# Presentation: 665091

## 117 Pharmacy Reengineering FY07 Update

- A Perfect World

## Faculty

- Mike Mims, Program Manager   Pharmacy Reengineering (PRE)
- Cathryn Herren   Analyst, PRE
- Lina Bertuzis   Analyst, PRE

## PRE Background

- Many VHA technology problem areas and weaknesses identified
- Prior to 2001 First Consulting study
- Included patient safety issues
- SwRI awarded multi-year, fixed-price contract
- FY04 to develop new pharmacy system
- Period of performance ends September 2008

## PRE Proof of Concept Demo

- December 14, 2006
- Purpose: Demonstrate viability of Pharmacy Enterprise Product System (PEPS)
- Successfully interoperated VistA pharmacy with COTS database (First DataBank-FDB)

**Notes:**
Demonstrated integration between 
PEPS and COTS
PEPS and VistA
Used reduced set of 
PEPS functionality 
PEPS test data

## POC Summary

- Proof of  Concept
- Demonstrated key functionality
- Identified major risks for production system
- Tested VistA - PRE info flow
- Validated & refined PEPS system requirements
- Provided environment to evaluate VistA integration strategy
- Allowed Level of Effort (LOE) estimate adjustment for production build

## POC Lessons Learned

- Proof of Concept showed
- Level of effort > originally thought
- Testing Activities require significant time/ resources
- Health*e*Vet (HeV) architecture not maturing as quickly as hoped
- Dramatic funding reductions = significant project delays
- Cost estimates to continue current pace w/ SwRI greatly exceed original expectations

## POC Testing Activities

- 2006 Testing
- Usability
- Functional Acceptance Test
- Code Evaluation
- 508 Compliance

## FY07 - Changing Environment

- Entire VA Environment changed
- New Organizational Structure
- Continuing Resolution
- No Approved Budget (80% of FY06 Budget)
- Unable to move forward with New Contract with SwRI
- Generated Re-planning effort

## PRE Versions

- PRE v0.5, v1.0 and Remaining Work
- V. 0.5 pre-release
- V. 0.5 Enhanced Order Checks
- V. 1.0 Pharmacy Enterprise Product System (PEPS)
- Beyond PRE V. 1.0

## Risks

- Production environment
- Support staff
- Legacy system enhancements
- Performance
- COTS drug database licenses
- COTS drug database

**Notes:**
Both versions of PRE share the following risks:
	Production environment
	Support staff
	Legacy system enhancements
	Performance 
	COTS drug database licenses
PRE V.1.0 has two additional risks:
	COTS drug database

## Dependencies

- Standards & Terminology Services (STS)
- SwRI
- CPRS
- COTS Drug Database
- Clinical Data Services (CDS)
- Cross-Application Integration Protocol (CAIP)

**Notes:**
Both versions share the following Dependencies:
	Standards & Terminology Services (STS)
	SwRI
	CPRS
	COTS Drug Database
	Clinical Data Services (CDS)
	CAIP
PRE V.1.0 has two additional dependencies:
	Clinical Data Services (CDS)
	CAIP

## Beyond PRE v1.0

- Working with Business Owners
- Organize
- Prioritize
- Sequencing must consider
- Patient safety issues
- Funding requirements
- Availability of common services
- Ability of other applications to implement

## PRE V. 0.5 Pre-Release 

- Cathryn Herren

## Background Information

- Current Order Checks to be enhanced
- Using First Data Bank (FDB)
- New Dosing Order Checks
- Using FDB
- National Drug File Connection to FDB
- GCNSEQNo in VA Product File

## Why A Pre-Release

- Data required for FDB dosing checks
- Not currently in VistA
- FDB medication route for dosing
- FDB drug unit for dosing
- Numeric dose and corresponding unit for Local Possible Dosages
- Needs checking in VistA
- Administration Schedule Frequency

## Medication Route Mapping

## Standard Routes
Created by Standards and Terminology Service (STS)
Approved by Pharmacy Benefits Management (PBM)
Mapped to FDB dose route table by STS
To be exported as a Pharmacy Data Management (PDM) file

- Created by Standards and Terminology Service (STS)
- Approved by Pharmacy Benefits Management (PBM)
- Mapped to FDB dose route table by STS
- To be exported as a Pharmacy Data Management (PDM) file

- STANDARD MEDICATION ROUTE file (#51.23)

## STANDARD MEDICATION ROUTE file (#51.23)

- No local editing allowed
- Future updates by STS
- via New Term Rapid Turnaround (NTRT)

## Mapping Local to Standard Medication Routes

- New field in MEDICATION ROUTES file (#51.2)
- Pointer to STANDARD MEDICATION ROUTES file (#51.23)
- Required only for Medication Routes marked for ALL PACKAGES
- In PACKAGE USE field (#3)

## Auto-population of new field
Exact matches to Standard Medication Route
Exact match to FDB route
Mapped to Standard Medication Route for that entry

- Exact matches to Standard Medication Route
- Exact match to FDB route
- Mapped to Standard Medication Route for that entry

- Mapping Local to Standard Medication Routes

## Options for mapping
Medication Route File Enter/Edit
Map Local Medication Route to Standard
Find Unmapped Local Medication Routes

- Medication Route File Enter/Edit
- Map Local Medication Route to Standard
- Find Unmapped Local Medication Routes

- Mapping Local to Standard Medication Routes

## Medication Route File Enter/Edit

- Modified for mapping to standard medication route
- User to get warning if route not mapped when required

## Map Local Medication Route to Standard

- Option only for mapping to Standard Medication Route
- User selects route to map
- FDB route is displayed when mapping to Standard
- Displays mapping for a route already mapped
- Redisplays the mapping and FDB route after mapped to standard

## Map Local Medication Route to Standard

** **
**Select MEDICATION ROUTES NAME:   OPHTHALMIC      OPH**
**OPHTHALMIC**
** **
**Select STANDARD MEDICATION ROUTES NAME: ****O****     1   OPTHALMIC    FDB Route: OPTHALMIC****     2   ORAL         FDB Route: ORAL****     3   OTIC         FDB Route: OTIC****CHOOSE 1-3: 1  OPTHALMIC  FDB Route: OPTHALMIC**
** ****Local Route 'OPHTHALMIC' has been mapped to****    ‘OPTHALMIC'       FDB Route: ‘OPTHALMIC'**
** **
**Select MEDICATION ROUTES NAME:  SWISH AND SWALLOW      SAS**
** ****SWISH AND SWALLOW**
** **
**Already mapped to:****    ‘OTIC'            FDB Route: 'OTIC'**
** **
**Select STANDARD MEDICATION ROUTES NAME: ****ORAL****    FDB Route: ORAL**
** **
**Local Route ‘SWISH AND SWALLOW' has been mapped to****    ‘ORAL'            FDB Route: ‘ORAL'**
**  **
**Select MEDICATION ROUTES NAME: <****Enter****>**
** ****Select Enhanced Order Checks Setup Menu Option:**

