Potential Patient Safety Alert: Medication Favorites (18-Apr-2019)
Office Practicum is committed to patient safety, and as such we prioritize concerns that may impact safe use of software to deliver care. Safe medication prescribing is a key component of providing safe care. OP will be implementing 4 changes to address these concerns:
- Re-deploying a safety check in our e-prescribing processing software so that no potentially unsafe prescription can reach the pharmacy and will be failed. (user action required: none, impact: all customers)
- Changes to OP that streamline your ability to address medication favorites which are not conformant to the current pharmacy database. (update information below)
- Changes to OP that identify potentially at risk prescriptions and prevent you from sending from OP. (update information below)
- Changes to OP so saved favorites can no longer be edited in a way that impacts NDC/name/form/strength (already deployed as OP 14.9.29 and OP 14.10.6)
In order to minimize interruption in your practice’s ePrescribing, please review the urgent information below.
As you should be aware, it has recently come to Office Practicum’s attention that some customers were editing favorite medications in a way that created a mismatch between the NDC and the drug description itself. An NDC is an ID number that uniquely identifies a prescription’s medication name/dose/strength/
This was particularly concerning when some users inadvertently changed the name/strength/form for controlled substances used for ADD/ADHD. Some practices have favorites that have different strengths of a medication all inappropriately linked to the same NDC. (For example, Adderall XR comes in different strengths, all of which should have a different NDC). The prescriber thinks in “words” (I want Adderall XR 10 mg), while the pharmacy systems think in NDC (the prescriber sent the NDC for Adderall XR 30 mg). Patients could potentially be getting a different strength/form (or potentially even medication) than what the prescriber intended. There is a “safety check” at the pharmacy level, where pharmacists may notice this mismatch, which is what brought this discrepancy to our attention.
PLEASE: go to your favorites (Utilities/Manage Clinical Features/Medication Favorites) and look at these high risk medications. If you have NDC numbers that are the same for more than one drug, this is an error and needs to be addressed immediately. Each medication (drug name, form, strength) should have a unique NDC. Effective 4/19/19 mismatched prescriptions will fail.
It may be appropriate for a single drug/single NDC to have more than one favorite. For example, banded weight dosing for Tamiflu has the same NDC attached to different templates. However, the Drug/Form/Strength is also the same:
In this example, there are multiple Favorites using NDC 00004082205, but they all reference Tamiflu Suspension, 6 mg/ml. These are likely to be appropriate.
You can identify problematic Favorites by seeing the same NDC attached to drugs that have different Drug/Form/Strengths.
In this case, the same NDC number (33358029440) is attached to two different drugs: the 10 mg and 20 mg forms of prednisone. Only one can be correct.
Office Practicum has instituted a patch so that in the future, favorites cannot be edited to perpetuate this problem. (Cloud clients already have this change. We encourage users to update to OP 14.9.30 or OP 14.10.8 as soon as it is available so that they also have this improvement, which will reduce the impact of failed prescriptions.) Unfortunately, it is impossible to know which favorites individual practices had inadvertently changed, so we must implement additional rigorous safety checks. You will receive a follow-up communication when these OP versions are available and as always the detailed release notes to review included changes.
In order to prevent mismatched medications from reaching the pharmacy and creating potential safety issues, Office Practicum is adding a “safety check” every time you prescribe a medication that you choose from a favorite, or renew from the patient’s medication list (where you might have used a favorite initially.) This safety check will look at the updated drug database and compare what the drug database name/form/strength is for the NDC. If they do not match what you are currently attempting to prescribe (allowing for case sensitivity and spaces), OP will fail the prescription.
Prescriptions go from your OP instance to another piece of software in OP Cloud called OPEN/Crab Key before being forwarded through the e-prescribing network (Surescripts) to the pharmacy. Since all prescriptions that are e-prescribed go through OPEN/Crab Key, OPEN/Crab Key is where the final safety check occurs.
Earlier this week, Office Practicum updated OPEN to include this safety check, and thousands of prescriptions failed. We apologize for the unintended consequence created by attempting to protect potentially unsafe prescriptions. We have learned that since many of us created medication favorites, the standard descriptions for medications have changed. For example, what used to be called “suspension for reconstitution” has been changed to “suspension, reconstituted, oral.” Unfortunately, the computer cannot decide what constitutes an insignificant mismatch and what changes the true meaning of the prescription. For example, albuterol solution comes both in both a “solution for nebulizer” which you mix with saline and a “vial for nebulizer,” which translates to premixed vials. The prescription instructions for families are distinctly different for those medications.
We have updated OPEN/Crab Key to allow for small non-material discrepancies in spaces and upper/lower case, but our determination is that there is no other safe way to allow additional kinds of differences to be sent to the pharmacy. Depending on when you created your favorites, many of them may no longer be valid. In addition, any medication you have on a patient’s medication list that was created by initially using an out-of-date favorite may be impacted if you attempt to renew/refill. While we recognize and apologize for the burden on our customer community, patient safety must be our first priority. As clinicians we are trained to “first do no harm.” OP must support that commitment and the OPEN/Crab Key safety check will be re-deployed on 4/18/19 at midnight.
