Section 21.2: Order Composer and Verification Workflow

21.2.1 The “Why”: From Ambiguous Scribble to Structured Data

In your pharmacy career, you have deciphered countless prescriptions that were masterpieces of ambiguity. The hastily scribbled “Tylenol prn” or “resume home meds” that required a 15-minute phone call to clarify dose, frequency, indication, and intent. Every moment spent on clarification was a moment not spent on clinical review, a moment of potential delay in patient care, and a moment where a transcription error could introduce harm. The primary goal of Computerized Provider Order Entry (CPOE) is to eliminate this ambiguity, transforming a provider’s clinical intent into structured, discrete, and unmistakable data.

The two most critical arenas where this transformation happens are the provider’s Order Composer and the pharmacist’s Verification Workflow. The Order Composer is the digital interface that replaces the prescription pad. It is the cockpit from which providers fly the aircraft of patient care. Its design, layout, and embedded logic directly influence the quality and safety of every medication order placed in the hospital. A well-designed composer guides the provider to create a perfect order every time. A poorly designed one is the digital equivalent of a blank sheet of paper, inviting ambiguity and error.

Once an order is placed, it enters the pharmacist’s domain. The Verification Workflow is the digital triage system that replaces the chaotic pile of faxes and paper scripts. It is an intelligent system that sorts, prioritizes, and presents orders to the pharmacy team. It ensures that the STAT order from the Emergency Department is seen before the routine refill from the med-surg floor. It equips the pharmacist with a comprehensive view of the patient’s profile, labs, and history, transforming the act of verification from a simple “check” into a robust clinical review.

As a pharmacy informatics analyst, you are the architect of this entire process. You will build the cockpit for the providers and design the air traffic control system for the pharmacists. The safety, efficiency, and satisfaction of both groups rest heavily on the quality of your build. Mastering the tools within this section is not just a technical exercise; it is a profound responsibility. You are building the very infrastructure of medication safety for your entire organization.

Part 1: The Order Composer Masterclass

The Order Composer (OC) is the primary tool providers use to enter medication orders. It is a highly configurable screen that appears after a provider selects a medication (`ERX` record). The configuration of this screen is stored in records within the Order Composer Configuration (`OCC`) master file. A single `OCC` record, for example, one designed for oral medications, can be linked to thousands of different `ERX` records, ensuring a consistent ordering experience for providers.

Your goal as an analyst is to build a library of `OCC` records that are intuitive, safe, and efficient. You want to capture all necessary information for the pharmacist without overburdening the provider with unnecessary clicks or questions. It is a delicate and critical balancing act.

Deconstructing the `OCC` Record: Items, Screens, and Components

An `OCC` record is not a single entity, but a collection of settings, called items, that control various components on the ordering screen. Think of it as a control panel with dozens of switches and dials. Each switch controls a piece of the user interface.

`OCC` Item Category	Function	Example Configuration
General Settings	Controls the overall behavior and appearance of the Order Composer window itself.	Allow comments to pharmacy, Display patient allergies in header, Set default order priority to Routine.
Screen Configuration	Determines which major sections (screens) are available to the user.	For a simple oral med, you might only show the “Dosing” and “Scheduling” screens. For a complex IV, you would add the “IV Fluid Information” screen.
Component Configuration	Controls the individual fields (components) within each screen. This is where the most detailed build work happens.	Making the “Dose” field numeric-only, requiring a selection for “Route,” or hiding the “Duration” field entirely.

Masterclass Deep Dive: Key Order Composer Components

Let’s explore the most important components you will configure. For each, we’ll discuss the build options and the informatics principles behind them.

