# Ordering Medications Overview

Using CPRS, providers can order inpatient and outpatient medications with simple doses or complex doses. Providers can place medications orders for unit dose or infusion orders for inpatients. Also, CPRS enables providers to quickly order medications that will be given in clinics.

There are a few items that deal with how CPRS works that providers need to be aware of when ordering medications, such as

1. the need for inpatient medications to have a valid schedule, including the option to use the schedule builder
2. a possible error if there is mismatch between the CPRS order number and the pharmacy order number
3. how CPRS displays unit dose routes
4. how CPRS displays non-formulary drugs
5. requirements for Clozapine treatment

This section then goes through how to order medications for inpatients, outpatients, and patients seen in clinic. The various sections will also include how to write medication orders for unit dose and infusion orders.

## Valid Routes for Inpatient Medications

Inpatient medication orders now require a valid schedule. If users do not find the appropriate schedule in the list, they can choose to create a day-of week/administration time schedule using the new Schedule Builder. This feature also works for renewing, copying, and changing inpatient medication orders. The procedure for ordering medications is described below.

Note: Because a valid schedule is required, if you attempt to modify an existing medication order that does not have a valid schedule, you will receive a message box stating that and will have to enter a valid schedule.

## Order Number Mismatch between CPRS and Pharmacy

When a user takes actions on an order, such as renewing, changing, or discontinuing it, an infrequent error sometimes occurs where the order number in CPRS and the order in Pharmacy do not match. In this case, CPRS displays a warning that there is an “invalid pharmacy order number” and instructing the user to contact someone in the Pharmacy service to complete the action.

## Rules for the Display of Unit Dose Routes in CPRS

CPRS displays unit dose routes based on the following rules:

1. If a default medication route is defined in the orderable item file, CPRS displays only the default medication route for the Unit Dose orderable item in the medication route selection list.
2. If there is no default medication route defined for the orderable item, CPRS displays all possible medication routes for the dosage form to the provider for selection.
3. If there is only one possible medication route, it will be used as the default.
4. If a medication route name or its abbreviation is not included in the selection list, a user may type it in.

## How CPRS Designates Non-Formulary Drugs

Also, medications that are not in the formulary display in the list with the letters “NF” after the name or synonym, which is also displayed. CPRS checks for nonformulary dosages (e.g., the VA formulary may not have a 2.5 MG pill, but it may have a 5.0 MG pill) and for non-formulary orderable items (e.g., the VA may not carry a specific kind of allergy medication).

## New Clozapine Requirements

Note: The following information was provided by the National Clozapine Coordination Project completed in Mental Health patch YS*5.01*122.

Enhanced and new functionality includes updated FDA guidelines for using ANC lab results exclusively for treating and monitoring patients taking clozapine, as shown in the following table. The new guidelines replace previous requirements which included both white blood cell (WBC) count and ANC lab results. The Mental Health software’s code replaces the WBC/ANC results combination and supports ANC values solely as the lab value of choice.

Note: FDA REMS prescribed dosage and monitoring is based on the ANC value only; however, VA requires a matching WBC, indicating the WBC is from the same draw date/time as the ANC.

FDA ANC Levels and Monitoring Guidelines

ANC Level | ANC Monitoring | Frequency of ANC lab tests
Normal range | ANC ≥ 1500 cmm | Weekly (W) for patients 1 – 6 months on therapy Bi-weekly (B) for patients 6 – 12 months on therapy Monthly (M) for patients >12 months on therapy
Mild neutropenia | 1000 – 1499 cmm | ANC labs 3 times weekly until ANC stabilizes to 1500 cmm or greater
Moderate neutropenia | 500 – 999 cmm | ANC labs Daily until ANC stabilizes to 1000 cmm or greater, then 3 times weekly until ANC stabilizes to 1500 cmm or greater
Severe neutropenia | < 500 cmm | ANC labs Daily until ANC stabilizes to 1000 cmm or greater, then 3 times weekly until ANC stabilizes to 1500 cmm or greater

Note: The ANC unit of measure is expressed as cells per cubic millimeter (cmm) which is equivalent to cu mm, mm3 or µL.