Do you have to do anything to update your OPEN/Crab Key? No. Office Practicum will be deploying the safety-checking version of OPEN/Crab Key 4/18/19 at midnight. Going forward, all prescriptions being sent from OP practices will go through this safety check. All of our customers, whether cloud or on-premise server, can have full confidence that you are sending safe prescriptions.
We realize this is going to be a significant burden on practices to clean up all of their favorites.
While someone in your practice is doing this work, you may want to tell your prescribing clinicians to initiate all medications from the Master List. In order to assist you in this process, the “Validate NDC button” is being updated to include the same safety check. This functionality will be available with OP update OP 14.9.29 and OP 14.10.8.
Starting with versions OP 14.9.29 and OP 14.10.8 and going forward, whenever you select a medication from the favorites list, or renew a prescription on the patient’s medication list, OP will do a safety check internally, and if there is a mismatch, will tell you that this is not able to be safely prescribed. It will behave in the same way the prescriptions currently do if you attempt to send a prescription without a valid NDC. This will prompt the prescriber to choose a medication that has a correctly matched NDC and description before it leaves OP. Using this validation check inside OP, will prevent numerous failures after the user hits send (as the prescription passes through OPEN/Crab Key.)
Why can’t OP just ask me to update my favorites if they find this mismatch or automatically fix them for me? We have determined that changing the name/strength/form may have implications for changing the sig, such as different strengths leading to different dose amounts or frequency. In an abundance of caution, we do not feel it is safe for OP to do this behind the scenes for the prescriber. In addition, we determined that it is likewise risky to give that opportunity to every user in the context of writing a prescription for one patient. When you are choosing from the favorite, it has not yet been applied to that particular patient. If we give you a chance to “fix on the fly” it may have implications on the favorite itself, which is not appropriate for other patients.
How can I start cleaning up my favorites even if I don’t have the latest version?
If you know that you likely have some “old favorites” with out of date descriptions (such as albuterol solution below), choose the edit button:
And use the functionality to go to the master list:
You may find that the name doesn’t even map to something that you were intending:
You have to change the search name, in this case just “albuterol”
And find the medication that you intended on the favorite and re-choose from the master list:
Which will update your favorite to the most up-to-date drug details (noticed the difference from above) so that your NDC and description will be matched appropriately and will not be able to be edited going forward.
Why doesn’t the Validate NDC button fix all this for me?
In the current build of OP, the “Validate NDC” button only confirms that each medication currently has a valid NDC; it does not confirm that the medication you intend to prescribe currently has the correct NDC to match your description. OP can’t safely know which of the favorites have insignificant mismatches, and which of the favorites have significant implications for patients. In addition, OP can’t know whether the original intent of the prescription (including the liquid calculations, rounding rules and sig) was intended to be for the wording or the NDC.
How can I minimize the impact to my practice?
- Communicate this information to your entire practice team
- Advise prescribing clinicians to consider prescribing from the Master List until a Favorites Champion can be identified and the Favorites list has been validated and updated
- Use caution when renewing a prescription from within the patient’s medication list, as it may have been created from a favorite that has invalid NDC/descriptions or may contain name/form/strength descriptions that are no longer valid
- Update your instance of OP as soon as possible so you can implement the improvements in the Validate NDC for favorites and the OP validation/safety check. This will make sure the safety check occurs prior to hitting send (thereby minimizing the number of failed prescriptions). Additional communication about cloud and on-premise update availability will be sent as soon as possible.
We know that this is disruptive to your prescribing workflow and apologize for the hardship it causes. Thank you for joining OP in our commitment to making patient safety a priority. Feel free to email me directly with additional questions or concerns that are not already answered by this or prior communications, or can be found on our Help center.
With deep appreciation for all you do for patients and families,
Susan J. Kressly, MD, FAAP
This morning (April 16, 2019), you may have experienced that more medications than usual were failing to reach pharmacies on the first pass. That’s because last night we issued a patch to the component that exchanges eRx data with Surescripts to remediate a potential patient-safety issue related to mismatched medication details. After reviewing today’s rejection logs, we decided to withdraw that patch temporarily because we determined that all rejected prescriptions whose drug details did not match perfectly nonetheless carried the same meaning. We apologize for the inconvenience this may have caused you and your staff.
We are working to analyze the data from this morning and to define an improved solution, because matching medication details remains a high priority. Why do these checks need to become more rigorous? Because greater patient safety is always our top priority and the prevention of mismatches, no matter how trivial, aligns with this goal.
