The Pert - 3q95 Pages 5 & 6

3Q95 Pages 5 & 6

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The second non-client SMS Pharmacy Corporate Education Class is scheduled for the week of September 18th. The Pharmacy Tools Class is set for the week of September 26th. The Tools Class will be open for clients and will include the following topics: Overview of Day End, File Editor, Printer Utilities and DAS Reporting.
Roger Braun and I have been on site at North Shore Medical Center in Salem, Massachusetts beta testing and QAing the SMS Pharmacy to INVISION Med/IV Orders interface. While QAing the interface, we are also providing feedback to Development and gaining implementation experience for future installs. Development recently delivered Phase 1b of the interface software for testing. Doug Kent in Product Planning released the tentative schedule for the SMS Pharmacy Med/IV Orders interface project:

Phase 1 (8/7/95): Basic Med/IV Orders inbound to INVISION:

Enter Verified Order

Cancel Order

Discontinue Order

Revise Order (Using DC/Enter Order)

Renew Order (Using Enter Order)

Resend Order

Alternating IV and TPN

Outpatient IV

Phase 2: (12/11/95): Expanded Med/IV Orders inbound to INVISION:

Shift IV

Refill Order

Enter Unverified Order

Revise Order

Verify Order

Hold/Resume Order

Process Occurrences (Cancel Occurrence)

Message Override Notification

Rx Notes

Phase 3: (3/23/96): Med/IV Orders outbound to SMS Pharmacy, plus these additional functions:

Review Order

Misc Charge/Credit

Process Occurrences (for Charge on Chart)

Rx Notes

Complex Med Processing

Allergy Processing

Phase 4: (TBD): SMS Pharmacy Drug Master/ INVISION Service Master interface and support of NDDF Master Tables.

All dates above are subject to change. No GA date has been set for any of the phases.

The following features and functions are not included in the current development plan and will therefore not be supported by the interface. These functions, along with the ones marked with an asterisk (*) in the "Confessions..." article (page 1) in this issue, are functions supported either by INVISION or SMS Rx but not supported on the corresponding Rx system. For this reason, most features will not be available for use when installing SMS Pharmacy when a Med/IV Interface is used to send orders to INVISION.

SMS Pharmacy Order User Fields

Intermittent TPNs and Alternating IVs

Open Ended TPNs and Alternating IVs

Differ Dose

Last Occurrence Run-in Time Included in Ord Duration

Start D/T before first Occurrence

SMS Pharmacy Patient Merge Processing

Fractional Rates

Fractional Frequencies

IV Run-in/hang times default on the 1/4 hour

Greater than 8 Non-Standard TOAs

Non-Formulary IV

Bottle Numbering

Receiving Dispensed Occurrences from SMS Pharmacy Cart Processing

Alt IVs with greater than 3 unique bottles

INVISION Order User Fields

Non-Standard Weekly Frequency

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PRN PAR Levels: Many pharmacies elect to not include the full compliment of unit dose PRN DUs on their daily carts. Instead, only part (i.e., partial is where the ‘PAR’ comes from) of the maximum quantity is set, knowing the patient usually does not receive the full amount. This cuts down on inventory levels, daily handling of drug doses and potential pilferage opportunities. Unfortunately, the model INVISION Pharmacy system is quite literal in the handling of PRN (or non PRN) doses. For example, an order for ‘650 mg Tylenol Q4H PRN’ will have a quantity of 12 DUs calculate for a 24 hr Cart Fill List (CFL) (325mg = 1 DU; 2 DU/dose x 6 doses/24 hr). The pharmacy may only wish to set four DUs . A previous Rx-Pert outlined two accommodations for processing PRN PAR levels. Here are two new (and improved!) OAS adaptations for handling a PRN PAR situation.

Use a ‘PRN Baggie’ method of distribution; i.e., conditionally change C1396 (Ord Disp Meth) to ‘2’ (traditional) whenever C1220 (Ord Prio Class) = 6 (PRN). The PRN orders are then handled like traditional orders: set once, credited once and refilled as needed. A PAR level is essentially established outside of the cart processing. Besides solving the PRN PAR level issues, PRN unit dose orders do not have to be credited (actually, charged on no return) daily on the Cart Returns step. For further information on this process, please refer to the material I included in the INVISION Pharmacy education material.

