Pharmacy Reengineering Update
August 2011
Amy K. Colón, R.Ph.Clinical Analyst, PBM
Michael J. Martinko, R.Ph.Clinical Analyst, PBM
PRE-MOCHAMedication Order Check Healthcare Application• MOCHA is the first increment of Pharmacy
Reengineering to be released to VAMCs• Data comes from a commercial database, First
DataBank (FDB), and from a VA Pharmacy Enterprise Customization System (PECS)– MOCHA 1 - Non-dosing, enhanced order checks– MOCHA 2 - Dosing checks
Types of Dosage Information
• Max single dose – this is the individual dose amount, whether it is given once a day or 24 times a day
• Total daily dose – Dose x Frequency (per 24h)• General Dosage Range – Is provided when
there is a problem with the order and dosage checks cannot be performed
Outpatient Single Dose Warning
Order details: Orderable Item: METFORMIN HCL TAB,ORAL Dosage Ordered: 3000 (MG) Dispense Units: 6 Noun: TABLETS Route: ORAL (BY MOUTH) Schedule: BID-WF
Dose warning text: METFORMIN HCL 500MG TAB: Single dose amount of 3000 MILLIGRAMS exceeds the maximum single dose amount of 1000 MILLIGRAMS.
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Dose Warning for Multi-Ingredient Drug
Order details: Orderable Item: CARBIDOPA/LEVODOPA TAB,SA Dosage Ordered: 5 TABLETS Route: ORAL (BY MOUTH) Schedule: TID SIG: TAKE 5 TABLETS BY MOUTH THREE TIMES DAILY
Dose warning text: CARBIDOPA 25/LEVODOPA 100MG TAB: Single dose form amount of 5 TABLET(S) exceeds the maximum single dose form amount of 2 TABLET(S).
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Dose Checks Calculations Dependent on Body Surface Area or Weight Data
Patient data: DOB: MAR 13,1944 (66) Ht(cm): 182.88 (12/04/2010) Wt(kg): 81.82 (12/04/2010)
Dose warning text: ENOXAPARIN 40MG/0.4ML INJ SYRINGE 0.4ML: Single dose amount of 400 MILLIGRAMS exceeds the maximum single dose amount of 129 MILLIGRAMS.
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Error Message for Dose Not PerformedOrder details: Orderable Item: METOPROLOL TAB Dosage Ordered: 500MG Route: ORAL (BY MOUTH) Schedule: Before sunrise SIG: TAKE TESTING DOSE TABLET(S) BY MOUTH TWICE A DAY
Dose warning text: Dosing Checks could not be performed for Drug: METOPROLOL SUCCINATE 100MG SA TAB Reason(s): Invalid or Undefined Frequency
General dosing range for METOPROLOL SUCCINATE 100MG SA TAB (ORAL): 12.5 MG/DAY to 400 MG/DAY
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Factors Used to Derive a Recommended Dose
• Patient Age• Height/Weight/BSA (when applicable)• Dose Form• Dose Unit• Medication Route• Frequency
Factor: Patient Age
• Recommended doses vary according to a patient’s age
• FDB stores dose data according to patient age• Doses are not always established and available
for a certain age, but this is more common with pediatric dosing than geriatric dosing
Factor: Patient Height, Weight, BSA
• Calculated doses for specific drugs are done when a weight or BSA value is relevant in the determination of an appropriate dose
• Some drug dosages are only weight/BSA dependent for specific age groups (i.e. weight may be relevant on a 90 year old, but not on a 50 year old
Factor: Dose Form
• Doses are stored differently based on the drug’s dosage form (i.e. oral, IV, transdermal)
• Some dosage forms are excluded from order checks (i.e. creams, ointments)
Factor: Dose Units• The dose unit on an order must either match
the unit that FDB has stored, or else be able to convert to that unit.
• If the dose unit does not match the FDB dose unit, then the order check will not occur and an error message will display
• FDB stores 2 different types of dose units intheir dosing table – “Mass type”units and “Dose form” type units
Sub-factor: Mass Type Dose Units• Generally used for single ingredient drugs
that are administered via po, SC, or IM • The most common type of dose unit (mg, gm,
units)• Possible types of FDB Dose Unit Conversions
• Metric conversions – wide range (i.e.. mcg to mg)• Numeric conversions between standard units and
metric units (i.e. Cm to In, Oz to Tsp, Tsp to mL, MMU to IU)
Sub-factor: Dose Form Type Dose Units• Dose form type units – Used for non-po solids
(patches, inhalers), multi-ingredient drugs• FDB selects the type of dose units for an item
• Patch dose unit is “ 1 patch”, rather than 75mcg• Inhaler dose units are variable and include
inhalations, sprays, puffs, etc. Currently, they sometimes also include metric doses.
