dur

1

Understanding DUR Management

Workbook

Course 206055

2

Table of Contents Introduction ................................................................................................................ 3

How are Drug Utilization Review (DUR) Warnings Generated? ................................. 4

Understand the DUR Engine ...................................................................................... 4

Hard Stop vs. Soft Stop .............................................................................................. 5

DUR Clinical Module Descriptions ............................................................................. 7

Third Party DUR and Prescriber DUR ...................................................................... 13

Workflow steps that affect DUR ............................................................................... 14

Other DUR Considerations ....................................................................................... 15

Next Steps ................................................................................................................ 16

Payroll ...................................................................................................................... 16

Appendix: Knowledge Check Answer Key .............................................................. 17

Understanding DUR Management: Workbook

3

Introduction Drug Utilization Review (DUR) is a core clinical function that Pharmacists perform to keep our patients safe and provide quality health care. When a prescription is processed through RxConnect, the system checks for clinical alerts against several DUR modules. As a Pharmacist, you are responsible for addressing all DUR warnings. Upon completion of this course, you should be able to: Identify the DUR Engines role in the process of managing DUR Identify all of the modules that generate DUR alerts You will learn the steps to complete final verification, including DUR verification, in the Introduction to Quality Assurance Workstation web-based training (LEARNet #206050). This training guide is provided in a self-paced format. Answers to each knowledge check are in the appendix at the end of this workbook. It will take you approximately 20 minutes to complete this workbook.


4

How are Drug Utilization Review (DUR) Warnings Generated? After all necessary information is entered for a prescription (including the User Credentials of the team member completing data entry), the RxConnect system assigns a number to the prescription. When adjudication is complete, this prescription is then sent to the DUR Engine for centralized systemic evaluation.

Understand the DUR Engine The DUR Engine is a computer process that compares the prescription being filled and others on the patients profile (as well as conditions, allergies and patient age) against a library of clinical data to generate warning alerts that Pharmacists can use at point of care to complete a thorough DUR. The library of clinical data used at CVS retail pharmacies is provided by First Data Bank (FDB). A prescription is eligible for screening as soon as data entry and adjudication are complete, including those pending final verification. The DUR Engine checks against a number of modules, which will be described below. The information returned is shown during the verification step of workflow.


5

Hard Stop vs. Soft Stop There are two different ways to display DUR warnings at verification in RxConnect: Hard stops and soft stops. Hard stops are clinically significant alerts that are likely to require action. Pharmacists must use their professional judgment to determine whether to fill the prescription and document interventions. Soft stops are clinically significant, but may not require intervention for all patients. DUR warnings are assigned to be hard stops or soft stops by CVS/pharmacy based on the clinical module and/or severity.

Hard stop intervention codes can be entered into the system after ALL hard stops have been viewed. The system allows the user to view soft stops before and after entering an intervention code. The intervention codes available are:

A. Prescriber Consulted B. Medication Review C. Patient Consulted

Note: Hard stops can become soft stops on refills if no new DUR warnings are present. This process is called FILTERING. When an alert is filtered, it will be noted on the screen with an asterisk (*) and a statement.


6

Knowledge Check

Circle the correct answer for each question below. 1. DUR Checks are performed on those prescriptions in a patients

profile that have been completed or are pending final verification. a. True b. False

2. Those prescriptions that result in a(n) ______ DUR warning require

a DUR Intervention Code. a. Automatic DUR/Informational b. Hard Stop c. Soft Stop d. Therapeutic DUR/Soft Stop


7

DUR Clinical Module Descriptions In the following pages, you will find a list of clinical modules, descriptions, and related information to help you better understand DUR warnings at final verification.

Title Title Statement What does the module check for?

What will the screen display?

How should a Pharmacist address the DUR warning?

Drug-Drug Interaction

The Drug-to-Drug Interaction Module (DDIM) identifies clinically significant drug-to-drug interactions between the prescription being filled and eligible prescriptions in RxConnect and for enterprise patients, Caremark Mail order and Specialty Mail order.

The database covers every product that is approved for marketing in the United States. It also covers many commonly used herbal and nutritional products available at CVS.

Every drug fill is checked against all eligible prescriptions in the patients central profile, including enterprise prescriptions Eligible prescriptions are determined by the system, taking into account factors like: Fill date Days supply If there is another

prescription on the profile for the same drug

Some drugs will be screened indefinitely once on a patient profile (for example, nitroglycerin)

If a compound is being dispensed, the DUR Engine will check drug interaction codes for each individual ingredient

The alert will show: The FDB severity

level The interacting

medication and prescription details

A brief explanation of the clinical effect

*Note You can access the full monograph by selecting M in the navigation bar.

