Integrated Hospital Medicines Management


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Elizabeth Plant
Director of Medication Management
Taranaki District Health Board Health Intelligence Ltd
(Friday, 2.45pm, Forum Room)

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  • Changing from one healthcare provider to another, often results in confusion, time wastage and medication errors, as clinicians piece together medicines information Duplicate medications Unnecessary medications Accidentally stopped medications Unintentional changes to strength and dose Adverse reactions and allergies Serious harm to patients Unplanned admissions Increased length of stay
  • Phase 2 (2012) – Partial roll-out across lead DHBs Clinical engagement to ensure systems are fit for purpose for national roll-out A partnership with vendors that is mutually beneficial Collaboration forum Confirm patient, clinical and cost benefits and update business case Sapere evaluation framework Confirm readiness of other DHBs to invest in eMM Readiness assessment Confirm national implementation roadmap Phase 3 Rapid, cost effective and successful national roll-out
  • Taranaki presentation will discuss details of integration…
  • Integrated Hospital Medicines Management

    1. 1. Integrated Hospital Medicines Management Elizabeth Plant Director of Medication Management Dr Kanaka Ramyasiri Clinical Architect Taranaki District Health Board, Health Intelligence Ltd
    2. 2. This presentation• The problem with medication and allergy management within the hospital setting.• The national response – Integrated Hospital Medicines Management• Taranaki DHB’s experience as a local champion
    3. 3. The Problem I Iguess I’ll give you guess I’ll give you I I have no have no what you used to what you used to idea what’s idea what’s have, as well as have, as well as going on now. going on now. these new things. these new things. GP GP Did the GP really Did the GP really I Ican’t read the can’t read the mean that mean that hand written hand written medication? I’d medication? I’d Outpatient clinic Outpatient clinic script. Who do I I script. Who do Pharmacy Pharmacy ? Pharmacy Pharmacy better phone. better phone. call? call? What medications What medications are you being are you being I Iwonder why wonder why prescribed right prescribed right you are taking aa you are taking now? now? med that’s not med that’s not Out- Out-listed in your last listed in your last patient patient Patient Hospital Hospital Can I Isee all Can see all discharge discharge Clinic Clinic the pills you the pills you summary? summary? brought in brought in with you? with you? I Iwish I Icould Pharmacy Pharmacy wish could see aacopy of see copy of I Iwonder why wonder why the discharge the discharge you are on that you are on that summary! summary! medication? medication?
    4. 4. Adverse Drug Events• Adverse drug events occur in 0.7% of all patients admitted. (Harvard Medical Practice Study, N Engl J Med.1991)Extrapolated to New Zealand• 50,000 patients per year admitted to acute care hospitals will experience an adverse drug event each year.• 120 people will die from an adverse drug event.• Preventable annual hospital drug cost = $411 million.
    5. 5. The response• HQSC | Medication Safety Programme• NHITB | Medicine information is a key component in every feature of the National Health IT Plan• Hospital eMM programme is jointly sponsored by HQSC and NHITB• 4 Lead DHB sites being supported to implement two key initiatives: – eMedicines Reconciliation (eMR) – ePrescribing and Administration (ePA)
    6. 6. Orion solution eMR•Reconciles medicines on admission with what charted with what they are discharged on.Communicates reasons for changes:•Allows results of inpatient medication reconciliation to be seen as a table in theeDischarge Summary (eDS) sent to GPs•This information remains available within the hospital for re-use
    7. 7. ePrescribing and eAdministrationCSC solution - MedChart•Replaces paper charting processes•Enables electronic prescribing and administration management within thehospital•Information can feed through to the hospital dispensing system(ePharmacy)•Information can feed through to the discharge eMR and eDS being sent toGPs
    8. 8. Taranaki District Health Board (TDHB)• Small provincial hospital, 245 beds• Serves a population of 104,000 people – or 2.8% of New Zealand’s population (4,430,689)• General medical / surgical and full range of services• Pharmacy Department operating Monday to Friday 8am – 5pm; Saturday and Sunday 10am – 12noon• One small remote hospital (Hawera) - one hour away, 20 beds, as well as an ED• New hospital project underway• e-Medication Management Project seen as key to drive change
    9. 9. TDHB e-Medication Management Vision “…Clinicians and other stakeholders will be able to prescribe, dispense, and review medications reliably via online electronic tools accessed through the TDHB Clinical Portal or their local system of choice (such as their GP practice management system).”“Patients will have appropriate online access to their medication history.” “Bedside verification will be used within the hospital setting.”