Absolute Neutrophil Count (ANC) is lab test of choice | Per the REMS document, “the WBC count is required in order to calculate the ANC; however, ANC is a more relevant indicator of drug-induced neutropenia than WBC count.” New and enhanced functionality is based on the presence of an ANC result in the last 7 days.
ANC less than 1000 cmm | The FDA recommends that clozapine treatment be discontinued if the ANC is less than 1000 cmm; however, with correct documentation and justification by the provider, the NCCC Director has the discretion to continue treatment through a National Override.

Note: Recently the FDA offered continuation of clozapine when a patient’s ANC result is less than 1000 cmm. To continue clozapine in this situation, VA requires the patient to sign a special informed consent form in which the patient accepts the risks of continuation and prescriber’s clinical justification for medical review is documented by the Director of NCCC.

The other order checks related to clozapine will continue to work as they have prior to these changes.

Additionally, the values of the Days Supply, Quantity, and Refills fields are restricted based on the type of patient that Mental Health designates in their files when the provider is ordering clozapine. This can be a 7, 14, or 28-day recipient of the clozapine drug. For refills, the following rules apply:

- Patients on a 7-day monitoring frequency have no refills available.
- Patients on a 14-day monitoring frequency can receive a full 14-day supply or a 7-day supply and ONE refill.
- Patients on a 28-day monitoring frequency can receive EITHER a full 28day supply, or a 14-day supply and ONE refill, or a 7-day supply and THREE refills.

CPRS now prevents the user from renewing outpatient and inpatient clozapine orders.

Note: Clozapine orders should not be renewed and each order for clozapine should be entered as a new order. Renewal of clozapine is not allowed in CPRS from the Orders tab of the chart and renew is also blocked in the VistA Pharmacy Software. CPRS currently allows clozapine renewal from the CPRS Meds tab. This is a known issue and users should not attempt to renew orders for clozapine.

## Normal ANC Results

The FDA defines Normal – sometimes referred to as “safe” or “passing” ANC results – as equal to or greater than 1500 cmm. When the system identifies that the ANC results are Normal and a matching WBC is present, the provider completes the prescription/order which is sent as a Pending Order to pharmacy. There are no message updates in CPRS for a Normal ANC result.

## Mild Neutropenia

The FDA defines Mild neutropenia as an ANC result from 1000 to 1499 cmm. New ANC lab test monitoring guidelines for Mild neutropenia are presented to the ordering provider in a new CPRS message:

Test ANC labs 3x weekly until levels stabilize to greater than or equal to 1500 cmm.

## Moderate and Severe Neutropenia

FDA defines Moderate neutropenia as ANC 500-999 cmm and severe neutropenia as ANC less than 500 cmm. Both Moderate and Severe neutropenia require the same lab test monitoring guidelines as they are both less than 1000 cmm. A new CPRS message includes:

Test ANC labs daily until levels stabilize to equal to or greater than 1000 cmm, then test ANC labs 3x weekly until levels stabilize to greater than or equal to 1500 cmm.

When there is Moderate or Severe neutropenia with a matching WBC result present, a National Override is required. If a matching WBC result is not present, the system will alert the provider that the system will address the ‘No Matching WBC’ issue first. See information on No Matching WBC.

## Moderate and Severe Neutropenia – National Override in Effect

When a National Override for Moderate or Severe Neutropenia has been approved by the NCCC and is in effect, modified CPRS screens display, including instructions for testing ANC.

## No ANC Results

The system relies on the presence of an ANC result to treat patients receiving clozapine, with exceptions as noted to override in certain conditions. The system requires an ANC within the last 7 days.