If you prefer to keep your PRNs on the cart as unit dose items but still want to set PRN PAR levels, consider this technique: Have the user key in the PRN order as usual, specifying the dose, frequency and priority (650 mg Q4H PRN). Create a new Class 2 daily frequency called ‘PRNPAR’ which is really Q24H behind the scenes. Put a probe on the review screen called !PRN PAR. When probed, moved the daily frequency (C1215, e.g., ‘Q4H’) to directions (C1286, if unvalued, else C1287, etc.), $D C1314 (DU Quantity) and set the daily frequency to ‘PRNPAR’. The user will then have to key in a DU quantity to leave the screen. Procedurally, the pharmacy should be instructed to key the desired PRN PAR amount into the #DU field (a help screen can be provided to guide the user). In this special PRN PAR scenario, the #DU does not refer to the #DU/dose. Instead, it is the #DU to be dispensed as a PRN PAR amount. They system thinks it will process a ‘Q24H’ order with a quantity = your PAR amount (‘4’ in the Tylenol example). The CFL will show a quantity of four for a 24 hour cart. This will not impact charting or cart returns.

You may be scheduling reports on TEST such as the MAR/IVAR From Automated Charting or the Multiple Patient Uncharted/Charted Orders Report. Just a reminder to remember to delete the scheduling option when you are done testing the reports. Running these type of reports unnecessarily is a resource drain and could not only compromise your TEST environments’ response time, but the response time of other clients sharing your region’s TEST environments.

Your hospital may be taking advantage of the Service Master’s (SM) Default Duration field. Valuing this field for selected drug items unloads/ defaults a duration in the enter order pathways (can be overridden). Several of you have called to ask why the default duration does not work for IV orders. The reason is because processing was never developed to evaluate which ingredient’s default duration to use. Some IVs can have up to 19 ingredients. Each ingredient theoretically can have its own SM default duration. Current SM unloading is not sophisticated enough to evaluate which ingredient has the shortest SM default duration and therefore is not supported.

Don Driggers (ID, Atlanta) et al. at The Children’s Hospital of Alabama reached into their OAS toolbox and developed the following processes: calculate dose based on weight and body surface area, created dosing CPR sheet for the "code blue" team and created a way to back calculate the decant volume of the first IV ingredient (solution) for pediatric IVs. Don also built a min/max dose check feature (both total daily dose and dose by weight and body surface area). Please contact Don for details.

The MAR/IVAR From Automated Charting possesses capabilities for producing a report with relative window formatting with respect to midnight. One way to accomplish pre-midnight processing is to take advantage of the %OCPRCFL valuation. %OCPRCFL can have three settings: ‘0’, ‘ALL’ or the name of a valid nurse station. If %OCPRCFL is valued to a nurse station name (and the nurse station is activated in PROC5), an MAR/IVAR will produce for that specific nurse station (can be used if an individual nurse station is responsible for pulling their own end-of-shift worklist/MAR). If %OCPRCFL is valued to ‘0’ or ‘ALL’, then all nurse stations activated in PROC5 will produce an MAR/ IVAR. The ‘0’ setting however will look at PROC4 to evaluate the run date. If the run date in PROC4 is equal to %SYSDATE, the program knows the report has already run and will not run a second time (this option was formerly necessary to prevent the MAR/ IVAR from processing more than once/day should the CICS be recycled outside of day end when the process TCL was executed as a GHST command in the card input deck). Having %OCPRCFL=0 also assumes the MAR/IVAR program is being executed after midnight, and will produce an MAR with an end date = %SYSDATE - 1 (i.e., yesterday - assuming an explicit end date was not passed to the program through %OCMARED). If %OCPRCFL=ALL, the PROC4 run date is not evaluated and the MAR/ IVAR end date is processed as %SYSDATE. All of the scenarios above assume %OCMARWF=1 to produce the MAR/IVAR window based on admit date (rather than start/stop window dates fed through %OCMARBD/%OCMARED). So what does this mean, practically? Here are some useful applications:

If you are running the MAR/IVAR after midnight, make sure %OCPRCFL=0. This will assure the program establishes the MAR/IVAR end date window as %SYSDATE-1.

If you wish to run the MAR/IVAR before midnight (to gain extra time to process, distribute and check the MAR/IVAR before use) make sure %OCPRCFL=‘ALL’.

