# Presentation: 110140

## 112 Pharmacy Applications Enhancements Overview 

- Jamie Crumley
- Jesse Staab
- Elaine White

## Agenda

- Remote Data Interoperability (RDI)
- General Outpatient Pharmacy
- Support for EVC
- CPRS GUI v27 Pharmacy Changes
- Inpatient Medications Project Initiatives
- General BCMA
- Project Initiatives
- Q&A

## Remote Data InteroperabilityOutpatient Pharmacy

- Elaine White
- Outpatient Pharmacy Developer

## RDI - Background and  Context

- The 2003 Congress mandated that the Department of Defense (DoD) and Department of Veterans Affairs (VA) exchange clinical data for shared patients.  To accomplish this it was necessary to:
- Centralize standardized VA patient record data into the Health Data Repository (HDR) for allergy and outpatient pharmacy (HDR project).
- Extend the existing local order checks to include all remote data now housed in the HDR (RDI project).
- Include DoD data stored in the HDR for order checks against VA med orders. (CHDR project)

**Notes:**
In 2003 Congress mandated the DoD and VA to exchange clinical data for shared patients.  The first step in this process was the standardization and centralization of VA allergies and outpatient medications in the HDR.  At the same time, the DoD was sending standardized clinical data to their CDR , equivalent to our HDR.  CPRS modified the order checking logic to not only check for adverse reactions and drug interactions or duplicate drugs on the local system but also to check the data in the HDR to determine if allergies or medication orders existed that had the potential to be detrimental to the patient.

## How Does Remote Order Checking Work?

- When new order processed by provider or pharmacist, retrieves Outpatient Pharmacy and Allergy data from the Health Data Repository (HDR) for drug-drug and drug-allergy order checking.
- If HDR is not reachable, order checks made against local data only
- Remote Data Views (RDV) or VistaWeb can be used to see more details for medications or allergies.

**Notes:**
Clinical Data Services, or CDS, is a middle layer that interacts with both CPRS and the HDR.  CDS is responsible for accepting requests for data from CPRS and retrieving data requested from the HDR and returning it to CPRS.  CPRS and the HDR do not interact directly with each other.

If the HDR is not reachable across the network, order checking will be done on local data only.

In the event that problems arise, the link to the HDR can be shut off and order checking will continue against local data only.

## CPRS Order Check Example

- Order checking dialog with the name of the originating site for the data displayed.

**Notes:**
This dialog box shows the order check dialog box with the name of the reporting site for any remote order checks.  This will appear for medication orders only.  For allergies the report will display “Local” if the order check is generated by an allergy at the users’ site, “Remote” if the order check is generated by an allergy reported at a remote site and “Local and Remote” if the allergy exists on both local and remote sites.

Notice the >> in the order check.  Information following those is remote data retrieved from the HDR.

## Inpatient Medication Order Checks Before RDI

- Order Checks Performed Against:
- IV and Unit Dose Orders
- Pending
- Active
- Non-Verified
- Renewed
- Outpatient
- Active

**Notes:**
Before RDI was instituted these order were checked by inpatient meds.

## Inpatient Medications Remote Order Checks Process

- When HDR is available, order checks will be done as before and will also be performed against outpatient prescriptions and allergies from:
- Other VAMCs
- DoD (after implementation of CHDR)
- Order checks against all Outpatient Orders
- Regardless of status (except DELETED (entered in error))
- Expired or discontinued prescriptions are included in order checks if expired or discontinued within the last  30 days.

**Notes:**
After RDI is instituted, there are additional processes.  Please note that outpatient orders will be checked regardless of status, except Deleted.  Expired or discontinued prescriptions will be included only if they expired or were discontinued within the last 30 days.  This is a shorter timeframe that was previously used by pharmacy.

## Inpatient Medications – New Display

## Outpatient Pharmacy Remote Duplicate Drug Class

- Enter an order for CLOZAPINE (MYLAN) 100MG TAB
- Now doing remote order checks. Please wait...    ****** remote Rx data is retrieved**
**                                                    ****at this point if not already in cache**
- ------------------------------------------------------------------------------
-      *** SAME CLASS *** OF DRUG IN REMOTE RX FOR CLOZAPINE (CLOZARIL) 100MG TAB
- >> CHEYENNE HDR SQA
- CLASS: CN709
-                Rx #: 787641
-             Status: ACTIVE                                               Issued: 08/01/07
-                 SIG: TAKE ONE TABLET BY MOUTH EVERY DAY
-                QTY: 14
-          Provider: PROVIDER,REMOTE        Refills remaining: 0
-                                                                           Last filled on: 08/01/07
-                                                                           Days Supply: 14
- Press Return to continue...

