$TXT Created by at DVACACHE.FO-BIRM.DOMAIN.EXT (KIDS) on Thursday, 07/31/14 at 15:00 ============================================================================= Run Date: SEP 02, 2014 Designation: PSO*7*313 Package : PSO - OUTPATIENT PHARMACY Priority: Mandatory Version : 7 SEQ #368 Status: Released Compliance Date: OCT 03, 2014 ============================================================================= Associated patches: (v)PSO*7*337 <<= must be installed BEFORE `PSO*7*313' (v)PSO*7*362 <<= must be installed BEFORE `PSO*7*313' (v)PSO*7*417 <<= must be installed BEFORE `PSO*7*313' (v)PSO*7*431 <<= must be installed BEFORE `PSO*7*313' Subject: TITRATION/MAINTENANCE RX Category: - Enhancement (Mandatory) - Routine - Data Dictionary - Other Description: ============ This patch PSO*7*313 includes the following enhancements: 1. Complex Orders Duration Field 2. Titration/Maintenance Rx 1. Complex Orders Duration Field ================================ This Enhancement is related to Patient Safety Issue PSI-07-167 and Remedy Ticket # 203088. The Outpatient Pharmacy application currently allows the entry of a complex order, which contains a "THEN" conjunction. This type of order is allowed to leave the Duration field preceding the "THEN" conjunction as null. This null duration field is causing issues when the Outpatient Pharmacy order was being transferred to an Inpatient Medication Order(s). The default stop dates were for thirty (30) days for the two (2) new inpatient orders created and the Start/Stop dates in the sequence were incorrect. The pharmacist did not notice the incorrect dates and finished off the orders. Upon transfer of a complex order from Outpatient Pharmacy to Inpatient Medication order(s), the resulting order will start at the first step rather than continue at the step the patient was at as an Outpatient. It looks like a new complex order to the finishing pharmacist, since the Start date is populated with the date of finishing so that the patient would be started on the first step, which may not be correct. This would pertain to complex orders that taper or titrate doses up or down and potentially impacts patients by receiving too much or too little medication. The Outpatient Pharmacy is being modified to require the entry of a duration for a dose preceding a THEN conjunction if the schedule for such dose is not a ONE-TIME type schedule. If the dose preceding the THEN conjunction is a ONE-TIME type schedule the software will continue to allow the Duration field to be left blank (optional). The corresponding change to CPRS will be done in a future CPRS patch. Example of an acceptable SIG ('NOW' is ONE-TIME type schedule): -------------------------------------------------------------- TAKE ONE TABLET BY MOUTH NOW THEN TAKE TWO TABLETS EVERY 8 HOURS No longer acceptable SIG ('Q4H' is not ONE-TIME type schedule): -------------------------------------------------------------- TAKE ONE TABLET BY MOUTH EVERY 4 HOURS THEN TAKE TWO TABLETS EVERY 8 HOURS Note: The SIG above is not acceptable because it does not have a Duration for the first dose. In order to be acceptable the SIG above would have to have a duration like the one below: TAKE ONE TABLET BY MOUTH EVERY 4 HOURS FOR 3 DAYS THEN TAKE TWO TABLETS EVERY 8 HOURS The Duration field is not required for the dose following the last "THEN" conjunction. Below is an example of a complex order being entered via Patient Prescription Processing [PSO LM BACKDOOR ORDERS] : : VERB: APPLY ROUTE: PO// PO ORAL Schedule: QD (EVERY DAY) LIMITED DURATION (IN DAYS, HOURS OR MINUTES): CONJUNCTION: THEN Duration field required for the dosage entered prior to this THEN conjunction. LIMITED DURATION (IN DAYS, HOURS OR MINUTES): : : 2. Titration/Maintenance Rx =========================== This Enhancement is related to PSI-06-176 and Remedy Ticket #168928. The Outpatient Pharmacy (OP) application was modified to accommodate Titration/Maintenance prescription functionality. The existing software presented patient safety risks