5th Annual PBM Pharmacy Informatics Conference
Are You Ready for MOCHA V 2.0?
Jim Hewins, Kansas City MO
Dionne Roney, Charleston SC
DATE/MONTH 2012
MOCHA 2.0 Objectives
• Discuss the timeline the sites will need to consider prior to
implementing MOCHA V 2.0
• Explain the tasks that need to be completed prior to
implementing MOCHA V 2.0
• Describe the setup for doses to enable the dose checks to
occur properly
• Explain how to trouble shoot problem order checks
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Types of Dosage Information
• Max single dose – this is the individual dose
amount, whether it is given once a day or 24
times a day
• Total daily dose – Dose x Frequency (per 24h)
• General Dosage Range – Is provided when
there is a problem with the order and dosage
checks cannot be performed
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MOCHA 2.0 – four increments
• Increment A - Maximum single dose check for simple
and complex medication orders. First increment to be
released
• Increment B - Daily dose range check. Includes general
dosing information when a dosing check cannot be
performed – simple orders only
• Increment C - Daily dose range for complex orders.
Includes general dosing information when a dosing check
cannot be performed
• Increment D - TBD
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MOCHA 2.0
• Both Outpatient Pharmacy and Inpatient Medications
• Provides error messages with reasons at the order level when
a Maximum Single Dose Order Check cannot be performed for
Pharmacy users
• Provides a generic error message at the order level when
Maximum Single Dose Order Check cannot be performed for
CPRS users
• Adds a check during installation to see if Pre-Release setup
work has been completed (PSS*1*129 & PSS*1*147, PRE v0.5
PRE-RELEASE patches).
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MOCHA 2.0
• Adds new fields to the Administration Schedule file (#51.1)
• Modify Standard Schedule Edit (PSS Schedule Edit) option to
allow editing of the new dosing exclusion fields
• Modify Administration File Report (PSS Schedule Report)
• Apply the ‘all Dosage Checks exclusion’ for a schedule when
processing outpatient and inpatient medication orders
• Creates a new Pharmacy Data Management (PDM) option
called Lookup Dosing Check Info for Drug
• Adds new entries to the VistA DOSE UNIT file (51.24)
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CPRS versus Vista Order Checks
Maximum Single Dose Check could not be performed for Drug:
IPRATROPIUM BROMIDE 17MCG 200D ORAL INHL
Reason: No dosing information found in database.
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Dose Warning for Single Ingredient Drug
Order details:
Orderable Item: METFORMIN HCL TAB,ORAL
Dosage Ordered: 3000 (MG)
Dispense Units: 3
Noun: TABLETS
Route: ORAL (BY MOUTH)
Schedule: BID-WF
Dose warning text:
METFORMIN HCL 1000MG TAB: Single dose amount of 3000 MILLIGRAMS
exceeds the maximum single dose amount of 1000 MILLIGRAMS.
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Dose Warning for Multi-Ingredient Drug
Order details:
Orderable Item: HYDROCHLOROTHIAZIDE/LISINOPRIL
Dosage Ordered: 5 TABLETS
Route: ORAL (BY MOUTH)
Schedule: QAM
SIG: TAKE 5 TABLETS BY MOUTH EVERY MORNING FOR BLOOD PRESSURE
Dose warning text:
HCTZ 12.5/LISINOPRIL 20MG TAB: Single dose form amount of 5 TABLET(S)
exceeds the maximum single dose form amount of 4 TABLET(S).
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Dose Checks Calculations Dependent on
Body Surface Area or Weight Data
Patient data:
DOB: SEP 6,1946 (65)
Ht(cm): 129.54 (03/13/2012)
Wt(kg): 64.04 (03/14/2012)
Dose warning text:
ENOXAPARIN 150MG/ML INJ SYRINGE 1ML: Single dose amount of
150 MILLIGRAMS exceeds the maximum single dose amount of 105.66
MILLIGRAMS.
