Medication ordering is common in all clinical contexts. Developing medication order skills can speed workflows, improve patient safety and simplify medication reconciliation at care transitions. Inpatient medication orders are constrained by Alberta Health Services (AHS) formulary considerations, and possibly facility availability. Outpatient orders have fewer limitations, although it remains important to consider regulatory and insurance constraints.
Medication Order Search Lists
A medication order is initiated by performing a search for the desired item, form and dose. Order search results default to present any matching personalizations ("favourites" organized in a "Browse" tab in order search) first. The next "Preference List" tab gathers search results commonly ordered by one's specialty. Finally, a "Facility List" shows results matching those available at one's local facility.
It is important to appreciate the difference between Preference and Facility lists:
This seeks a match of the search term within a list of medications selected to reflect common usage by the "Department" (specialty) of the currently signed-on user. Only one set of preferences is maintained for each specialty in the province.
This seeks a match of the search term within a list of medications and mix options available within the clinical facility where the order is being placed.
It is possible for a medication appearing in the Preference tab to not be locally available, and so not listed in the Facility tab. It is also possible for an item to be available via the Facility tab when that item is not included in the Preference tab listing of search results. This can be easy to forget, especially for prescribers who work infrequently at a particular facility. Resulting delays, and re-checks with the ordering physician, could affect care.
Effective mitigations include:
Familiarity with local ordering options
Prescribers familiar with a facility will have developed awareness of any limitations to what can be ordered and promptly provided at that facility. Prescribers less familiar can always ask a colleague, or check with the facility on-call pharmacist.
Saving specific medications, including details of the form, dose, route and frequency, can build up a highly relevant quick-list that makes ordering easier and also ensures a good fit with fast facility medication provisioning.
Medication Order Challenges
Prescribers moving from a paper to a digital health record may find certain types of medication orders challenging. These are easy to write when one can rely solely upon pharmacist interpretation of prose instructions. It can take a bit more effort, and skill, to enter complex medication orders using CPOE. The benefits are worth the effort (decision supports, safety checks, interaction checks, etc.) and the effort is dramatically reduced if personalizations are used to save the initial work of order-entry so that it is automated at next need.
Dose Range Orders
It may be desirable for patients to be provided a medication dose that falls within a pre-determined range, with discretion provided for adjustments based upon symptoms or other considerations (e.g., laboratory results).
Most dose range requests are best handled through two linked orders. The first sets a regular baseline dose at consistent intervals. The second sets an as-needed (PRN) dose that can supplement the baseline, possibly at a different administration frequency.
When prescribers order a single scheduled medication with ranged dosing, system restrictions (such orders cannot work well with decision supports) cause delays as extra pharmacist resources are required to interpret the prescriber's intent. Accordingly, ranged dosing should be restricted to the very few situations where a combination of regular and as-needed orders is not possible or appropriate.
Prescribers who enter range-dosing requests inappropriately can expect to receive an In Basket message requesting correction:
"Range dosing is not allowed for scheduled orders. Please modify your order to use one dose. If appropriate, you may wish to use the lower dose in this scheduled order and place an additional linked PRN order for *** to allow for dosing flexibility."
Dose Range Size
When dose ranges are provided in PRN orders, these should be kept as narrow as possible.
Wide does ranges can be clinically dangerous, especially with pain management medications. Wide ranges also create challenges within Connect Care and pharmacy services because the range may exceed what can be covered with a particular medication vial concentration.
When patients are admitted to Connect Care facilities, prescribers may want to continue home medications. On occasion, a specific medication or formulation cannot be found in the list of items orderable within an inpatient encounter, even after checking spelling, generic names and facility lists. It is likely that the medication is not on the AHS drug formulary, and so is "Non Standard" for inpatient use. Clinically equivalent formulary medications are usually available for substitution.
There may be strong clinical reasons for continuing a home medication that is non-formulary. The ordering prescriber needs to place a "Non Standard Medication" order (search for "non-standard"). This facilitates entry of the generic name of the requested medication, together with details about dose, route, formulation and duration. Such orders are routed to a pharmacist who checks if the medication can be provided. If not, the ordering prescriber is contacted to explore alternatives (such as facilitating use of patient-provided medications).