## Find Unmapped Local Medication Routes

- Loops through unmapped medication routes for mapping to Standard Medication Route
- System displays routes to user for mapping
- FDB route is displayed when mapping to Standard

## Find Unmapped Local Medication Routes

- Redisplays the mapping and FDB route after mapped to the standard
- If route not mapped, user is presented with next route requiring mapping
- User can enter ^ to exit the loop

## Find Unmapped Local Medication Routes

**Select Enhanced Order Checks Setup Menu Option: ****Find**** Unmapped Local Medication Routes **
** **
**This option will find local Medication Routes marked for 'ALL PACKAGES' not ****mapped to a Standard Medication Route, and prompt you to map the local route.****This mapping is necessary to perform Dosage checks.**
** **
**Searching for unmapped Med Routes... **
**Mapping local Med Route of 'INHALATION'             **
** **
**Select STANDARD MEDICATION ROUTES NAME: ****?****    Answer with STANDARD MEDICATION ROUTES NAME****   Choose from:****   INHALATION           FDB Route: INHALATION****   INTRA-ARTERIAL           FDB Route: INTRA-ARTERIAL****   INTRA-ARTICULAR          FDB Route: INTRA-ARTICULAR**
**'^' TO STOP:  ^**
**  ****Select STANDARD MEDICATION ROUTES NAME: ****INHALATION****    FDB Route: INHALATION**
** ****Local Route 'INHALATION' has been mapped to    ****  ****‘INHALATION'   FDB Route: ‘INHALATION'**
** **
**Mapping local Med Route of ‘INTRA-ARTERIAL'  **
**<The next local Med Route that needs mapping is displayed>**
** **
**Select STANDARD MEDICATION ROUTES NAME:** *<***Enter***>*
**<If user just enters <ret>, the next unmapped local med route is displayed>**
- (Continued...)

## Find Unmapped Local Medication Routes

-  **Mapping local Med Route of 'INTRA-ARTICULAR'          **
**Select STANDARD MEDICATION ROUTES NAME: ****^****        **
** **
**Do you want to continue mapping Med Routes? Y// ****NO ****     **
**<User prompted if they want to continue, since user entered "^" previously>**
**Checking for any remaining unmapped Local Med Routes...  **
**<On exit system checks if all local med routes are mapped>**
**There are still local Med Routes marked for 'ALL PACKAGES' not yet mapped. See 'Medication Route Mapping Report' option for more details.  **
**< System will display this message if all not mapped>**
- **OR**
**All local Med Routes marked for ‘ALL PACKAGES’ have been mapped.**
**<System will display this message if all are mapped>**
**Select Enhanced Order Checks Setup Menu Option: **

## Dosage Form File Enter/Edit

- Modified to not allow entry of a new Medication Route

## Medication Routes Mapping Local to Standard 

- Reports
- Medication Route Mapping Report
- Medication Route Mapping History Report

## Medication Route Mapping Report

- Displays all medication routes requiring mapping or just unmapped medication routes
- Displays medication routes alphabetically
- Displays Standard Medication route when mapped

## Medication Route Mapping Report

- Displays FDB route when mapped
- Displays Outpatient Expansion for the medication route

## Medication Route Mapping Report

## Medication Route Mapping Report

## Medication Route Mapping History Report

- Report of mapping changes between local medication routes and standard medication routes
- Display all medication routes or a single medication route
- User selects time range

## Medication Route Mapping History Report

## Medication Route Mapping History Report

**This option provides a report that displays changes made to mapping of Medication Routes in the MEDICATION ROUTES file (#51.2) to Medication Routes in the STANDARD MEDICATION ROUTES file (#51.23).**
**Print report for a Single Med Route, or All Med Routes:  (S/A): Single // ****A****  All**
**This report will be sorted by Medication Route, and within Medication Route will be**
**sorted by Date/time. A beginning and ending date must now be entered for the search.**
**Beginning Date: ****4-20-07****  (ARP 20, 2007)**
**Ending Date: ****T **** (JUN 22, 2007)**
**DEVICE: HOME//   ****P-35****      Right Margin: 80// <****Enter>**
**Medication Route mapping changes for ALL Medication Routes             PAGE: 1**
**made between APR 20, 2007 and JUN 22, 2007**
**----------------------------------------------------------------------------**
**Medication Route: BOTH EYES**
**         ****Date/time: APR 25, 2007@08:36:19**
**         ****Edited by: PHARMACY,RPH20**
**         ****Old Value: <no previous value>**
**         ****New Value: INTRAOCULAR**
**         ****Date/time: APR 25, 2007@08:36:19**
**         ****Edited by: PHARMACY,RPH20**
**         ****Old Value: INTRAOCULAR**
**         ****New Value: OPTHALMIC**
**End of Report**

- Medication Route Mapping History Report

## Drug Units Mapping

## Drug Units Mapping

- New field to associate possible dosages to FDB drug unit for dosing

## Local Possible Dosages

- Two new fields added to DRUG file (#50) within the LOCAL POSSIBLE DOSAGES multiple (#904)
- UNITS – FDB drug units for dosing
- NUMERIC DOSE – a numeric representation of the dosage based on the unit defined

## Local Possible Dosages

- Population of two new fields
- Not required for supply items
- Not required for FDB topical dosage forms
- Software to auto populate, if possible

## Options for Population

- Enter/Edit Dosages
- Drug Enter/Edit
- Edit Local Possible Dosages
- Edit All Local Possible Dosages

## Enter/Edit Dosages 

- Modified to allow editing of the two new fields
- User to get a warning if the DRUG file (#50) strength does not match the VA Product strength
- Redisplays data once entered

## Drug Enter/Edit

- Modified to allow editing of the two new fields
- User to get a warning if the DRUG file (#50) strength does not match the VA Product strength
- Redisplays data once entered

## To allow editing of the two new fields
User selects drug
System prompts for entry of two new fields
Redisplays data once entered

- User selects drug
- System prompts for entry of two new fields
- Redisplays data once entered

