Dr. Peter Kennedy, Deputy Chief Executive Officer – CEC, Chair of EMM Steering Committee - PANEL - Electronic Medication Management in the Context of eHealth in NSW
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Dr. Peter Kennedy, Deputy Chief Executive Officer – CEC, Chair of EMM Steering Committee - PANEL - Electronic Medication Management in the Context of eHealth in NSW

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PANEL: NSW Health 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......

PANEL: NSW Health 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

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  • 1. Electronic Medication Management (EMM) Program State and local implementation lessons
  • 2. Play EMM Video
  • 3. Introduction by Dr Peter Kennedy Deputy Chief Executive Officer – CEC Chair of NSW EMM Steering Committee
  • 4. Session agenda • The role of eHealth in Supporting Patient Safety • The Clinical Perspective • EMM Program Update • Updates from our initial EMM sites • Questions for the Panel
  • 5. E-health NSW: Changing Patient Trajectories The Role of e-health in Supporting Patient Safety Dr Peter Kennedy Deputy Chief Executive Officer Clinical Excellence Commission 25 March 2014 3rd Annual Electronic Medication Management Conference
  • 6. Data from HIMSS AnalyticsTM Database 2011 HIMSS Analytics HIMSS Analytics Asia EMR Adoption Model Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Stage 7 Stage 1 Stage 0 CDR, Controlled Medical Vocabulary, CDS, may have Document Imaging; HIE capable Nursing/clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology CPOE, Clinical Decision Support (clinical protocols) Full Complement of Radiology PACS Physician documentation (structured templates), full CDSS (variance & compliance), Closed Loop Med Admin Complete EMR; CCD transactions to share data; Data warehousing; Data continuity with ED, ambulatory, OP Ancillaries – Lab, Rad, Pharmacy – All Installed All Three Ancillaries Not Installed
  • 7. EMRAMAverageStageScore 0 1 2 3 4 5 6 7 Local Health District (n=17) average EMRAM* Scores Mean ^The Healthcare Information and Management Systems Society *EMR Adoption Model • Overall low average (1.41) comparable when very small / MPS sites excluded • Goal NOT to get all hospitals to Level 6, however HIMMS assessed 40 hospitals have fulfilled the majority of pre-requisites • EMRAM is acute care focused – handover to and from Primary and Community Care important Maturity
  • 8. The most mature EMR in the country. Usage growing 100 orders placed and results viewed per minute Electronic Medical Record January 2014 activity Mar-12 Jan-14 Mar-12 Jan-14 Mar-12 Jan-14 % change Orders 127,000 131,000 3,861,000 4,000,000 46,000,000 48,000,000 4 Patient Charts Opened 180,000 206,000 5,462,000 6,200,000 65,544,000 75,000,000 14 Clinical documents created 16,500 21,000 502,000 640,000 6,024,000 7,700,000 28 Decision support alerts 6,900 10,600 211,000 323,000 2,532,000 3,900,000 54 Mar-12 Jan-14 % change Average transaction time 0.95 0.52 45 Transactions (Millions) 139 233 68 Monthly AnnualDaily Reduction is due to hardware and system upgrades Growth in system use Improved Performance: Growth in system use: Up 65% sine March 2012 Average transaction time: Down 45% since March 2012 Key activity per day: Orders: 131,000 up 4% since March 2012 Chart opens: 206,000 up 14% since March 2012 Clinical Documents Created: 23,000 up 28% since March 2012 Decision Support Alerts: 10,600 up 54% since March 2012
  • 9. Communication Leadership Team Work TeamSTEPPS Courtesy of the Agency for Healthcare Research and Quality
  • 10. Situational Awareness Shared Mental Model Mutual Support TeamSTEPPS
  • 11. Five Dysfunctions of a Team 1 Absence of trust 2 Fear of conflict 3 Lack of commitment 4 Unwillingness to hold one another accountable 5 Inattention to results Patrick Lencioni
  • 12. Executive Sponsorship Clinical Leadership Technical Expertise Equity Principles for EMR Rollout
  • 13. Policy Ministry Governance Strategy and Architecture Local Networks / Bandwidth Central Infrastructure (Data Centres) and Operations (EMR) eHealth NSW Local Project Management, Implementation and Training Program Management, Procurement End User Computing (PCs, Mobile Devices, TeleHealth Endpoints, Wireless Networks, Phones) Ownership Work Practice Review Standardisation and Content Knowledge Education Clinician Support Benefits Realisation ACI / CEC / HETI / NSW Kids and Families Local Health Districts EnablersChangeManagement Risk Category Owner 13
