mocha enhancements looking toward the horizon presented by amy k. colón, r.ph. michael j. martinko,...

MOCHA EnhancementsLooking Toward the HorizonPresented by

Amy K. Colón, R.Ph.Michael J. Martinko, R.Ph.

JUNE 27. 2012

VETERANS HEALTH ADMINISTRATION

MOCHA 1.0 Enhancements Increment 1

• Contains enhancements and fixes to issues that were reported through testing Pharmacy Reengineering (PRE) MEDICATION ORDER CHECK HEALTHCARE APPLICATION (MOCHA) 1.0.

• Will be released in a set of 5 patches PSJ*5*260, PSJ*5*268, PSO*7*390, PSS*1*164, and PSS*1*169

• Work is being done concurrently with MOCHA V. 2.0 by a separate team of developers and test sites

• Release is expected to occur Summer 2012• No additional hardware is required• Changes affect both the inpatient and outpatient pharmacy packages• Increment 2 is currently in the midst of a 6 month development period

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• Displays additional fields to the Drug-Allergy order check warnings– Historical/Observed, Severity, Signs/Symptoms

A Drug-Allergy Reaction exists for this medication and/or class! Prospective Drug: AMOXICILLIN 250MG CAP Causative Agent: PENICILLIN Historical/Observed: OBSERVED Severity: SEVERE Signs/Symptoms: ANAPHYLAXIS Drug Class: AM110 PENICILLIN-G RELATED PENICILLINS (LOCAL) Provider Override Reason: NOT READING ORDER CHECKS TODAY

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• Stores Drug –Allergy order check details with the applicable order

Select Item(s): Next Screen// DA Display Drug Allergies Drug Allergy Occurrence Event for Rx#: 2055124 Causative Agent: ERYTHROMYCINHistorical/Observed: OBSERVED Severity: MODERATE Ingredient: ERYTHROMYCIN Signs/Symptoms: DIARRHEA, NAUSEA AND VOMITING Drug Class: AM200 ERYTHROMYCINS/MACROLIDESProvider Override Reason: OK TO GIVE, DISCUSSED WITH PATIENT

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• Adds a field on the patient medication profile header for display of CRCL and BSA, when available

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Patient Information May 09, 2012@12:03:19 Page: 1 of 1 Name: Ward: PID: Room-Bed:

Ht(cm): DOB:

Wt(kg): Sex:

Admitted: Dx: Heart Ache Last transferred:

******** CrCL: 117.6(est.) (CREAT:1.0mg/dL 2/26/12) BSA (m2): 2.04



• Provides an option on the medication profile to allow a user to check for drug-drug interactions and allergies before the drug is entered for that patient

• Help Text:– “The following list of order checks is a comprehensive report of all

Outpatient, Non-VA, and Clinic medication orders on this patient's profile.It may include orders that are local, remote, active, pending, recentlydiscontinued, or expired. Please note that the sort order and formatdisplayed in this report differs from the display of MOCHA 1.0 orderchecks which occurs during order processing.”

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• Sample of hidden option “DX Check Interactions”

Drug: ERYTHROMYCIN STEARATE 250MG TAB

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*** DRUG INTERACTION(S) ***============================================================

***Critical*** with WARFARIN (COUMADIN) NA 5MG (PEACH) TAB and ERYTHROMYCIN STEARATE 250MG TAB

CLINICAL EFFECTS: Concurrent use of a macrolide antibiotic may result in increased effects of the anticoagulant with possible elevated INR and/or bleeding.=============================================================



• Provides an option independent of a patient profile which checks drug interactions on 2 or more meds. The option is placed on each of these menus:

– PDM Manager Menu, Outpatient Pharmacy Manager Menu, Pharmacist Menu, Unit Dose Medications Menu, and IV Menu

