louis cheung, clinical systems application pharmacist, peninsula health - exploring what is needed...

System Interface Between Two Vendors: Cerner Powerchart with

CSC iPharmacy

Louis Cheung, Peninsula Health

SERVICE • INTEGRITY • COMPASSION • RESPECT • EXCELLENCE

http://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=hD19W10V4uNHkM&tbnid=rsfgfDdvzgW20M:&ved=0CAUQjRw&url=http://protagonist.wikia.com/wiki/Bart_Simpson&ei=PHYVU9TTL8WxlAWwsYCIBw&bvm=bv.62286460,d.dGI&psig=AFQjCNEC_4fzeUCrxobUAN7RnrWFVc5rXQ&ust=1394001833572382


Peninsula Health - background

Major public health care provider serving metro and rural areas on Victoria’s Mornington Peninsula (catchment area of approx. 850 sq. kms)


Peninsula Health - background

Measure 2011-2012

Staff (EFT) Medical 373

Nursing 1517

Allied Health 328

Other 1168

Total 3386

Structure Facilities Acute (incl. Maternity), Sub-

acute (incl. residential care),

Mental Health and Community

Health

Beds 878 (Acute -527, Mental Health

– 74, Rehabilitation, Aged and

Palliative Care – 277)

Theatres 8

Throughput Admissions(Overnight/Day) 75,345

Community Occasions of Care 235,467

Babies Born 2675

Emergency Visits 79,311

Operations 15,121

Development of e-MR at Peninsula Health – Background/Timelines

2007 2002 October

2009 June

2011

June 2012 August

2013 Oct 2014

Investigated other

clinical solutions.

Business case

developed

Orion implementation: e-

results viewing, Dis Summ,

Dis meds &e-prescribing

(sub-acute)

Announced as Lead

Agency (with Austin

Health) to implement

HealthSMART Clinicals

using Cerner First Go-Live of

Stage 1, Phase A

Final Go-Live

of Stage 1,

Phase A

First Go-Live

of Stage 1,

Phase B Final Go-Live

of Stage 1

Phase B

Proposed

EDIS Go-Live

November

2011


Clinical system at Peninsula Health – 2013


Cerner

Millenium

iPM

Synapse

Dorevitch

Radiology

PAS

Pathology

Pharmacy iPharmacy


Why interface?

Marianne Lisby, Lars Peter Nielsen, and Jan Mainz. Errors in the medication process: frequency, type, and potential clinical consequences

Int J Qual Health Care (2005) 17 (1): 15-22

Dispensing

Inventory Control

Purchasing

PBS Claim

Reports

Prescribe in Cerner Powerchart

Clinical review & product assignment in

Cerner’s PharmNet e-Rx (inpatient &

discharge)

De

cisi

on

su

pp

ort

iPharmacy X

Integration between two vendors


ACK

Medication Process Workflow


http://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=hD19W10V4uNHkM&tbnid=rsfgfDdvzgW20M:&ved=0CAUQjRw&url=http://protagonist.wikia.com/wiki/Bart_Simpson&ei=PHYVU9TTL8WxlAWwsYCIBw&bvm=bv.62286460,d.dGI&psig=AFQjCNEC_4fzeUCrxobUAN7RnrWFVc5rXQ&ust=1394001833572382

Boy accepts dare…


"The Simpsons Movie" Copyright © Fox Network

http://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&docid=uQ_GAQ-CGSVoqM&tbnid=LlV9cuYWiXo9SM:&ved=0CAUQjRw&url=http://en.wikipedia.org/wiki/Bart_Simpson&ei=CXYZU4SkOsebkgXxnICQBQ&psig=AFQjCNGeK8KBFHxP36vmm72hOLHvaPlpZg&ust=1394263902190497

Boy loses control of his skateboard…


"The Simpsons Movie" Copyright © Fox Network

On admission


• Bart’s details are entered into iPM

• Weight and allergies are documented

• Pathology and radiology tests are ordered

Document home medication and Admission medication reconciliation


• Home medications are documented electronically

• Home medications are reconciled on admission and inpatient medications charted on the same screen

Clinical ordering


• Inpatient medications are ordered


Inpatient eRx

• Cerner Powerchart will differentiate between imprest and non-imprest items

• Only verified items will send an eRx message


Discern report to replace inpatient eRx

• PH has developed a discern analytics report + Excel macro to filter all non-imprest orders regardless of verification status

Doctor rounds


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Discharge reconciliation

• Home and inpatient medications are electronically converted and reconciled in Cerner Powerchart

iPharmacy


Refilling the prescription in PharmNet

Refill

• These discharge orders appear in PharmNet Retail ready to be ‘refilled’

• Select a dispensing pharmacy



• Pick the product off the shelf then select that product in the PharmNet product window