**Notes:**
This shows the display seen by a pharmacist when there is a duplicate drug class order check.

## Outpatient Pharmacy  Local and remote drug-drug interaction

- >> EVANSVILLE OPC
-      ** CRITICAL ** DRUG-DRUG interaction CIMETIDINE & WARFARIN
-      Remote RX # 46309524 Drug: WARFARIN NA 10MG TAB
-             Status: ACTIVE                                  Issued: 09/17/06
-                SIG: TAKE ONE-HALF TABLET BY MOUTH EVERY EVENING
-                QTY: 45
-           Provider: OPPHYS,REMOTE
-                                                       Refills remaining: 3
-                                                            Last filled on: 09/17/06
-                                                             Days Supply: 90
- Do you want to Process medication
- CIMETIDINE 400MG TAB: P// ROCESS
- Enter your Current Signature Code:    SIGNATURE VERIFIED
- Now creating Pharmacy Intervention
- for  CIMETIDINE 400MG TAB

## Backdoor Profiles Show Remote Allergies

**Example of Outpatient Pharmacy Patient Information Screen :**
- Prescription Mail Delivery: Regular Mail
- Allergies:  No Allergy Assessment
- Remote: ASPIRIN, PENICILLIN-G RELATED PENICILLINS
- Adverse Reactions:
-           Enter ?? for more actions
- EA  Enter/Edit Allergy/ADR Data         PU  Patient Record Update
- DD  Detailed Allergy/ADR List             EX  Exit Patient List
- Select Action: Quit//    QUIT

**Notes:**
Medication profiles seen by pharmacy staff will display remote allergies and adverse reactions.

## Example Patient Prescription Processing – HDR Unreachable

- Select PATIENT NAME: **OPPATIENT,ONE**  OPPATIENT,ONE   4-0-41    000006802
-      YES     SC VETERAN
-           OPPATIENT,ONE (000-00-6802)
-      No Allergy Assessment!
- Press Return to continue: **<Enter>**
- Remote data not available - Only local order checks processed.
- Press Return to continue...

## RDI/CHDR - Things to Be Aware of

- Remote _drug class_ order checks are performed when a new order is placed for a drug that is not matched to the NDF. (e.g. new or investigational drug). Future patches will also send/receive the drug class for these local drugs to the HDR. Then it will be possible for other VAMC’s to do duplicate drug class checks against these non-standardized drugs.
- Non-VA meds are not transmitted to the HDR
- Some DoD data visible in VistaWeb (BHIE data) may not be used in order checks because it is not standardized and stored in the HDR
- There is no automated method for communicating with ordering providers at remote sites
- Discussions are underway to determine a solution to provide this sort of communication capability

**Notes:**
As with all new software there are some things that are not available at the time of release.  Some may be added at a later time and some may not be possible due to the existing technology at the time of development.  This slide lists a few of those things.

It was determined when the pharmacy files were being standardized that the local drug file, file 50, would not be standardized.  Because of this, an order for a local entry in that file that is not matched to the National Drug File will not be transmitted to the HDR.  Pharmacy has determined a way to Medication profiles seen by pharmacy staff will display remote allergies and adverse reactions sent to the HDR, but it will require some additional work to accomplish this.  Even after this work has been accomplished there are still some drugs that will not be sent to the HDR.  Some research drugs may fall into this category.

Non-VA meds are not transmitted to the HDR.  Many of them do not have standardized nomenclature.

BHIE data from the DoD is text only, not standardized, and therefore not transmitted to the HDR even though it may display in RDV or VistAWeb as DoD data.

The RDI test sites pointed out early in the testing phase that they would like a method to efficiently communicate with users at a remote site when orders should be changed in some way because of actions at the site where orders are currently being placed.  This capability is not limited to RDI actions but RDI was the first application to bring this to light.  A group has been put together to look at possible ways to handle this, but the group is in its initial stages and has made no recommendations at this time.

