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Part 5: Data Entry & EHR Mastery (New Track)
Module 18: Epic (Willow Inpatient) — Order Entry & Verification
18.3 Handling BestPractice Advisories (BPAs): Your Clinical Co-Pilot
Developing the critical skill of interpreting, acting upon, and documenting your interaction with Epic’s automated safety net.
You have mastered the command center of the verification queue and the high-tech workbench of the Order Composer. Now, we introduce your co-pilot. BestPractice Advisories (BPAs) are Epic’s real-time, automated clinical decision support system. These are the pop-up alerts that fire during the verification process, designed to be a critical safety net that catches potential errors, enforces clinical guidelines, and provides crucial information at the exact moment you need it. However, in an environment of constant information flow, these alerts can quickly become overwhelming. The master-level skill you will develop in this section is not just *seeing* these alerts, but *interpreting* them with clinical wisdom. You will learn to distinguish a routine suggestion from a catastrophic “never-event” warning, to document your clinical judgment with precision and professionalism, and to use these tools not as an interruption, but as an integral part of a collaborative, human-computer approach to patient safety.
Retail Pharmacist Analogy: The DUR Alert vs. The Intelligent Co-Pilot
In your retail practice, you are an expert at navigating DUR (Drug Utilization Review) alerts. You see alerts for drug interactions, therapeutic duplications, and high doses hundreds of times a day. You quickly learn to assess their clinical significance—you know that a “high dose” alert for a chronic pain patient’s opioid is different from a high dose alert for a child’s antibiotic. You use your judgment to decide whether to counsel the patient, call the doctor, or override the alert.
Epic’s BPA system is this concept evolved into an intelligent co-pilot. Imagine if, instead of just flashing a generic “drug interaction” warning, your retail software could also read the patient’s latest lab results and say, “Warning: This patient’s potassium is already 5.2, and you are adding an ACE inhibitor. This could cause severe hyperkalemia.” Furthermore, imagine it gave you a button to instantly message the provider with a recommendation to check a repeat potassium level in 3 days. This is the power of BPAs. They are not just simple warnings; they are data-driven, context-aware advisories designed to guide your clinical decision-making and streamline your communication. Your existing skill in DUR analysis is the perfect foundation for mastering this more advanced system.
18.3.1 Anatomy of a BPA: Deconstructing the Alert
To respond effectively, you must first learn to read a BPA with precision. They are designed to convey a large amount of information in a small space. Your eyes must be trained to instantly parse the signal from the noise. Let’s break down a simulated interruptive BPA.
MAJOR DRUG-DRUG INTERACTION
Simvastatin is contraindicated with Itraconazole.
This combination significantly increases the risk of rhabdomyolysis and myopathy due to inhibition of CYP3A4 metabolism of simvastatin.
Patient: DOE, JOHN (MRN 789123456)
Existing Med: Itraconazole 200 mg PO DAILY
New Order: Simvastatin 40 mg PO QHS
Recommendation:
Discontinue simvastatin. Consider an alternative statin not metabolized by CYP3A4, such as pravastatin or rosuvastatin.
18.3.1.1 Key Components to Analyze in Seconds:
- The Header/Title: This is your first clue to the severity. A title like “MAJOR INTERACTION” or “ALLERGY ALERT” in red demands your full attention. A title like “Formulary Suggestion” in blue is less critical.
- The “Why” Statement: The first line of the body is the most important sentence. It tells you the core problem in plain language (e.g., “Simvastatin is contraindicated…”).
- The Patient Context: The BPA should always show you the specific patient and the specific orders that triggered the alert. This confirms it’s not a generic warning but is tailored to the patient in front of you.
- The Recommendation: A well-built BPA doesn’t just identify a problem; it suggests a solution. This is a powerful tool that helps you formulate your intervention quickly.
- The Action Buttons: These are your tools for execution. The available buttons (“Override,” “Discontinue,” “Route,” “Acknowledge”) will change depending on the severity and type of alert.
18.3.2 A Taxonomy of BPAs: From Nuisance to “Never-Event” Stopper
Not all alerts are created equal. A crucial part of developing expertise is rapidly categorizing an alert’s severity and required action. We can broadly classify BPAs into a hierarchy of importance.
18.3.2.1 Level 1: Hard Stops (The “Red Light”)
These are the most critical alerts, designed to prevent catastrophic, or “never-event,” errors. A hard stop is a digital red light. The system will not allow you to proceed with the current order. There is no simple override. Your only path forward is to fundamentally change the therapy.