- Edit Local Possible Dosages

## Edit All Local Possible Dosages

- Loops through local possible dosages eligible for dosage checks that do not have either the Numeric Dosage or Units entered
- System displays drug and local possible dosage requiring the needed fields
- System prompts for entry of two new fields

## Edit All Local Possible Dosages

- Redisplays data once entered
- If no data is entered, user is asked if they want to continue
- User can enter ^ to exit the loop

## Reports

- Strength Mismatch Report
- Review Dosages Report
- Local Possible Dosages Report

## Strength Mismatch Report

- Displays dosage information
-  For entries in the DRUG file (#50) with local possible dosages whose strength is  different than the strength of the VA Product match
- Displays strength of DRUG file (#50) entry and strength of VA Product match entry
- Displays VA Product match entry

## Strength Mismatch Report

**Select Pharmacy Data Management Option: ****EN****hanced Order Checks Setup Menu**
** **
**Select Enhanced Order Checks Setup Menu Option: ****ST****rength Mismatch Report**
** **
**This report will print Dosage information for all entries in the DRUG (#50)****File that have a different Strength than what is in the VA Product (#50.68)****match. If these drugs have Local Possible Dosages, you need to be careful when****setting the new Units and Dosage field to be used for Dosage checks. This report can only identify Strength mismatches if the Drug has Possible Dosages, and the Strength has been****edited. This report cannot identify Strength mismatches where no Possible Dosages****have been created.**
** **
**   ****This report is designed for 132 column format!**
** **
**DEVICE: HOME// <****Enter****>**
**Mismatched Strength Report                               Outpatient Expansion     PAGE: 1****-----------------------------------------------------------------------------------------**
**(156)              GUAIFENSESIN 100MG/5ML SYRUP                       Inactive Date: **
**            ****Strength: 50                   Units:                Application Package: OX**
**    ****Possible Dosages:**
**   ****Dispense Units Per Dose: 1              Dose: 50MG/2.5ML****	****	****	**** Package: I**
**   ****Dispense Units Per Dose: 2              Dose: 100MG/5ML****	****	****         Package: I**
**    ****Local Possible Dosages: **
**   ****1 TEASPOONFUL     Numeric Dose: 100       Units: MG                       Package: O**
**   ****2 TEASPOONFUL(S)  Numeric Dose: 200       Units: MG                       Package: O**
**   ****Note: Strength 50 does not match NDF strength of 100.**
**   ****VA PRODUCT MATCH: GUAIFENESIN 100MG/5ML SYRUP.**

## Review Dosages Report

- Modified to display two new fields defined for Local Possible Dosages

**Select Pharmacy Data Management Option: ****EN****hanced Order Checks Setup Menu**
** **
**Select Enhanced Order Checks Setup Menu Option: ****R****eview Dosages Report**
** **
** ****Select one of the following:**
**          ****A         ALL**
**          ****S         SELECT A RANGE**
**Print Report for (A)ll or (S)elect a Range: S// ALL**
**This report will be for all drugs.**
**Is this correct? Y// ES **
**   **
**This report is designed for 132 column format!**
** **
**DEVICE: HOME// <****Enter****>**

## Review Dosages Report

**Dosage report for all drugs                                      Outpatient Expansion**
**-----------------------------------------------------------------------------------------**
**(699)              GUAIFENESIN 100MG/5ML SYRUP                    Inactive Date:**
**           ****Strength: 100                  Units:           Application Package: OX**
**    ****Possible Dosages: **
**   ****Dispense Units Per Dose: 1               Dose: 100MG/5ML            Package: I**
**   ****Dispense Units Per Dose: 2               Dose: 200MG/10ML           Package: I**
**    ****Local Possible Dosages: **
**   ****1 TEASPOONFUL****        ****Numeric Dose: 100     Units: MG****             ****Package: O**
**   ****2 TEASPOONSUL(S)****     ****Numeric Dose: 200     Units: MG****             ****Package: O**
**(2280)             IBUPROFEN 300MG TAB    *N/F*                  Inactive Date: **
**           ****Strength: 300                  Units: MG       Application Package: OX**
**    ****Possible Dosages: (None)**
**    ****Local Possible Dosages: **
**      ****900MG****                ****Numeric Dose: 900    Units: MG****              Package: IO**
**      ****1200MG****               ****Numeric Dose: 1200   Units: MG****              ****Package: IO**
**(5249)             IBUPROFEN 400MG (120'S)    *N/F*              Inactive Date: **
**            ****Strength: 400                  Units: MG       Application Package: OX**
**    ****Possible Dosages: **
**   ****Dispense Units Per Dose: 1          Dose: 400MG             Package: IO     1 TABLET**
**   ****Dispense Units Per Dose: 2          Dose: 800MG             Package: IO     2 TABLETS**
**    ****Local Possible Dosages: (None)**
**(1676)             TIMOLOL 0.25% OPTH SOLN (10ML)                Inactive Date: **
**            ****Strength:                      Units:         Application Package: OXU**
**    ****Possible Dosages: (None)**
**    ****Local Possible Dosages: **
**      ****2 DROPS****              ****Numeric Dose: 2     Units: DROPS****              ****Package: IO**
**End of Report**

## Local Possible Dosages Report

- Displays drugs in the DRUG file (#50) with local possible dosages that have missing data in the numeric dose and units fields
- Excludes supplies and FDB topical dosage forms
- User can print all drugs or a specific alphabetic range of drugs

## Local Possible Dosages Report

- Displays local possible dosage information
- Displays strength of NDF match (if strength does not match DRUG file (#50) entry)
- Prints VA Product match when strength mismatch

## Local Possible Dosages Report

** ****Local Possible Dosages Report for Drugs G through G                    PAGE: 1****-----------------------------------------------------------------------------------**
**(30)               GELUSIL TABLES                                      Inactive Date: **
**Strength:                      Units:             **
**Local Possible Dosages: **
** ****1 TABLET          Numeric Dose:         Units:                            Package: I**
** ****2 TABLET(S)       Numeric Dose:         Units:                            Package: I**
**(156)              GUAIFENSESIN 100MG/5ML SYRUP                        Inactive Date: **
**Strength: 50                    Units: MG             Application Package: OUX**
**Local Possible Dosages: **
**1 TEASPOONFUL     Numeric Dose:         Units:                            Package: IO**
**2 TEASPOONFUL(S)  Numeric Dose:         Units:                            Package: IO**
**Note: Strength 50 does not match NDF strength of 100.**
**VA PRODUCT MATCH: GUAIFENESIN 100MG/5ML SYRUP**