Check Drug InteractionDrug 1: SELEGILINE HCL 5MG Drug 2: FLUOXETINE HCL 20MG CAP Drug 3:Now Processing Enhanced Order Checks! Please wait...*** DRUG INTERACTION(S) *** ***Critical*** with FLUOXETINE HCL 20MG CAP and SELEGILINE HCL 5MG CAP

CLINICAL EFFECTS: Concurrent use...8



• Simplifies the prompts seen in Inpatient Pharmacy, when a therapeutic duplication message allows an existing order to be discontinued

This patient is already receiving the following INPATIENT and/or OUTPATIENT order(s) for a drug in the same therapeutic class(es) as FLUOXETINE 20MG CAP: ClomiPRAMINE HCL CAP,ORAL C 05/09 06/08 A Give: 25MG PO QHS (BEDTIME)Class(es) Involved in Therapeutic Duplication(s): Antidepressants ======================================================================Do you wish to continue with the current order? YES//

ClomiPRAMINE HCL CAP,ORAL C 05/09 06/08 A Give: 25MG PO QHS (BEDTIME)

Enter DC to discontinue the above order or press <RETURN> to continue:

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• Provides order checks against IMO Clinic Orders in the Inpatient pharmacy. This will include recently discontinued and/or expired clinic orders that have a stop date within the last 90 days.

Unit Dose Example:======================================================================This patient is already receiving the following INPATIENT and/or OUTPATIENTorder(s) for a drug in the same therapeutic class(es) as RISPERIDONE 50MG INJ SA 50MG/ML INJ : Clinic Order: RISPERIDONE 25MG INJ SA(DISCONTINUED) Schedule: Q30D Dosage: 25MG Start Date: JUN 7, 2012@13:00 Stop Date: JUN 15, 2012@15:22:27

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• Decouples the automated dispensing machine interface calls from the current Inpatient Medication (IP) package routines.– The beneficiaries of this enhancement will be the IRM departments of

sites with interfaces for inpatient automated dispensing machines – These sites will not have to recreate local medications for numerous

routines whenever PRE releases new versions of these routines• Adds order checks to the verification process when verification is being

done as a separate (re-entry of patient record) function from order acceptance

• Adds new report in the PEPS Services option to list the Vendor Interface unavailable times

• Provides the ability to print the ‘Check PEPS Services Setup’ messages

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Introduction to MOCHA 2.0 Functionality

• MOCHA V. 2.0 uses the same interface to First Databank (FDB) as MOCHA V. 1.0.

• MOCHA V. 2.0 implements the first increment of dosage checks• Maximum Single Dose Checks for simple and complex orders are

introduced for both Outpatient Pharmacy and Inpatient Medications applications.

Text of Single Dose Warning Message: METFORMIN HCL 500MG TAB: Single dose amount of 3000 MILLIGRAMS exceeds the maximum single dose amount of 1000 MILLIGRAMS.

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MOCHA 2.0 Functionality

• In the pharmacy packages, when a Maximum Single Dose Order Check cannot be performed, then a detailed Order Level Error Messages (with reasons ) is provided

Maximum Single Dose Check could not be performed for Drug: LOMUSTINE100MG CAP Reason: Body surface area required

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• In CPRS, when a Maximum Single Dose Order Check cannot be performed, then a generic Order Level notice is provided

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• Creates a new Pharmacy Data Management (PDM) option called Lookup Dosing Check Info for Drug so that a user can view all data that can affect dosing checks for a drug. The screen shot is abbreviated to fit this slide.