Component: The Dose Field

Configuration Option	Description	Best Practice & Rationale
Data Type	Set the field to be Numeric, Alphanumeric, or Custom List.	Always use Numeric whenever possible. This ensures the dose is a discrete number that can be used for dose-range checking and calculations. A custom list can be used for things like “1 tab”, “2 tabs”.
Requiredness	Make the field Required, Recommended, or Optional.	The Dose field should always be Required. It is fundamentally unsafe to sign an order without a dose. This is a critical “hard stop.”
Dose Range Checking	Link the dose to the checks configured in the `MED` record and `DCS` master file.	The `OCC` should be configured to fire both soft-stop (warning) and hard-stop (blocking) dose range alerts. You can configure which user classes can override soft stops.
Calculators	Embed a calculator to determine the dose.	For pediatric or chemotherapy drugs, embed a weight-based or BSA calculator. The `OCC` should be configured to pull the patient’s weight automatically, calculate the dose, and populate the dose field. This prevents manual math errors.

Component: The Frequency Field

Configuration Option	Description	Best Practice & Rationale
Frequency Selection	Providers can select from a pre-defined list of schedules (from the `EFW` master file) or enter free-text.	Strictly limit or disable free-text frequency. Use a curated list of standard, unambiguous schedules (e.g., “DAILY”, “Q4H”, “BID”). Free text like “every other day” is notoriously prone to error.
PRN Settings	If the frequency is “PRN”, additional fields can be displayed.	Always require a PRN Reason. This is critical for nurses to know when to administer the medication. Also, configure a required “minimum time between doses” to prevent unsafe re-dosing.
Taper/Complex Schedules	The `OCC` can be configured to open a special editor for building complex taper schedules (e.g., for steroids) or cycles (for chemo).	For drugs that are commonly tapered, linking to the taper scheduler from the `OCC` saves time and improves accuracy over trying to enter multiple separate orders.

Component: Order Questions

Order Questions are the “smart logic” of the Order Composer. They are questions that can be configured to appear based on the drug, class, route, or other order properties. They are built as records in the Question (`LQL`) master file and linked within the `OCC`.

Example Order Question	Triggering Logic	Answer Format	Rationale
“Indication for Use?”	Appears if the ordered medication has the “Antibiotic” flag.	Custom list of common indications (e.g., “CAP”, “UTI”, “Cellulitis”).	Supports antimicrobial stewardship by forcing providers to state the reason for the antibiotic, which helps pharmacists assess appropriateness and duration.
“Target INR?”	Appears if the medication is “Warfarin.”	Numeric with a reasonable range (e.g., 1.5-4.0).	Ensures this critical safety parameter is documented with every new warfarin order, guiding future dose adjustments.
“Infusion Rate?”	Appears if the Route is “IV.”	Numeric with units (e.g., mL/hr).	Captures essential information for IV medication administration that isn’t part of the standard dose/frequency paradigm.

Part 2: The Verification Workflow Masterclass

Once a provider signs an order, it leaves their world and enters yours. The Verification Workflow is the system that manages the intake, triage, and processing of these orders by the pharmacy department. A well-built workflow ensures that pharmacist time—one of the most valuable resources in the hospital—is spent on the most critical tasks. The goal is to present the right order to the right pharmacist at the right time with the right information.

This system is primarily controlled by two key components: the Willow Router, which acts as the intelligent gatekeeper, and Verification Queues, which are the organized worklists pharmacists use.

The Willow Router: Your Intelligent Triage Technician

The Router is a sequence of rules that the system processes for every single new or modified medication order. Each rule is an “IF/THEN” statement. The system checks the order against the “IF” condition of the first rule. If it matches, it performs the “THEN” action (usually “Send to Queue X”) and stops. If it doesn’t match, it moves to the next rule in the sequence. This is why the order of the rules is critically important.