## General Outpatient Pharmacy

- Behind the scenes enhancements including VMP Outpatient PSI’s
- Quarterly enhancements including development Outpatient Pharmacy PSI’s

## Behind the scenes enhancements

-  PSO*7*257 – PSI-06-177 Med status of renewed past stop date
- Update nightly expire job to keep track of last time that it ran and run from that date
- In nightly expire and manual auto-expire, send expiration update to CPRS and the HDR if CPRS is not already expired, discontinued, or cancelled
- Post-install clean-up:
- calculate and set expiration date, if missing
- Set active Rx’s to expired if past expiration date
- Update CPRS and the HDR to expired if backdoor is already expired, but CPRS is still active

**Notes:**
VDEF=VistA Data Extraction Framework 

## Outpatient Pharmacy Vista Maintenance Patches with PSI’s

- VMP Released patches:
- PSO*7*255 – PSI-06-086 – Send additional drug names to OPAI vendors to match VA’s local or CMOP labels
- PSO*7*259 – PSI-06-046 - MailMan alert sent to members of PSO EXTERNAL DISPENSE ALERTS if OPAI releases fill that has been DC’d
- PSO*7*265 – PSI-07-029 – Prevent incomplete non-VA med entries (caused by semicolon in dosage or schedule field)

## Outpatient Pharmacy Vista Maintenance Patches (continued)

- VMP Under development patches:
- PSO*7*271 – expiration date calculation – Remedy ticket 193305. Related to PSI-07-099
- PSO*7*169;PSS*1*78 – Remedy ticket 67766 - PSI-06-015 – Add a space between dosage and units for Possible Dosages. Also, if the Possible Dosage is fractional, add a zero (e.g. 0.5 MG)
- PSO*7*248 – PSI-05-119 Order check changes for DC’d/expired Rx’s.
- PSO*7*206; PSS*1*126 – DEA codes

## Outpatient Pharmacy Vista Maintenance Patches (continued)

- PSO*7*206; PSS*1*126 – Remedy ticket 68224
- DEA codes not working correctly
- Example: Drugs with 3A should be renewable and refillable (is, if it’s made 3AB)
- PSS*1*126 will identify any drug with 3A, 4A, or 5A and send a message to holders of the PSNMGR key to re-evaluate how they are handling refills and renews on these particular drugs.
- Before installing PSO*7*206, be sure PSS*1*126 is installed and drugs requiring DEA code changes are verified

## Outpatient Pharmacy Vista Maintenance Patches (continued)

**DEA, SPECIAL HDLG: 4AB// ?**
-      ANSWER MUST BE 1-6 CHARACTERS IN LENGTH
- THE SPECIAL HANDLING CODE IS A 2 TO 6 POSTION FIELD.  IF APPLICABLE,
- A SCHEDULE CODE MUST APPEAR IN THE FIRST POSITION.  FOR EXAMPLE,
- A SCHEDULE 3 NARCOTIC WILL BE CODED '3A', A SCHEDULE 3 NON-NARCOTIC WILL BE
- CODED '3C' AND A SCHEDULE 2 DEPRESSANT WILL BE CODED '2L'.
- THE CODES ARE:
- 0          MANUFACTURED IN PHARMACY
- 1          SCHEDULE 1 ITEM
- 2          SCHEDULE 2 ITEM
- 3          SCHEDULE 3 ITEM
- 4          SCHEDULE 4 ITEM
- 5          SCHEDULE 5 ITEM
- 6          LEGEND ITEM
- 9          OVER-THE-COUNTER
- L          DEPRESSANTS AND STIMULANTS
- A          NARCOTICS AND ALCOHOLS
- P          DATED DRUGS
- I          INVESTIGATIONAL DRUGS
- M          BULK COMPOUND ITEMS
- C          CONTROLLED SUBSTANCES - NON NARCOTIC
- R          RESTRICTED ITEMS
- S          SUPPLY ITEMS
- B          ALLOW REFILL (SCH. 3, 4, 5 ONLY)
- W          NOT RENEWABLE
- F          NON REFILLABLE
- E          ELECTRONICALLY BILLABLE

## Outpatient Pharmacy Vista Maintenance Patches (continued)

**DEA, SPECIAL HDLG: 4AB// ??**
-         DEA CODE TABLE
- CODE     ALLOW RENEWS    ALLOW REFILLS
-  1                            NO              NO
-  2                            NO              NO
-  2A                          NO              NO
-  3                           YES             YES
-  3A                         YES             NO
-  3AB                      YES             YES
-  4                           YES             YES
-  4A                         YES             NO
-  4AB                      YES             YES
-  5                           YES             YES
-  5A                         YES             NO
-  5AB                       YES             YES
-  ADDING W TO A SCHED. 3,4,OR 5 CODE DISALLOWS RENEWS.
-  ADDING F TO A SCHED. 3,4,OR 5 CODE DISALLOWS REFILLS.