when prescriptions dispensed with a titrating dose followed by a maintenance dose were being copied, renewed or refilled. The issue was that refills as well as the new prescriptions (derived from copy, renewals or edits) automatically carried over the initial titrating dose into the new fill/prescription, which was not always the user's intention. The new functionality provides two steps for processing Titration/ Maintenance prescriptions. a. First, the user will have the ability to mark prescriptions as 'Titration to Maintenance' when finishing prescriptions from CPRS as well as via the Patient Prescription Processing [PSO LM BACKDOOR ORDERS] option by invoking the new hidden action 'TM' - Mark Rx as Titration. This action will result in preventing the following actions to be taken on the prescription: Refill, Renewal (including via CPRS), Copy and editing of any field that requires a new Rx to be created. This action will also set the new field TITRATION RX FLAG (#45.3) in the PRESCRIPTION File (#52) as well as the new field TITRATION DOSE RX (#45.1) in the PRESCRIPTION File (#52). Prescriptions that are marked as Titration/Maintenance will have the letter 't' postfix to the RX # as seen below (entry #1): : : : ISSUE LAST REF DAY # RX # DRUG QTY ST DATE FILL REM SUP -------------------------------ACTIVE------------------------------- 1 100005024t AMOXAPINE 50MG TAB 30 S 09-26 09-26 2 30 2 100005022 AMOXICILLIN 250MG CAP 30 A 08-18 08-18 11 30 3 100005035 KALETRA 3 A 09-29 09-29 0 3 : : : Note: A prescription can be unmarked as Titration/Maintenance by invoking the same TM action on an already marked prescription. b. A new hidden action is being introduced in the Patient Prescription Processing [LM BACKDOOR ORDERS] option called TR (Convert Titration Rx). This action will populate the new field MAINTENANCE DOSE RX (#45.2) in the PRESCRIPTION File (#52). When a titration to maintenance prescription needs to be refilled so the patient can continue on the Maintenance Dose this option will allow the users to create a new prescription with the maintenance dose only. The process works similar to copying an existing prescription, however it can only be used on prescriptions with the following characteristics: - Rx is a complex order with a THEN conjunction - Rx was not digitally signed - Rx is released - Rx status is ACTIVE - Rx does not have refills previously ordered - Rx # Of Refills is greater than 0 (zero) Before the new Maintenance Rx can be accepted the Pharmacist is prompted to validate the QTY field for the new Rx, which may or may not be automatically re-calculated. Only the last dose from the original prescription is carried over to the new Maintenance Rx and the # of Refills field is decreased by 1 because the new Maintenance Rx counts as a fill. The Fill Date for the new Maintenance prescription is automatically set with the next possible fill date from the existing prescription, which can be changed by the pharmacist. Once the pharmacist verifies the information for the Maintenance Rx is accurate they can accept the Maintenance Rx. This action will trigger a Duplicate Drug check against the original complex order, which must be discontinued before the new Maintenance Rx can be accepted. After the new Maintenance Rx is accepted it will have the new indicator 'm' on the right side of the Rx # in the patient's Medication Profile as seen below (entry #1): : : : ISSUE LAST REF DAY # RX # DRUG QTY ST DATE FILL REM SUP -------------------------------ACTIVE------------------------------- 1 100005436m AMOXAPINE 50MG TAB 30 S 09-26 09-26 1 30 2 100005022 AMOXICILLIN 250MG CAP 30 A 08-18 08-18 11 30 3 100005035 KALETRA 3 A 09-29 09-29 0 3 : : : c. The new Titration/Maintenance indicator (t/m) will be included in the following menu options where the prescription number is displayed: View Prescriptions [PSO VIEW] Patient Prescription Processing [PSO LM BACKDOOR ORDERS] Complete Orders from OERR [PSO LMOE FINISH] ePharmacy Medication Profile (View Only) [PSO