSSIBLE DOSAGE: 1-2 TABLETS IO • LOCAL POSSIBLE DOSAGE: 1-2 TABLETS// @ • SURE YOU WANT TO DELETE THE ENTIRE '1-2 TABLETS' LOCAL POSSIBLE DOSAGE? Y • (Yes) • Strength: 400 Unit: MG • Select LOCAL POSSIBLE DOSAGE:

  36. Check quick order: • Create/Modify Quick Orders • Select QUICK ORDER NAME: PSOZ LOSARTAN 50MG DAILY • NAME: PSOZ LOSARTAN 50MG DAILY Replace • DISPLAY TEXT: Losartan 50mg DAILY// • VERIFY ORDER: YES// • DESCRIPTION: • No existing text • Edit? NO// • Medication: LOSARTAN TAB // • Complex dose? NO// • Dose: 50MG// ? • Enter the dosage instructions for this order, as a dose or amount. • Dose: 50MG// • Route: ORAL// • Schedule: DAILY// • ACE FAILURE • Patient Instructions: FOR KIDNEY PROTECTION AND/OR BLOOD PRESSURE • Include Patient Instructions in Sig? YES//

  37. Chronic Med?// Days Supply: 30// Quantity (TAB): 30// Refills (0-11): 11// Pick Up: WINDOW// Priority: ROUTINE// Comments: Edit? No// (No) -------------------------------------------------------------- Medication: LOSARTAN TAB 50MG Dispense Drug: LOSARTAN K= 50MG TAB Instructions: 50MG ORAL DAILY Sig: TAKE ONE TABLET BY MOUTH DAILY Patient Instructions: FOR KIDNEY PROTECTION AND/OR BLOOD PRESS ... Days Supply: 30 Quantity (TAB): 30 Refills (0-11): 11 Pick Up: WINDOW Priority: ROUTINE Comments: --------------------------------------------------------------

  38. Issue:Provider Requested Refill Too Soon • Pharmacy is screening today’s orders in OERR when they notice that the provider put in a refill request for a patient who recently had this medication filled. • The pharmacist can not process it due to the 30 day billing policy – so the pharmacist asks you how can they cancel the request without changing the original order.

  39. Issue:Provider Requested Refill Too Soon Medication Profile Jan 25, 2012 14:35:08 Page: 1 of 1 DEMO,PATIENT ALONZO <A> PID: XXX-XX-5296 (HRN: 150321) Ht(cm): 172.72 (09/06/2002) DOB: AUG 2,1952 (59) Wt(kg): 106.36 (09/06/2002) SEX: MALE ISSUE LAST REF DAY -------------------------------------ACTIVE------------------------------------- 1 3498823 BB-LISINOPRIL 10MG TAB 30 A 12-26 01-10 11 30 ------------------------------------PENDING------------------------------------ 2 BB-LISINOPRIL 10MG TAB Refill Request Rx #: 3498823 Enter ?? for more actions PU Patient Record Update NO New Order PI Patient Information SO Select Order Select Action: Quit//

  40. Potential Solution: Provider Requested Refill Too Soon • At the “Select Action” prompt, type in “DC” and then choose the line item you need to discontinue. • Enter a comment, and use yourself as the requesting provider. • This discontinues the REQUEST only, and not the original ORDER.

  41. Potential Solution: Provider Requested Refill Too Soon Medication Profile Jan 25, 2012 14:35:08 Page: 1 of 1 DEMO,PATIENT ALONZO <A> PID: XXX-XX-5296 (HRN: 150321) Ht(cm): 172.72 (09/06/2002) DOB: AUG 2,1952 (59) Wt(kg): 106.36 (09/06/2002) SEX: MALE ISSUE LAST REF DAY -------------------------------------ACTIVE------------------------------------- 1 3498823 BB-LISINOPRIL 10MG TAB 30 A 12-26 01-10 11 30 ------------------------------------PENDING------------------------------------ 2 BB-LISINOPRIL 10MG TAB Refill Request Rx #: 3498823 Enter ?? for more actions PU Patient Record Update NO New Order PI Patient Information SO Select Order Select Action: Quit//DCDC Select Orders by number: (1-2): 2 Comments: TOO SOON TO FILL, LAST FILLED 1/10/2012 Nature of Order: SERVICE CORRECTION// S Requesting PROVIDER: NIESEN,MARY ANN PHARM D//

  42. Issue: Orders in EHR are not showing in the Pharmacy Package • A Pharmacist contacts you about orders in EHR that are not showing up in RPMS. They were not aware of any problems until patients started to present to pharmacy about the long wait for their prescriptions. • They don’t understand why the orders are not showing up in the pharmacy package and request your help in solving this mystery.

  43. Potential Solution: Orders in EHR are not showing in the Pharmacy Package • Look at the “CPRS ORDERING INSTITUTION” field in your Outpatient Pharmacy Site Parameters. • You may have a division that orders medications in EHR that the pharmacy package is not set-up to receive orders from.

  44. Issue:Inpatient sig codes are not expanding • The Pharmacist calls to report that the codes used to build the sig in the orders expands properly on the outpatient side but is NOT expanding on the inpatient side...for example, “BID” will show on the outpatient label as “two times each day” but still says “BID” on the inpatient MAR that was printed from RPMS. What is wrong?

  45. Issue:Inpatient sig codes are not expanding • This is intentional…expansion is needed on the outpatient side since these need to be “patient-friendly”. • Inpatient instructions will be used by other medical personnel, who should be familiar with the abbreviations used, and it will save space and prevent formatting issues on the printed MARs • Pharmacy package set up of these codes should take into account the “approved abbreviations” and/or “unapproved abbreviations” lists for the facility and medication safety organizations • Non-standard abbreviations should be avoided (e.g. “BTID” to mean “two to three times each day”)

  46. Issue: A new option shows in the orders tab called “Delayed Orders” • A User calls and states that “Delayed Orders” now shows at the top of the list of options on the orders tab…what is it? Can you move it to the bottom because I don’t like it there…

  47. Potential Solution: Delayed Orders • “Delayed Orders” is related to admissions, to allow the provider write orders that will not be active until the patient is actually admitted to the unit • It will always occupy the top position

  48. Issue: How do I view just the Discharge Medications in EHR? • The billing office calls stating they need to get a list of medications that only includes those ordered at discharge…how can they get such a list?

  49. Issue:How do I view JUST the discharge medications in EHR? • Users can customize the ORDER view to show only outpatient pharmacy orders from a certain date or date range

  50. Issue: Option to Finish as an IV is Missing DC Discontinue FL Flag ED Edit FN Finish Select Item(s): Next Screen// FN Finish COMPLETE THIS ORDER AS IV OR UNIT DOSE? IV// • The last prompt is missing for some orders.

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