## Outpatient Pharmacy Quarterly Enhancements

- Work discussed/refined/prioritized with Pharmacy Workgroup
- PBM provides advisory when patches released
- Regular release schedule every quarter for identified tasks
- FY07 Q1 – PSO*7*258
- FY07 Q2 – PSO*7*200;PSS*1*122
- FY07 Q3 – PSO*7*268;PSS*1*125;PSA*3*64;PSD*3*66
- FY07 Q4 – PSO*7*264; PSX*2*58

## FY07 Q2 – PSO*7*200;PSS*1*122

- Outpatient Pharmacy Automation Interface (OPAI)
- Send new warning label text from commercial data source to OPAI
- Bad Address Indicator info sent to OPAI
- Laser labels
- print last 4 digits of SSN instead of last 6
- Signature log enhancements

**Notes:**
4. Signature log enhancements:
   a. Print current date at top
   b. Do not print user name (if more than 1 prescription was included to
      be signed, the user name could be different for each one).
   c. Correct the spacing and continuation paging issues if one or more 
      of the prescriptions has been discontinued before printing the 
      signature log.
   d. Add a barcode to enable scanning to remove the patient's name from 
      the Bingo Board.
   e. Add as much of the drug name as will fit on the label.
   f. Add hidden action "RS" for Reprint Signature log to the prescription
      profile screen.
   g. While printing original labels (not reprint of the signature log), 
      if all of the fills have a routing of mail, the signature log will
      not be printed.
   h. The line "Relationship_________________ Counseled? _____" is changed
      to "Relation_____ Counseling Refused__ Accepted__".

## FY07 Q2 – PSO*7*200;PSS*1*122 (continued)

- E3R 19820
- Add capability to tie a ScripTalk printer to a regular pharmacy printer to control where the ScripTalk label prints for multi-divisional sites
- Add new FINISH DATE/TIME field to the PRESCRIPTION file
- If patient has Bad Address Indicator or is set to “Do Not Mail”
- If routing is mail, do not print from suspense. Update activity log and send MailMan message first time

**Notes:**
4. Signature log enhancements:
   a. Print current date at top
   b. Do not print user name (if more than 1 prescription was included to
      be signed, the user name could be different for each one).
   c. Correct the spacing and continuation paging issues if one or more 
      of the prescriptions has been discontinued before printing the 
      signature log.
   d. Add a barcode to enable scanning to remove the patient's name from 
      the Bingo Board.
   e. Add as much of the drug name as will fit on the label.
   f. Add hidden action "RS" for Reprint Signature log to the prescription
      profile screen.
   g. While printing original labels (not reprint of the signature log), 
      if all of the fills have a routing of mail, the signature log will
      not be printed.
   h. The line "Relationship_________________ Counseled? _____" is changed
      to "Relation_____ Counseling Refused__ Accepted__".

## FY07 Q3 - PSO*7*268

- Cache v5 locking
- Display patient eligibility before Rx patient status prompt
- SERVICE REJECT Nature of Order
- PSI-06-186 – edit of dispense drug & SIG
- PSI-06-184 – No Allergy Assessment
- RDI - Local order checks only message at patient selection instead of each order

## FY07 Q3 - PSO*7*268 (continued)

- Example 1 - Patient Prescription Processing:
- Select Action: Next Screen// NO   New Order
- Eligibility: SERVICE CONNECTED 50% to 100%     SC%: 60
- RX PATIENT STATUS: AUTH ABS -96// SC
-      1   SC
-      2   SC LESS THAN 50%
- CHOOSE 1-2: 1  SC

## FY07 Q3 - PSO*7*268 (continued)

- Example 2 - Complete Orders from OERR:
- Select By:  (PA/RT/PR/CL/E): PATIENT// ROUTE
- Route:  (W/M/C/E): WINDOW// MAIL
-           OPPATIENT,ONE (666-00-0777)
-      No Allergy Assessment!
- Eligibility: NSC
- RX PATIENT STATUS: SC// OPT NSC

## FY07 Q3 - PSO*7*268 (continued)

- Add SERVICE REJECT to current list of selections for Nature of Order prompt (requires provider signature):
- Nature of Order: WRITTEN// ?
-    Choose from:
-    1            WRITTEN     W
-    2            VERBAL     V
-    3            TELEPHONED     P
-    4            SERVICE CORRECTION     S
-    5            POLICY     I
-    6            DUPLICATE     D
-    12           SERVICE REJECT     R

## FY07 Q3 – PSO*7*268 PSI-06-186

- Dispense drug edit – prompt to edit SIG
- Remedy ticket 170298
- Restrict editing of dispense drug to same orderable item in Patient Prescription Processing option.
- Complete Orders from OERR - If dispense drug is changed, redisplay the SIG before prompting “Do You want to Edit the SIG? YES//”

## FY07 Q3 - PSO*7*268 PSI-06-184

- No Allergy Assessment
- Remedy ticket 169850
- When selecting patient, display “No allergy assessment!” after patient name and SSN.
- Display <NO ALLERGY ASSESSMENT> in reverse video on header line.
- Display “No Allergy Assessment” in allergy section of Patient Information screen.
- If user proceeds to place a new order, Prompt for intervention.

