Module 19: Meditech (Expanse) — Order Entry & Verification

19.2.1 Provider Order Sets: The Foundation of Standardized Care

An Order Set is a pre-configured group of orders for a specific diagnosis or condition (e.g., “Community-Acquired Pneumonia Admission Orders,” “Sepsis Protocol”). A provider can launch an Order Set and, with a few clicks, generate dozens of coordinated orders for medications, labs, nursing care, and consults. While this improves efficiency, it creates a new challenge for the pharmacist: the “shotgun” verification, where a dozen or more orders for a single patient appear in your queue simultaneously. Your ability to assess this bolus of information holistically is a critical skill.

19.2.1.1 The Pharmacist’s Role: Context is Everything

When you see a group of orders from a single Order Set hit your queue, your job is not to verify each line item in isolation. Your primary responsibility is to perform a holistic review of the entire set in the context of the specific patient. You must elevate your thinking from a component checker to a system validator.

19.2.1.2 Masterclass: Verifying a “Community-Acquired Pneumonia” Order Set

Scenario: A 78-year-old male is admitted from the ED with CAP. The provider initiates the “CAP Admission” Order Set. The following orders appear in your queue.

Your Verification Process:

1. Holistic Review: The combination of ceftriaxone + azithromycin is the standard of care for inpatient CAP. The supportive care orders (fluids, albuterol, VTE prophylaxis) are appropriate. The overall plan is clinically sound.
2. Patient-Specific Checks: You open the patient’s chart.
   • Allergies: No beta-lactam or macrolide allergy. OK.
   • Renal Function: You check the labs. SCr is 2.5 mg/dL, CrCl calculates to ~30 mL/min.
     • The ceftriaxone dose (1g daily) does not require adjustment for this level of renal impairment. OK.
     • The azithromycin dose does not require adjustment. OK.
     • The enoxaparin dose, however, is now incorrect. The standard prophylactic dose of 40mg daily is for patients with CrCl > 30. For a CrCl of 30 or less, the dose should be reduced to 30mg daily. INTERVENTION REQUIRED.
   • QTc Interval: You know that azithromycin carries a risk of QTc prolongation. You check the patient’s EKG report or telemetry data. The QTc is 490ms, which is borderline prolonged. The addition of azithromycin could push this into a dangerous range. INTERVENTION REQUIRED.
3. Intervention: You would contact the provider to discuss two critical modifications to the standardized order set: (1) Changing the enoxaparin dose to 30mg daily based on renal function, and (2) Discussing the risk/benefit of azithromycin in the setting of borderline QTc prolongation, perhaps suggesting a non-macrolide alternative like doxycycline if clinically appropriate.

19.2.2 Masterclass: Initiating Pharmacy-Driven Panels

This is where your role evolves from a passive verifier to a proactive initiator of therapy. Pharmacy Panels are your primary tool for executing clinical interventions efficiently and consistently. They represent your department’s trust in your clinical judgment. Based on your review of a patient’s chart, you can use these pre-approved Panels to optimize their therapy, often without needing to contact the provider for a new order. Let’s walk through two of the most common and impactful examples: IV-to-PO conversions and renal dose adjustments.

19.2.2.1 Scenario 1: The IV-to-PO Conversion Panel

The Situation: You are performing your daily clinical review for patients on your assigned floor. You are looking at the profile of Jane Smith, a 65-year-old female on Day 3 of her admission for community-acquired pneumonia. You see an active order for “Ceftriaxone 1g IV DAILY.” You open her chart in PCS and conduct a systematic review for conversion criteria:

• Fever: Temperature log shows she has been afebrile (<38°C) for the past 36 hours.
• WBC Count: Labs show the WBC count is trending down and is now 8.5 K/uL (within normal limits).
• GI Function: Nursing notes indicate she is “tolerating a regular diet with good appetite.” There is no mention of nausea, vomiting, or diarrhea. She is not NPO.
• Clinical Stability: Vitals are stable. She has no contraindicating conditions like bacteremia, endocarditis, osteomyelitis, or signs of malabsorption (e.g., ileus, short gut syndrome).

Your Clinical Judgment: This patient is a perfect candidate for conversion to an oral antibiotic. Continuing IV therapy increases the risk of line-related infections, is more costly, and tethers the patient to an IV pole, limiting mobility and potentially delaying discharge. Your hospital has an approved IV-to-PO conversion protocol that empowers pharmacists to make this change.

The Meditech Workflow:

1. Initiate the Panel: From within the PHA module, with the patient’s chart selected, you will search for and launch the “IV to PO Antimicrobial Conversion Panel.” This is an action you are initiating, not one that appeared in your queue.
2. Select the Components: The panel will present you with a series of pre-built orders. It’s designed like a checklist.