• Check that the order (quantity, SIG) is OK to be sent to iPharmacy



• Repeat for other eRx orders


Dispensing the prescription in iPharmacy

• Open iPharmacy 5.7.1002 build 6 or later version

• Click on Dispensing > e-Rx orders



• Search for patient UR and select appropriate eRx orders



• Check that the orders are OK to be dispensed and click ‘Process’



• iPharmacy will do a patient entitlement and financial values check



http://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=hvAeeOod72yc-M&tbnid=tbJnEwenUNCE1M:&ved=0CAUQjRw&url=http://whattalking.com/picasa/Simpson&ei=XpEVU6e3BYS-kQWinYGYCw&bvm=bv.62286460,d.dGI&psig=AFQjCNGEWCjanTS1HFeRnkIfaswjIW0fJA&ust=1394008740957054


Records of dispensing in Powerchart

• Right click the discharge prescription order in Powerchart > click ‘Order Info’ > History tab

Difference between inpatient and discharge eRx

Data Inpatient Discharge

Application Med Manager Retail

Product Automatic Manual

Verification/Refill Automatic Manual

SIG translation No Yes

Quantity Automatic (system) Automatic (doctor)

Other Cartfill reports


• Pilot wards for discharge eRx: ED, ESSU, ESW

Build Design


e-Chinese Whispers

Cerner PharmNet

CSC iPharmacy

HSS IE

PH IE


Testing, testing and more testing…

Devil is in the details

Prescriber

• Name, alias, PBS prescriber #

Patient

• Name, Medicare, concession, address, etc

Order details

• Product, Order ID, dispense ID, SIG, quantity, UOM

PBS data

• PBS restriction, streamline, authority codes, reg 24


Where’s Wally?

MSH|^~\&|CERNERPHARM|FH|PHIE|FH|20140307191711||ORMÔ01|Q77776745T80839191|P|2.3.1

PID|1||0000000^^^FH^MR~~ERROR^^ÂUSHIC^PEN~~30026770712^^ÂUSHIC^MC||Dummy^Fred^John^^^^CURRENT~Dummy^Fred^Tester^^^Â||19210101000000|M||8|Kkljklk.^3 Frankston-Dandenong Rd^Frankston^VIC^3199Âustralia^4~10 Olive St^Ôverseas^VIC^8888Ôverseas^3~Po Box 25 Bruce Stre^^Mentone^VIC^3194Âustralia^2||(097)870-9999^PRN^PH||8179|5|2011||||||||0|||||N

PV1|1|PBS Outpatient Invoice|E2220^F020^F020^2220^^Bed170^2220|6|||^^^^^^^^^^^^BUILD_ERROR||||||||||PH00129^HEWITT^Helen^^^Dr.^^^^^^Êxternal Identifier~R173^HEWITT^Helen^^^Dr.^^^2220^^^ÔRGANIZATION DOCTOR~0584286A^HEWITT^Helen^^^Dr.^^^2220^^^^Provider Num|E|6583907^^^2220|NON PBS||Y|||||||||||||||||2220||C|||20130920080000|20130920152255

ORC|NW|185227631^HNAM_ORDERID|15072268^DISPENSEID|15072270^HNAM_RUNID|NW||^^D1^20140307000000^20150307235959^CD:7159890^^Take 6 mL FOUR times a day||20140307191710||^CHEUNG^LOUIS|PH00090^PH00090 PH00090 Katherine BRISTOW^0874363~~|CD:18579840^^^CD:9572758^^Pha193^2220||20140307191710|NW|CD:28549375

RXO|12601011000036104^Panamax elixir 240 mg/5 mL oral liquid: solution, 200 mL, bottle^Stocca|1||^bottle(s)|CD:318203^|||E2220^F020|||1||0||||15072268

RXR|Ôral

RXE|^^D1^20140307000000^20150307235959^CD:7159890^^Panamax elixir 240 mg/5 mL oral liquid: solution, 200 mL, bottle T6 ELIXIR QID #1|12601011000036104^Panamax elixir 240 mg/5 mL oral liquid: solution, 200 mL, bottleÂMT-TPP^22589011000036109^paracetamol 240 mg/5 mL elixir 200 mLÂMT-MPP|1||mls^mL|CD:318203|^T6 ELIXIR QID~^Take 6 mL FOUR times a day~^Take 6 mL FOUR times a day||Y|1|mls^mL|0|PH00090^BRISTOW^Katherine^^^Dr.^^^^^^Êxternal Identifier~0874363^BRISTOW^Katherine^^^Dr.^^ÂUSHIC^^^^PRES~SS10^BRISTOW^Katherine^^^Dr.^^^2220^^^ÔRGANIZATION DOCTOR~2049737X^BRISTOW^Katherine^^^Dr.^^^2220^^^^Provider Num|PH04471^Cheung^Louis^^^^^^^^^Êxternal Identifier|33723628-||00|20140307000000|||~^PBS~~OPDRXÔutpatient Pharmacy

RXR|Ôral|||MED

RXC|B|12601011000036104^Panamax elixir 240 mg/5 mL oral liquid: solution, 200 mL, bottleÂMT-TPP^22589011000036109^paracetamol 240 mg/5 mL elixir 200 mLÂMT-MPP|1|mls^mL|1

OBX|1||1770E^N||||||||


Aligning the databases

• 1,200 doctors mapped and cross-checked.