• On the contrary, drug that dosage forms of suppositories or packets, are dosed in “mass type” units
Possible Dose Units Conversions• Metric conversions – wide range (i.e.. mcg to mg)• Numeric conversions between standard units and
metric units (i.e. Oz to Tsp, Tsp to mL, MMU to IU)• Non-metric allowable conversions:
• “EA” is a flexible term relating to the dose form. If dose form is packet, then “EA” is considered to be 1 unit of that dose form (i.e. EA to Packet)
• FDB has a limited capability to convert from one dose form type unit to another dose-form type unit (spray=inhalation=puff)
Non-Standard Doses• Fractional doses – no problem• Free-text doses – different assumptions in
CPRS vs. backdoor, because of the way that a dispense drug is selected in each package
• The pharmacy packages can perform some sophisticated auto-population logic for free-text doses (i.e. three and one-half tablets = 3.5 tablets). If a match cannot be determined, then no order check will be performed
Factor: Medication Route• If a medication route is not accurately
mapped, then a dose check will not occur• FDB Doses are tied to specific routes (IV vs
IM), error messages will display if an invalid route is selected
• Sometimes FDB is too limiting with its expected med route.
• Ie. Transdermal vs. Topical (Patches)• Ie. Nebulization vs. Inhalation (Albuterol Solution)
Factor: Frequency
• Used to calculate a total daily dose• If an order for a long acting injectable drug
is written with a schedule that is too frequent, then the user will be warned of the frequency issue.
• Two new fields were created in file 51.1• EXCLUDE FROM ALL DOSING CHECKS: • EXCLUDE FROM DAILY DOSE CHECK:
Dose Check Exclusions• Supplies (bandages, syringes)• Compounded items not matched to NDF• Large volume IV solutions• Items that don’t require a dose check, but that
have a dosage form that does generate checks• Drugs with excluded dosage forms (i.e.. creams,
ointments) but, the exclusion can be overridden at the NDF level
MOCHA 2 Preparation SummaryReview and update the following:
• Unmatched drug file entries• DEA/special handling field• Standard schedule file• Med route mappings• Orderable item medication route defaults for
potentially problematic dosage forms• Local possible doses
Guidance lists for FDB exceptions will be provided…
Inpatient Pharmacy Dosage Checks• Same factors as Outpatient (backdoor VistA or
CPRS order entry)– Patient age– Height/Weight/BSA (when applicable)– Dose form– Dose unit– Medication Route– Frequency– Duration– Rate
Inpatient Dosage Check Triggers (1)Note that the triggers for dosing are different than triggers for MOCHA v1.0
enhanced order checks• Entering a new IV or Unit Dose medication order through pharmacy options• Finishing a pending IV or Unit Dose medication order • Renewing an IV or Unit Dose order• Creating a new Unit Dose order when editing the orderable item (to a new
orderable item) through pharmacy options• When editing the IV additive fields (changing existing additive or adding new
additive) for an IV order through pharmacy options• When editing the IV solution fields (changing existing solution or adding a new
solution) for an IV order through pharmacy options -This applies only to IV solutions marked as a PreMix.