## FY07 Q3 - PSO*7*268 PSI-06-184(continued)

- _Example 1_:
- Select PATIENT NAME:    OPPATIENT,ONE        8-0-19    000000779     NO     NSC V
- ETERAN     OPPROVIDER,ONE
-           OPPATIENT,ONE (000-00-0779)
-      No Allergy Assessment!
- Press Return to continue:
- _Example 2_:
- Patient Information           Jul 07, 2007@07:50:33          Page:    1 of    1
- OPPATIENT,ONE                                   <NO ALLERGY ASSESSMENT>
-   PID: 000-00-0779                                 Ht(cm): _______ (______)
-   DOB: AUG 0,1919 (87)                             Wt(kg): _______ (______)

## FY07 Q3 - PSO*7*268 PSI-06-184 (continued)

- _Example 3_:
- Prescription Mail Delivery: DO NOT MAIL Expire Date: DEC 16, 2007
- Allergies: No Allergy Assessment
- Adverse Reactions:
- _Example 4_:
- Now doing drug interaction and allergy checks.  Please wait...
- There is no allergy assessment on file for this patient.
- You will be prompted to intervene if you continue with this prescription
- Do you want to Continue?: N// YES
- Now creating Pharmacy Intervention
- for  BACITRACIN OINTMENT 1OZ
- PROVIDER:

## FY07 Q4 PATCHES

- PSO*7*264;PSX*2*58
- Internet Refill Automation and Reporting
- Refill Processing – separate “CNH” and “Inpatient”
- Mailouts ** FOREIGN ADDRESS **
- Add indicator for Bad Address, Do Not Mail, or Foreign address to Log of Suspended Rx's by Day (this Division) option
- Queuing/Requeuing CMOP Rx

## FY07 Q4 – PSO*7*264 (continued)

- Internet Refill Automation and Reporting
- All entries in the PRESCRIPTION REFILL REQUEST file (#52.43) will be processed and placed on suspense for the appropriate calculated fill date and a routing of Mail.
- Separate site parameters will process inpatient or CNH prescriptions (Yes or No.

## FY07 Q4 – PSO*7*264 (continued)

***Barcode Batch Prescription Entry***** - Example**

## FY07 Q4 – PSO*7*264 (continued)

- For patients whose mailing address is foreign, “*** FOREIGN ADDRESS ***” will print on the mailing label and the rest of the address will not print.
- The *Print from Suspense File* option is modified to not send the Rx fill to the automated filling equipment or print a label if the address is foreign and the routing is not Window.

## FY07 Q4 - PSX*2*58

- Remove "B" (Bad Address Indicated) from status column when transmitted to CMOP.
- Keep BAI Rx's on CMOP suspense until corrected or pulled early. Send reject message only once.

## Support for Enrollment Vista Changes (EVC)

- PSO*7*225
- New Environmental Indicator prompt for Shipboard Hazard and Defense – “Was treatment related to PROJ 112/Shad?”
- Change prompt “Is this Rx for treatment of Environmental Contaminants exposure?” to “Was treatment related to service in SW Asia?”

## Support for CPRS GUI v27 (Outpatient Pharmacy)

- PSO*7*225
- New sorting sequences for patient medication profile
- Pharmacist comments to CPRS when Rx is put on hold, DC’d, or returned to stock (instead of “per pharmacy request”)
- If pending renewal DC’d, check for an active Rx for same drug. If so, prompt “There is an active Rx for this pending order, Discontinue both (Y/N)”
- Change message “Unable to locate order” to “Invalid Pharmacy order number” if provider DC’s from Orders Tab
- Add flagging for Outpatient Pharmacy pending orders

## Inpatient Medications

- Jamie Crumley
- Inpatient Medications Developer

## GUI v27 Inpatient Changes

- Picture is worth a thousand words
- Most significant changes are in the IV ordering dialog

## Continuous

## Intermittent

## Order Dialog

## Inpatient Medications Project Initiatives

- WDDE
- IMR Phase III
- IMR Phase IV
- Clozapine for Inpatients

## Project Disclaimer

- These are the items that were ‘on the list’ when the presentation went to press.
- Prioritization and budgeting can change the list.
- Requirements gathering is under-way.