## Administration Schedule Frequency

- Administration Schedule File Report
- Displays
- Administration schedules (all or just those with no frequency defined)
- Standard administration times (ward specific administration times if defined)
- Outpatient Expansion
- Other Language Expansion
- Schedule Type
- Frequency (in Minutes)

## Administration Schedule Frequency

**ADMINISTRATION SCHEDULE FILE REPORT                    Page:   1**
**----------------------------------------------------------------------------**
**BID**
**    ****STANDARD ADMINISTRATION TIMES: 09-17 ****(rest of administration times, if needed)**
**    **
**    ****OUTPATIENT EXPANSION: TWICE A DAY**
**    ****OTHER LANGUAGE EXPANSION: **
**    ****WARD: 5NM**
**          ****WARD ADMINISTRATION TIMES: 08-16 ****(rest of administration times, if needed)**
**          **
**    ****WARD: 6AS**
**          ****WARD ADMINISTRATION TIMES: 10-22 ****(rest of administration times, if needed)**
**          **
**    ****SCHEDULE TYPE: CONTINUOUS**
**    ****FREQUENCY (IN MINUTES): 720**
**MO-WE-FR**
**    ****STANDARD ADMINISTRATION TIMES: 09 ****(rest of administration times, if needed)**
**    ****OUTPATIENT EXPANSION: TWICE A DAY**
**    ****OTHER LANGUAGE EXPANSION: **
**    ****WARD: 5NM**
**          ****WARD ADMINISTRATION TIMES: 08 ****(rest of administration times, if needed)**
** **
**    ****SCHEDULE TYPE: DAY OF THE WEEK**
**    ****FREQUENCY (IN MINUTES):**
**QD**
**    ****STANDARD ADMINISTRATION TIMES: 09 ****(rest of administration times, if needed)**
** **
**        ****OUTPATIENT EXPANSION: EVERY DAY**
**    ****OTHER LANGUAGE EXPANSION: **
**    ****WARD: 5NM**
**          ****WARD ADMINISTRATION TIMES: 10 ****(rest of administration times, if needed)**
**    ****WARD: 6AS**
**          ****WARD ADMINISTRATION TIMES: 08 ****(rest of administration times, if needed)**
**    ****SCHEDULE TYPE: CONTINUOUS**
**    ****FREQUENCY (IN MINUTES): 1440**

**Notes:**
User selects all administration schedules 

## Administration Schedule Frequency

**ADMINISTRATION SCHEDULE WITHOUT FREQUENCY REPORT             Page:   1**
**-----------------------------------------------------------------------------**
**MO-WE-FR**
**    ****STANDARD ADMINISTRATION TIMES: 09 ****(rest of administration times, if needed)**
**    **
**    ****OUTPATIENT EXPANSION: TWICE A DAY**
**    ****OTHER LANGUAGE EXPANSION: **
**    ****WARD: 5NM**
**          ****WARD ADMINISTRATION TIMES: 08 ****(rest of administration times, if needed)**
**    ****SCHEDULE TYPE: DAY OF THE WEEK**
**    ****FREQUENCY (IN MINUTES):**
**Q3H**
**    ****STANDARD ADMINISTRATION TIMES: 03-06-09-12-15-18-21-24 ****(rest of administration**
**   **** ****times, if needed)**
**    ****OUTPATIENT EXPANSION: EVERY 3 HOURS**
**    ****OTHER LANGUAGE EXPANSION: **
**    ****SCHEDULE TYPE: CONTINUOUS**
**    ****FREQUENCY (IN MINUTES): **
**End of Report**

**Notes:**
User selects administration schedules without a frequency defined 

## New Menu

*Enhanced Order Checks Setup Menu* option

- Select Enhanced Order Checks Setup Menu Option: **?**
-           **Find Unmapped Local Medication Routes**
-           **Map Local Medication Route to Standard**
-           **Medication Route Mapping Report**
-           Medication Route File Enter/Edit
-           **Medication Route Mapping History Report**
-           **Edit All Local Possible Dosages**
**          ****Edit Local Possible Dosages**
-           **Local Possible Dosages Report**
-           **Strength Mismatch Report**
-           Enter/Edit Dosages
-           **Administration Schedule File Report**

## PRE V. 0.5 Enhanced Order Checks 

- Lina Bertuzis

## Enhanced Order Checks

- Use FDB Drug Information Framework (DIF) APIs and database
- Enhance Existing Order Checks
- Drug-Drug
- Duplicate Drug
- Duplicate Class
- Add New Dosing Order Checks
- Max single & daily dose range
- General Dosing range information

## Enhanced Order Checks

- Incorporate Dosing Checks in Verification Process
- CPRS Order Checks added
- Order Check History
- New - Check Drug Interaction Option
- New Hidden Action – Order Check vs. Med Profile
- Consistent Pharmacy Order Check Display

## Enhanced Order Checks Plus...

- Hidden Action - Intervention Menu
- Identify Recently Discontinued/Expired Orders
- Identify D/C and Hold Action

## Order Checks – Data Flow

**Notes:**
When a HealtheVet VistA application (i.e. Outpatient Pharmacy) requests and order check to be performed, an XML message is sent from VistA to FDB via VistAlink. The PRE V. 0.5 application PEPS services will receive; validate the format and triage the request before sending on to FDB Drug Information Framework (DIF) which will perform the requested order check(s) and return the results.

## Drug-Drug Interaction - FDB

- FDB Drug-Drug Interaction Module (DDIM)
- Supports drug products marketable in US
- Reports only most clinically significant interactions
- Evaluated at ingredient and route levels
- Four Severity levels
- classify drug interactions based on degree of patient risk
- do not incorporate level of documentation for an interaction

## Drug-Drug Interaction - FDB

- _Severity Level 1_ Contraindicated Drug Combination
- _Severity Level 2_ Severe Interaction* *
- _Severity Level 3_ Moderate Interaction
- _Severity Level 9_ Undetermined Severity- Alternative Therapy Interaction

## Drug-Drug Interaction - FDB

** **Professional Interaction Monograph
- Monograph Title
- Severity Level
- Mechanism of action
- Clinical Effects
- Predisposing factors
- Patient Management
- Discussion
- References

## Drug-Drug Interaction - FDB

- Consumer Interaction Monograph
- Monograph Title
- Medical Warning
- How the Interaction Occurs
- What Might Happen
- References

