Chemo Order Entry offers quick and easy access to all of the orders applicable to the care of the patient during a course of chemotherapy. This online ordering system greatly reduces the chance of errors by delivering clear and complete information to all providers: physician, nurse, and pharmacist.
Protocols—Protocols are defined as investigational courses of chemotherapy treatment. The Chemotherapy Protocol Player presents orders for a selected protocol based on the patient's Quality Assurance for Clinical Trials (QACT) registration.
Regimens—A regimen is a standard course of care that has been accepted by the provider institutions of Dana Farber Partners Cancer Care as best practice. Regimens are associated with one or more diagnoses.
Order status and activation—Chemo orders can be written as either preadmission or new inpatient orders. In either case, once appropriately reviewed and signed off by an attending oncologist, the orders must be activated to be put into use. Pre-Admit hem/onc orders split into two (2) groups for activation: associated non-chemo orders (hem/onc session #1) and chemo orders (hem/onc session #2). New inpatient chemo orders file as a single session for activation.
The Pod Monitor order status for patients with pre-admission hem/onc or new inpatient chemo orders to be activated is NICO.
Safety and efficacy—The order entry system checks the vital information and dependencies that ensure the safety and efficacy of treatment, such as the record of the patient's weight and height used to calculate body surface area. All medication orders are automatically checked for possible adverse reactions, based on the patient's allergy record, as well as potential drug-drug interactions (DDIs).
All of the orders associated with a particular regimen or protocol are presented at your fingertips as you write. The system automatically calculates such values as the patient's BSA, and dosing based on this information. If applicable to the usual course of treatment, doses are calculated and presented based on a set ideal or dosing weight, or age-dependent or weight-dependent dosing, or AUC dosing.
Chemo height and weight—Weight and height values used for chemotherapy calculations are stored independently from other Order Entry weight and height records for the patient. For inpatients, the weight and height must be entered every time you order chemo; for pre-admission orders, the information is carried forward up to 30 days.
Ordering—Regimens and protocols are grouped into treatment episodes. These episodes may be defined as cycles that are numbered sequentially, or weekly treatments that are not numbered. Each set of orders is tracked by its day1/day 0 date, and its cycle number if applicable.
Some treatments are relatively simple, repeating the same orders during each cycle or week until the end of treatment. For these treatments, a single group of orders is offered, to be reused for each cycle or week.
Other therapies are considerably more complex, however. When a therapy requires differing strategies or sets of orders for each cycle, those orders are defined and grouped separately. When ordering, you must select the appropriate group of orders for the current cycle. This may mean reusing a group, or if the right stage is reached, choosing the next group of orders in the flow. Groups are labeled to guide you to the appropriate choice.
Orders in a regimen or protocol may be optional, or may require tailoring to meet the patient's needs. MDs can add exception orders to the chemo set. This customizes the treatment to the specific patient.
Exception orders—Exception orders can only be written when ordering from a regimen. Options include:
Adding non-standard chemo orders to those already included in a regimen
Increasing the dosing of a standard chemotherapy agent
Selecting orders from a regimen not usually associated with the patient's primary diagnosis
Building a custom regimen for the individual patient
Infusion Flowsheet—To get a look at how the treatment administration has gone, you can access the Oncology Infusion Flowsheet in the LMR (Longitudinal Medical Record). You must be authorized to view the LMR Web to access the flow sheets. Call the Help Desk number on your device for instructions on getting authorization for the LMR Web.
Chemotherapy View of Historic Orders: Providers can display a list of previously activated orders for the selected patient when writing, reviewing, approving, and activating orders for chemotherapy. The list includes chemo order sessions from all sites that were activated in the last 6 months, and includes chemotherapy and chemo-related (chemo sessions #1 and #3) orders as well as non-chemo (session #2) orders. The orders are sorted by activation date, most recent to oldest. The list can be limited to orders from selected sites, as well as a defined time frame. The list can be filtered to show only chemotherapy and chemo-related (chemo sessions #1 and #3) orders or only non-chemo (session #2) orders. The sessions can be sorted by regimen or protocol. See Viewing Historical Chemo Information.
Cumulative Dosing For Activated Anthracyclines: Values for cumulative dosing are derived from activated anthracyclines chemotherapy medication orders. The information does not reflect ACTUAL doses administered. The dosing is listed separately for the same medication when it has been ordered with different dosing units—for example, mg/kg (milligrams of medication per kilogram of patient weight) and mg/m2 (milligrams of medication per square meter of patient body surface area). The display includes a link to open the oncology treatment history for the patient in the LMR (Longitudinal Medical Record).
Orders included in the data:
All Dana Farber Partners Cancer Care (DFPCC) sites—MGH inpatient and ambulatory, Dana Farber (DFCI), and BWH inpatient and ambulatory locations
Activated orders only—no orders awaiting activation
Anthracyclines Daunorubicin, Doxorubicin, Epirubicin, Idarubicin, and Mitoxantrone for adult and pediatric patients, and Bleomycin for pediatric patients only
Duplicates, change to orders and discontinue orders; if there is more than one activation for the same chemo medication, for the same date, the higher dose is displayed
The Cumulative Dose button is accessible from the current Chemo orders list, the regimen/protocol selection form, and the chemo regimen/protocol player. See Evaluating Cumulative Dose Information.