– Name, unique ID and prescriber #

– Currently 1,400 doctors mapped

– IT provisioning send doctor codes to pharmacy

• iPM (PAS) feeds patient information into both Cerner applications and iPharmacy

– no mapping required between Cerner & iPharmacy



• Using the Trade Product Pack (TPP) code,

– 3,200 formulary items mapped and cross-checked

• Generic, brand, strength, form and pack size

– 3,200 product unit of measure (UOM) cross-checked and discrepancies addressed

– 5,600 item formulary statuses mapped

– Review every 3 - 6 months



• 3,200 drug imprest locations mapped

– Only non-imprest items are sent through the inpatient eRx

• 40 inpatient wards mapped

– Outpatient wards not currently using Powerchart

• PBS codes

– Various salts (e.g. clopidogrel)

– Dispersible vs. non-dispersible (e.g. omeprazole)

– Various pack sizes (e.g. Slow-K vs. Span K)


Building/translating the SIG


Dosage Form

Verb Quantity per dose

Unit of measure

Route Frequency

Tablet Take x Tablet -

Capsule Take x Capsule -

Inhaler Inhale x Puff -

Liquid Take x mL by metric measure

-

Eye Drops Instill x Drop [route]

Patch Apply x Patch To the skin

• Example of SIG translations

Lessons Learnt



Issues

• Problems on both sides of the fence

• PharmNet Retail

– unable to check PBS codes

– not suitable for PBS claiming

– Reg 24 and PRN not immediately obvious

– SIG does not always generate

• ‘Zz’, SIG = [dose][route][freq][duration][PRN][spec inx]

• iPharmacy issues


iPharmacy issues

Date Issue

16/08/13 When Editing a dispensing written by a doctor processed via e-Rx, it only allows us to choose a

16/08/13 Doctor prescribed Clopidogrel-DRLA with PBS code 5436D. In e-Rx pharmacist changed product to Pla

7/03/13 Want to be able to tick the 'Own Supply' tickbox from the e-Rx orders screen

5/07/12 Want to be able to alter the number of repeats from the e-Rx orders screen

19/03/12 The Total Qty being displayed in the Rx Details window is incorrect for orders passed from the

1/10/12 Cannot get the 'Team' field in the e-Rx screen to populate with the Prescriber's Team in i

28/05/12 The e-Rx module is unable to dispense an item not listed in the PBS/RPBS list but has been approved

10/05/12 In the e-Rx interface for Cerner, the Script Classification matches the first word in i.Pharmacy.

8/05/12 When the TPP from the ORM message does not automatically assign a product in the eRx window and

14/02/12 The "On Imprest" 'Action' default in the e-Rx window needs to consider the 'Check Imprest' value

14/02/12 Patient Price and PBS Claim Price are appearing as 0

19/01/12 Placer Filler number (Dispense_ID from Cerner) according to specs supposed to populate dspn_order_id

18/06/13 When dispensing a script from eRx functionality for a patient with GOLD card and SN card, it is rej


Issues

• Initial testing shows increased time taken to dispense

– Due to iPharmacy issues

• Doctors don’t always get the quantity right

– Direct information to iPharmacy

• SIG is not always correct

– E.g. Spiriva inhalation capsules

• iPharmacy (Stocca) will reject messages


Lessons Learnt

• Novel approach

– Process could be more streamline

– Preferable if eRx order could be dispensed straight from the eRx window

– Potential full roll-out across network if successful

• Testing, testing, testing…

• Vlookups will be your best friend

• Development/maintenance is a full-time job


Thank you

http://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=hvAeeOod72yc-M&tbnid=tbJnEwenUNCE1M:&ved=0CAUQjRw&url=http://whattalking.com/picasa/Simpson&ei=XpEVU6e3BYS-kQWinYGYCw&bvm=bv.62286460,d.dGI&psig=AFQjCNGEWCjanTS1HFeRnkIfaswjIW0fJA&ust=1394008740957054

louis cheung, clinical systems application pharmacist, peninsula health - exploring what is needed...

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