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Factors Used to Derive a Recommended Dose
•
•
•
•
•
•
•
•
Patient Age
Height/Weight/BSA (when applicable)
Dose Form
Dose Unit
Medication Route
Frequency
Duration
Rate
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Factor: Patient Age
• Recommended doses vary according to a patient’s
age
• FDB stores dose data according to patient age
• Doses are not always established and available for a
certain age, but this is more common with pediatric
dosing than geriatric dosing
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Factor: Patient Height, Weight, BSA
• Calculated doses for specific drugs are done when a weight or
BSA value is relevant in the determination of an appropriate
dose
• Some drug dosages are only weight/BSA dependent for
specific age groups (i.e. weight may be relevant on a 90 year
old, but not on a 50 year old
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Factor: Dose Form
• Doses are stored differently based on the drug’s
dosage form (i.e. oral, IV, transdermal)
• Some dosage forms are excluded from dosing order
checks (i.e. creams, ointments)
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Dose Check Exclusions
•
•
•
•
Supplies (bandages, syringes)
Compounded items not matched to NDF
Large volume IV solutions – non Premix
Items that don’t require a dose check, but that have a
dosage form that does generate checks
• Drugs with excluded dosage forms (i.e.. creams,
ointments) but, the exclusion can be overridden at the
NDF level
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Lookup Dosing Check Info For Drug
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Dose Check Exclusions
Exclude Dosage Form
Override Exclusion
What happens
No
No
Order Checks Occur
No
Yes
Order Check doesn’t Occur
Yes
No
Order Check doesn’t Occur
Yes
Yes
Order Checks Occur
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Factor: Dose Units
• The dose unit on an order must either match the unit
that FDB has stored, or else be able to convert to
that unit.
• If the dose unit does not match the FDB dose unit,
then the order check will not occur and an error
message will display
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Dose Units for Single Ingredient Drugs
• Generally used for single ingredient drugs that are
administered via po, SC, or IM
• The most common type of dose unit (mg, gm, units)
• Possible types of FDB Dose Unit Conversions
• Metric conversions – wide range (i.e.. mcg to mg)
• Numeric conversions between standard units and
metric units (i.e. Cm to In, Oz to Tsp, Tsp to mL,
MMU to IU)
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Dose Units (continued)
• Dose form type units – Used for non-po solids
(patches, inhalers), multi-ingredient drugs
• FDB selects the type of dose units for an item
• Patch dose unit is “ 1 patch”, rather than
75mcg
• Inhaler dose units are variable and include
inhalations, sprays, puffs, etc. Currently,
they sometimes also include metric doses.
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Non-Standard Doses
• Fractional doses – no problem
• Free-text doses – different assumptions in CPRS versus.
backdoor, because of the way that a dispense drug is selected
in each package
• The pharmacy packages can perform some sophisticated
auto-population logic for free-text doses (i.e. three and onehalf tablets = 3.5 tablets). If a match cannot be determined,
then no order check will be performed
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Dose Unit versus FDB Dose Unit
Dosage Ordered
Single Dose
Amount
Dose Unit
FDB Dose Unit
325 MG
325
MG
MILIGRAMS
0.5 GM
0.5
GM
GRAMS
1 TABLET
1
TABLET(S)
TABLET(S)
20 MEQ
20
MEQ
MILLIEQUIVALENTS
10 ML
10
ML
MILLILITERS
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Factor: Medication Route
• If a medication route is not accurately mapped,
then a dose check will not occur
• FDB Doses are tied to specific routes (IV versus
IM), error messages will display if an invalid
route is selected
• Sometimes FDB is too limiting with its expected
med route.
• Patches – must be transdermal not topical
• Inhalers – Nebulization versus Inhalation; Oral Inhalation versus Oral
(Albuterol Solution)
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Medication Route Issues
Maximum Single Dose Check could not be performed
for Drug: DIGOXIN (LANOXIN) 0.25MG TAB
Reason(s): Invalid or Undefined Dose Route
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Medication Route Issues
NAME: NEBULIZATION//
Already mapped to:
Stnd Route: 'INHALATION' FDB Route: 'INHALATION‘
Order Check Returned:
Maximum Single Dose Check could not be performed for Drug: ALBUTEROL 0.5%
(MULTI-DOSE) INHL SOLN
Reason: No dosing information specific to maximum single dose is
available from the database.
Local Route: 'NEBULIZATION' has been remapped to
Stnd Route: 'NEBULIZATION' FDB Route: 'NEBULIZATION‘
Order Check Returned:
ALBUTEROL 0.5% (MULTI-DOSE) INHL SOLN: Single dose form amount of 3
MILLILITERS exceeds the maximum single dose form amount of 2 MILLILITERS.