    10. 10. Hospital eMM ADMISSION TO HOSPITAL DISCHARGE FROM HOSPITAL Allergy Warning + ADR Medication Medication Key and allergy and allergy Documents: information e-Medicine Reconciliation (eMR) information from: to: e-Prescribing & e-Administration (ePA)• Patient (+ family,caregivers) • Patient • Dx summary (inc MCS) e-Dispensing (ePM)• GP/specialist • Dx scripts • GP/specialist• Community • MCS Automated Drugpharmacy Distribution System • Yellow Card • eMR • Community• Rest homes pharmacy • Patient • Input by qualified professionals Information• Other hospitals Leaflet • 3+ sources used • Rest homes• Ambulance • Discrepancies listed as • Other hospitals unintentional / intentional Discrepancies must be resolved by a doctor within 24 hours of arriving in HospitalPatients own medicines into “green bag”MCS = medication changes summary
    11. 11. End-to-End Medicines Management (simple)
    12. 12. PyxisMedstation in ICU
    13. 13. Benefits of an Integrated System• No transcribing between systems• Reduction in error• Improved efficiency• Reduced time for clinicians on data entry• New Model of Care - will change the way clinicians deliver care to patient• Medication information and decision support available at patient bedside
    14. 14. Project Phases to Date• November 2010 – Pharmacy Dispensing System implemented with improved integration to Pyxis.• June 2011 – Electronic Medication Reconciliation System implemented with associated clinical change management.• April 2012 – Allergy Project to go-live in MedChart (e-Prescribing system) hospital wide for all patients; allergy status and process of verification to be built around this.
    15. 15. Project Phases to Date• 9 July 2012 – Electronic prescribing / administration to go-live – beginning of staged rollout – Ward 1 AT&R.• December 2012 – eMR to ePA Integrated solution to be tested as soon as new integration development available from software vendors.• From August 2013 – Full hospital rollout for e-Prescribing / administration scoped and underway.
    16. 16. Clinical Change Process Key Principles for Success• “Clinical Change Champion” on the floor• Branding for the project• Training needs to be targeted and preferably one-on-one• Initial training, followed by audit of six interventions (eMR), then specific one-on-one training to fix deviations• Identify the barriers to using the system and fix as soon as possible
    17. 17. Use Measurement Tools and Make Relevant Goals• Use a dashboard to report results regularly – must be visible in the ward• Make the targets relevant to the clinician group – ie use targets that they can influence• Have positive incentives: – “Go for Gold” Coffee Cups! (something they like!) – regular newsletter with names of excellent achievers – presentations and morning teas to thank the team – praise and encouragement goes a long way
    18. 18. Photos of Dashboard
    19. 19. “Going for Gold” Coffee Cup
    20. 20. Clinical Change Management Lessons• International literature indicates the following factors are important for the success of e-Prescribing systems: – This is a complex redesign of clinical processes, which will change virtually all processes around medication management and thus will be challenging for clinicians.1, 2, 3 – Workflow analysis is essential. – Barriers to the use of new technology need to be identified and addressed before and after implementation, to ensure appropriate use of electronic medication management systems.1, 18
    21. 21. Clinical Change Management Lessons– Socio technological change depends more on organisational context than technology change. 17– e-Prescribing systems can lead to increased mortality if implemented poorly ie too rapidly, low efficiency and with a lack of consideration to changes in workflow processes. (Han Y, 2006) • Two paediatric hospitals implemented same system - one well, one poorly (in six days), with different mortality outcomes.