PMP] Medication Profile [PSO P] d. External refill requests such as from AudioFax and Internet will not be processed for Titration/Maintenance marked prescriptions. Subj: ALBANY External Application Refills: Not processed List [#101509] 01/28/09@13:52 11 lines From: POSTMASTER In 'IN' basket. Page 1 ------------------------------------------------------------------------- Refills Not Processed Report for the ALBANY Division. The following refill requests were not processed: Patient: OPPATIENT,TWO (9999) Rx #: 100005122 (REF #1) Qty: 55 Drug: ZINC SULFATE 66MG TAB Reason: 'Titration/Maintenance Rx' cannot be refilled. e. CPRS refill requests will not be automatically processed for Titration/Maintenance marked prescriptions. The refill request will remain in the patient's Medication Profile as PENDING and the mailman message above (item d) will also be sent to PSOAUTRF security key holders. f. The activity logs for both Titration and Maintenance Rx's will record the corresponding Titration and Maintenance Rx # if they exist as seen below: Titration Rx: ------------ # Date Reason Rx Ref Initiator of Activity ====================================================================== 1 09/29/08 EDIT ORIGINAL OPUSER,ONE Comments: Maintenance Dose Rx: 100005130 Maintenance Rx: -------------- # Date Reason Rx Ref Initiator of Activity ====================================================================== 1 09/29/08 EDIT ORIGINAL OPUSER,TWO Comments: Titration Dose Rx: 100005392 g. The VistA Integration Control Registration (ICR) #2398 provided to Computerized Patient Record System V. 1.0 (CPRS) was modified to prevent the renewal of a Titration dose order with the following message: "Prescription was marked as Titration to Maintenance Dose by Pharmacy and cannot be renewed. To repeat the titration, enter a new prescription or copy the prior titration order. To continue the maintenance dose, refill this prescription if refills are available or enter a new prescription for the maintenance dose." h. When using the Barcode Batch Prescription Entry option [PSO BATCH BARCODE], if the prescription has been marked as a Titration/Maintenance Rx, and the user attempts to renew or refill the prescription, the following message will display: For a renewal: "Rx# XXXXXX is marked as Titration Rx and cannot be renewed." For a refill: "Rx# XXXXXX is marked as Titration Rx and cannot be refilled." i. The PSO HIDDEN ACTIONS Protocol in the PROTOCOL File (#101) will be modified to include the two new Hidden Actions introduced by this enhancement. PSO LM BACKDOOR MARK AS TITRATION and PSO LM BACKDOOR TITRATION RX REFILL are both new protocols added to the PROTOCOL File (#101). ****************************** IMPORTANT ****************************** The enhancements related to Titration/Maintenance dose Rx are made only for Outpatient Pharmacy package. The corresponding changes to CPRS package are not included at this time. Therefore, the CPRS Order Copy and Order Change functionalities will continue to function as is. Furthermore, there will be no indication of a Titration/Maintenance order in the CPRS application. ************************************************************************* 3. Remedy Ticket #1022059 This patch fixes an issue that could create duplicate prescriptions on a patient profile. When a complex order is copied and the duration field is edited, upon accepting the order, the message to discontinue the original order is not triggered. This causes duplicate prescriptions to appear on the patient profile. This patch corrects this problem by prompting the user to discontinue the original order. Patch Components ================ Files & Fields Associated: File Name (#) Field Name (#) New/Mod/Del ------------- -------------- ----------- PRESCRIPTION (#52) TITRATION DOSE RX (#45.1) New PRESCRIPTION (#52) MAINTENANCE DOSE RX (#45.2) New PRESCRIPTION (#52) TITRATION RX FLAG (#45.3) New Forms Associated: Form Name File # New/Mod/Del --------- ------ ----------- N/A Mail Groups Associated: Mail Group Name New/Mod/Del --------------- ----------- N/A Options Associated: Option Name Type New/Mod/Del ----------- ---- ----------- N/A Protocols Associated: Protocol Name New/Mod/Del Action ------------- ----------- ------ PSO HIDDEN ACTIONS Modified USE AS A LINK FOR MENU/ITEM PSO LM BACKDOOR MARK AS TITRATION New SEND TO SITE PSO LM BACKDOOR TITRATION RX REFILL New SEND TO SITE Security Keys Associated: Security Key Name ----------------- N/A Templates Associated: Template Name Type File Name (#) New/Mod/Del ------------- ---- ------------------ ----------- N/A Additional Information: ----------------------- ICR #2398 - Modified as outlined above. New Service Requests (NSRs): ----------------------------- N/A Patient Safety Issues (PSIs): ------------------------------ PSI-07-167, PSI-06-176 Remedy Ticket(s) & Overviews: ----------------------------- 203088 Outpt complex order (using then) was transferred to Inpt and start/stop dates are one month apart 168928 Means of allowing 2 active RXs for same dispense drug needed to accommodate titration regimens; 1022059 Duplicate prescriptions created. TEST SITES: =========== DURHAM, NC LOUISVILLE, KY MUSKOGEE, OK OKLAHOMA CITY, OK TENNESSEE VALLEY HCS Documentation Retrieval: ======================== The documentation is available on the ANONYMOUS.SOFTWARE directory at one of the following Office of Information (OI) Field Offices: Albany Hines Salt Lake City Sites may retrieve documentation in one of the following ways: (1) The preferred method is to FTP the files from download.vista.domain.ext, which will transmit the files from the first available FTP server. (2) Sites may also elect to retrieve documentation directly from a specific server as follows: Albany ftp.domain.ext Hines ftp.domain.ext Salt Lake City ftp.domain.ext The documentation distribution includes: File Name File Description FTP Mode -------------------------------------------------------------------------- PSO_7_MAN_UM_R0814.PDF Outpatient Pharmacy V. 7.0 Manager's (binary) User Manual PSO_7_PHAR_UM_R0814.PDF Outpatient Pharmacy V. 7.0 Pharmacist's (binary) User Manual PSO_7_TECH_UM_R0814.PDF Outpatient Pharmacy V.7.0 Technician's (binary) User Manual PSO_7_TM_R0814.PDF Outpatient Pharmacy V. 7.0 Technical (binary) Manual/Security Guide PSO_7_P313_RN.PDF Release Notes (binary) (3) Documentation can also be retrieved from the VistA Documentation Library (VDL) on the Internet at the following address: http://www.domain.ext/vdl. Installation Instructions: ========================== Do not install this patch while Outpatient Pharmacy users are on the system or when Outpatient orders are being entered and signed through Computerized Patient Record System. Installation will take no longer than 5 minutes. 1. Use the INSTALL/CHECK MESSAGE option on the PackMan menu. 2. From the Kernel Installation & Distribution System (KIDS) menu, select the Installation menu. 3. From this menu, you may select to use the following options (when prompted for INSTALL NAME, enter PSO*7.0*313): a. Backup a Transport Global - this option will create a backup message of any routines exported with the patch. It will NOT backup any other changes such as DDs or templates. b. Compare Transport Global to Current System - this option will allow you to view all changes that will be made when the patch is installed. It compares all components of the patch (routines, DDs, templates, etc.). c. Verify Checksums in Transport Global - this option will ensure the integrity of the routines that are in the transport global. d. Print Transport Global - this option will allow you to view the components of the KIDS build. 4. Use the Install Package(s) option and select the package PSO*7.0*313. 