## Drug-Drug Interaction - FDB

- Customization
- Severity level may be changed
- Clinical effect codes for the interaction may be changed
- Custom messages may be assigned to the interaction
- Custom interaction may be created

## Enhanced Drug-Drug Interaction Order Check - VistA

- Continue to use VistA severity levels
- Critical
- Significant
- Customize FDB severity level and add custom interactions at National Level
- No change to current user actions in VistA

## Enhanced Drug-Drug Interaction Order Check – VistA (continued)

- Provide new warning message
- Display VistA severity
- Short description of interaction’s clinical effects
- Provide optional display of detailed interaction monograph (professional)

## Enhanced Drug-Drug Interaction Local Order Check - Outpatient

## Enhanced Drug-Drug Interaction Remote Order Check - Outpatient

## Enhanced Drug-Drug Interaction IV Order Check - Inpatient

## Enhanced Drug-Drug Interaction

## Enhanced Drug-Drug Interaction (continued)

## Professional Drug Monograph

## Professional Drug Interaction Monograph (continued)

## Enhanced Drug-Drug Interaction – Pharmacy Data Management

- Modify *Enter/Edit Local Drug Interaction* option
- No changes to Drug Interaction file (#56) locally
- Request severity change @ National
- Request add of drug interaction @ National
- Provide option to check if FDB link is up
- Notification when FDB link is down
- Provide report on order checks that could not be performed and that corrective action can be taken.

## New Option Check Drug Interaction

- Allows user to check drug interactions between two or more drugs
- Provided on Outpatient Pharmacy & Inpatient Medication (UD & IV modules) menus
- Selection from DRUG file (#50)

## New Option Check Drug Interaction (continued)

- User will see the following information:
- Numbered list of interacting drug pairs
- VistA severity
- Short description of drug interaction
- Detailed professional monograph (optional)
- Consumer interaction monograph (optional)

## New Option Check Drug Interaction (continued)

## New Option Check Drug Interaction (continued)

## New Option Check Drug Interaction (continued)

- New Option Check Drug Interaction (continued)

## New Option Check Drug Interaction (continued)

- New Option Check Drug Interaction (continued)

## Duplicate Ingredient & Duplicate Therapy Check - FDB

- FDB Duplicate Therapy Module
- Duplicate Ingredient checking compares ingredients of the drugs
- Duplicate Therapy Class checking
- uses therapeutic drug classes developed specifically for duplicate therapy selection
- identifies drug groups involved and provides a duplicate therapy class name relative to the duplication

## Drugs assigned to one or more classes 
classification category = MOA (e.g. Beta-Adrenergic Receptor Blockers, ACE inhibitors)
classification category = Therapeutic Indication (e.g. Anticonvulsants, Antimalarials)
Each Duplicate Therapy Class is assigned a duplication allowance 
Customization
Change duplication allowance for therapy class

- classification category = MOA (e.g. Beta-Adrenergic Receptor Blockers, ACE inhibitors)
- classification category = Therapeutic Indication (e.g. Anticonvulsants, Antimalarials)
- Each Duplicate Therapy Class is assigned a duplication allowance
- Customization
- Change duplication allowance for therapy class

- Duplicate Ingredient & Duplicate Therapy Check – FDB (continued)

**Notes:**
Each Duplicate Therapy Class is assigned a duplication allowance. The duplication allowance specifies the maximum number of duplicate therapy matches that can occur with a class without creating a warning.  Example follows:
Example 1:
Drug: Chloroquine Phosphate
Duplicate Therapy Class: Antimalarials
Duplication Allowance: 0
Number of duplications present?  1
Exceeds Allowance?   Yes
For the example above, the duplication allowance is zero. If more than one drug in the Antimalarial class is prescribed, a match occurs and a warning should be generated.
Example 2:
Drug 1:   Lovastatin
Drug 2: Atorvastatin
Duplicate Therapy Classes: Antihyperlipidemics; HMG-CoA Reductase Inhibitors
Duplication Allowance:   Antihyperlipidemics = 1 ; HMG- CoA Reductase Inhibitors = 0
Number of duplications present:  1 for both
Exceeds allowance:  No for Antihyperlipidemics & Yes for HMG – CoA Reductase Inhibitors
In the example above, 2 duplicate therapy matches occurs. For the Antihyperlipidemic match, the warning is suppressed because the duplication allowance for this class is one and therefore allowed.  The other match would exceed the allowance of zero and generate a warning message.

## Enhanced Duplicate Drug & Duplicate Class Checks - VistA

- VistA changes:
- Use FDB Enhanced Therapeutic Classification instead of VA drug class (order checks only)
- Outpatient Pharmacy Application
- left current VistA duplicate drug check
- added FDB duplicate ingredient check
- replaced VistA class check with FDB duplicate therapy check
- combined duplicate ingredient & therapy warnings
- no change in user actions to be taken

## Local Duplicate Drug - Outpatient

## Local Therapeutic Duplication - Outpatient

## Local and Remote Therapeutic Duplication - Outpatient

## Local/Remote Therapeutic & Ingredient Duplication - Outpatient

## Enhanced Duplicate Ingredient & Duplicate Therapy Checks - VistA

- VistA changes (continued):
- Inpatient Medications Application
- replaced duplicate drug with FDB duplicate ingredient
- replaced duplicate class with FDB duplicate therapy
- combined duplicate ingredient & therapy warnings
- no change in user actions to be taken

## Local Therapeutic Duplication  Inpatient

## Local/Remote Outpatient Orders  Therapeutic Duplication - Inpatient

## Local Therapeutic and Ingredient Duplication - Inpatient

## Local Therapeutic and Ingredient Duplication – Inpatient (continued)

## Therapeutic and/or Ingredient Duplication - Inpatient

## Dosage Checks - FDB

- Maximum Single Dose Check
- Daily Dosage Range Check
- General dosing range – Common Indicator

## Dosing Checks – FDB (continued)

- Information required by FDB:
- Patient parameters passed to API
- Age (in days) - required
- Weight (in Kg) – only req’d for certain drug/age combos
- Body Surface Area (BSA in m2) using DuBois formula – only req’d for certain drug/age combos

## Order information passed to API:
Drug – GCNSEQNO map to FDB
Single Dose Amount – Number or decimal value
Dose Unit  -  FDB Dose Unit (from VistA Drug unit map)
Dose Route – FDB Dose Route (from VistA Med Route map)

- Drug – GCNSEQNO map to FDB
- Single Dose Amount – Number or decimal value
- Dose Unit  -  FDB Dose Unit (from VistA Drug unit map)
- Dose Route – FDB Dose Route (from VistA Med Route map)

- Dosing Checks – FDB (continued)

## Order information passed to API
Dose Type – Maintenance, Single Dose, etc
Dose Rate – DAY, HOUR, MINUTE
Frequency - # of Administrations per Day; derived from VistA schedule
Duration - # of days dosing regimen administered
Duration Rate – DAY, HOUR, MINUTE
Common dose indication – when general dosing required.

