Electronic Management System
12 Months on Experience
Austin Health
Major tertiary health provider in
northeast Melbourne
Three campuses
– The Austin Hospital
– Heidelberg Repa...
Organisational Statistics
Measure 2012 – 2013 Year
Staff (EFT)
Medical 647
Nursing 2,098
Allied 471
IT / Informatics 50
To...
2011
Radiology orders
Pathology orders
e-Prescribing
Discharge Summaries
Results & Results Endorsement
2012-13
Inpatient m...
Usage
Average of 4300 users for the Month of February, 2014
Objectives
• Clinical Governance Group
• Medications Design and Build
• Customisation of Reports and Auditing
• Interfacin...
Governance
Internal Governance:
• Medication Safety Committee: Standard Four NQSHS
• Medication Governance Group: Sub-comm...
IP Medication Implementation
•NIMC replaced by Cerner Powerchart
•MAR administration Nursing
•Caresets / PowerPlans
•Nurse...
1. Dr’s Prescribing: Pre-Built Order Sentences are commonly prescribed doses
2. Default Administration instructions: MAR
Medication Administration Record
Care Sets
Ordering: Glyceryl Trinitrate Patch
Care Sets
Nurse Initiated Medications
Patient Self Administration
•Specific Subacute wards
•Self Administration (Dosette or PRN):
Medication list on MAR
•Admini...
MAR: Self Administration
Has implementing an eMM system
Made a Difference?
Pharmacy Annotations (NIMC)
• A pilot review of paper drug charts showed that 61%
included appropriate pharmacy annotation...
Error Prone Abbreviations Study
It is recognised, that no matter how
accurate or complete an order is, it may
be misinterp...
Error Prone Abbreviations Study
NSW Therapeutic Advisory Group define Unacceptable
Error-Prone Abbreviations
– Drug names,...
Accreditation: NSQHS Standard 4
• To ensure Cerner incorporates the full range of National Safety
and Quality Health Servi...
NSQHS Standard 4
4) Clinical Decision Support with drug interaction and allergy
checking
5) Standard Administration instru...
Other Interesting Facts
• Nursing Survey revealed
• Whilst local IV Guidelines, MIMs Online and
ward pharmacist remain the...
Warfarin Therapy: Design
• Warfarin Therapy Careset: Initiating/Maintenance
• Daily dose checks
• Specific times for admin...
Warfarin: Mandatory INR Range
Warfarin Initiation
Warfarin Maintenance
MAR
Report: Warfarin
• Identifies patients prescribed warfarin in the last 10
days
• Generated according to specific location ...
Warfarin Report
• Division of work with Gen Med & Endocrine Units
• Patients identified
– Undiagnosed and/or Uncontrolled Diabetes
• Autom...
HbA1c Results
• Alerts auto applied based on result value of HbA1c% test.
–Result value 6.5% - 8.0%
»Apply Medical – ‘Poss...
Communication to GP - Discharge Summary
Normal Hb A1c result
Abnormal Result > 6.4%
No comment will populate if there is n...
Inpatient Management of Diabetes
BMJ Diabetes Action Set = PowerPlan in Cerner
Austin Health’s ‘Good Antimicrobial Prescribing Practice (GAPP)’ policy
required custom build in to Cerner.
Currently usin...
Antimicrobial Stewardship
Entering an
Approval
Number is
Mandatory
Antimicrobial Stewardship
In ICU, compliance with the GAPP alert has dramatically
improved from 45% in October 2012 to 87%...
ID Reports
• Powerful reporting in real time
– Infectious Diseases utilise reports for their daily reviews
– Report looks ...
Real time reports on medications ordered
Medication Administration Reports
Using Discern Analytics
– Ability to do reports on Medication Administration
events
– Al...
Medication Administration Reports
• Examples:
– Usage vs. Supply
– Recently Panadeine Forte & Tramadol taken off
imprest
VTE and Allergy Recording
Allergy Recording in Cerner
Integration
Cerner integrates with
•Pharmacy dispensing system (Inpatient
Meds>Merlin)
•Pathology system (Pathology orders...
Single Encounter Issue
• ED> WARD Two Drug Charts!
– New drug chart requires copying medications from ED to
transferred wa...
Managing Downtime
Planned/Unplanned
- Down Time is pre-scheduled
- Unplanned is not!
- Notification to Clinical Areas
- Ad...
Conclusion
• 12 Months post roll-out of IP medications powerful data is being generated
that is real-time and otherwise co...
Questions?
Melissa Fodera, Pharmacist & Clinical Systems Analyst, Austin Health - The Implementation Process of an Electronic Clinica...
Melissa Fodera, Pharmacist & Clinical Systems Analyst, Austin Health - The Implementation Process of an Electronic Clinica...
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Melissa Fodera, Pharmacist & Clinical Systems Analyst, Austin Health - The Implementation Process of an Electronic Clinical System and a Medication Administration Record (MAR): 12 months post implementation review.

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Melissa Fodera delivered this presentation at the 3rd Annual Electronic Medication Management Conference 2014. This conference is the nation’s only event to look solely at electronic prescribing and electronic medication management systems.