WARFARIN (COUMADIN) NA 1MG (PINK) TAB (GCNSEQNO: 014198)==========================================================================VA PRODUCT NAME: WARFARIN NA 1MG TABNDF DOSAGE FORM: TABDEA, SPECIAL HDLG: 6PR VA DRUG CLASS: BL110EXCLUDE DOSAGE FORM FROM DOSAGE CHECKS: NOOVERRIDE DOSAGE FORM DOSE CHECK EXCLUSION FOR VA PRODUCT: NO ***DRUG ELIGIBLE FOR DOSAGE CHECKS***

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MOCHA 2.0 Functionality Lookup Dosing Check Info for Drug

(Continued)

Strength: 1 Unit: MGPOSSIBLE DOSAGES: DISPENSE UNITS PER DOSE: 1 DOSE: 1MG PACKAGE: IO BCMA UNITS PER DOSE: FDB ROUTES: ORALFDB DOSE UNITS: EA, MGBSA REQUIRED FOR DOSAGE CHECKS: NOWEIGHT REQUIRED FOR DOSAGE CHECKS: YES for Age in Days: 0-4744 (ORAL) 30-4744 NO for Age in Days: 23725-40150 (ORAL) 6570-23724 (ORAL) 4745-6569 (ORAL) 6570-23725 23726-40150

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How Dosage Checks are Excluded

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Dosage Form Field – EXCLUDE FROM DOSAGE CHECKS

VA Product Field – OVERRIDE DF DOSE CHK EXCLUSION

Dosage Check Performed? (Y/N)

Yes No No

Yes Yes Yes

No No Yes

No Yes No

• No dosing checks will be performed on supply items.• No dosing checks will be performed on items with excluded dosage forms, unless an individual override is set at the product level• Conversely, dosing checks will be performed on items with dosage forms that are marked for dosing checks, unless and individual exclusion is set at the product level


MOCHA 2.0 Specifics

• Dosage checks occur after all enhanced order checks (clozapine, allergy, aminoglycosides, dangerous meds for patients >64, metformin lab results, drug level errors, local and remote drug interactions, local and remote duplicate therapy)

• If a dosage check cannot be done, then an order level error message occurs after all other enhanced order checks

• If a dosage is within range, then no dose message will appear• The most recent values for height and weight found in the VITALS

application are used to calculate the BSA in m2 for a patient

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Data Required for Dose Checks to be Performed

• Patient Parameters: (Age, Weight and Body Surface Area (BSA in m2)• Drug• Single Dose Amount• Dose Unit (FDB Equivalent)• Dose Rate Unit• Dose Route (FDB Equivalent)• Dose Type• Frequency• Duration• Duration Rate

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How FDB Interprets Possible Doses

Dosage Single Dose Dose Unit FDB Dose UnitOrdered Amount=====================================================325MG 325 MG MILLIGRAMS0.5GM 0.5 GM GRAMS

1 TABLET 1 TABLET(S) TABLET(S) 20MEQ 20 MEQ MILLIEQUIVALENTS10ML 10 ML MILLILITERS

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How FDB Interprets Doses for Solutions Marked as Premixes

IV Type Volume Infusion Drug Single Dose FDB Dose

Rate Unit Amount Unit

========================================================Piggyback 20 ML 20 MILLILITERSAdmixture 125 ML 125 MILLILITERS

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How FDB interprets Local Possible Doses for Single Ingredient Products

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Further Commentary on FDB Dose Units

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How FDB interprets Local Possible Doses for Multi Ingredient Products

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How FDB interprets Dosages for Continuous IVs

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MOCHA Credits

by Lina Bertuzis

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Portions of the previous MOCHA 2.0 slides were excerpted from documentation prepared by Lina Bertuzis. Lina’s PRE team work is largely done behind the scenes. She is extremely talented at defining pharmacy functionality and has written a requirements document that is greater than 700 pages in length.

Many thanks to Lina!


Comparing Enhanced & Dosing Order ChecksEnhanced Order Checks (MOCHA v1.0)

• MOCHA v1.0 enhanced order checks consist of duplicate drug, therapeutic duplication, and drug interaction order checks based on FDB data.

• Usually occur after a dispense drug or orderable item have been identified.

• A message is displayed before the order checks occur:Now Processing Enhanced Order Checks! Please Wait...