    22. 22. Clinical Change Management Lessons– End to end systems are more successful than ad hoc systems. 1– The two hospitals most successful in implementing e-Prescribing systems have both designed the systems to fit their own workflows. 1, 5, 6, 7– Many adverse drug events result from poor design rather than human error. 1, 16– Administrative type errors (ie; documentation and “completeness”) will decrease with electronic solutions due to forced compliance. 8, 9– To decrease clinical errors and “patient harm”, some degree of decision support is essential but this should be introduced slowly as clinicians adjust to the changes and to avoid “alert fatigue”. 10, 11, 1, 12– Customisation of decision support is important for ownership and adherence. 13, 14
    23. 23. Lessons from the Westbrook StudiesComparison of two e-Prescribing Systems on Prescribing Error Rates• Both systems were associated with a statistically significant reduction in total prescribing error rates (>55%) – mainly attributed to a reduction in administrative prescribing errors {incomplete, illegal and unclear prescriptions} NOT clinical prescribing errors• The rate of system related errors can be significant (35% error rate introduced)• The same system can produce different outcomes in different wards – don’t assume that you can just go from one ward type to another without considering the different variables• The different prescribing systems (Cerner and MedChart) introduced different types of system related error (e-iatrogenesis)Reference : January 2012 Vol 9 Issue 1 e1001164
    24. 24. Clinical Change management lessons Westbrook et al: •Clinicians’ greatest concern was the associated work practice changes •Qualitative and observational studies may identify the nature of these changes •The results highlight the need to continually monitor and refine the design of these systems to increase their effectiveness, appropriateness and safety •The complexity of undertaking real world studies should not be underestimatedReference : January 2012 Vol 9 Issue 1 e1001164
    25. 25. Sittig et al Significant Body of Experts in the USAPrinciples:• If the system is not available then you won’t get the benefit• If users choose not to use it then you won’t get the benefit• If the system is not efficient then you won’t get the benefit• So you need to get workflow, structure and process right firstbefore measuring the outcome measures.• The measures need to be ones that can reasonably bemeasured in hospital organisationsReference : AIMA 2007 Symposium Proceedings
    26. 26. A Closer Look at Allergies •Patient Allergy & ADR information is typically held in disparate sources within the hospital setting and communicated via various channels. –Patient administration system –NHI sourced information –Clinical Portal –Pharmacy Dispensing System –Paper drug charts –Paper clinical notes –Paper or electronic Medicines Reconciliation documentation –Discharge summaries –Etc etc. •Disparate locations of allergy information which often “drop off” on subsequent patient episodes, or during the admission on recharting). •We attempted to consolidate the source of truth of coded allergy information within the hospital as much as possible as part of the solution architecture.Demonstration: Allergy Management within the system.
    27. 27. Allergies – Electronic Information Flow ePharmacy Dispensing MedChart SMT Decision Prescribing Support Discharge Decision Summary Support & eMR NHI MedChart Concerto Medical Portal PAS Allergies Warning Patient System Service Summary
    28. 28. A look at the system – Allergies
    29. 29. A look at the system – Allergies
    30. 30. A look at the system – Allergies
    31. 31. A look at the system – Allergies
    32. 32. A look at the system – Allergies
    33. 33. Recommendations (Early Lessons)• Identify the barriers and the workarounds as they occur to either fix them or remove them. Make sure you have the resources to be able to be responsive.• Ensure vendor provides training environment early.• Super User Training needs to happen well in advance of Go-Live.• It is essential that the people who are to be trained at all levels are identified well in advance and that all their details are correct.• Dedicated clinical Super User resource is a must, especially from nursing perspective since the nursing workflow changes are significant.• Involvement of a Junior Doctor at the detail process level pays dividends.
    34. 34. Recommendations (Early Lessons)• Implementation of ward infrastructure (wireless networking, laptops, trolleys) at least two months before Go Live greatly eased workflow changes and encouraged staff to “go electronic” well before the prescribing started. It also allowed a good timeframe to remove any issues and impediments with laptops, wireless infrastructure and other network issues.• Involve the unions early to ensure they are comfortable with the project and have confidence in the team.• Procuring equipment takes longer than anticipated so ensure plenty of time is allowed for this.• Ergonomic workplace assessment needs to be carried out in relation to the COWS (computers on wheels) to prevent occupational overuse syndrome. We already have one nurse with indications of uncomfortable arm movements.