## Interface Components

- ADT Interface (already exists)
- Admission
- Discharge
- Transfer
- Inpatient Medications Orders
- Order by order
- Upload a patient’s profile

**Notes:**
There are four major components to the interface.

The first is ADT information. Some of you may already by using this piece. We are going to be taking advantage of the ADT interface that is already being used from Controlled Substances.

The second involves Inpatient Medication orders. This part of the interface will send new and modified order information to the dispensing machines. In addition, the user will be provided the ability to upload an entire patient’s profile to the dispensing machine.

## Interface Components (cont.)

- Inventory Transactions
- Stock loading/unloading
- Dispense activities
- Waste, return, destroy
- Formulary updates
- As they occur
- Upload the entire formulary

**Notes:**
Third are the inventory updates. When stock is added to the dispensing machine or removed from it, HL7 messages will be transmitted to VistA and sent by Inpatient Medications to the appropriate package for handling. When a medication is dispensed, returned, wasted or marked for destruction, HL7 messages will be sent to VistA. It is important to note that not all point-of-care dispensing machines are created equal. For example: not all machines have a drawer for waste/destroy type functions. It is also possible that each VAMC may have different policies that preclude their use of those functions on the machines.

Last, but not least, are formulary updates. When changes are made to the VistA drug file, these updates will be sent to the dispensing machines. And, like orders, the user will have the ability to send a full formulary update on demand.

## Reports

- New menu option* “Maintenance Reports” *in Controlled Substances
- Automation Cabinet Reconciliation Report
- Unaccounted Wastage Report
- Delayed Wastage Report
- Vault Reconciliation Report
- Invoice Reconciliation Report
- Dispensing/Receiving Report (Modified)

## IMR Phase III and IV

- Order check display information
- Add prompt for Pharmacy
- Send Provider and Pharmacist override comments to BCMA
- Order Validation
- Order should display properly in BCMA
- Schedules
- Drug file

## Clozapine Enhancements

- Order checks
- Stop date calculations
- Renewal/edit restrictions
- Monthly roll-up

## Inpatient MedicationsPatient Safety Issues

- Behavior of ‘same stop date on all orders’.
- Special Instructions/Other Print Info
- IV Pre-Mix Order Checks

## PSI-06-043

- Problem with behavior of the ‘WALL’
- Several expiring orders were renewed
- New order created
- Pharmacy finished the new order first

## PSI-03-041

- Expand Special Instructions and Other Print Info to unlimited
- Matches CPRS
- Label Print
- BCMA Changes required

## PSI-06-012

- No order checks on IV Premix
- Challenging due to no method to identify significance of the solution

## BCMA

- Jesse Staab
- BCMA Delphi Developer

## BCMA Project Status

- BCMA – CCOW	(PSB*3*13)
- BCMA – MSF   	(Mng. Scanning Failures)
- BCMA – 508	(BCMA 508 Compliance)
- BCMA – IHS	(Param. of BCMA PT ID)
- BCMA – HSCIII 	(Reports 1 / Coversheet 2)
- BCMA – HSC IV (Reports 2 w/Misc)

**Notes:**
This slide outlines many of the BCMA projects, some of which have been recently released, others which are on hold as well as some that have yet to be started. We’ll discuss these in further detail in a few slides.

## BCMA - CCOW

- Patch PSB*3.0*13
- Released on  08/17/06
- Joined CPRS and other VistA applications in implementing patient context management
- PSI-06-145 which resulted in the decision to disable CCOW

**Notes:**
Patch PSB*3.0*13 was released on 08/17/06. This patch contained the CCOW functionality that enabled the patient context management functionality as implemented in other applications, such as CPRS. As a result of the implementation of CCOW in BCMA, PSI-06-145 was entered for CPRS. Because of the implementation of CCOW, a specific scenario between BCMA and CPRS could occur that caused mismatched information to display in CPRS. A patient safety notice was released for BCMA that asked everyone to disable CCOW until a patch could be released for CPRS to correct the problem. The Patient Safety Office tested the CPRS patch and while testing the patch, they found numerous usability issues pertaining to the CCOW implementation in general. The CPRS patch was quickly released to the field to correct the problem. However, because of the additional usability issues found, it was decided that the BCMA patient safety notice should not be rescinded at this time. As a result, BCMA’s CCOW functionality should remain disabled until further notice.

## BCMA - 508

- Patch PSB*3.0*10
- Released 01/30/07
- “Role-Based” 508 evaluation of BCMA to ensure 508 compliance where appropriate without impacting existing features.

**Notes:**
PSB*3.0*10 which contained the BCMA 508 functionality was released 01/30/07. A role based 508 evaluation occurred to ensure that BCMA was 508 compliant where appropriate while ensuring that existing functionality was not impacted.