• Order checks can be triggered by:– New order entry via backdoor pharmacy options– Finishing a pending order– Renewing an order– Copying an order– Editing an order which results in creation of a new order– Reinstating an order

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Comparing Enhanced & Dosing Order ChecksDosing Order Checks (MOCHA v2.0)

• MOCHA v2.0 dosing order checks will consist of a maximum single dose order check based on the patients demographics (age, weight, body surface area) pertinent to that medication.

• Dosing order checks will have some differences from the enhanced order checks.

• In CPRS will be displayed along with enhanced order checks.• In backdoor pharmacy will occur AFTER the enhanced order checks, many

times after the “accept” prompt.• NO message is displayed before the dosing order checks occur. If no dose

warning or error message is displayed (dosage entered is within normal limits), the order check is invisible to the user.

• Dosing checks have different triggers than the enhanced order checks.

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Comparing Enhanced & Dosing Order ChecksDosing Order Checks (MOCHA v2.0)

• Dosing order checks are generated by all of the actions that trigger the enhanced order checks, PLUS:

• 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)

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Examples of Dosing Order ChecksDosing Order Checks (MOCHA v2.0)

• Dosing examples will be created utilizing a 75 year old female test patient with a height of 71 inches (180.3cm) a weight of 206.5 lb (93.7 kg) and a calculated body surface area (BSA) of 2.14 (using the system’s Dubois formula).

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Examples of Dosing Order ChecksCPRS Dosing Order Checks (MOCHA v2.0) Example #1

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• Entering an inpatient medication order for lisinopril 80mg.



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• A dosing warning message is displayed.



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• Entering an inpatient medication order for lithium carbonate 600mg.



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• A drug interaction warning message and a dosing warning message are displayed.


Examples of Dosing Order ChecksCPRS Dosing Order Checks (MOCHA v2.0) response required

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Examples of Dosing Order ChecksBackdoor Pharmacy Dosing Order Checks (MOCHA v2.0)

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XXXXXXXXXXXXXXXXXXXXX Ward: C MEDIC D PID: 999-99-9999 Room-Bed: XXXXX Ht(cm): 180.34 (00/00/00) DOB: 00/00/00 (75) Wt(kg): 93.86 (00/00/00) Sex: MALE Admitted: 00/00/00 Dx: PHLEBITIS/ STABLE Last transferred: ******** - - - - - - - - - - - - - - - - P E N D I N G - - - - - - - - - - - - - - - - 1 LISINOPRIL TAB ? ***** ***** P Give: 80MG PO QD-(EVERY DAY) 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//



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*(1)Orderable Item: LISINOPRIL TAB <DIN> Instructions: 80MG *(2)Dosage Ordered: 80MG Duration: (3)Start: 04/23/12 14:03 *(4) Med Route: ORAL (BY MOUTH) REQUESTED START: 04/24/12 09:00 (5) Stop: 05/23/12 18:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: QD-(EVERY DAY) (9) Admin Times: 09 *(10) Provider: XXXXXXXXXXXX [es] (11) Special Instructions:

(12) Dispense Drug U/D Inactive Date LISINOPRIL 40MG TAB 2

+ Enter ?? for more actions BY Bypass FL FlagDC Discontinue FN FinishSelect Item(s): Next Screen//



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CPRS Order Checks:

LISINOPRIL 40MG TAB: Single dose amount of 80 MILLIGRAMS exceeds the maximum single dose amount of 40 MILLIGRAMS. Overriding Provider: XXXXXXXXXXX Overriding Reason: these are the provider comments

SIGNIFICANT drug-drug interaction: LISINOPRIL 40MG TAB and LITHIUM CARBONATE 300MG CAP [UNRELEASED] - Concurrent use of ACE inhibitors or ARBs may result in elevated lithium levels and lithium toxicity. - Monograph Available Overriding Provider: XXXXXXXXXXXX

ORDER NOT VERIFIED Enter ?? for more actions BY Bypass FL FlagDC Discontinue FN FinishSelect Item(s): Quit// FN Finish