    35. 35. Challenges• There are existing e-Prescribing systems but none are integrated with electronic medication reconciliation, dispensing and automated drug distribution.• Led to requirement for three different software vendors to partner in project.• Integration complexity slows the project timelines. – required TDHB to change the order of implementation • Stand alone components • Subsequent joining up• Evaluation framework not defined in time for baseline data to be collected pre-Go Live.
    36. 36. Challenges• The different professional domains involved adds to the complexity of needing to find a solution that meets the requirements of all groups: – eg requirements for generic prescribing for doctors, compared to dispensing of specific brands for pharmacists or administering specific doses for nurses.• Bringing all the professional domains together: – Technically – Professionally• Integration into the Clinical Portal environment.• Challenge of future need for linking into GP/ community pharmacy e-Prescribing and centralised data repositories, to enable true end to end medication management for Taranaki.
    37. 37. References1 Ammenwerth E et al. The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. JAMIA2008; 15:585-600.2 Gay T. Report - A Case Study on Computerized Physician Order Entry - A Blueprint for a Beginning. E-Health A division of the MassachusettsTechnology Collaborative 2006; December.3 Ormond C. Discussion paper: CPOE. Institute for Health Policy 2005;1-22.4 Sittig D F et al. Recommendations for Monitoring and Evaluation of In-Patient Computer-based Provider Order Entry Systems:Results of a Delphi Survey. AMIA .Annu Symp Proc 2007; 671-675.5 Khajounei et al. CPOE system design aspects and their qualitative effect on usability. Stud Health Technol Inform. 2008;136:309-14.6 Khajounei et al. The impact of CPOE medication systems design aspects on usability, workflow and medication orders. Methods InfMed 2010; 49:3-197 Sengstack P et al. CPOE configuration to reduce medication errors: a literature review on the safety of CPOE systems and designrecommendations. JHIM 2010;24(4): 26-32.8 Colpaert K et al. Impact of computerised physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial. Critical Care2006; 10(1): R21.9 Kaushal R et al. Effects of CPOE and CDSS on medication safety: a systematic review. Arch Intern Med 2003; 163(12):1409-1416.10 Nebeker J et al. High rates of adverse events in a highly computerised hospital. Arch Int Med 2005; 165:1111-111611 Semple S J et al. Medication safety in acute care in Australia: where are we now? Part 2: a review of strategies and activities forimproving medication safety 2002-2008. Australia and NZ Health Policy 2009; 6 (24): 1-1412 Kuperman G et al. CPOE: benefits, costs and issues. Annals Int Medicine 2003; 139:31-3913 Garg A et al. Effects of computerised CDSS on practitioner performance and patient outcomes: a systematic review. JAMA 2005;293(10): 1223-123814 Kawamoto K et al. Improving clinical practice using CDSS: a systematic review of trials to identify features critical to success. BMJ2005; 330(7494): 76515 Ash et al. Categorizing the unintended socio-technical consequences of CPOE. Int J Med Inform 2007; 76(supp 1): S21-s2716 Koppel R et al. Role of CPOE systems in facilitating medication errors. JAMA 2005; 293(10):1197-120317 Eslami S et al. Impact of CPOE in hospitalised patients – A systematic review. Int J Med Informatics 2008; 77:365-37618 Classen D et al. Meaningful use of CPOE. J Patient Saf 2010; 6(1): 15-23.19 Shamliyan T et al. Just what the doctor ordered. Review of the evidence of the impact of CPOE system on medication errors. HealthServices Research 2008; 43(1): 32-52.20 Wolfstadt J et al. The effect of CPOE with clinical decision support on the rates of adverse drug events: a systematic review. J GenIntern Med. 2008; 23(4): 451-458.