How can a mismatch occur? Doctors mostly focus on the medication name, form, and strength when they create a prescription, but by the time an order reaches the pharmacy, the pharmacist also cross-checks the provided National Drug Code (NDC). This essential secondary safety check matches the text of the name, form, strength, and brand/generic indicator on the prescription against those same characteristics from the NDC master table. If they don't match, the pharmacist is left with a choice that only the prescriber can resolve: Did they mean the medication as described, or as specified by the NDC that came along for the ride?
This issue doesn't occur when you create a new prescription from scratch (Master List), but there are two primary reasons why prescriptions created from Favorites or refills might mismatch. First, the drug database that OP software uses to look up medications is continually updated to stay current with national standards. But the details on a Favorite or refill would reflect back to the day it was created. In this case, using a Favorite or refill that was previously saved without rechecking the details as of today could lead to mismatches when it is sent. Most rejections this morning were based on these kinds of discrepancies, such as your Favorite having the form “suspension for reconstitution,” while the current national standard is “suspension, reconstituted, oral”. Yes, human beings understand at a glance that these descriptions are effectively identical, but the computer is not that smart when simply trying to match exact text.
The second reason for mismatches is due to direct edits to Medication Favorites. Older versions of OP did not prevent users from modifying the name, form, strength, and brand/generic indicator after these details had been pulled from the NDC master list. Such changes might be well intended, but they could lead to prescribing mistakes. A user might have simply changed the text of the drug strength (e.g.,"20 mg" in lieu of "10 mg") and without changing the NDC to match, by looking up a different medication with a different NDC at the desired strength.
Our focus is to ensure patient safety and convey your intentions unambiguously to the pharmacist. We are working on a more robust user-friendly solution to protect the safety of our patients while not disrupting your workflow unless absolutely necessary. Again, we apologize for the inconvenience and appreciate your patience while we fine tune this important feature.
Introducing OP's New Solution for Contacting Support
In order to continue improving and enhancing your Support experience with Office Practicum, we are upgrading our Contact Center Communications solution on Tuesday, March 26th.
We are calling this a Communications Solution, because we are starting off by optimizing your customer experience when calling into Support. Throughout this year, we will be evaluating and pulling in other Support communications channels into this system.
On March 26th, when you call into Support, you will notice new prompts under the Support option that ensure we get you to the right team or department to work with you on your issue. This solution will enable us to more intelligently route calls to the right representative, team or department, and provides lookup functionality in the background that we anticipate will expedite your service.
One piece of information that will be important to know when calling into Support will be your OP MED ID.
Where is my OP MED ID?
You can find your ID in OP software by clicking Help, then About. Your OP Medical ID is the parenthesized number in the Client ID field.
What will be changing?
- When you press “2” for Support, you’ll hear the following menu:
- If are an existing OP client and are unable to use the application, press 7.
- If you're having an issue with a new feature, press 1
- If you would like to learn how to do something in OP or run a report press 2.
- For Technical Support, press 3. Some examples of why you would select this prompt is when you can’t access OP software, are receiving backup errors, can’t print, or can’t scan.
- For Billing Support, press 4. Some examples of why you would select this prompt is if you’re having issues with claims rejections or payments.
- For all other issues, press 5 or hold for the next available representative. You would use this if you have a question or issue that is not covered by any of the previous prompts.
- We are going to try to identify your Practice. We have enhanced our system to try to locate your account based on the number from which you dialed. If this phone number is associated with your account, we won’t prompt you for more information. After you are connected by phone number, our representatives will validate who you are by asking for your name and Practice Name.
- If we can’t find your account based on the phone number from which you dialed, we will ask you for your OP Medical ID. Remember: You can find your OP Med ID in OP software by clicking Help, then About. Your OP Med ID is the parenthesized number in the Client ID field (see the screen cap above).
- If you are calling about an existing issue, and you only have one existing open support issue assigned to one of our representatives, we will make every effort to route your call to the assigned representative. If they aren’t available, you will then have the option to leave a voicemail for the representative to return your call or to be assisted by another representative.
- In order to help you save some valuable time and to be able to assist other callers with critical issues, we are encouraging self-service for those issues you may be able to resolve quickly. Part of our Communications Solution includes the new How-To prompt. When you call in and are holding for a representative to assist you, we will encourage you to visit the OP Help Center while waiting. If you can’t find the information you’re looking for, you have the option to receive a callback when your call is at the top of the queue, to leave a message for a representative to call you back, or to continue holding for a representative.
Did You Know?
Over half the calls we get at OP are from users with questions that can be answered in seconds on the OP Help Center at support.officepracticum.com? If you have a question about ‘how’ the solution works, we encourage you to search the OP Help Center first and get a little more time back in your busy day..
- For security purposes and to validate against the OP Med ID (if provided), our representative will ask for your practice name and your name.
This is the first phase on our journey toward providing you with a more optimal Support experience. In a subsequent phase, we will introduce a new chat solution. As always, we will keep you informed on our progress.