- Dose Type – Maintenance, Single Dose, etc
- Dose Rate – DAY, HOUR, MINUTE
- Frequency - # of Administrations per Day; derived from VistA schedule
- Duration - # of days dosing regimen administered
- Duration Rate – DAY, HOUR, MINUTE
- Common dose indication – when general dosing required.

- Dosing Checks – FDB (continued)

## FDB Dosing Checks screen out
 Topicals
 Medical Supplies

-  Topicals
-  Medical Supplies

- Dosing Checks – FDB (continued)

## Dosage Checks - VistA

- VistA Changes
- Outpatient Pharmacy application
- For simple orders
- Dosing checks performed after conjunction prompt
- For complex orders
- Business rules defined for type of check(s) performed per dosing sequence
- Dosing checks performed after conjunction prompt

## Dosage Checks - VistA (continued)

- User must log intervention to continue
- Screened out supply items
- Dosing Check unable to be performed against vendor database
- User informed
- Reason for failure provided

## VistA changes:
Inpatient Medications application
Dosing checks after administration times prompt
Business rules defined for type of check(s) performed for order types 

- Inpatient Medications application
- Dosing checks after administration times prompt
- Business rules defined for type of check(s) performed for order types

- Dosage Checks - VistA (continued)

## User must log intervention to continue 
Screened out supply items
Dosing Check unable to be performed against vendor database
User informed
Reason for failure provided

- Screened out supply items
- Dosing Check unable to be performed against vendor database
- User informed
- Reason for failure provided

- Dosage Checks - VistA (continued)

## Dosage Checks - VistA (continued)

## Dosing ChecksPharmacy Data Management

- Pharmacy Data Management
- Add entries in APSP Intervention Type file (#9009032.3)
- Exceeds Max Single Dose
- Exceeds Daily Dose Range
- Exceeds Max Single Dose & Daily Dose Range

## Outpatient Pharmacy Verification Options – Dosing Checks

- Verification Options modified to incorporate dosing checks
- Same business rules as critical drug interaction
- Dosing warning displayed, no action required
- Non-verified status assigned to order
- Warning displayed on Rx label

## Verification OptionsDosing Checks

- Update Options
- Pharmacy Prescription Processing
- Complete Orders from OERR
- Rx Verification by Clerk
- Process Drug/Drug Interactions (renamed Process Order Checks)
- List Non-Verified Scripts

## Verification OptionsDosing Checks (continued)

## Verification OptionsDosing Checks (continued)

- Verification OptionsDosing Checks (continued)

## Verification OptionsDosing Checks (continued)

- Verification OptionsDosing Checks (continued)

## Verification OptionsDosing Checks (continued)

- Verification OptionsDosing Checks (continued)

## Verification OptionsDosing Checks (continued)

- Verification OptionsDosing Checks (continued)

## CPRS Order Checks Added

- CPRS Checks included in Pharmacy Checks (backdoor)
- Aminoglycoside Ordered
- Dangerous Meds for Pt over 64
- Glucophage- Lab Results

## Order Check History

- Order check details stored
- Types of order checks included
- Clozapine order checks
- CPRS order checks (front door generated)
- Pharmacy order checks (backdoor generated)
- Viewable through Activity log (OP & IP)

## Order Check History Details

- Date/Time
- Order Check Name
- Severity (drug-drug interactions)
- Interacting Rx #  (OP orders)
- Interacting Drug(s)
- Dosage (if complex order)

- Warning message (text)
- Override Reason
- Override Provider
- Pharmacy Intervention IEN
- Pharmacy Intervention Recommendation

- Information stored (depending on type of order/ order check)

## Order Check History Details

## Order Checks Against Patient Active Medication Profile

- A new ListMan hidden action - Medication profile screen
- User can perform order checks for one or more drugs against a patient’s active medication profile (IP & OP)
- Drug selection from DRUG file #50

## Order checks performed
Drug-Drug
Duplicate Ingredient
Duplicate Therapy 
Allergy/Adverse drug reaction (ADR) - against VistA database
Users can select order statuses to check against

- Drug-Drug
- Duplicate Ingredient
- Duplicate Therapy
- Allergy/Adverse drug reaction (ADR) - against VistA database
- Users can select order statuses to check against

- Order Checks Against Patient Active Medication Profile (continued)

## Optional detailed drug interaction monograph (consumer and professional)
For Inpatient Profile output - A list of drugs (from the outpatient profile) common to both inpatient & outpatient profiles  

- For Inpatient Profile output - A list of drugs (from the outpatient profile) common to both inpatient & outpatient profiles

- Order Checks Against Patient Active Medication Profile (continued)

## Order Checks Against Patient Active Medication Profile (continued)

- Order Checks Against Patient Active Medication Profile (continued)

## Order Checks Against Patient Active Medication Profile (continued)

- Order Checks Against Patient Active Medication Profile (continued)

## Order Checks Against Patient Active Medication Profile (continued)

## Order Checks Against Patient Active Medication Profile (continued)

- Order Checks Against Patient Active Medication Profile (continued)

## Order Checks Against Patient Active Medication Profile (continued)

- Order Checks Against Patient Active Medication Profile (continued)

## Pharmacy Order Check Display Order

- Make display order consistent between Outpatient and Inpatient
- When finishing pending orders
- Entering new orders via backdoor
- Allow user action after display - Inpatient
- Minimize performance issues
- Decrease Number of Warning Displays

## Enhance Allergy/ADR Order Check Display

- Display the same order check information for Outpatient Pharmacy and Inpatient Medication applications
- Combine Local and Remote Allergy/ADR warnings

## Enhance Allergy/ADR Order Check Display (continued)

## Pharmacy Order Check Display Order

- Outpatient Pharmacy
- Allergy/ADR (local and remote combined)
- CPRS order checks (new)
- Local Critical and Significant drug interactions
- Remote Drug Interactions
- Local & Remote Duplicate Therapy/Duplicate Ingredient or Drug
- Dosing Checks