There is No “Overriding” a True Hard Stop
If you encounter a hard stop, your mindset must be absolute: “The current order is unsafe and cannot be given to this patient.” Your actions are not about justifying the order; they are about correcting it. You must stop, contact the prescriber, and document the mandatory change.
| Hard Stop Trigger | Clinical Rationale | Your Mandated Action |
|---|---|---|
| Documented Anaphylactic Allergy | Patient has a documented history of anaphylaxis to the ordered medication or a cross-reactant. | Immediately discontinue the order. Call the provider to inform them of the allergy and recommend a safe alternative from a different drug class. |
| Contraindicated Drug Combination | A “do not co-administer” interaction with a high likelihood of severe harm (e.g., Simvastatin + Itraconazole). | Discontinue the new order. Contact the provider with a recommendation for a non-interacting alternative. |
| Wrong Route Alert | Attempting to order a known neurotoxic agent (e.g., vincristine) for intrathecal administration. | This is a “never-event” scenario. Discontinue the order immediately and escalate to a pharmacy manager while also contacting the provider. This requires a systems-level investigation. |
18.3.2.2 Level 2: Soft Stops (The “Yellow Light”)
These are the most common BPAs and the ones that require the most clinical judgment. A soft stop is a yellow light. It’s telling you to “proceed with caution” and is asking for your professional opinion. The system is flagging a *potential* issue, but it trusts you to determine if it’s clinically relevant for this specific patient.
This is Where You Practice Pharmacy
Navigating soft stops is the essence of clinical pharmacy. The EHR can identify a potential problem based on data, but only you, the pharmacist, can integrate that data with the full clinical picture—the provider’s notes, the patient’s history, the goals of care—to make an informed decision. Every soft stop is an explicit request for your clinical expertise.
| Soft Stop Trigger | The Question the BPA is Asking You | Your Investigation & Action |
|---|---|---|
| High Dose Warning | “Is this high dose intentional and safe for this specific patient?” | Review the patient’s profile. Is this an opioid-tolerant cancer patient? If yes, the dose is likely intended; override with a clear comment. Is this an opioid-naïve elderly patient? If yes, the dose is likely unsafe; contact the provider to recommend a lower starting dose. |
| Therapeutic Duplication | “Is there a valid clinical reason for this patient to be on two drugs from the same class?” | Check the MAR. Two different NSAIDs? Likely an error; contact provider to clarify which one is intended. An ACE inhibitor and an ARB? This is a high-risk duplication; contact provider to discontinue one. An IV and PO version of the same drug? This could be intentional for IV-to-PO transition; verify the timing and discontinue the IV once the PO is absorbed. |
| Renal/Hepatic Warning | “Have you considered this patient’s organ dysfunction when evaluating this dose?” | Calculate the CrCl or review the Child-Pugh score. Does the dose need adjustment? If the provider has already ordered the renally-adjusted dose, override and document “Dose appropriate for renal function (CrCl = X).” If not, contact the provider to recommend the correct adjustment. |
18.3.3 The Art of the Override: Documenting Your Clinical Judgment
Clicking “Override” is not an act of dismissal. It is an act of professional documentation. When you override a BPA, you are creating a permanent, auditable record that states, “I have seen this alert, I have applied my clinical judgment, and I have determined that for this specific reason, the order is safe and appropriate to proceed.” This documentation is your primary defense against medico-legal scrutiny and is a hallmark of a professional pharmacist.
18.3.3.1 Masterclass: “Good” vs. “Bad” Override Documentation
The quality of your override documentation speaks volumes about your clinical diligence. Vague, lazy comments create risk. Clear, concise, and specific comments demonstrate professionalism and protect both you and the patient.
| Scenario | “Bad” (Lazy/Unprofessional) Documentation | “Good” (Clear/Professional) Documentation |
|---|---|---|
| High Dose Opioid Alert | “MD aware.” | “Patient has documented opioid tolerance for chronic cancer pain. High dose is clinically appropriate and intended per oncology note. Acknowledged.” |
| Therapeutic Duplication (Lovenox + Apixaban) | “ok” | “Spoke with Dr. Jones. Apixaban is being held while patient is bridged with Lovenox for VTE treatment. Will resume apixaban upon Lovenox discontinuation. This is intentional, planned therapeutic bridge.” |
| Renal Dose Warning (already adjusted) | “override” | “Provider has already ordered the correct, renally-adjusted dose of 750mg IV Q24H based on patient’s CrCl of 25 mL/min. Alert acknowledged as informational.” |
18.3.4 The Interruptive BPA Workflow: Your Step-by-Step Action Plan
When a critical alert fires, you must have a systematic, reflexive process to handle it. This prevents panic and ensures all safety steps are taken in the correct order.
18.3.4.1 The “S-A-F-E” Method
S – Stop & See
The very first step is to stop what you are doing. Do not reflexively click “close” or “override.” Take your hands off the mouse. See the alert. Read the entire text, from the title to the recommendation. Absorb the information before reacting.
A – Analyze & Assess
Now, engage your clinical brain. Look at the Clinical Context Pane. Is the alert valid? Does it make sense for this patient? Is it a true risk, or a known, managed exception? Assess the severity of the potential harm.
F – Formulate & Forward
Based on your assessment, formulate a clear action plan. If the order is unsafe, what is the best and safest alternative? Now, forward your recommendation. Use the “Route Clarification” or “In Basket” button directly from the BPA to send a concise, professional message to the provider proposing your solution.
E – Execute & Exit
Execute the plan. If you are overriding, write your high-quality documentation. If you are waiting for a response, change the order status to “Clarification Needed.” If you are discontinuing the order, do so. Once the appropriate action is taken, you can safely exit the alert and the order, knowing you have completed a thorough safety check.