  • 14. IT Platform eMR & eMM Clinician led and data driven HIE Patient Portal Clinical Analytics Value added Outcome measures Drives change Validates process measures, projects & priorities Business applications Infrastructure Standardisation Technovigilance Interoperability Is key to success
  • 15. It has to work for both Clinicians and Patients in improving patient care and safety. Key Themes for EMR Rollout
  • 16. Key Themes: I. It is an opportunity to look at work practices and clinical practice II. Will require increasing standardisation of care III. Will provide opportunities for much better information on what we do and also in terms of outcomes Key Themes for EMR Rollout
  • 17. Key Issues: I. The Firewall and moving information between hospitals, General Practitioners and patients II. Use of own devices III. Standardisation IV. Evaluation Key Themes for EMR Rollout
  • 18. Key to Successful Implementation of Programs: I. Training and education at facility level II. Ongoing support at each facility III. Adequate infrastructure at the facility level – devices, wireless network, speech recognition etc. Key Themes for EMR Rollout
  • 19. We need to define with each project what are the quality parameters that we want to achieve from the implementation. We need to build them into the development process. Quality cannot be an afterthought, it must be a driver. Quality in the EMR
  • 20. IT is going to be introduced in to the performance review process for all LHDs and LHNs in NSW. This means there will be key performance indicators and regular review of progress at the 3 monthly meetings. Executive Buy-In
  • 21. Associate Professor Kathy Gibson Staff Specialist Rheumatologist Liverpool Hospital EMM Program Clinical Secretariat Lead The clinical perspective
  • 22. Background • In Australia, 2-4% of all hospital admissions are medication related. • Includes admissions due to adverse drug reactions and those due to medication errors which together are termed adverse drug events (ADEs) • Overall, about 43% of these are deemed preventable (1) • Errors occur at every step of the medication management pathway • But most occur during prescribing 1. Runciman WB et al. (2003) Adverse drug events and medication errors in Australia Int J Qual Health Care 15 (suppl 1): i49-i59.
  • 23. • Australian research shows that errors can be reduced by more than 55% with the introduction of electronic systems to help manage medication prescribing, dispensing and administration (2) 2. Westbrook JI et al. (2012) Effects of two commercial electronic prescribing systems on Prescribing error rates in Hospital patients: A before and after study. PLoS Med 9 (1):e1001164. doi:10.1371/journal.pmed.1001164
  • 24. What is EMM? • Managing tasks and documents involved in prescribing, administering and dispensing medications to patients using an electronic system • Includes automated tools to assist in choosing medications and doses to be prescribed (decision support) • Includes automated checking for allergies and other patient factors that make certain medications unsafe to prescribe
  • 25. Why do it? • Improve accuracy and visibility of medication information being communicated between professionals and health care settings • Improve communication with patients about their medication • Increase legibility of medication orders • Reduce variance in prescribing practice • Reduce medication errors and associated adverse events
  • 26. CASE HISTORY 1 • 64 year old male patient brought to the ED by ambulance with fever, low oxygen levels and coughing up black sputum • History of end stage lung cancer self discharged against medical advice 3 days before this presentation • In ED patient confused and agitated • Seen by the ED registrar and the Oncology registrar and admission arranged
  • 27. • ED registrar agreed to write the medication chart because Oncology registrar called away • ED registrar looked up the patient’s previous medications and recharted them by hand • Wrote oral Hydromorphone 20mg • Previous dose was oral Hydromorphone 2mg • In ED two junior nurses checked the chart and gave the patient oral Morphine 20mg
  • 28. • Oral Morphine 20mg = Hydromorphone 3mg • Patient admitted to ward and subsequently received oral Hydromorphone 20mg as charted and breakthrough subcutaneous Hydromorphone 0.5mg (equivalent to about 1.5mg oral Hydromorphone) overnight • Patient died the following morning although not necessarily as a direct result of high dose of Hydromorphone
  • 29. So what went wrong? • ED registrar incorrectly charted 20mg Hydromorphone instead of 2mg. • 2 ED nurses gave Morphine 20mg orally not Hydromorphone. • Nobody overnight recognised the error in the Hydromorphone dose charted.