Severity Level 1 interactions are contraindicated drug combinations. They require RPh professional judgment to fill, prescriber authorization and documentation

Severity Level 2 interactions are severe interactions. Pharmacists should exercise professional judgment and review the profile/contact the patient/ consult the physician as required

Severity Level 3 interactions are moderate interactions. Pharmacists should exercise professional judgment and review the profile/contact the patient/ consult the physician as required

Severity Level 9 is of unknown potential or between prescription and herbal products. Pharmacists should assess the risk and act as needed

Geriatric Pre-cautions

The Geriatric Precautions Module identifies medications that cause increased risk in patients over 65 years old. The database covers every product that is approved for marketing in the United States.

Every fill dispensed checks if the patient is over 65 years old against the NDC that will be dispensed for geriatric precautions.


level Drug being filled and

specific agent of concern


Physiological system affected

Severity Level 1 alerts are contraindications in geriatric patients. They require RPh professional judgment to fill, prescriber authorization and documentation

Severity Level 2 alerts indicate precautions. Pharmacists should exercise professional judgment and review the profile/contact the patient/ consult the physician as required


8




Drug Condition Alerts

The Drug-Condition Contraindications Module identifies clinically significant drug-condition interactions. The database covers every product that is approved for marketing in the United States.

Every fill dispensed NDC is checked against the conditions coded in the patient profile. Conditions are entered in the profile by ICD code, but have clinical tags on them called DXIDs. FDB will trigger an alert if an NDC and DXID have a clinical interaction. ICD codes can have one, many or no DXIDs tied to them, which is determined by FDB.




ICD code, condition description, and date entered


Severity Level 1 interactions are absolute contraindications. They require RPh professional judgment to fill, prescriber authorization and documentation

Severity Level 2 interactions are relative contraindications. Pharmacists should exercise professional judgment and review the profile/contact the patient/ consult the physician as required

Severity Level 3 interactions are warnings. Pharmacists should assess the risk and act as needed

Drug Allergy Alerts

The Drug Allergy Module identifies clinically significant interactions between active drug ingredients and the patient allergy codes. The database covers every product that is approved for marketing in the United States.

Every fill dispensed NDC is checked against the allergies coded in the patient profile. Allergies are entered in the profile by ingredient, drug, or drug class using a unique FDB coding system. Although active and inactive ingredient allergies can be coded in the system, the allergy module only checks ACTIVE ingredients.

The alert will show: Drug being filled and


Allergy code, type of allergy, and date entered


Reported allergy symptoms and allergy notes

These alerts do not have severity levels, but may require RPh professional judgment to fill, prescriber authorization and documentation. Pharmacists should exercise professional judgment and review the profile/contact the patient/ consult the physician as required


9




Duplicate Therapy

The Duplicate Therapy Module identifies medications with overlapping therapeutic or pharmacological uses that can create added toxic effect, adverse events or therapeutic redundancy without benefit for the prescription being filled and eligible prescriptions in RxConnect and for enterprise patients, Caremark Mail order and Specialty Mail order. The database covers every product that is approved for marketing in the United States.

Every fill dispensed NDC is checked against all eligible prescriptions in the patient central profile, including enterprise prescriptions Eligible prescriptions are determined by the system, taking into account factors like: Only systemic

drugs are considered for duplicate therapy

Fill date Days supply If there is another


*Note Some therapeutic classes have thresholds that must be met before duplicate therapy will trigger. For example, a patient must be on more than 2 anticonvulsants for the system to warn against duplicate therapy.

The alert will show: Drug being filled Interacting

prescriptions, including the medication names



10




Minimum / Maximum Dosing

The Min/Max Dosing Module checks the appropriateness of the total daily dose for drugs that have established dosing schedules. The database covers every product that is approved for marketing in the United States.

Every fill dispensed NDC is checked to see if there is a dosing schedule and if the patient is being provided a total daily dose within that range. Total Daily Dose is calculated by data entered quantity divided by days supply. Dosing is split into the following age bands: Pediatric 31 days

to 14 years old Adult 15 years to

64 years old Geriatric 65+

years old Infants below 31

days old or when no dosing available specific hard stop alerting you no dosing is available

*Note Pediatric dosing is mostly weight based, using the 5th and 95th weight percentile to calculate an acceptable min and max range. Adult and geriatric weight-based drugs will not run DUR, but will return an alert telling you to perform manual DUR.