• Entering a new Unit Dose medication order through pharmacy options using order sets
Inpatient Dosage Check Triggers (2)• Editing the following for a Unit Dose order:
– Dosage Ordered– Units per Dose (for Dispense Drug)– Med Route– Schedule
• Editing the following for an IV order– Infusion rate (only applies to IV types of ‘Admixture’, ‘Hyperal’, ‘Chemotherapy
Admixture’, ‘Continuous Syringe’ or ‘Chemotherapy Continuous Syringe’)– Schedule (only applies to IV types of ‘Piggyback’, ‘Intermittent Syringe’,
‘Chemotherapy Piggyback’, or ‘Chemotherapy Intermittent Syringe’)– Med Route – Volume (does not apply to orders with IV types of ‘Piggyback’, ‘Intermittent
Syringe’, ‘Chemotherapy Piggyback’, or ‘Chemotherapy Intermittent Syringe’ with IV Solution not marked as PreMix)
Inpatient Order #1MJMTESTFRANK,SIX F Ward: C MEDIC PID: 666-66-6696 Room-Bed: 327-1 Ht(cm): 172.72 (03/24/10) DOB: 06/06/21 (90) Wt(kg): 60.45 (03/24/10) Sex: MALE Admitted: 03/24/10 Dx: ADVANCED PSYCHOSIS Last transferred: ******** - - - - - - - - - - - - - - - - - A C T I V E - - - - - - - - - - - - - - - - - 1 ASPIRIN TAB,EC C 06/28 07/28 A Give: 325MG PO QD-(EVERY DAY) - - - - - - - - - - - - - - - - P E N D I N G - - - - - - - - - - - - - - - - 2 LITHIUM CARBONATE CAP,ORAL ? ***** ***** P Give: 600MG PO BID-WF
Enter ?? for more actions PI Patient Information SO Select OrderPU Patient Record Update NO New Order EntrySelect Action: Quit//
Inpatient Order #1MJMTESTFRANK,SIX F Ward: C MEDIC PID: 666-66-6696 Room-Bed: 327-1 Ht(cm): 172.72 (03/24/10) DOB: 06/06/21 (90) Wt(kg): 60.45 (03/24/10) Sex: MALE Admitted: 03/24/10
*(1)Orderable Item: LITHIUM CARBONATE CAP,ORAL Instructions: 600MG *(2)Dosage Ordered: 600MG Duration: (3)Start: 07/13/11 14:22 *(4) Med Route: ORAL (BY MOUTH) REQUESTED START: 07/13/11 17:30 (5) Stop: 08/12/11 18:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: BID-WF (9) Admin Times: 0730-1730 *(10) Provider: MARTINKO,MICHAEL [es] (11) Special Instructions:(12) Dispense Drug U/D Inactive Date LITHIUM CARBONATE 300MG CAP 2
(7)Self Med: NO
Entry By: MARTINKO,MICHAEL Entry Date: 07/13/11 14:22
Inpatient Order #1CPRS Order Checks:
LITHIUM CARBONATE CAP,ORAL : Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Overriding Provider: MARTINKO,MICHAEL Overriding Reason: High Dose testing purposes MJM
ORDER NOT VERIFIED
Enter ?? for more actions BY Bypass FL FlagDC Discontinue FN FinishSelect Item(s): Quit//
Inpatient Order #1CPRS Order Checks:
LITHIUM CARBONATE CAP,ORAL : Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Overriding Provider: MARTINKO,MICHAEL Overriding Reason: High Dose testing purposes MJM
ORDER NOT VERIFIED
Enter ?? for more actions BY Bypass FL FlagDC Discontinue FN Finish
Select Item(s): Quit// FN Finish
Inpatient Order #1CPRS Order Checks:
LITHIUM CARBONATE CAP,ORAL : Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Overriding Provider: MARTINKO,MICHAEL Overriding Reason: High Dose testing purposes MJM
ORDER NOT VERIFIED
Enter ?? for more actions BY Bypass FL FlagDC Discontinue FN FinishSelect Item(s): Quit// FN Finish
Now Processing Enhanced Order Checks! Please wait...
Press Return to continue...
Inpatient Order #1CPRS Order Checks:
LITHIUM CARBONATE CAP,ORAL : Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Overriding Provider: MARTINKO,MICHAEL Overriding Reason: High Dose testing purposes MJM
ORDER NOT VERIFIED
Enter ?? for more actions BY Bypass FL FlagDC Discontinue FN FinishSelect Item(s): Quit// FN Finish
Now Processing Enhanced Order Checks! Please wait...
Press Return to continue...
LITHIUM CARBONATE 300MG CAP: Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS.
Do you want to Continue? NO//
Inpatient Order #1CPRS Order Checks:
LITHIUM CARBONATE CAP,ORAL : Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS. Overriding Provider: MARTINKO,MICHAEL Overriding Reason: High Dose testing purposes MJM
ORDER NOT VERIFIED
Enter ?? for more actions BY Bypass FL FlagDC Discontinue FN FinishSelect Item(s): Quit// FN Finish
Now Processing Enhanced Order Checks! Please wait...
Press Return to continue...
LITHIUM CARBONATE 300MG CAP: Single dose amount of 600 MILLIGRAMS exceeds the maximum single dose amount of 300 MILLIGRAMS.