For more information, please visit http://www.healthcareconferences.com.au/emed14

Published in: Health & Medicine
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Melissa Fodera, Pharmacist & Clinical Systems Analyst, Austin Health - The Implementation Process of an Electronic Clinical System and a Medication Administration Record (MAR): 12 months post implementation review.

  1. 1. Electronic Management System 12 Months on Experience
  2. 2. Austin Health Major tertiary health provider in northeast Melbourne Three campuses – The Austin Hospital – Heidelberg Repatriation Hospital – Royal Talbot Rehabilitation Centre Major services – Liver & Gastro-intestinal transplantation – Spinal Cord Injuries – Oncology – Vic Respiratory Services – ONJ Centre
  3. 3. Organisational Statistics Measure 2012 – 2013 Year Staff (EFT) Medical 647 Nursing 2,098 Allied 471 IT / Informatics 50 Total 5184 Structure Facilities 3 campuses Beds 900+ beds Theatres 22 theatres Throughput Admissions (Overnight / Day) 99,363 WIES 70,783 Attendances 183508 Emergency Visits 68,170 Operations 24,192
  4. 4. 2011 Radiology orders Pathology orders e-Prescribing Discharge Summaries Results & Results Endorsement 2012-13 Inpatient medications MAR Fluid balance chart 724 Access 2014 Clinical Documentation First Net Physician Handover Nursing Task Manager Referrals Allied Health The Austin Health EMR Journey Clinical System Chosen:
  5. 5. Usage Average of 4300 users for the Month of February, 2014
  6. 6. Objectives • Clinical Governance Group • Medications Design and Build • Customisation of Reports and Auditing • Interfacing existing systems: Pharmacy, Pathology, Radiology • Single Encounter Reconfiguration • System Down-Time Management
  7. 7. Governance Internal Governance: • Medication Safety Committee: Standard Four NQSHS • Medication Governance Group: Sub-committee of the MSC Content/Functionality Approval • Local Steering Committee: Project Governance • Policy Framework: Update existing policies External Governance: • Agency and Government Groups approval process
  8. 8. IP Medication Implementation •NIMC replaced by Cerner Powerchart •MAR administration Nursing •Caresets / PowerPlans •Nurse Initiated Meds •Patient Self Administration Meds
  9. 9. 1. Dr’s Prescribing: Pre-Built Order Sentences are commonly prescribed doses 2. Default Administration instructions: MAR
  10. 10. Medication Administration Record
  11. 11. Care Sets
  12. 12. Ordering: Glyceryl Trinitrate Patch Care Sets
  13. 13. Nurse Initiated Medications
  14. 14. Patient Self Administration •Specific Subacute wards •Self Administration (Dosette or PRN): Medication list on MAR •Administration by other: Parenterals/Orals with Doses Due on MAR
  15. 15. MAR: Self Administration
  16. 16. Has implementing an eMM system Made a Difference?
  17. 17. Pharmacy Annotations (NIMC) • A pilot review of paper drug charts showed that 61% included appropriate pharmacy annotations: – Medication Strength, Generic/brand Name or administration comments ie Take with food. – This was inconsistently applied depending on pharmacist doing the review • Most of the time, ‘pharmacist field’ signature/initial was unidentifiable on NIMC. • Electronic system allows for consistency of administration details and legibility of name
  18. 18. Error Prone Abbreviations Study It is recognised, that no matter how accurate or complete an order is, it may be misinterpreted if it cannot be read Cerner eliminates this patient safety risk: electronic medication orders are 100% legible. In addition to this, hard-coding of terminology by use of order sentences and care sets achieves consistent prescribing terminology and avoids use of unsafe abbreviations and symbols.
