Overview of Chemo Order Entry

Chemo Order Entry: The purpose of the Chemotherapy Order Entry system it to streamline the writing and administration of orders while automating the features and checkpoints that optimize efficacy and patient safety.

Regimens: A regimen is defined in Order Entry as a course of chemotherapy treatment accepted as best practice throughout the Partners HealthCare community. Regimens are provided as options based on the diagnosis that you pick when ordering. The regimens that are available for a particular diagnosis are based on the specialty of the provider who is writing the orders—adult oncology, pediatric oncology, or non oncology treatment.

Protocols: Protocols are defined as investigational treatments for oncology use only. Adult patients must be enrolled through Quality Assurance Clinical Trials (QACT) to participate in investigational protocols. QACT will assign the study group—high versus low dose, or age-based cohort, for example. A similar function is performed for pediatric patients via the MGH Pediatric Protocol enrollment. When you write chemo orders for a patient who is properly enrolled, the applicable protocol is presented automatically.

A patient can be enrolled for one or more protocols. Protocols can be therapeutic, ancillary, or ancillary-therapeutic; Order Entry chemotherapy orders include only therapeutic or ancillary-therapeutic.

A patient can only be registered to one therapeutic protocol. Patients on therapeutic protocols cannot be placed on a standard regimen unless the end treatment and/or off study dates for the protocol are recorded (see Ending Treatment From a Protocol).

If the patient is registered to one or more ancillary-therapeutic protocols but no therapeutic protocol, you have the option to order from a regimen (based on the diagnosis) or one of the registered ancillary-therapeutic protocols. If you choose a regimen, the next time you write chemo that regimen come up automatically.

You can order from more than one ancillary-therapeutic protocol by going through the chemo ordering process separately for each. That is, Write>Chemo>Add, then select a protocol when prompted, and complete the orders; then, Write>Chemo>Add again, selecting a different protocol option.

Indications: Indications for treatment are required for most chemotherapy regimens and protocols written for adults. Indications include curative versus non-curative intent for solid tumors, or adjuvant/neoadjuvant/curative intent versus palliative/metastatic for hematological malignancies. The indication must be updated when ordering chemotherapy after 60 days. See Ordering Chemotherapy.

Chemo and Additional Orders: All of the orders needed to complete a selected therapy are presented in the Chemotherapy Player in Order Entry. It is always possible to write additional orders to treat unrelated conditions—for example, Digoxin for arrhythmia, or blood glucose monitoring for diabetes. Some order types are offered only in the inpatient setting, or at particular sites, as appropriate.

Episodes of Treatment: The system defines an episode of treatment in one of four (4) ways: as cycles, numbered sequentially; as sequential or non-sequential weeks; as phases, not numbered; or as weekly treatments, without numbering. For example, for a therapy calling for cycles of monthly administrations over the course of six months, each monthly treatment is considered a cycle. When writing chemotherapy orders from regimens or protocols with cycles or weeks of treatment, you must indicate what cycle or week number you are ordering. See Ordering Chemotherapy.

Dates and Schedules: Treatment dates and administration schedules are based on the individual episode rather than the entire multiple-week/month course of treatment. You must enter a date to define the start, either Day 0 or Day1 (depending on the therapy). Day 1/ day 0 is the date from which the scheduled administration days (numbered consecutively each day forward from that) are counted. Chemo meds and associated treatments are scheduled for administration on a day number (1, 8, 15, for example). You can change the date for day1/day 0 before the treatment starts, and the dates of scheduled days, as needed.

When you write the next set of orders, the baseline date from the previous set is displayed. For adults, the next expected cycle/week number is displayed automatically. Because non-sequential treatments are possible for pediatric patients, the cycle/week number is left blank. Simply update the numbers to indicate the new cycle/week information. See Ordering Chemotherapy.

Chemo weight and height: Any time a clinician writes orders for chemotherapy, he or she must enter or confirm the patient's weight (and height). These values are used to calculate the patient's BSA (body surface area), as well as any weight-based dosing of chemotherapeutic agents.

Weight and height for chemo calculations is stored separate from any other order entry values—for example, the values used for weight-based dosing of medications ordered outside of a regimen or protocol. Weight must be re-entered every 30 days for oncology patients, every 90 days for patients getting chemotherapy for other treatments. See Ordering Chemotherapy.

If the patient has a weight record in the outpatient LMR (Longitudinal Medical Record), you can update the weight you enter when selecting a regimen or protocol with the click of a button. If you do not use the weight from the LMR, your entry is compared to the LMR record. If the difference between the weights is greater than 5%, you must confirm that this is your intention, and provide a reason; when you do so, the option to prevent recalculation of the weight-based dosing upon activation is selected automatically, with the same reason.

This automatic "Do Not Recalculate" setting applies to all weight-based orders in the chemo folder. To allow recalculation at activation of weight-based dosing for any chemo medication, select the order in the regimen or protocol Chemo folder, click the Do not change dosing calculation tab, and click to uncheck the option.

The setting is carried forward for ordering from previous. See Overview of Reusing Previous Chemo Orders.