## BCMA - MSF

- Intended to help nurses report problems and aid facilities in resolving those problems
- Captures information about failures from the user
- Creates reports to help identify system issues
- Sends notifications of problems so that they can be resolved in a timely manner
- 4 Change requests submitted after last year, CCB  approved 3, SRS updated and sent to unions for review
- See TSPR for the project reactivation date

**Notes:**
The BCMA Managing Scanning Failures project is contained in PSB*3.0*28 which is currently on hold. This patch is intended to help nurses report scanning problems as they occur and aid facilities in resolving the problems found. This functionality captures the information about the failures from the user and allows for the creation of reports to help identify the scanning issues. In addition, as the functionality is utilized, notifications are sent to a mail group so that the issues can resolved in a timely manner. During the beta test phase, four change requests were submitted. The change control board approved three of the requests and the SRS was updated and sent to the unions for review. See TSPR for the project reactivation date.

## BCMA - IHS

- 1st collaborative effort involving a GUI following the HSD&D development lifecycle
- Intended to provide Indian Health Service (IHS) with functionality required use BCMA
- Uses IHS’ patient identifier for scanning and reporting
- Records Pain Scores and retrieve Vital’s data from VMeasures
- Invisible to VA users
- See TSPR for project reactivation date

**Notes:**
BCMA IHS is the first collaborative effort involving a GUI following the HSD&D development lifecycle. This project is intended to provide Indian Health Service with the functionality they need to utilize BCMA. BCMA will use the IHS patient identifier for scanning and reporting purposes. In addition, BCMA will record and retrieve data pertaining to a patient vitals from the vitals package used by Indian Health Services. This project is currently on hold. Please see TSPR for the project reactivation date.

## BCMA – HSC III

- PSB*3.0*32
- New and modified reports
- Coversheet reports
- IV Bag status
- Med Therapy (no administration needed)
- Reports can be queued via GUI
- Reports can be directly printed without preview
- Inactive wards are now filtered out by default
- Reports can be printed by specific patients on a ward
- Coversheet changes
- New icons (flag / stat / no action IV)
- Reorder columns, added order start date
- Tools Menu

**Notes:**
BCMA HSC phase III, PSB*3.0*32, is currently being tested by the field. The enhancements, listed here will be discussed in further detail in the next several slides.

## BCMA – HSC III PSI Related Modifications

- PSI-06-019 – Patch order is discontinued or expired
- PSI-06-056 – Preventing extra PRN doses
- PSI-06-014 – Display full med route on VDL
- PSI-06-029 – Missed Med Report timeout
- PSI-06-160 – Limitation of row height on the VDL not   			     being able to display all additives and                            		     solutions

**Notes:**
In addition, BCMA HSC phase III contains several PSI related modifications which will be discussed in further detail.

## BCMA – HSC IIIMedication Therapy Report

**Notes:**
The Medication Therapy Report will allow a user to search for specific drugs and allow a report to be generated to view the administrations that have occurred involving the medications selected. The report format is based off on the existing Medication History Report. The user will be able to search a specific drug category, that is, they will be able to search by dispensed drugs, IV medications, orderable item, or VA drug class. Only one category can be searched at a time. The left screen shot displays the report parameters, the right screen shots displays the drug lookup dialogue.

## BCMA – HSC IIIMedication Therapy Report

**Notes:**
This is an example of the Medication Therapy Report.

## BCMA – HSC IIIIV bag status report

**Notes:**
The IV Bag Status report allows the user to run a report to view all IV orders based on the order state and bag status. The left screen shot displays the parameters for the report and the right side of the screen displays a sample report.

## BCMA – HSC IIIMedication Overview Report

**Notes:**
In addition, a report has been created for each coversheet view. There are four reports, the Medication Overview, PRN Overview, IV Overview and the Expired/DC’d/Expiring Overview. Each of these reports are a printable version of the data displayed on each view of the Cover Sheet. This screen shot is an example of the Medication Overview Report.

## BCMA – HSC IIIOther Enhancements

**Notes:**
Several general report enhancements exist in this patch. All reports are now printable by select patients on a ward. That is, once you select a ward, you can display a list of patients on that ward, and individually select which patients you want to run the report for. Also, the ward list now filters out inactive wards by default. If there is a need to view inactive wards for historical reporting purposes, the checkbox can be unchecked. Not shown here, all reports can now be queued from the GUI application. In addition, when running a report, all reports can be either previewed or printed. You are no longer forced to preview the report prior to printing the report. Another item not shown here, the missed med report has been modified to allow the report to be ran by a date range. In addition, held and refused administrations can now be included on the report as well as comments/reasons. In addition, you can now select from active, DC’d and expired orders.