5. When prompted "Want KIDS to INHIBIT LOGONs during the install? NO//" respond NO. 6. When prompted "Want to DISABLE Scheduled Options, Menu Options, and Protocols? NO//" respond NO. Routine Information: ==================== The second line of each of these routines now looks like: ;;7.0;OUTPATIENT PHARMACY;**[Patch List]**;DEC 1997;Build 76 The checksums below are new checksums, and can be checked with CHECK1^XTSUMBLD. Routine Name: PSOATRF Before: B79340036 After: B82128020 **264,322,388,313** Routine Name: PSOATRFC Before: B45655839 After: B47253705 **305,388,313** Routine Name: PSOBBC Before: B91849962 After:B104120785 **11,22,27,34,46,130,146,185, 242,264,300,337,313** Routine Name: PSOCPDUP Before: B32857063 After: B33663947 **11,27,32,130,132,192,207,222, 243,305,313** Routine Name: PSOLMPO2 Before: B590140 After: B829209 **46,71,225,313** Routine Name: PSON52 Before: B86376192 After: B91470672 **1,16,23,27,32,46,71,111,124, 117,131,139,157,143,219,148, 239,201,268,260,225,303,358, 251,387,379,390,391,313** Routine Name: PSONEW Before: B42013827 After: B43522881 **11,27,32,46,94,130,268,225, 251,379,390,417,313** Routine Name: PSOORCPY Before: B21376105 After: B32700347 **10,21,27,32,46,100,117,148,313** Routine Name: PSOORED1 Before: B68466079 After: B73633714 **5,23,46,78,114,117,131,146, 223,148,244,249,268,206,313** Routine Name: PSOORED3 Before: B61293813 After: B65846558 **46,78,99,117,133,148,249,251, 379,378,372,416,313** Routine Name: PSOORED4 Before: B54845404 After: B56835310 **46,91,78,99,111,117,133,159, 148,251,391,372,416,313** Routine Name: PSOORED5 Before: B58804005 After: B60490141 **46,75,78,100,99,117,133,251, 378,372,416,313** Routine Name: PSOOREDT Before: B72615864 After: B78897328 **4,20,27,37,57,46,78,102,104, 119,143,148,260,281,304,289, 298,379,377,391,313** Routine Name: PSOOREDX Before: B19671149 After: B19747673 **133,362,313** Routine Name: PSOORFI2 Before: B92022247 After: B94812114 **7,15,23,27,46,130,146,177, 222,225,338,313** Routine Name: PSOORNE1 Before: B72891193 After: B77126364 **11,21,27,32,37,46,71,94,104, 117,133,148,279,251,372,313** Routine Name: PSOORNE2 Before: B69776712 After: B68757551 **11,21,23,27,32,37,46,84,103, 117,131,146,156,210,148,222, 238,264,281,289,251,379,391, 313** Routine Name: PSOORNE3 Before: B68130643 After: B68981522 **11,9,39,59,46,103,124,139, 152,194,391,313** Routine Name: PSOORNE4 Before: B94257859 After: B98202057 **11,27,32,36,46,75,96,103,99, 117,131,225,386,390,391,313** Routine Name: PSOORNEW Before: B92549598 After: B93328649 **11,23,27,32,55,46,71,90,94, 106,131,133,143,237,222,258, 206,225,251,386,390,391,372, 416,431,313** Routine Name: PSOORNW1 Before: B44718806 After: B45684581 **23,46,78,117,131,133,172,148, 222,268,206,251,379,391,313** Routine Name: PSOORUT1 Before: B77790582 After: B78925499 **1,14,30,46,132,148,233,274, 225,305,289,251,387,385,313** Routine Name: PSOOTMRX Before: n/a After: B20486782 **313** Routine Name: PSOP Before: B45335172 After: B45480400 **2,15,98,132,148,326,313** Routine Name: PSOP1 Before: B26371231 After: B26639080 **15,46,103,132,148,233,326,251,313** Routine Name: PSOPMP0 Before: B81752801 After: B82071360 **260,281,303,289,382,313** Routine Name: PSOREF Before: B66253301 After: B71972514 **1,23,27,36,46,78,130,131,148, 206,313** Routine Name: PSORENW Before: B38307227 After: B44953613 **11,27,30,46,71,96,100,130, 148,206,388,390,417,313** Routine Name: PSORENW4 Before: B60124334 After: B62985403 **11,23,27,32,37,64,46,75,71, 100,130,117,152,148,264,225, 301,390,313** Routine Name: PSORXEDT Before: B45078409 After: B45205767 **21,23,44,71,146,185,148,253, 390,372,416,313** Routine Name: PSORXVW Before: B77494288 After: B81070397 **14,35,46,96,103,88,117,131, 146,156,185,210,148,233,260, 264,281,359,385,400,391,313** Routine Name: PSOSIG Before: B70011572 After: B70480726 **46,99,114,391,313** Routine Name: PSOUTL Before:B125518087 After:B132826044 **1,21,126,174,218,259,324,390,313** ============================================================================= User Information: Entered By : Date Entered : AUG 06, 2008 Completed By: Date Completed: AUG 28, 2014 Released By : Date Released : SEP 02, 2014 ============================================================================= Packman Mail Message: ===================== $END TXT