For adults (patients over 19 years old), this is the only weight data collected. Only chemo drugs use weight-based dosing for these patients.

For patients defined as pediatric (less than 19 years old), any weight-based orders included in a chemo order session are calculated using this chemo weight. These include chemotherapeutics, non- chemo medications, IV fluids, and blood products. These orders can be added to the chemo order session when the session is first written, or when editing a chemo session before it is activated.

For NICO (New Inpatient Chemo Orders), pre-admission, and ambulatory orders, the nurse must confirm the chemo weight when activating. Because the chemo weight can be used for orders other than chemo agents for pediatric patients, this weight must be confirmed for all orders when the patient is under 19 years old.

Preventing recalculation of weight-based dosing: For adult patients only, this option is selected automatically when there is a weight available from the LMR that is 5% greater or less than the chemo weight you entered when selecting this regimen or protocol, and you chose NOT to update the chemo weight with the weight from the LMR. Your reason for declining the update is stored as the reason to prevent recalculation of the weight-based dosing upon activation. This "Do Not Recalculate" setting applies to all weight-based orders in the chemo folder. You can deselect the setting for any order as needed.

Chemotherapy Over the Entire Course of Treatment: Some treatments are relatively simple, repeating the same orders during each episode until the end of treatment. For these treatments, a single group of orders is offered, to be reused for each episode.

Other therapies are considerably more complex, however. When a therapy requires differing strategies or sets of orders for each episode, those orders are defined and grouped separately. When ordering, you must select the appropriate group of orders for the current episode. 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.

Chemotherapy View of Historic Orders: Providers can now 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.)

Customizing Orders for Treatment: Orders in a regimen or protocol may be optional, or may require tailoring to meet the patient's needs. You can add orders as needed to any non-chemo set. Non-chemo orders include antiemetics, IV for hydration, blood products, non-chemo medications, and general care, among others. MDs can also add exception orders to the chemo set. All of this customizes the treatment to the specific patient.

The system not only adds these orders to the patient record when you sign them, but also "remembers" the exact setup for the next time you order. When a treatment repeats the same group of orders for each episode, you have the option to reuse that setup, or return the orders to their original state.

Reusing Previous Orders: "Previous" is an automatic process that stores any changes you make to the treatments—dosing, instructions, exceptions, and so on—when you sign. If you edit orders while they are awaiting activation or after they are active, the changes are also saved for future use for that patient.

If you opt to use the previous setup for a treatment, any group of orders has been used previously for the selected patient is displayed with a red check. The check does not appear if you opt for the standard treatment setup, or if the last group of orders has been used previously and the treatment is completed. Treatment completion is based on the date of day1/ day 0 and the pre-defined treatment length (days to completion).

To ensure the safety and efficacy of the treatment, there are many built-in safeguards for the reuse of previous orders. See Overview of Reusing Previous Chemo Orders.

Exception Orders: Additions and some changes to chemotherapy medication orders follow a particular set of rules. For details, see the overview on Exception Orders.

Reusing Single Use Treatments: You will be prompted to select a treatment if the previous orders have been defined as "single use." This is a double check to ensure that you do want to order a single-use treatment more than once.

Changes to the Chemo Agents in the Standard Treatment: The use of the previous setup may be prevented if the chemotherapy medication orders in the standard regimen have been changed significantly since you wrote the previous orders. In this case, a message about the edit will be presented when you write new orders. You will not be able to reuse your previous settings. A general care order is added to the set to inform nursing and pharmacy that previous settings did not automatically carry over, and that all dosing should be checked.

Changes to the Non-Chemo Medication Orders in the Standard Treatment—If non-chemo medication orders have been changed significantly since the last time you wrote orders from the regimen or protocol, but the chemo agents have not been edited, you have the option to order the treatment setup as previous, except for those non-chemo medication orders. Read the description of previous orders when the option is offered. Non-chemo orders revert to the standard setup when you order from previous in this case.

Orders Discontinued After The Session Was Signed: The affect of discontinuing a chemo order that has been signed—whether it has been activated or not—is to delete the scheduled days, not to omit or uncheck it on the order set. You must enter the days to administer that drug if you want to include it in the orders. See Discontinuing Active Chemo Orders.

Editing Active Orders: You must notify nursing and pharmacy that you have changed an active chemo order. Change orders for chemotherapy must be activated by an RN before they can be administered. You have the option to carry over edits of active chemo orders to the existing orders that are awaiting activation in the future. See Editing Active Chemo Orders.

Non-chemo vs. chemo orders: If you write orders that are not drawn from a chemotherapy regimen or protocol (that is, not ordered via the chemo player), you must sign the session before you can write chemo orders. This separates the ancillary orders from chemotherapy-related orders. When you write both ancillary and chemotherapy orders for a single treatment date, the final result is one session of ancillary orders, one pair of chemo-related sessions (Session#1, and Chemotherapy Session #2), and any subsequent pairs of new inpatient chemo order (NICO) or pending ambulatory chemo sessions for each week of scheduled treatment. Ancillary orders are not replicated with the chemo-related orders. In the ambulatory units, the pending ancillary and chemo-related orders can be activated in any sequence, and activating one session does not affect the other.