## Inpatient Medications
Allergy/ADR (local and remote combined)
CPRS order checks (new)
Local Critical and Significant drug interactions 
Outpatient  Medication Orders (local and remote) –Drug Interactions
Duplicate Therapy - Local Inpatient, Outpatient Local & Remote 
Duplicate Therapy/Duplicate – Local Inpatient, Outpatient Local & Remote
Dosing Checks 

- Allergy/ADR (local and remote combined)
- CPRS order checks (new)
- Local Critical and Significant drug interactions
- Outpatient  Medication Orders (local and remote) –Drug Interactions
- Duplicate Therapy - Local Inpatient, Outpatient Local & Remote
- Duplicate Therapy/Duplicate – Local Inpatient, Outpatient Local & Remote
- Dosing Checks

- Pharmacy Order Check Display Order (continued)

## Intervention Hidden Action

- Provide Intervention Menu Hidden Action to
- Delete an intervention
- Edit an intervention
- Enter an intervention
- Print an intervention
- View an intervention

## Intervention Hidden Action (continued)

- Place on Outpatient and Inpatient ListMan screens
- Patient Information
- Medication Profile
- Detailed Order

## Discontinued/Expired Medication Orders

- Identify Recently Discontinued/Expired Orders on Medication Profile
- Outpatient Pharmacy
- Displayed via reverse video
- Inpatient Medications
- Listed under New profile sub header

## Provide parameters to define ‘recently discontinued/expired’ timeframe
Outpatient Pharmacy
 Outpatient Site Parameter (7- 45 day range; If no value assigned, system assumes 7 days)
 Use Site Parameter Enter/Edit option

- Outpatient Pharmacy
-  Outpatient Site Parameter (7- 45 day range; If no value assigned, system assumes 7 days)
-  Use Site Parameter Enter/Edit option

- Discontinued/Expired Medication Orders (continued)

## Inpatient Medications
System Parameters (1-120 hour range, If no value assigned, system assumes 24 hours)
Use Systems Parameter Edit option 
Ward Parameters (1-120 hour range; no default; takes precedence over system parameter value)
Use Inpatient Ward Parameters Edit option

- System Parameters (1-120 hour range, If no value assigned, system assumes 24 hours)
- Use *Systems Parameter Edit* option
- Ward Parameters (1-120 hour range; no default; takes precedence over system parameter value)
- Use *Inpatient Ward Parameters Edit* option

- Discontinued/Expired Medication Orders (continued)

## Discontinued/Held Medication Orders

- Quick identification of action by which orders were discontinued/held
-  Display new code on medication profile
-  No change in order status

## Discontinued/Held Medication Orders (continued)

- Outpatient  Discontinue Type Codes
- DF – Discontinued due to edit by provider through CPRS
- DE – Discontinued due to edit via backdoor Pharmacy
- DP – Discontinued by provider through CPRS
- DC – Discontinued via backdoor Pharmacy
- DD – Discontinued due to death
- DA – Auto discontinued due to admission

## Discontinued/Held Medication Orders (continued)

- Inpatient Discontinue Type Codes
- DF – Discontinued due to edit by a provider through CPRS
- DE – Discontinued due to edit via backdoor Pharmacy
- DP – Discontinued by provider through CPRS
- D – Discontinued via backdoor Pharmacy
- DD – Auto discontinued due to death
- DA – Auto discontinued due to patient movements

## Discontinued/Held  Medication Orders – Hold Action

- Hold Action Type Codes (Outpatient & Inpatient)
- HP – Placed on hold by provider through CPRS
- H – Placed on hold via backdoor Pharmacy

## Outpatient Medication Profile

## Inpatient Medication Short Profile

## Inpatient Medication Long Profile

## PRE V. 1.0 Pharmacy Enterprise Product System (PEPS)

- Cathryn Herren

## PRE 1.0 Focus

## General Information 

- Replacement for National Drug File (NDF) and Pharmacy Data Management (PDM) applications
- Involves integration with COTS
- Involves integration with VistA

**Notes:**
PEPS = Pharmacy Enterprise Product System
COTS = Commercial Off the Shelf product

## PEPS  Roles

- PEPS National Manager
- Manages PEPS items at an enterprise level
- Reviews new item requests
- Reviews new COTS items
- Determines state of VA Data Fields
- PEPS Local Manager
- Manages PEPS items at a local level
- Requests new item additions
- Determines values of VA Data Fields for local use

## PEPS Functionality

- Search Items
- Add Items
- Review Items
- Manage Items
- VistA File Synchronization

- Examine PEPS
- Order Checks
- VA Data Fields

## Add New Item

- Search PEPS
- Local and National
- Enter using existing item as template
- Local and National
- Enter without using existing item as template
- Local and National

## Add New Item (continued)

- Mark Item for local use (Local)
- Product entered into Local Drug file (#50)
- Orderable Item Auto Created
- Vista Notification to requestor and locally created mail group
- Request sent to National PEPS Manager (Local)
- Ability to Lock down VA Data Fields (National)

## Review Requests at National

- List of pending requests ready for review
- Makes data edits as needed
- Ability to lock down VA Data Fields
- Second Review prior to approval

## Review Approved by National

- National and local NDF updated
- PDM files updated if marked for local use
- Auto Match to NDF
- Orderable Item Auto Created (if changed)
- VistA Notification of NDF and PDM update sent to local

## Review Rejected by National

- National NDF & Local NDFs NOT updated
- IF product had been marked for local use at requesting facility
- Unmarked for local use in PEPS
- Inactivated in Drug File #50
- VistA Notification of  PDM update sent to local
- Includes orders containing the product

## Manage Items at Local

- Mark for Local Use
- Edit VA Data Fields
- Product entered into Local Drug file (#50)
- Orderable Item Auto Created
- Vista Notification to requestor and locally created mail group

## Manage Item at Local (continued)

- Edit VA Data Fields
- For items previously marked for local use
- Unmark for Local Use
- Item inactivated in Local Drug File #50
- Vista Notification to requestor and locally created mail group

## Manage Items at National

- Edit VA Data Fields
- Ability to Lock Down VA Data Fields
- Ability to have second review
- National NDF and Local NDFs updated once approved by second review
- PDM files updated locally if marked for local use
- VistA Notification of NDF and PDM update sent to local

## National Review of COTS Update

- List of COTS Items Pending Review
- Makes VA specific data edits as needed
- Ability to lock down VA Data Fields
- Second Review prior to approval
- National NDF and Local NDFs updated once approved by second review
- VistA Notification of NDF  update sent to local