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Factor: Frequency
• Used to calculate a total daily dose
• Two new fields were created in file 51.1
• EXCLUDE FROM ALL DOSING CHECKS:
• EXCLUDE FROM DAILY DOSE CHECK:
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IV Orders
– IV orders based on various business rules, the
single dose amount (SDA) and Dose Unit (DU)
could be derived from
• IV solution volume
• IV Additive strength/unit
• Infusion Rate
• Calculated via a formula
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IV Orders (continued)
IV Orders
Strength
Drug Unit
Single Dose Amount
FDB Dose Unit
20
MEQ
20
MILLEQUIVALENTS
0.5
GM
0.5
GRAMS
2
MU
2
MILLIONUNIT(S)
30
IU
30
UNIT(S)
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IV orders (continued)
•
Intermittent Order:
– Cefazolin 10 gms in Dextrose 5% 100 ml IVPB over 60 minutes q12h
• Single dose amount: 10
• Drug unit: grams
•
Intermittent Order marked as Premix:
– Cefazolin 10 gms in Dextrose 5% 500 ml IVPB over 60 minutes q12h
– Single dose amount: 500
– Drug unit: milliliters
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IV orders (continued)
•
Continuous Order marked as Premix:
– Cefazolin 10 gms in Dextrose 5% 500 ml IV at 100 ml/hr
– No dosing information in FDB
•
Continuous Order marked as Premix:
– Heparin 20,000 units in 500 ml 42ml/hr
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IV Orders (continued)
If the Drug can be administered via a ‘CONTINUOUS’ FDB Dose Route, the single dose
amount shall be derived using the following formula:
Single Dose Amount/Dose Rate =
(IV Additive Strength & Unit/Volume of IV Solution) * Infusion rate (ML/HR)
Example: (20000Units/500ML) * 42ML/HR = 1680 Units/HR
Single Dose Amount = 1680
Dose Units = Units (FDB EQUIVALENT is UNIT(S))
Dose Rate Unit = HOUR
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Free Text Infusion Rates
• If the infusion rate is in the free text format of ‘XML/HR@0’
– ‘X’ = single dose amount
– The FDB equivalent of ‘ML’ shall be sent to the interface for the Dose Unit
– Applies to CPRS and Pharmacy backdoor
• Continuous Order marked as Premix:
– Heparin 20,000 units in 500 ml Infuse at 42 ml/hr@0
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Free Text Infusion Rates con’t
•
•
If the infusion rate in the format ‘XY/P/R@N’ or ‘X<space>Y/P/R@N’
– ‘X’ shall represent the numeric dose
– ‘Y’ shall represent the dose unit
– ‘P’ shall represent a patient parameter
• If the values for ‘P’ are ‘KG’ or ‘M2’, the software will multiply the
parameter value for the patient by the numeric dose to calculate the
single dose amount sent into the interface
– ‘R’ shall represent the dose rate unit/duration rate
• If the values for ‘R’ are ‘MIN’, ‘HR’ or ‘DAY’, the software shall set the Dose
Rate Unit/Duration Rate equal to ‘MINUTE’, ‘HOUR’ or ‘DAY’ respectively.
– ‘N’ shall represent a numeric value
Applies to CPRS entered order only
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Free Text Infusion Rates con’t
Infusion Rate
Single Dose Amount
Drug Unit
FDB Dose Unit
50 mcg/kg/min@0
50*Patient’s weight in KG
MCG
Micrograms
1.5 MG/M2/DAY@1
1.5*Patient’s BSA in M2
MG
Milligrams
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Free Text Infusion Rate Example
• Free Text Infusion rate:
– Dobutamine 1000 in 250 ml Premix IV at 42 mcg/kg/min@0
– Pt 129.09 kg
– Finishing it in Vista
Backdoor Vista:
Rate: 42mcg/kg/min ml/hr
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What do I need to do?
• Local Medication Route Mapping
– As you are changing medication routes, remember to check
orderable items as well as CPRS quick orders that may be using
old/invalid medication routes
• Local Possible Dosage Setup
– FDB uses dose units to calculate and match a dose from their database.