Placing a Non Standard Medication order is a safer than trying to modify a formulary medication by adding comments to its order composer. These medication modification requests could be missed by pharmacy or nursing, or the request may neglect key details.
Note: A medication name beginning with the prefix "INV" is an investigational medication. If a study drug is not wanted and the same medication without the INV prefix cannot be found, use the Non Standard Medication order.
Tracked Prescriptions for Controlled Substances
The Alberta Tracked Prescription Program (TPP, tppalberta.ca, formerly known the "triplicate prescription program") monitors use of prescription drugs prone to abuse. It does this by ensuring that such prescriptions are recorded using prescription pads with security features and copies. Normally, prescribers are required to keep a (paper) copy of the prescription. Please note that the new Connect Care eFax workflow cannot be used for prescriptions for drugs classified as Type 1 under the TPP; these prescriptions still require the use of a paper TPP secure prescription form.
Permission from TPP is obtained for Connect Care prescribers to order the controlled substance in Connect Care, produce a handwritten prescription on official TPP prescription pads, add the TPP identification number to the Connect Care record (comments section of Connect Care order), provide the primary handwritten prescription to the patient or pharmacist, and destroy any remaining paper copies of the prescription.
Patients may present for care while participating in one or more research studies. The study may involve use of an investigational treatment (usually medication) that is not on the AHS inpatient formulary, or on listings of medications available in the community.
When studies are registered in Connect Care, it is likely that the investigational agent is added to the facility list of orderable medications. In such cases, prescribers can search for the medication and will find its name prefixed with "INV" (e.g., "INV bamlanivimab IV solution..."). If the study drug is not wanted and the same medication without the "INV" prefix cannot be found, then a Non Standard Medication order should be used.
Medication Order Personalization
Personalizing medication orders with a well-organized list of favourites is one of the best ways to speed Connect Care order workflows.
Use chart search (or Epic menu) to find and open the "Preference List Composer".
Select the "Show Empty Lists" button at the bottom of the Preference List Selector if Medications are not already shown. Preferences can be managed for Inpatient and Outpatient medications independently.
Once in either the Inpatient or Outpatient medications preference composer, follow usual order personalization guides to build any sections and/or subsections desired to categorize medication personalizations.
Add items to categories, setting dose, route, frequency, duration and other details as desired.
Any added items should reflect what is available where one usually works.
Prescribers working in multiple facilities can set up sections for each in the Preference List Composer and so be rapidly reminded, during ordering, of any facility differences in medication formulations frequently ordered.
Direct eFax of Prescriptions to Community Pharmacies
AHS and AHS partner facilities using the Connect Care clinical information system can send medication prescriptions directly to community pharmacies via an electronic fax (“eFax”) process, without the need for a printed prescription or handwritten signature. This avoids the prior need to print, hand-sign, then fax a prescription. Community pharmacists receive these prescriptions via fax, following their usual procedures.
The new Connect Care eFax workflow cannot be used for prescriptions for drugs classified as Type 1 under the Tracked Prescription Program (TPP); these prescriptions still require the use of a paper TPP secure prescription form. Furthermore, the eFax option is available for medications only, not supplies such as diabetic supplies.
For security and safety, electronically faxed Connect Care prescriptions include an electronic signature linked to the unique username, password and professional registration number of each prescriber (such as a physician's College of Physicians & Surgeons of Alberta registration number). The electronic signature replaces a handwritten (“wet”) signature; consequently, graphic signatures are not required and do not appear on direct-faxed prescriptions. Additionally, each prescription has a unique order number that is specific to that prescription. Community pharmacists have access to an online real-time validation tool that can verify the authenticity of Connect Care electronic prescriptions.
To send a prescription via direct electronic fax to a community pharmacy, there are two steps for the ordering prescriber:
Confirm or enter the patient's preferred pharmacy (or pharmacies); and
Change the order class to "Fax" (the default is "Print", including for refills) and select the destination pharmacy (or pharmacies).
A tip sheet further explains these steps. (Note: This workflow should not be used for treatment [therapy] plan medications, as these have specific settings that should not be changed.)