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Now Processing Enhanced Order Checks! Please wait...================================================================================This patient is receiving the following order(s) that have a SIGNIFICANT DrugInteraction with LISINOPRIL 40MG TAB:

LITHIUM CARBONATE CAP,ORAL ? ***** ***** P Give: 600MG PO BID-WF

*** REFER TO MONOGRAPH FOR SIGNIFICANT INTERACTION CLINICAL EFFECTS================================================================================

Display Professional Interaction Monograph(s)? NO//



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Do you want to Intervene with LISINOPRIL 40MG TAB? NO//



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Do you want to Intervene with LISINOPRIL 40MG TAB? NO// NO



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LISINOPRIL 40MG TAB: Single dose amount of 80 MILLIGRAMS exceeds the maximum single dose amount of 40 MILLIGRAMS.

Do you want to Continue? NO//



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Do you want to Continue? NO// YES

Now creating Pharmacy InterventionFor LISINOPRIL 40MG TAB

PROVIDER:



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PROVIDER: PROVIDER: XXXXXXXXXXXXRECOMMENDATION: 8 NO CHANGE

See 'Pharmacy Intervention Menu' if you want to delete thisintervention or for more options.

Would you like to edit this intervention? N// O



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XXXXXXXXXXXXXXXXXXXXX Ward: C MEDIC D PID: 999-99-9999 Room-Bed: XXXXX Ht(cm): 180.34 (00/00/00) DOB: 00/00/00 (75) Wt(kg): 93.86 (00/00/00) *(1)Orderable Item: LISINOPRIL TAB <OCI><DIN> Instructions: 80MG *(2)Dosage Ordered: 80MG Duration: (3)Start: 04/23/12 14:03 *(4) Med Route: ORAL (BY MOUTH) REQUESTED START: 04/24/12 09:00 (5) Stop: 05/23/12 18:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: QD-(EVERY DAY) (9) Admin Times: 09 *(10) Provider: XXXXXXXXXXXX [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date LISINOPRIL 40MG TAB 2

ED Edit AC ACCEPTSelect Item(s): Next Screen//



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*(1)Orderable Item: LISINOPRIL TAB <OCI><DIN> Instructions: 80MG *(2)Dosage Ordered: 80MG Duration: (3)Start: 04/23/12 14:03 *(4) Med Route: ORAL (BY MOUTH) REQUESTED START: 04/24/12 09:00 (5) Stop: 05/23/12 18:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: QD-(EVERY DAY) (9) Admin Times: 09 *(10) Provider: XXXXXXXXXXXX [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date LISINOPRIL 40MG TAB 2

ED Edit AC ACCEPTSelect Item(s): Next Screen// 8 Order Check Overrides/Interventions exist for this order. Display? (Y/N)? Y//



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*(1)Orderable Item: LISINOPRIL TAB <OCI><DIN> Instructions: 80MG *(2)Dosage Ordered: 80MG Duration: (3)Start: 04/23/12 14:03 *(4) Med Route: ORAL (BY MOUTH) REQUESTED START: 04/24/12 09:00 (5) Stop: 05/23/12 18:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: QD-(EVERY DAY) (9) Admin Times: 09 *(10) Provider: XXXXXXXXXXXX [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date LISINOPRIL 40MG TAB 2

ED Edit AC ACCEPTSelect Item(s): Next Screen// 8 Order Check Overrides/Interventions exist for this order. Display? (Y/N)? Y// NO SCHEDULE: QD-(EVERY DAY)// Q4H 01-05-09-13-17-21NOTE: This change in schedule also changes the ADMIN TIMES and SCHEDULE TYPE. Enter RETURN to continue or '^' to exit:



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XXXXXXXXXXXXXXXXXXXXX Ward: C MEDIC D PID: 999-99-9999 Room-Bed: XXXXX Ht(cm): 180.34 (00/00/00) DOB: 00/00/00 (75) Wt(kg): 93.86 (00/00/00) *(1)Orderable Item: LISINOPRIL TAB <OCI><DIN> Instructions: 80MG *(2)Dosage Ordered: 80MG Duration: (3)Start: 04/23/12 14:03 *(4) Med Route: ORAL (BY MOUTH) REQUESTED START: 04/24/12 09:00 (5) Stop: 05/23/12 18:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: Q4H (9) Admin Times: 01-05-09-13-17-21 *(10) Provider: XXXXXXXXXXXX [es] (11) Special Instructions:

(12) Dispense Drug U/D Inactive Date LISINOPRIL 40MG TAB 2 + This change will cause a new order to be created. ED Edit AC ACCEPTSelect Item(s): Next Screen//



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Do you want to Continue? NO//



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PROVIDER:



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PROVIDER: XXXXXXXXXXXXRECOMMENDATION: NO CHANGE

See 'Pharmacy Intervention Menu' if you want to delete thisintervention or for more options.

Would you like to edit this intervention? N// O

NATURE OF ORDER: SERVICE CORRECTION// S...discontinuing original order...

...creating new order...(you will now work on this new order).



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XXXXXXXXXXXXXXXXXXXXX Ward: C MEDIC D PID: 999-99-9999 Room-Bed: XXXXX Ht(cm): 180.34 (00/00/00) DOB: 00/00/00 (75) Wt(kg): 93.86 (00/00/00) *(1)Orderable Item: LISINOPRIL TAB <DIN> Instructions: *(2)Dosage Ordered: 80MG Duration: (3)Start: 04/23/12 14:03 *(4) Med Route: ORAL (BY MOUTH) (5) Stop: 05/23/12 18:00 (6) Schedule Type: CONTINUOUS *(8) Schedule: Q4H (9) Admin Times: 01-05-09-13-17-21 *(10) Provider: XXXXXXXXXXXX [es] (11) Special Instructions: (12) Dispense Drug U/D Inactive Date LISINOPRIL 40MG TAB 2 + Enter ?? for more actions HD (Hold) RN (Renew)FL Flag VF VerifySelect Item(s): Next Screen//


Key Ingredients for Successful Dosing ChecksStaying away from dosing error messages

• Site file set up plays a critical role in successful dosing checks.– Dose units file, local possible doses, correct default medication routes,

matched medication routes and drug file entries. • See previous presentation “Site Readiness for MOCHA drug dose package”

by Jim Hewins & Dionne Roney for file set up hints and FAQs• A FAQ document is being prepared and will be circulated before

implementation.53


MOCHA v2.0 ImplementationLessons Learned from the MOCHA v1.0 Roll Out

• MOCHA v2.0 dosing order checks will be “rolled out” instead of one set implementation date.

• System performance and network traffic predicted & monitored before release– Server monitoring software applications in place

• System performance monitored during rollout• Functionality emergency back-out strategy• Pre-implementation participation of the VHA Office of Health

Information’s Product Effectiveness group – Interviews documenting MOCHA v1.0 implementation results– Creating a site operational readiness assessment– Available to support future site deployments

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Release Date & Implementation ScheduleDosing Order Checks (MOCHA v2.0)

• MOCHA v2.0 maximum single dose order check functionality – Training schedule– Release date– Implementation schedule

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Dosing Order Checks Beyond MOCHA v2.0 Future Proposed Dosing Releases

• MOCHA v2.0

• MOCHA Dosing UFT-2



• Maximum Single Dose Order Checks

• Maximum Daily Dose Range Order Checks (simple orders only)

• Maximum Daily Dose Range Order Checks (complex orders)

• Enhancements to previous increments

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MOCHA EnhancementsLooking Toward the Horizon

Questions or Comments?57

mocha enhancements looking toward the horizon presented by amy k. colón, r.ph. michael j. martinko,...

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