  19. 19. Error Prone Abbreviations Study NSW Therapeutic Advisory Group define Unacceptable Error-Prone Abbreviations – Drug names, Frequencies, Dosing designations – 100 Paper Medication charts (NIMC/M85) compared with 100 Cerner charts – Preliminary results show error prone abbreviations were reduced from 37% to 2% with the introduction of the Cerner (p<0.001). – Further investigation is required for the clinical significance of these results
  20. 20. Accreditation: NSQHS Standard 4 • To ensure Cerner incorporates the full range of National Safety and Quality Health Service (NSQHS) Standard 4 Medication Safety • The analysis found that Cerner exceeded the requirements and provided additional elements or functionality that improve clinical workflows and patient safety. 1) Remote Access to Cerner 2) Electronic Medication orders are legible and include prescribing terminology according to National Standards 3) Medication Order changes are tracked and can be viewed clearly
  21. 21. NSQHS Standard 4 4) Clinical Decision Support with drug interaction and allergy checking 5) Standard Administration instructions for medications incorporated in the order and available to nursing staff immediately 6) Include all essential prescribing requirements for an Electronic Prescription 7) Allergy and patient specific details easily Recorded and Retrieved 8) Easy retrievable pathology result
  22. 22. Other Interesting Facts • Nursing Survey revealed • Whilst local IV Guidelines, MIMs Online and ward pharmacist remain the most common medication references • Cerner Reference Information was used in the past by 20% of nursing staff surveyed • This will probably increase when IV Chart (M100 Chart) is in Cerner
  23. 23. Warfarin Therapy: Design • Warfarin Therapy Careset: Initiating/Maintenance • Daily dose checks • Specific times for administration • Withhold dose • Specific Details for the order (OEF) • INR pathology order included
  24. 24. Warfarin: Mandatory INR Range
  25. 25. Warfarin Initiation
  26. 26. Warfarin Maintenance
  27. 27. MAR
  28. 28. Report: Warfarin • Identifies patients prescribed warfarin in the last 10 days • Generated according to specific location or clinical unit. • Benefit – Clinical Staff can instantly identify warfarin patients – Prioritise higher risk patients – Usage report shows Warfarin Report is used daily by Pharmacy and HMO on Cardiac Ward and CCU
  29. 29. Warfarin Report
  30. 30. • Division of work with Gen Med & Endocrine Units • Patients identified – Undiagnosed and/or Uncontrolled Diabetes • Automated ordering of HbA1c – Rule to order automatically for Patients over 54 » Inpatients LOS > 1 day » Who have not had an HbA1c result in last 90 days Mental Health Patients over 29 yrs Identifying Patients- Diabetes
  31. 31. HbA1c Results • Alerts auto applied based on result value of HbA1c% test. –Result value 6.5% - 8.0% »Apply Medical – ‘Possible Diagnosis of Diabetes’ alert »Send a message to generic Diabetes – New Patient Inbox »Monitored by General Med Unit as Inpatients –Result value >8.1% »Apply Medical – ‘Possible Poorly Controlled Diabetes’ alert »Monitored by Endocrine Unit -utilise existing Alerts report
  32. 32. Communication to GP - Discharge Summary Normal Hb A1c result Abnormal Result > 6.4% No comment will populate if there is no result in Cerner with the previous 3 months
  33. 33. Inpatient Management of Diabetes
  34. 34. BMJ Diabetes Action Set = PowerPlan in Cerner
  35. 35. Austin Health’s ‘Good Antimicrobial Prescribing Practice (GAPP)’ policy required custom build in to Cerner. Currently using an online approval system (IDEA3S) to generate approval numbers based on selection criteria On paper - Approval number is written on the drug chart - Required before administration but not always followed In Cerner - Creative use of Discern Alert - Cannot proceed with order unless approval number is documented in appropriate field Antimicrobial Stewardship
  36. 36. Antimicrobial Stewardship Entering an Approval Number is Mandatory
  37. 37. Antimicrobial Stewardship In ICU, compliance with the GAPP alert has dramatically improved from 45% in October 2012 to 87% in August 2013
  38. 38. ID Reports • Powerful reporting in real time – Infectious Diseases utilise reports for their daily reviews – Report looks at all antimicrobials that are currently – in real time- being ordered for patients – Allows Infectious Diseases unit to be proactive in monitoring antimicrobial use at the Austin – Report analyses all wards at the Austin Hospital but can filtered down to a specific ward or unit
  39. 39. Real time reports on medications ordered
  40. 40. Medication Administration Reports Using Discern Analytics – Ability to do reports on Medication Administration events – All information pertaining to medication administrations such as who gave it, what was given, how much was given, when it was given – Which specific medications are currently ordered within the hospital? – Incredible advantage due to speed of access to information
  41. 41. Medication Administration Reports • Examples: – Usage vs. Supply – Recently Panadeine Forte & Tramadol taken off imprest
  42. 42. VTE and Allergy Recording
  43. 43. Allergy Recording in Cerner
  44. 44. Integration Cerner integrates with •Pharmacy dispensing system (Inpatient Meds>Merlin) •Pathology system (Pathology orders and results>Kestrel) •Radiology (Radiology>RIS)
  45. 45. Single Encounter Issue • ED> WARD Two Drug Charts! – New drug chart requires copying medications from ED to transferred ward. • Redesign integration of Patient Administrative System (Trakcare) HL7 messaging to Cerner. • Ignoring HL7 message allowed the ED encounter to update the MAR to the new ward location • SINGLE ENCOUNTER LOGIC SOLVED! ONE Drug Chart! • Intercampus transfers or transfers from Acute to Subacute, are separate encounters/Drug Charts.
  46. 46. Managing Downtime Planned/Unplanned - Down Time is pre-scheduled - Unplanned is not! - Notification to Clinical Areas - Additional Cerner staffing requirements for support - Printing the MAR to NIMC prior to downtime - Pathology Orders Report printed and sent to Pathology - Pathology/Radiology on Paper - Post Downtime
  47. 47. Conclusion • 12 Months post roll-out of IP medications powerful data is being generated that is real-time and otherwise could not be obtained on paper • Reports can assist with – identifying patients – Determine medication usage/appropriateness • Helped improved compliance with National Safety and Quality Health Service (NSQHS) Standard 4:Medication Safety • Standardising Patient Care through medication design, use of order sentence/CareSets/PowerPlan/Nursing orders/ Patient self administering • Lesson’s learnt from our experience. Obtain baseline data of current workflow on paper before comparison can be made using EMM. • Regularly review update medication catalogue accordingly
  48. 48. Questions?
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