Maximum Daily, Weekly, or Lifetime Cumulative Dose: Providers writing new orders for anthracyclines at all sites except NSMC are notified automatically if the dose they are writing exceeds the maximum daily and/or weekly dose, or pushes the patient’s lifetime cumulative dose to equal or exceed the maximum lifetime dose for that medication. See Responding to the Chemo Lifetime Maximum Dose Warning.
Laboratory Results: Laboratory results are displayed beneath the orders list. These are results that have been reported in the previous 21 days, which are defined as relevant to the chemo medications for the current regiment or protocol. Today’s results are bold and underlined. Results outside of the reporting lab's reference range are flagged in red followed by H (high) or L (low). If no results are displayed, check the Results viewer by clicking Results in the CAS toolbar on the left. (See Checking Last Known Values for Lab Results.)
Approval—Orders written from a protocol or regimen must also be appropriately reviewed. All chemo orders written by an oncology fellow or by a physician assistant (PA) must be approved by an attending oncologist before a nurse can review or administer the treatment. Approval is also required when an oncology fellow edits or discontinues chemo orders.
Recalculation of dosing at activation—A nurse must activate both hem/onc order sessions (non-chemo and chemo orders), in the process verifying the patient's height and weight. If either is changed, weight-based dosing is recalculated. If dosing changes significantly because of this, the session must be approved by an attending before it becomes active. If appropriate, you can prevent recalculation of dosing at activation when you write chemo orders.
Editing—When you originally write chemo orders, you can edit the treatment by changing the dosing or omitting a chemo med. You can also make dose changes or discontinue chemo orders before or after they are activated.
Active chemo orders are edited or discontinued using the O Order Entry > Z Chemotherapy pathway. When you discontinue or edit an active order, you're actually writing another order—a D/C or change order.
When they are inactive, you cannot access NICO or preadmission orders using the Order Entry function. To access the inactive sessions list before the orders are due for activation, access the BICS Order Entry (O) Pre-Admission menu (A). After selecting Add to Signed Pre-Admit (R), select the order session you want to edit. Once you enter your key, you can call up the orders in the list via Z Chemotherapy.
Chemo orders edited or discontinued by oncology fellows must be approved by an oncology attending. Changes to chemo orders written by PAs do not require approval.
Dose modifications—For chemotherapy medications, dose changes are often predefined as modifications for clinical reasons. Dose modifications may include a decrease to the dose by a defined percentage, based on a clinical result (e.g. platelets < 50,000), or a decrease to a defined dose, for a specified length of time. Dose increases may also be defined.
There are rules regarding changing the dose of a chemotherapy medication:
Dosing for investigational protocols cannot be increased
The dose for a standard chemo med order can be increased only if the change is defined as a dose modification for the regimen
You must enter a reason for any D/C orders for chemo drugs
You must enter a reason for omitting (by unchecking the order) a pre-checked chemo med
Change or D/C orders written by fellows are new orders that must, like all new chemo orders from these clinicians, be approved by an attending
Changes to exception orders are considered new exceptions
Switch regimens—You also have the option to switch the patient mid-treatment from one regimen to another. This process will allow you to discontinue the current active orders. Orders created this way follow the same approval rules as other chemo orders.
Expiration of chemo orders—NICO and pre-admission orders for chemotherapy are flagged as Expired at midnight on the expected treatment/admission date if still inactive.
Changing the activation date (change day 1 / day 0)—Chemo orders awaiting activation expire at midnight on the expected activation date if the session isn't activated. To change the admission date (pre-admission hem/onc) or the day 1/day 0 date (pre-admission hem/onc or NICO) before activation, use the Change Day 1/Day 0 Hem/Onc NICO (D) option under the BICS Order Entry (O) Pre-Admit (R) menu.
Scheduled days are numbered sequentially from the day 1/day 0 date that starts a treatment stage. When a chemo session is activated, the date of the scheduled day is set relative to the date of the day 1/day 0 start date. Each chemo/med order expires on the day after its last scheduled day. If you reset the activation date for orders that are to be activated on day 1/day 0, check the day 1/day 0 date. If day 1/day 0 is before the activation date, the dates for day 1/day 0 will be set in the past—the orders will expire as soon as they're activated.
Changing the treatment day—If you must postpone administration after chemo orders have been activated, you can prevent orders from expiring by changing the date of the appropriate scheduled day. Changing the date of a scheduled day generates a general care order for nursing for each chemo medication that is affected by a change of treatment date.
To postpone treatment after orders have been activated, use the Change Treatment Day function in the General Care - Chemo Related (Z) options, found under the Order Entry (O) General Care order type.
Instructions: Ordering Chemotherapy