   — IV to PO Conversion Panel —

   [X] Discontinue existing IV Antimicrobial -> (You select this. A new field appears prompting you to select the active IV order from a list. You choose “Ceftriaxone 1g IV DAILY”).

   [X] Initiate new PO Antimicrobial -> (You select this. A new field appears allowing you to choose the oral agent).

       Select Oral Agent: (You click this, and a dropdown list of protocol-approved conversions appears).

        – Ceftriaxone -> Cefpodoxime

        – Levofloxacin -> Levofloxacin

        – Amp/Sulbactam -> Amox/Clav

   (You select “Cefpodoxime.” The panel automatically populates the standard dose and frequency: “Cefpodoxime 200 mg PO Q12H”).

   Set Duration: (You enter a duration to complete a total of 5 days of therapy, as per your hospital’s CAP guideline).

3. Review and Sign: The panel bundles these two actions—the discontinuation of the IV and the initiation of the PO—into a single intervention. You review it for accuracy and then sign it using your credentials.
4. The Result: The system automatically processes your commands. The ceftriaxone order is discontinued on the eMAR, and the new cefpodoxime order appears, ready for the next administration time. This is a seamless, pharmacist-driven therapeutic interchange.
5. Documentation: Your final step is to create a record of your action and rationale.
   Pharmacist Note (Intervention): “Patient meets clinical criteria for oral antibiotic conversion (afebrile, tolerating PO, WBC WNL). Initiated IV to PO conversion panel per hospital protocol. Discontinued IV ceftriaxone and initiated PO cefpodoxime to complete a 5-day total course of therapy. This action promotes antimicrobial stewardship and facilitates patient discharge.”

19.2.2.2 Scenario 2: The Renal Dosing Adjustment Panel

The Situation: You receive a new order in your UNV queue for “Tobramycin 350 mg IV Q24H” for a 70 kg patient with HAP. You immediately recognize this as an aminoglycoside, a high-risk, nephrotoxic drug. Your clinical “sixth sense” tells you to scrutinize renal function before proceeding.

• Patient Weight: 70 kg (The ordered dose of 5 mg/kg is appropriate).
• Serum Creatinine today: 2.4 mg/dL (up from 1.2 at admission).
• Age: 75 years.

Your Clinical Judgment: The patient has a significant acute kidney injury. A standard Q24H interval for this aminoglycoside is unsafe and creates a high risk of drug accumulation and subsequent nephrotoxicity and ototoxicity. The dose must be adjusted based on an extended-interval nomogram (e.g., the Hartford nomogram). Your hospital has a “Pharmacy to Dose” protocol for aminoglycosides that empowers you to make this change.

The Meditech Workflow:

1. Action on the Original Order: First, you will “Discontinue” or “Cancel” the provider’s original, unsafe order for Tobramycin Q24H.
2. Initiate the Panel: You will then launch the “Aminoglycoside – Pharmacy to Dose Panel.”
3. Enter Data & Select Path: The panel is an interactive tool. It will first prompt you to enter the patient’s key data: Age, Weight, and SCr. You enter these values, and the panel automatically calculates the CrCl (~25 mL/min). Based on this result, the panel’s built-in logic will guide you to the correct, protocol-approved dosing interval from the nomogram.

   — Aminoglycoside Dosing Panel —

   Calculated CrCl: 25 mL/min

   Select Interval based on Nomogram:

   ( ) Q24H (CrCl > 60)

   ( ) Q36H (CrCl 40-59)

   (X) Q48H (CrCl 20-39) <– Panel logic directs you here.

   ( ) Dose per random level (CrCl < 20)

4. Order Linked Labs: A critical safety feature of a well-built panel is that it forces you to order the necessary follow-up. You will be required to select the lab monitoring order before you can sign.
   Required Monitoring:
   [X] Order random tobramycin level 6-14 hours after start of first infusion.
5. Review and Sign: The panel bundles the new, correct medication order (“Tobramycin 350 mg IV Q48H”) with the required lab monitoring order. You sign it as a single, complete therapeutic intervention.
6. Documentation:
   Pharmacist Note (Intervention): “Original tobramycin order D/C’d due to acute kidney injury. Re-ordered per Pharmacy to Dose protocol. Patient’s calculated CrCl is ~25 mL/min. Adjusted frequency to Q48H per Hartford nomogram to minimize risk of further nephrotoxicity. Ordered random drug level to assess clearance. Will monitor labs closely.”