Everyone should now be taking advantage of the Report Scheduler to kick off the MAR/ IVARs, instead of using the card input deck GHST command processing. If you are using the Scheduler, you should be aware that the MAR/IVAR will not kick off if the CICS is down for the entire hour in which the report is scheduled. For example, if you schedule the MAR/IVAR for 01:15, the report will produce as long as the CICS is up any time between 01:15-01:59. If the CICS comes up anytime after 02:00 you will not receive the report. To avoid this no-report situation, you could redundantly schedule the MAR/IVAR and place the process TCL in the Task Controller*. The process TCL in the Task Controller should have a delay parm to delay processing by at least the amount of time the report is normally scheduled past midnight (e.g., if 01:15 is the normal schedule time, then set %INTRVAL = 013000 (hhmmss) to delay the MAR/IVAR for one hour and 30 minutes after the CICS is available). The Task Controller process TCL should have %OCPRCFL=0. This will prevent the MAR/ IVAR from kicking off twice in one day (checking the date in PROC4 to see if the report has run already for today). Normally the MAR/IVAR will kick off as a result of the scheduler and will not kick off a second time as a result of the Task Controller entry. Should the CICS be unavailable for the entire hour the scheduler is set to run the report, the Task Controller entry will automatically take over and produce the report after the delay has been reached (1hr and 30min after the CICS is available in our example above). Normally, the MAR would have already run through the scheduler. But if the MAR did not run because the scheduler was not available due to an extended outage, the Task Controller will do the job.

The Task Controller allows batch jobs to initiate transactions (including GHST commands) to the on-line environment through the CICS, and monitors progress of these transactions through their execution and then report back their execution to batch. See the Delivery Systems Day End Manual for more specific information on how to utilize the Task Controller (thanks to Bradd Fischer for insite into this subject).

When scheduling the MAR/IVAR For Manual Charting (Report Library = RXSHRLY; Report Name = RXSMAR/RXSIVAR), you must use the model process TCLs, RXPMAR02 (for the MAR) and RXPIVAR2 (for the IVAR). The Report Scheduler is "hard coded" to use these TCLs. There is no accommodation in the Selection Options screen to specify any other TCL. Scheduling the MAR/IVAR From Automated Charting (Report Library = CHTHRLY; Report Name = MAR/IVAR) does allows you to specify your driver TCL (e.g., OCDEMA01 for model) on the Selection Options screen.

When charting a dose administered at a date or time different than the scheduled date or time, you should consider taking advantage of two %fields. By adding %OCEFFDT (OC-ORD-OCCR-STS-EFF-DATE) and %OCEFFTM (OC-ORD-OCCR-STS-EFF-TIME) to source screens, OCDSPL13 and OCDSPL03, nursing will be able to see the actual administration D/T in addition to the scheduled D/T. For example, if a 23:00 5/1 dose was actually administered at 01:00 5/2, using the above %fields will allow nursing to see the 23:00 5/1 and the 01:00 5/2 D/Ts on the charting info screen and later in display charting info. You should also value %OCADMDI=1 in the MAR/IVAR From Automated Charting process TCL. This %field will print the actual admin time’s Admin Date in the previous/next date column should the actual admin date be different than the scheduled admin date (e.g., 5/2 will print in the 5/1 MAR/IVAR column for the 01:00 admin time in the above example).

How to handle (one time) pre-op orders with respect to charting and order entry: Nursing usually does not want an occurrence time associated with the on call order since the patient could be called at any time. To support this, Carilion Health Systems created the following order:

Daily Frequency = 'ONCE' (Class 1 - 0800 time)

Weekly Frequency = 'ON CALL' (Class 2 - 01 interval)

Priority = 'ONCALL' (Priority Class 6)

TCL = WHERE ALL OF "C1220" IS VAL AND "C1220" EQ 'ONCALL' THEN "C1216"=25, "C1264"='H', "C1246"="C1213"+00001, "C1219"='ON CALL'

The TCL is placed in the pathway after the frequency/priority screen (RXIMEO02) is processed. The user selects a 'ONCE' daily frequency and the

'ONCALL' priority. A "PRN" order with no occurrences (i.e., no times of administration) is built and labeled as an 'on call' order. A duration of greater than 24 hours (e.g., 25 hrs) is needed otherwise CHPPO190 will force the start/stop D/T to be equal for a PRN order. The order will show on the nurse's worklist for the given day and the nurse can chart the order and specify the actual administration time.

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