– Review Local Possible Dosages Report (PSS LOCAL POSSIBLE DOSAGES ) option
to verify
– Populate the dose Unit and corresponding Numeric Dose field
• Frequency Review
• Enter/Edit Additive Frequency for IV Additives
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Local Possible Dosage Report
(10167)
TESTOSTERONE (ANDROGEL) 1% 2.5GM/PKT GEL *N/F*
INJECTION, THEN PATCH, THEN GEL
Strength:
Units:
Application Package: XOUN
Local Possible Dosages:
ONE PACKET (2.5 GMS)
Numeric Dose:
Dose Unit:
Package: IO
VA PRODUCT MATCH: TESTOSTERONE (ANDROGEL) 1% 2.5GM/PKT GEL,TOP
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Error Message – Local Possible Dose
Dosing Checks could not be performed for Drug: TESTOSTERONE
(ANDROGEL) 1%
2.5GM/PKT GEL
Reason: No dosing information found in database.
Dosing Checks could not be performed for Drug: TESTOSTERONE
(ANDROGEL) 1%
2.5GM/PKT GEL
Reason(s): Free Text Dosage could not be evaluated
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Fixing Local Possible Dose
TESTOSTERONE (ANDROGEL) 1% 2.5GM/PKT GEL *N/F* Inactive Date:
This drug has the following Local Possible Dosages:
ONE PACKET (2.5 GMS)
PACKAGE: IO
BCMA UNITS PER DOSE:
NUMERIC DOSE: DOSE UNIT:
Do you want to merge new Local Possible Dosages? Y// NO
Strength: 1
Unit: %
Select LOCAL POSSIBLE DOSAGE: ONE PACKET (2.5 GMS) IO
LOCAL POSSIBLE DOSAGE: ONE PACKET (2.5 GMS) Replace
PACKAGE: Both//
BCMA UNITS PER DOSE:
DOSE UNIT: GMS GRAM(S)
NUMERIC DOSE: 2.5
Strength: 1
Unit: %
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Dosage Unit for Inhaler
IPRATROPIUM BROMIDE 17MCG 200D ORAL INHL
1 PUFF
NUMERIC DOSE: 17 DOSE UNIT: MICROGRAM(S)
Order Check Returned:
Maximum Single Dose Check could not be performed for Drug: IPRATROPIUM
BROMIDE 17MCG 200D ORAL INHL
Reason: No dosing information found in database.
IPRATROPIUM BROMIDE 17MCG 200D ORAL INHL
1 PUFF
NUMERIC DOSE: 1 DOSE UNIT: INHALATION(S)
Order Check Returned:
IPRATROPIUM BROMIDE 17MCG 200D ORAL INHL: Single dose form amount of 12
PUFF(S) exceeds the maximum single dose form amount of 8 PUFF(S).
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What happens if you can’t figure out
the dosage unit?
Dispense Drug: FENTANYL 50 MCG/HR PATCH
Local Possible Dose: 50 MCG/HR (1 PATCH)
Schedule: q72h
Route: Topical
Dose Unit: Micrograms
Numeric Dose: 50
Order Check Text:
PECS Information:
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Dosepacks
Dispense Drug: METHYLPREDNISOLONE 4MG TAB DOSEPAK,21
Local Possible Dose: TABLET(S)
Dose Unit: Each
Schedule: As Directed
Numeric Dose: 1
Route: Oral
PECS Information:
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No information in PECS
Dispense Drug: MAGNESIUM CITRATE LIQUID 300ML
Local Possible Dose: 300
Dose Unit: Milliliters
Schedule: Once
Numeric Dose: 300
Route: Orally
Order Check Text:
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Review and Update
•
•
•
•
•
•
•
•
Unmatched drug file entries
DEA/Special handling field
Med route mappings
Orderable item medication route defaults for potentially problematic
dosage forms
Local Possible Doses
Edit any quick orders that might be affected
Process for staff to report any issues and error messages
CPRS Parameters – as of right now, dosing is an order check that can be
turned off. This may become mandatory in the future or you may want to
make it mandatory at your site.
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QUESTIONS?
Please use the Q&A Function on Live Meeting
OR
Email: Rosemary.Grealish@va.gov
Debra.Macdonald@va.gov
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