For registered patients with a history of normal ANC results, the requirement for a normal ANC result in the last 7 days may be bypassed to meet an urgent need under special conditions.

In CPRS, when the provider is notified that there are no ANC results in the last seven days, they will decide based on the following:

1. Non-emergency

   If this is not an emergency, the provider will request a National Override to dispense the clozapine at the patient’s normal frequency. When the National Override is authorized and recorded in the local VistA system, the provider reenters the order and a Pending prescription/order to dispense clozapine at the patient’s normal frequency is sent.

   For example, this may be used when:

   1. The patient’s last blood test was done at another facility and isn’t in the local VistA system, but the provider has seen the results

   2. The provider feels it is unnecessary – perhaps the patient is at end of life or some other medical condition – and there is no need to keep drawing blood

2. Emergency 4-day supply – Special Conditions Local Override

   In an emergency where a 4-day supply is needed, the provider may choose to use a Special Conditions Local Override which optionally allows a one-time 4-day emergency supply to be dispensed for specific prescriber-approved reasons.

   Note: A written prescription or order is required. Special Conditions Local Override is not supported in CPRS – no Pending Order is available.

If the patient is an Outpatient, the prescriber-approved reason must be one of the following:

1. Weather-related conditions
2. Mail order delay
3. Inpatient going on leave

If the patient is an Inpatient, the prescriber-approved reason will be:

IP Order Override with Outside Lab Results

When there is No ANC result for the last 7 days, a new CPRS screen displays notifying the provider of the missing results. The top part of the new CPRS message indicates the option to request a National Override when the condition is not an emergency and clozapine is to be dispensed at the patient’s normal frequency.

If this is an emergency, the bottom part of the new CPRS message is dependent on whether this is an Outpatient or and Inpatient.

### Outpatient

If this is an Outpatient, the second part of the message is to instruct the provider to write a prescription and include an approved reason from the list.

### Inpatient

If this is an Inpatient, the second part of the message is to instruct the provider to write an order and include the single approved reason – IP Order Override with Outside Lab Results.

## No Matching WBC (ANC Present)

When there is an ANC result in the last 7 days but no matching WBC, regardless of whether it is a normal result or indicates mild or moderate to severe neutropenia, the system will address the ‘No Matching WBC’ condition first. A warning message to the provider will require a National Override in order to dispense clozapine. The system can only address one condition at a time.

Note: A Matching WBC result is collected at the same draw date/time as the ANC.

## Emergency Registration Override

An Emergency Registration Override is typically warranted for the following reasons:

1. The patient has a current NCCC registration at another VistA facility
   - Inpatient transferred from another facility
   - Outpatient from another facility becomes an inpatient
2. The patient has never been registered at the local facility
3. The patient status has changed from Active to Discontinued
4. An Outpatient with a prescription that had previously been filled outside of the VA or at another VA facility arrives during NCCC non-duty hours

Note: A Clozapine Authorization Number is only valid for a patient at the facility where they were registered. When a Clozapine patient arrives at a new facility, they need to be re-registered with a new Clozapine Authorization Number before the facility’s CPRS and Pharmacy applications will allow a Clozapine order to be processed.

If the patient is not actively registered at NCCC, this new CPRS message displays to the provider prior to a hard stop:

*** This patient is not registered in the clozapine treatment program or has been discontinued from the program. A new registration number must be assigned. If this is not an emergency, contact the NCCC. For emergency registration during non-NCCC duty hours, a written order to the pharmacist can be used to process a registration override. ***

Related Topics

Viewing Medications

Sorting the Medications View

Ordering Inpatient Medications (Simple Dose)

Ordering Inpatient Medications (Complex Dose)

Ordering Outpatient Medications (Simple Dose)

Ordering Outpatient Medications (Complex Dose)

Change Medication Order

Discontinue Medication Order

Hold Medication Order

Renew Medication Order

Other Medication Actions (popup menu)