Do you want to Continue? NO// YES
Inpatient Order #1Do you want to Continue? NO// YES
Now creating Pharmacy InterventionFor LITHIUM CARBONATE 300MG CAP
PROVIDER:
Inpatient Order #1Do you want to Continue? NO// YES
Now creating Pharmacy InterventionFor LITHIUM CARBONATE 300MG CAP
PROVIDER: PROVIDER: MARTINKO,MICHAEL MJM 192 OI&T STAFFRECOMMENDATION: NO CHANGE
See 'Pharmacy Intervention Menu' if you want to delete thisintervention or for more options.
Would you like to edit this intervention? N// YESPROVIDER: MARTINKO,MICHAEL// PHARMACIST: MARTINKO,MICHAEL// DRUG: LITHIUM CARBONATE 300MG CAP// INSTITUTED BY: PHARMACY// INTERVENTION: MAX SINGLE DOSE// <<<<<<<<<<<<<<<<<< DOSE// <<<<<
Inpatient Order #2MJMTESTFRANK,SIX F Ward: C MEDIC PID: 666-66-6696 Room-Bed: 327-1 Ht(cm): 172.72 (03/24/10) DOB: 06/06/21 (90) Wt(kg): 60.45 (03/24/10) Sex: MALE Admitted: 03/24/10 Dx: ADVANCED PSYCHOSIS Last transferred: ******** - - - - - - - - - - - - - - - - - A C T I V E - - - - - - - - - - - - - - - - - 1 ASPIRIN TAB,EC C 06/28 07/28 A Give: 325MG PO QD-(EVERY DAY) - - - - - - - - - - - - - - - - P E N D I N G - - - - - - - - - - - - - - - - 2 in NITROGLYCERIN 25MG/D5W 250 ML TITRATE ? ***** ***** P
Enter ?? for more actions PI Patient Information SO Select OrderPU Patient Record Update NO New Order EntrySelect Action: Quit//
Inpatient Order #2MJMTESTFRANK,SIX F Ward: C MEDIC PID: 666-66-6696 Room-Bed: 327-1 Ht(cm): 172.72 (03/24/10) DOB: 06/06/21 (90) Wt(kg): 60.45 (03/24/10) Sex: MALE Admitted: 03/24/10*(1) Additives: Type: ADMIXTURE *(2) Solutions: NITROGLYCERIN 25MG/D5W 250 ML IV Limit: 3 days (4) Start: 07/14/11 10:42 *(3) Infusion Rate: TITRATE@1 *(5) Med Route: IV (6) Stop: 07/17/11 24:00 *(7) Schedule: Last Fill: ******** (8) Admin Times: Quantity: 0 *(9) Provider: MARTINKO,MICHAEL [es] Cum. Doses: (10) Other Print:
(11) Remarks : IV Room: CHEYENNE RM#272 Entry By: MARTINKO,MICHAEL Entry Date: 07/14/11 10:42
DC Discontinue FL FlagED Edit FN FinishSelect Item(s): Next Screen//
Inpatient Order #2CPRS Order Checks : Maximum Single Dose Check could not be done for Drug: NITROGLYCERIN 25MG/D5W INJ,SOLN 250 ML, please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL
Enter ?? for more actions DC Discontinue FL FlagED Edit FN FinishSelect Item(s): Quit//
Inpatient Order #2CPRS Order Checks : Maximum Single Dose Check could not be done for Drug: NITROGLYCERIN 25MG/D5W INJ,SOLN 250 ML, please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL
Enter ?? for more actions DC Discontinue FL FlagED Edit FN FinishSelect Item(s): Quit// FN Finish IV TYPE: ADMIXTURE// Select ADDITIVE:
Inpatient Order #2CPRS Order Checks : Maximum Single Dose Check could not be done for Drug: NITROGLYCERIN 25MG/D5W INJ,SOLN 250 ML, please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL
Enter ?? for more actions DC Discontinue FL FlagED Edit FN FinishSelect Item(s): Quit// FN Finish IV TYPE: ADMIXTURE// Select ADDITIVE:
Now Processing Enhanced Order Checks! Please wait...
Press Return to continue...
Inpatient Order #2CPRS Order Checks : Maximum Single Dose Check could not be done for Drug: NITROGLYCERIN 25MG/D5W INJ,SOLN 250 ML, please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL
Enter ?? for more actions DC Discontinue FL FlagED Edit FN FinishSelect Item(s): Quit// FN Finish IV TYPE: ADMIXTURE// Select ADDITIVE:
Now Processing Enhanced Order Checks! Please wait...
