Improve Linked Medication Order Entry and Administration Processes

1. Linked medication orders would ideally be able to be linked via "AND" (levothyroxine 125mcg+25mcg to equal 150mcg) or "OR" (ex. IV or PO acetaminophen). Physician, nursing and pharmacy should have the option to link upon order entry, and pharmacy order verification.

2. Adding a Link Order button on order entry and pharmacy order verification. Put the order visually together in ORder Chron, the MAR, etc.

3. See #2

4. No, adding linked orders would not rule out the need to add components to non-IVs. For example, we compound oral solutions the Pharmacy and send out a bulk bottle. I wouldn't want staff trying to retrieve those items from Pyxis after the item has already been compounded. They would need to scan the bulk bottle.

We'd like to see a "patch check" item on the MAR for the days when the patch isn't due, where the nurse has to chart where the patch is and that they are verifying that the patch is still present. It should be either part of the patch item setup itself, or a separate order that we can link to the medication patch order so that the provider doesn't have to remember to order it. We currently have a field for this on our physical assessment flowsheet, but it really belongs on the MAR.

There should be several options to "link medications" on the MAR. I believe physicians and pharmacists should be the ones entering complicated scheduled tapering doses. If it's simple medications, i.e., suppository docusate and PO docusate, then nursing should be able to link them if given a telephone order. I've worked with other EHRs that have these abilities. The linked medication order should be an option only on ordering medications. "Do you want to link the medications?" Or have a button below the medication to "link medication" and choose a list of medications it can be linked to, or something along those lines. Medications should only be linked to the same medications; i.e., tylenol linked to tylenol.

• If it's an either PO or IV version of the medication, then if one is given, the other should automatically drop off the MAR. For instance, IV tylenol or PO tylenol on MAR. If PO tylenol is scanned, then the IV tylenol would drop off the MAR, making it not scannable and have the option/"CDS pop-up alert" for a suggested recommendation to D/C the IV tylenol, as the pt is now taking PO. Then automatically cancel the order and it appear in the verification tray before the order is officially processed to cancel the IV tylenol. (Especially since the IV version is more expensive.)

• If suppository vs PO options of the same medication; i.e., docusate, then if one is scanned (PO option), then the other route option for rectal administration should cancel / disappear off MAR. Both should remain linked to have that option.

• Combination of dosages for 1 medication administration. If scan one, can scan the next dose and the MAR automatically calculate the total dose to be administered. (If 20mg ordered, but only 10mg available, then if 10mg med scanned x2, it would automatically calculate the total dosage without giving an error of "wrong med" or "not ordered for this pt". Should never have to be another one off order for the same medication, especially when we can't stock a certain dosage at all times.)

• If titration protocol for tapering medications; i.e., phenobarbital used in alcohol withdrawal. There's recommended doses and frequencies, which should go in order, instead of a "guessing game" and a "max dose" option, as they would all appear on the MAR, causing confusion. For example:

  • ***PHENOBARBITAL PO TAPER OPTIONS***

    • **Phenobarbital PO Taper Option for ACTIVE DTs**

    • *STEP #1 for ACTIVE DTs: Phenobarbital 260mg IV x1*.

    • *STEP #2 for ACTIVE DTs: Phenobarbital 97.2mg (3 TABS) PO TID x6 doses*

    • *STEP #3 for ACTIVE DTs: Phenobarbital 64.8 mg (2 TABS) PO TID x6 doses*

    • *STEP #4 for ACTIVE DTs: Phenobarbital 32.4mg (1 TAB) PO TID x6 doses*

    • IF PT HAS ACTIVE DTs: 260mg IV x1, followed by 97.2mg PO TID x6 doses, followed by 64.8mg PO TID x6 doses, followed by 32.4mg PO TID x6 doses

      • (There's no safe way to time this, unless the ordering provider can predict a "future start date/time" of the doses or remember to order the next step. It's difficult to build this in an order set.)