## VA Data Fields - PEPS

- Data fields stored in PEPS, but not in VistA
- Data pulled from PEPS for use in VistA Pharmacy applications
- Outpatient Pharmacy
- Inpatient Medications
- Automatic Replenishment/Ward Stock
- BCMA

## Lab Results/Vital Measurements Display

- Define for a specific product in the EPL
- Lab test, specimen, functional area
- Vital measurement, functional area
- Information displayed in
- Outpatient Pharmacy
- Inpatient Medications
- BCMA

## An indicator ‘!’ in reverse video is shown on the medication profile and detailed order display 
No indicator if order status is ‘expired’ or ‘discontinued’

- No indicator if order status is ‘expired’ or ‘discontinued’

- Lab Results/Vital Measurements Display (continued)

## Where Lab results/vital measurements are displayed based on functional area defined:
Order Entry
Finishing a Pending order
Medication Administration (BCMA)
Information displayed before order checks performed

- Order Entry
- Finishing a Pending order
- Medication Administration (BCMA)
- Information displayed before order checks performed

- Lab Results/Vital Measurements Display (continued)

## Three new hidden actions 
LAB  Lab Results
VIT  Vital Measurements 
LV  Latest Lab/Vital
All hidden actions available from medication profile & detailed order screens

- LAB  Lab Results
- VIT  Vital Measurements
- LV  Latest Lab/Vital
- All hidden actions available from medication profile & detailed order screens

- Lab Results/Vital Measurements Display (continued)

## Parameters provided to set a default 
System/Ward level for Inpatient Medications
System/Outpatient Site level for Outpatient Pharmacy
Occurrence Limit (LAB & VIT)
Time limit (LAB & VIT)

- System/Ward level for Inpatient Medications
- System/Outpatient Site level for Outpatient Pharmacy
- Occurrence Limit (LAB & VIT)
- Time limit (LAB & VIT)

- Lab Results/Vital Measurements Display (continued)

## Do Not MailOutpatient Pharmacy

- Currently user can indicate that Patient’s meds cannot be mailed
- Added functionality
- Identify products in EPL that cannot be mailed
- Pharmacy Orderable Items for a patient that cannot be mailed (VistA)
- Patient for which Controlled Subs cannot be mailed (VistA)

## If patient/drug marked ‘Do Not Mail’
Mail routing defaults to ‘Window’ 
User cannot edit routing
‘Patient or drug for patient is DO NOT MAIL’ displayed 
During various order entry process (finishing, editing, renewing, etc)
On detailed display of order

- Mail routing defaults to ‘Window’
- User cannot edit routing
- ‘Patient or drug for patient is DO NOT MAIL’ displayed
- During various order entry process (finishing, editing, renewing, etc)
- On detailed display of order

- Do Not MailOutpatient Pharmacy (continued)

## Dispense Limit (Qty)Outpatient Pharmacy

- Maximum quantity to dispense (number) for a specific time period (days) defined in EPL for a product
- Used to calculate default quantity for an order if value defined in EPL < result using schedule & days supply values
- If user enters a quantity exceeding this value
- warning message is displayed
- Override reason required
- Override reason stored with each Rx fill

## Dispense Limit (Days Supply) Outpatient Pharmacy

- Maximum days supply limit for product identified in the EPL
- Maximum upper limit for a drug = 90 days
- Maximum upper limit for a supply = 365 days
- Default upper limit for a CS = 30 days

## Limit Days Supply (new field)
Created in Rx Patient Status file #53
Data type – set of codes (Y/N)
Export with value of ‘Yes’ for
AUTH ABS +96
AUTH ABS -96
EMPLOYEE
Rx Patient Status Enter/Edit (new option)
Created to maintain all fields in Rx Patient Status file #53

- Created in Rx Patient Status file #53
- Data type – set of codes (Y/N)
- Export with value of ‘Yes’ for
- AUTH ABS +96
- AUTH ABS -96
- EMPLOYEE
*Rx Patient Status Enter/Edit (new option)*
- Created to maintain all fields in Rx Patient Status file #53

- Dispense Limit (Days Supply) Outpatient Pharmacy

## During order entry, the days supply default will be...
Days supply defined for Rx Patient Status (order) if Limit Days Supply field is set to Yes
Dispense limit (days supply) if defined in EPL for the product when Limit Days Supply field is set to ‘No’ or null
Days supply defined for Rx Patient Status (order) if dispense limit (days supply) IS NOT defined in the EPL for the product

- Days supply defined for Rx Patient Status (order) if Limit Days Supply field is set to Yes
- Dispense limit (days supply) if defined in EPL for the product when Limit Days Supply field is set to ‘No’ or null
- Days supply defined for Rx Patient Status (order) if dispense limit (days supply) _IS NOT_ defined in the EPL for the product

- Dispense Limit (Days Supply) Outpatient Pharmacy

## Product Storage Requirements

- Product Identified in EPL
- Protect from light
- Inpatient Medications
- IV label
- Requiring refrigeration
- Inpatient Medications
- Unit Dose Pick List & Updated Pick List
- Pre-exchange Unit Report
- Automatic Replenishment/Ward Stock (AR/WS)
- Pick List

## Patient Specific Labels

- Product Identified in EPL
- Inpatient Medications
- Pre-exchange Unit Report
- Extra Units Dispensed
- BCMA
- Missing Dose e-mail and printed copy

## New BCMA Functionality 

- Provides a means to quickly identify
- Controlled Substances
- Drugs that require a witness (2nd signature) and capture the 2nd signature
- High-Risk drugs that require follow-up and document the follow-up action
- Display Lab and Vital information based on the drug being administered
- Create/modify BCMA reports to support this functionality

**Notes:**
While some of the requirements shown are long standing BCMA requests, the implementation of PEPS allows BCMA to move forward with their implementation in a meaningful way.

An example of this is the display of Labs and Vitals information. As many of you know the PRN dialog boxes in BCMA already display vitals information. But, since there was no way to determine what vital sign should be displayed for a specific drug... BCMA implemented a generic display of the “Big 5” 

Now with the implementation of PEPS specific information can be displayed with a specific order based on the relationship of the Lab or Vital to the drug.

## BCMA - Visual Queues

- “Provide a means to quickly identify”...
- 	Three new icons have been added to BCMA to quickly relay information related to a specific administration or order:
- Controlled Substance
- Drug that requires a Witness (2nd signature)
- High-Risk drug requiring a Follow-Up

## Questions?