Press Return to continue...
Maximum Single Dose Check could not be performed for Drug: NITROGLYCERIN25MG/D5W 250 ML Reason: Unable to convert rate.
Press Return to continue...
Inpatient Order #3CPRS Order Checks:
Maximum Single Dose Check could not be done for Drug: ACETAMINOPHEN/CODEINE ELIXIR , please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL
BY Bypass FL FlagDC Discontinue FN FinishSelect Item(s): Quit//
Inpatient Order #3CPRS Order Checks:
Maximum Single Dose Check could not be done for Drug: ACETAMINOPHEN/CODEINE ELIXIR , please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL
BY Bypass FL FlagDC Discontinue FN FinishSelect Item(s): Quit// FN Finish
PLEASE NOTE: This order must have at least one DISPENSE DRUG before it can be finished.
CHOOSE FROM: 1. CODEINE 12/ACET 120MG/5ML ELIX 120ML 2. ACETAM/CODEINE 120/12MG 5ML SOLN (ML)
Select DISPENSE DRUG(S) for this order:
Inpatient Order #3CPRS Order Checks:
Maximum Single Dose Check could not be done for Drug: ACETAMINOPHEN/CODEINE ELIXIR , please complete a manual check for appropriate Dosing. Overriding Provider: MARTINKO,MICHAEL
BY Bypass FL FlagDC Discontinue FN FinishSelect Item(s): Quit// FN Finish
PLEASE NOTE: This order must have at least one DISPENSE DRUG before it can be finished.
CHOOSE FROM: 1. CODEINE 12/ACET 120MG/5ML ELIX 120ML 2. ACETAM/CODEINE 120/12MG 5ML SOLN (ML)
Select DISPENSE DRUG(S) for this order: 1
CODEINE 12/ACET 120MG/5ML ELIX 120ML: Single dose form amount of 30 MILLILITERS exceeds the maximum single dose form amount of 25 MILLILITERS.
Inpatient Order #5Select DRUG: SIMVASTAT SIMVASTATIN 20MG TAB CV350 VISN RESTR *** AUTOMED & SCRIPTPRO *** Now Processing Enhanced Order Checks! Please wait...
Press Return to continue...
Available Dosage(s) 1. 20MG 2. 40MG
Select from list of Available Dosages or Enter Free Text Dose: 5 TABLETS <<<<<<<<<<<<
Inpatient Order #5Select DRUG: SIMVASTAT SIMVASTATIN 20MG TAB CV350 VISN RESTR *** AUTOMED & SCRIPTPRO *** Now Processing Enhanced Order Checks! Please wait...
Press Return to continue...
Available Dosage(s) 1. 20MG 2. 40MG
Select from list of Available Dosages or Enter Free Text Dose: 5 TABLETS
Select Item(s): Next Screen// AC ACCEPT
SIMVASTATIN 20MG TAB: Single dose form amount of 5 TABLET(S) exceeds the maximum single dose form amount of 2 TABLET(S).
Do you want to Continue? NO//
MOCHA v2Drug Dosing Order Checks
MOCHA v2.0 Incremental Delivery
Increment A - Maximum Single Dose Check Warning
Increment B - Daily Dose Range Check Warning
Increment C - Daily Dose Range Check Complex
Increment D - TBD
MOCHA v2 ScheduleApr Jun Aug Oct Dec Feb Apr Jun Aug
2011
Oct
iA - Max Single Dose Check Warning
iB - Daily Dose Range Check Warning Simple
iC- Daily Dose Range Check Warning Complex
Nov 1 National Release
March 31 National Release
Aug 31 National Release
2012
‘Frequently Asked Questions’Document
Based on PRE test site experiences…
• A Frequently Asked Questions (FAQ) document was prepared and disseminated prior to MOCHA v1.0 release.
• There are plans to create similar documents for MOCHA v2.0 releases.
Product Effectiveness Team
• PBM is working with the VHA Office of Health Information’s Product Effectiveness group to support the Pharmacy Reengineering (PRE) Medication Order Check Healthcare Application (MOCHA) v2.0.
• As part of this support, Product Effectiveness is conducting an operational readiness assessment to ensure each respective medical center is ready to receive MOCHA v2.0.
• The Product Effectiveness team will also be gathering lessons learned around these operational readiness assessments and MOCHA v2.0 activities in order to support future site deployments.
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