The alert will show: Drug being filled Graphic with

Dispensed total daily dose, Recommended min/max daily dose and the % over or under



11




Pediatric Precautions

The Pediatric Precautions Module identifies medications that cause increased risk in patients under 15 years old. The database covers every product that is approved for marketing in the United States.

The system checks if the patient is under 15 years old against the NDC that will be dispensed for pediatric precautions. Some alerts only apply to a specific age segment of pediatric patients. In these cases, alerts will only appear based on the patient age. For example, a 13 year old patient will not receive an alert for dextromethorphan, which is contraindicated in patients younger than 6.





Physiological system affected

Severity Level 1 alerts are contraindications in pediatric patients. They require RPh professional judgment to fill, prescriber authorization and documentation

Severity Level 2 alerts indicate relative contraindications. Pharmacists should exercise professional judgment and review the profile/contact the patient/ consult the physician as required

Severity Level 3 alerts indicate no studies have been done, but warning exist. Pharmacists should exercise professional judgment and review the profile/contact the patient/ consult the physician as required

Pregnancy Precautions

The Pregnancy Precautions Module identifies medications that cause increased risk in patients reported as pregnant, or those of childbearing age. The database covers every product that is approved for marketing in the United States.

The system checks if the patient is: Female Pregnant (via ICD

code or pregnancy patient indicator)

Of childbearing age (15-45 years old)

The system checks if the drug is: FDA Category C, D,

or X First Data Bank

Category 1 or 2 (if no FDA category exists or FDB severity override)



Pregnancy Category A brief explanation of

the clinical effect Reason for alert

(whether reported pregnant or childbearing age caution)

If reported pregnant: o Category X - The drug

SHOULD NOT BE DISPENSED. Pharmacists must notify the physician.

o Category D or Severity 1- requires RPh professional judgment to fill, prescriber authorization and documentation

o Category C or Severity 2 - Pharmacists should exercise professional judgment and review the profile/contact the patient/ consult the physician as required

If childbearing age: o Pharmacists should

determine pregnancy status and update in RxConnect. Pharmacists should exercise professional judgment and review the profile/contact the patient/ consult the physician as required


12




Lactation Precautions

The Lactation Precautions Module identifies medications that cause increased risk in patients reported as breastfeeding, or those of breastfeeding age. The database covers every product that is approved for marketing in the United States

Every fill dispensed checks if the patient is: Female Breastfeeding (via

ICD code or lactation patient indicator)

Of breastfeeding age (15-45 years old)



If excreted in milk and effect on infant


Reason for alert (whether reported breastfeeding or breastfeeding age caution)

Severity Level 1 alerts are contraindications. They require RPh professional judgment to fill, prescriber authorization and documentation

Severity Level 2 alerts indicate precaution. Pharmacists should exercise professional judgment and review the profile/contact the patient/ consult the physician as required

Severity Level 3 alerts indicate no known risk have been done, but warning exist. Pharmacists should exercise professional judgment and review the profile/contact the patient/ consult the physician as required


13




Inferred Condition

The Inferred Condition Module identifies clinically significant drug-condition interactions by inferring conditions based on drugs that the patient is taking.

Every fill dispensed NDC is checked against the conditions that are inferred by the system. The system infers medical conditions by first identifying eligible prescriptions. Then the system will look at what indications the medication is used for. An alert will only be generated for drugs that strongly infer a specific condition (for example, metformin for diabetes). Eligible prescriptions are determined by the system, taking into account factors like: Fill date Days supply If there is another


*Note Limited conditions will be inferred from medications during a pilot phase of the module.



Inferred condition description, and date entered


Severity Level 1 interactions are absolute contraindications. They require RPh professional judgment to fill, prescriber authorization and documentation

Severity Level 2 interactions are relative contraindications. Pharmacists should exercise professional judgment and review the profile/contact the patient/ consult the physician as required

Severity Level 3 interactions are warnings. Pharmacists should assess the risk and act as needed

Third Party DUR and Prescriber DUR

Third Party Processors frequently provide Patient-Specific information to help the DUR decision process. Additionally, Electronic Medical Records and Electronic Health Records have the capability to send DUR warnings along with electronic prescriptions. RxConnect will set these alerts as hard stops and soft stops based on type and clinical severity.