## BCMA – HSC IIICover Sheet Enhancements

**Flagged order**
**Stat order**
**IV with no action taken**

**Notes:**
Three new indicators have been added to the coversheet. The first column, if it contains a question mark icon, indicates that the IV order has had no actions taken on the order. The second column, when it contains an exclamation point icon, indicates that the order is a stat order. The third column, when red, indicates that the order has been flagged by the Pharmacists or Provider. For flagged orders, the user can right click on the order to view the flag comments. In addition, the order start date was added to the cover sheet. One additional enhancement that is not displayed here, is the ability to extend the time frame of the Expired/DCd/Expiring Overview that allows the user to extend the view up to 72 hours into the past and the future. This will allow the user to see what orders have recently expired as well as what orders will expire soon. One last enhancement to BCMA that does not have a slide is the addition of a Tools menu that functions the same as the Tools menu in CPRS.

## BCMA – HSC III PSI-06-019

**Notes:**
PSI-06-019 pertains to patches that are still in a given state but have either expired or have been DCd. When a user opens the patient record, a screen will be displayed for each patch that is currently at a given state and the order is expired or DCd. This screen displays the pertinent information about the patch including the current status. The user can enter an optional comment and then select to either remove the patch or ignore the patch. The screen will repeatedly display for each given patch that is either expired or DCd. If the patch is ignored, this screen will display again the next time the patient record id opened.

## BCMA – HSC III PSI-06-056

**Notes:**
To aid  in preventing repeated PRN administrations, the existing PRN administration dialogue has been modified so that it now displays the schedule and last given information to the right of an icon in the lower left corner of the screen. Additionally, a check box has been added that requires the user to acknowledge that they have reviewed the schedule and last administration time. The screen has been rearranged as to well logically group the components that are likely to be interacted with.

## BCMA – HSC III PSI-06-014 & PSI-06-160

**Notes:**
Disclaimer, please disregard this order as it was only created to demonstrate issue pertaining to the second PSI listed. PSI-06-014 was concerned with displaying abbreviated medication routes. To remedy this PSI, BCMA will now display the full medication route instead of the abbreviation. PSI-06-160 has to do with a physical limitation of the software. Each row on the VDL has a maximum row height of 255 pixels. This PSI revolved around a scenario where an IV order had 18 plus additives and solutions, thus causing the row to be over 255 pixels. When this occurs, the row height would end up at a height that might only display a row or two of data. The top screen shot shows a similar order. The lower screen shot shows the same order, only the cell width was decreased, thus causing the row height to expand beyond 255 pixels. The workgroup decided that the best course of action was to not display any additives, solutions, dispensed drugs or special instructions if there was a chance that the information could be truncated. Instead, BCMA will display a canned message prompting the user to view the order details for further information. This modification was also required to handle an upcoming enhancement will allow the special instructions field will to be unlimited in length and BCMA will need to be able to display the information accordingly. One additional PSI that does not have slide is PSI-06-029. This PSI concerns the missed med report timing out in the GUI at a site that has a long term care ward and where the orders have been repeatedly renewed. Essentially, the report would take a long time to generate and broker would time out in the GUI while waiting for the report to complete. Modifications were made to the Missed Med Report to shorten the amount of time it will take to generate the report. As mentioned earlier, the reports can be queued to a printer which will prevent a user from having to run the report to the screen.

## Clinic Orders

- Expands IMO functionality
- Not just for medications
- Enabling BCMA for Clinic Orders
- User interface changes to cleanly display and administer all orders
- Report changes to accurately identify and report administration information
- No-count wards not required

## Double-Scan Issue

- BCMA Double-Scan:  new service request
- http://vista.med.va.gov/pas/ViewTrackingRecord.asp?RequestID=20070205
- Patient Safety Alert AL07-09

## BCMA – HSC IV

- Reports Re-Design 2 :
- Query Builder (custom reporting tool to select and sort data to print)
- Export feature to allow data to be exported from BCMA into various formats.
- Cover Sheet Enhancements:
- Displaying the patient photograph to provide a form of secondary form of identification (note Imaging pre-req)
- Displaying patient DNR
- Displaying override comments

**Notes:**
BCMA HSC Phase IV contains additional reporting functionality revolving around the creation of a query builder tool that will allow for custom reporting functionality and allow for the exportation of this data. In addition, numerous Cover Sheet enhancements will be made, including the display of the patient photograph (which has a dependency on imaging be able to supply this functionality), displaying a patient DNRs, and displaying override comments. 

## Questions?