#4 is a good idea. We need the ability to build compounded Non-IV orders like we can IV orders (multiple items within one item) but we also need to be able to scan each item within the item at administration. If there are some facilities that do not wish to use this function, they do not have to, just don't build the item... Also, if there is fear of a safety issue, make it a switch that can be turned on or off for your facility. Otherwise, when we make a compounded topical item, there is no way to scan each item without the link item functionality. Each separate item within the compound entered as a separate order would be a disasterous mess on the M.A.R.

We have not utilized linked pharmacy orders here for quite some time. I do like the idea of #4 being able to do component Non-IV items, although I wonder how difficult it would be for a nurse to complete in order entry or if there would be item master work,etc. and how this would impact CPOE and Non-Formulary issues, etc. Small sites do not have on site pharmacy 24/7 so that is something to keep in mind.

The other things I would find useful is a good way to incorporate multimodal pain management in a better way and PRN method order and indications. I know our state board of nursing and the accrediting bodies are really getting strict on indications on all PRNs, not duplicating the same class of PRNs for the same reason, and for more clear physician guidelines on which method the nurse should utilize first. It is difficult to fit all of this guidance into a comment area on the med and the instruction often varies based on whether it is a scheduled or PRN med.

Good morning everyone! The original idea entry has been updated with several questions:

Linked Orders = two or more medications needing to be given together that will share a frequency, start date/time, and stop date/time.

1. Is linked orders a functionality that is still needed? If so, does this need to be utilized just with Pharmacy and nursing or does this need to be added as a Physician option as well?

2. How can we improve the workflow from an Order Entry (Pharmacy, Nursing and Physician if needed) perspective?

3. How can we improve the workflow from the medication administration perspective?

4. If we were to go the route of adding the ability to add components/additives to Non-IVs, would this rule out the need for linked orders? An example of this use would be using Coumadin 2.5 MG and Coumadin 5 MG to make Coumadin 7.5 MG.

I have not permitted "linked" pharmacy orders for some time (years) related to safety and functionality.

I do think that per the conversation below, we need to make sure that everyone understands that the discussion is around "linked" orders and not "associated" orders

Lastly, nursing verifying lab orders is necessary depending on the site. If nursing is drawing, they need to verify but also if it is a time sensitive lab, say a drug level, they may need to have that knowledge of lab at med administration.

Chad, You gotta look at the big picture. It can't be an all fit in one with this. At my hospital, nurses need to verify the lab because they are the ones drawing it most of the time. How will they know if labs need to be drawn if it goes through lab first for instance over night or out of business hours.

It would be nice to use the same "save and link" functionality from pharmacy order entry in order sets.

From pharmacy's point of view, I think linking orders is working appropriately. I do, however, get calls from nurses after scanning one med, they can't seem to figure out what to do next. It seems that there is insufficient info on the screen to inform the nurse that the order is linked. They have difficulty finding the button to go to the next med.

I think "Guest" is describing Chartlink Associated Orders. Linked orders are something different. Pharmacists can link 2 or more orders. Any linked meds must be given together.

Having pharmacy/lab orders only linkable to ancillary orders (items) causes issues. There are numerous lab and pharmacy orders that include orders that should be carried out by nursing and respiratory. The solution to create mini order sets to make sure physicians include all of these orders is not efficient. The physicians do not like having the additional order sets for what they call "simple orders." Additionally, it is not efficient to have to create multiple zero charge items just to be able to create a linkable ancillary order for nursing. A physician should be able to order an insulin and then be prompted to include a linked bloodsugar check for nursing. Another example, a physician should be able to order an ABG and then be prompted to include a collection order to Respiratory (for those of us that don't have RT run their own labs). This could also be solved by having the option to have orders print to multiple printers.

We do not need nursing to verify Lab orders for hospital patients. Make it like ER where Lab orders go directly to the Lab.