14

Workflow steps that affect DUR

Please note the following information and share with colleagues to ensure specific care is taken when entering the following information, as it directly impacts how DUR runs and the quality of clinical information available to you at point of care:

Data Entered into RxConnect

DUR Module OPTIMIZING DUR Example

Dispensed Quantity & Day Supply

Minimum & Maximum Dosing

How? Correctly enter dispensed quantity and day supply

Why? Dispensed quantity and day supply are used to calculate a patients total daily dose (TDD). The TTD will then determine if the dose exceeds the minimum or maximum dose.

Rx: Fluticasone 50 mcg nasal spray SIG: 1 spray in each nostril daily Quantity: 16 gm

If day supply is entered as 30 instead of 60, the Min/Max Dosing module will alert the RPh based on TWICE the prescribed daily dose.

Allergy Symptoms and Notes

Drug Allergy Module

How? Document a patients allergy with the associated symptom(s) and other allergy notes

Why? Obtaining accurate allergy information ensures that each prescription is screened, to avoid a known allergic reaction. Allergy information is visible to pharmacy teams throughout the Enterprise.

Rx: Augmentin 875 mg/125 mg Previous Allergy Reported: Amoxicillin (symptoms: diarrhea & upset stomach)

Capturing complete allergy information, including associated symptom(s), allows the RPh to be better prepared when counseling that patient. Antibiotics often cause stomach upset, and through patient counseling, a prescriber call is usually unnecessary.


15

Data Entered into RxConnect

DUR Module OPTIMIZING DUR Example

Pregnancy Status & Due Date

Pregnancy Precautions

How? Enter pregnancy status with expected due date in the patients Reported Health Status fields

Why? The system will alert the RPh if a potentially dangerous drug is being dispensed to a pregnant patient. Once the due date has passed, RxConnect will prompt the RPh to update the pregnancy status in an effort to reduce system prompts in the future.

Jamie informs the Technician that she is pregnant with a due date of 12/25/15. The Technician documents the pregnancy status and due date which then instructs the pregnancy module to prompt the RPh with any available medication alerts.

Lactation Status

Lactation Precautions

How? Enter lactation status in the patients Reported Health Status field

Why? Some medications are excreted through breast milk and can potentially reach the child. The system will alert the RPh if a potentially dangerous drug is being dispensed to a patient that is nursing.

Linda informs a pharmacy team member that she has begun breast feeding. The pharmacy team member documents the patients lactation status which instructs the lactation module to prompt the RPh with any available medication alerts.

Other DUR Considerations Compounds will run all modules of DUR except dosing Nasal and ophthalmic medications have 25% buffer above the high dose and

below the low dose to avoid over messaging Key Training Takeaway RxConnect will provide DUR warnings to Pharmacists at the point of care based on patient profiles and the information that pharmacy teams enter into the system. Course Completion Congratulations! You have completed the Understanding DUR Management workbook.


16

If you have any additional questions regarding what you have learned in this course, contact your Pharmacy Supervisor or Trainer to discuss.

Next Steps In order to receive credit for the completion of this workbook, you need to complete an on-line assessment to test your understanding of what you have learned. This assessment is available from the Understanding DUR Management course description page on LEARNet. Please contact your Trainer with any questions/concerns.

Payroll In order to be paid properly for completing this workbook and assessment, your time for completing this training should be submitted on your Weekly Pharmacist Payroll Sheet as part of regular operating hours. *Include time spent reading the workbook and completing the on-line assessment.


17

Appendix: Knowledge Check Answer Key The following provide answers to the knowledge check questions from this course.

Circle the correct answer for each question below. 1. DUR Checks are performed on prescriptions that include those in

a patients profile that have been data entered or are pending final verification.

a. True b. False

2. Those prescriptions that result in a(n) ______ DUR Event require

a DUR Intervention Code. a. Automatic DUR/Informational b. Critical DUR/Hard Stop c. Informational/Soft Stop d. Therapeutic DUR/Soft Stop

Understanding DUR ManagementIntroductionHow are Drug Utilization Review (DUR) Warnings Generated?Understand the DUR EngineHard Stop vs. Soft StopDUR Clinical Module DescriptionsThird Party DUR and Prescriber DURWorkflow steps that affect DUROther DUR ConsiderationsNext StepsPayrollAppendix: Knowledge Check Answer Key

dur

Documents

dur alerts

dur verification

dur modules

party dur

prescriber dur

dur considerations

dur management workbook

dur engines role