Masterclass Table: Building Router Logic

Rule #	“IF” Condition (Properties of the Order)	“THEN” Action	Rationale
1	Priority = “STAT”	Send to “PHARMACY – STAT” Queue	The highest priority rule. Catches all STAT orders from any location and puts them in a single, constantly monitored queue for immediate action.
2	Medication Class = “Chemotherapy” OR Patient Location is an Infusion Center	Send to “PHARMACY – ONCOLOGY” Queue	Segregates complex, high-risk chemotherapy orders to a dedicated queue staffed by oncology specialist pharmacists. This rule comes after STAT, because a STAT chemo order should still go to the STAT queue first.
3	Patient Location = “Emergency Department”	Send to “PHARMACY – ED” Queue	Groups all non-STAT ED orders for the dedicated ED pharmacist, who understands the unique pace and needs of that environment.
4	Patient Location = Any “ICU” Unit	Send to “PHARMACY – ICU” Queue	Routes orders for critically ill patients to the ICU pharmacist specialists.
5	Order Type = “Patient’s Own Meds”	Send to “PHARMACY – POM” Queue	Creates a separate workflow for the time-consuming process of identifying and verifying medications patients have brought from home.
100	(No “IF” condition)	Send to “PHARMACY – GENERAL” Queue	The “catch-all” rule. Any order that did not meet the criteria for the rules above will land here. This ensures no order is ever missed. It must be the last rule in the sequence.

Verification Queues (`VCN`): The Pharmacist’s Worklist

Once the Router directs an order, it appears in a Verification Queue. These queues are highly customizable records built in the Verification Queue (`VCN`) master file. As an analyst, you will build and maintain these queues to optimize the pharmacist’s workflow. The goal is to provide maximum “at-a-glance” information so pharmacists can quickly assess the priority and nature of the work waiting for them.

Key Queue Configuration Points

• Queue Name and Description: The name should be clear, logical, and follow a standard convention (e.g., `PHARM – STAT`, `PHARM – ICU`).
• User and Security Assignment: You don’t want every pharmacist to see every queue. You will link queues to specific Epic security classes. For example, the `ONCOLOGY PHARMACIST` security class will be granted access to the `PHARM – ONCOLOGY` queue, while generalist pharmacists will not see it. This ensures specialized work is handled by specialists.
• Column Display Configuration: This is the most important part of the queue build. You decide what columns of information appear in the worklist. A well-designed set of columns allows a pharmacist to triage their own work within the queue.
• Sort Order: You can set a default sort order for the queue. For most queues, this will be by Order Priority (Stat first), then by Order Time (oldest first).

Masterclass Table: Designing Queue Columns

Column	Data It Displays	Why It’s Critical for Triage
Priority	Displays the order priority (e.g., STAT, NOW, ROUTINE). Often color-coded.	The most important piece of information for at-a-glance prioritization. A pharmacist should be able to instantly see the red “STAT” orders.
Time In Queue	A running clock showing how long the order has been waiting.	Helps identify bottlenecks and orders that may have been missed. A routine order waiting for 3 hours is now a problem.
Patient Name & Location	The patient’s name and their current unit/room/bed.	Provides context. An order for a patient in the OR is different from one for a patient on a med-surg floor.
Medication Name	The name of the ordered medication.	Allows pharmacists to visually scan for high-risk drugs (e.g., heparin, insulin) that might need more immediate attention even if they are not marked “STAT.”
Order Mode	Indicates if the order is New, Modified, Canceled, or a Discontinue.	Helps the pharmacist understand the nature of the task. A simple discontinue order is much faster to process than a complex new chemotherapy order.

The Verification Workspace: A Clinically Rich Environment

When a pharmacist selects an order from a queue, the Verification Workspace opens. While less configurable than the queues or router, your build work is still crucial here. The goal is to ensure that all relevant clinical and patient data is presented in a clear, logical manner, and that the Clinical Decision Support (CDS) alerts you’ve configured fire appropriately.

Your build work will focus on:

• CDS Alert Configuration: Tuning the sensitivity of allergy, drug-interaction, duplicate therapy, and dose range alerts. You want to eliminate low-value, noisy alerts while ensuring that critical warnings are unmissable.
• Patient Information Links: Ensuring that the verification screen has prominent, one-click links to the patient’s full MAR, lab results, and provider notes.
• Intervention Documentation Tools: Building the tools and templates pharmacists use to document their clinical interventions, ensuring this valuable data is captured in a structured format for later reporting.