  • 30. • Case 1, Opiate prescribing • 20mg Hydromorphone vs 2mg Hydromorphone – transcribing error EMM system with (existing) record of usual medication being taken on admission plus medication reconciliation process could help • 20mg oral Morphine vs 20mg oral Hydromorphone – administration error EMM system with alerts regarding look alike/sound alike meds and/or rules that only allow prescription of Hydromorphone using the trade name Dilaudid How could an EMM system help?
  • 31. • Lack of recognition of incorrect dose of Hydromorphone overnight EMM system could alert to high dose used and should contain record of medications being taken on admission for comparison/cross check 31 How could an EMM system help?
  • 32. CASE HISTORY 2 • 66 year old female admitted to investigate acute blurring of vision in her left eye and headache • On warfarin to thin her blood because of chronic atrial fibrillation • At admission changed to clexane (short acting anticoagulant) • Found to have a tumour in her brain • Clexane correctly witheld 24 hours before surgery
  • 33. • Clexane restarted 48 hours after surgery at full dose • A few hours after second Clexane dose given patient acutely deteriorated due to a large bleed into her brain • Bleed drained in theatre and patient sent to ICU but made no recovery and died 12 days later • The senior neurosurgeons consulted stated that full dose anticoagulation after this kind of brain surgery is contraindicated for several weeks post- op
  • 34. So what happened? • No clear verbal or written orders given to junior staff regarding peri-op anticoagulant management • Policy to guide junior staff found to be ambiguous • The medication order for Clexane expired on the day of surgery • It was recharted on a new chart that day but only the dose 24 hours after surgery was marked to be witheld • Therefore restarted the next day
  • 35. How could an EMM system help? • Case 2 • Full dose Clexane restarted 24 hours after brain surgery EMM can contain links to specific policy on anticoagulation and could have rule to prevent anticoagulation prescription within specific time frame from surgery • Clexane recharted by hand on day of surgery As above
  • 36. Will EMM prevent all errors? • No! E-systems can introduce new errors • Everybody (administrators, IT staff, clinicians, trainers etc) needs to be involved in testing, reviewing, implementing and refining these systems • Everybody who prescribes, dispenses, administers or takes a medication in a hospital is a stakeholder as is everybody involved in managing hospital care
  • 37. The Physician/Clinician Champion • What are they? • Who are they? • Why do we need them?
  • 38. The physician/clinician champion can provide expert input to project team • Clinical expertise assists the team in planning phases • Knowledge of clinical process helps define/change plan • Risk anticipation and remedies can be quickly identified
  • 39. The physician/clinician champion can communicate to and from physician colleagues • Physicians and other clinicians may “tune out” non-clinical experts • Nobody carries more authority than a respected colleague • Physician/clinician champion can listen, assess and translate colleagues concerns
  • 40. The physician/clinician champion can help make critical decisions • The effective clinician leader is a highly-skilled decision maker • Informed decisions require background on the entire project • Formal decisions should include clinician input
  • 41. Are physician and IT project leaders ready for this change? Of course I will be involved! I’d love to have physician input and leadership!
  • 42. Are physician and IT project leaders ready for this change? I will tell you exactly what you need to do for me! We don’t need to brief the physicians on every problem…
  • 43. Are physician and IT project leaders ready for this change? My partners can be so unreasonable! He needs to fix those demanding physicians.
  • 44. Are physician and IT project leaders ready for this change? This needs to be fixed by Friday or we cancel the project! I don’t do surgery, I wish he would stop trying to be my project manager!
  • 45. Clinical IT projects: A fork in the road for work processes Improve! Worsen! It is never neutral!
  • 46. Recommendation: Appoint clinical champions for all clinical IT projects and especially EMM! • Effective clinician input into clinical IT projects is necessary • The clinician champion role can assist in the two most important factors in project success: – Executive leadership – User involvement • Clinician champion education for clinical IT project leadership needs to be developed
  • 47. Dr Robin Mann EMM Program Director Program progress and plans
  • 48. EMM Challenges • Readiness • Capacity and capability – LHDs and vendors • Product maturity • Integration with existing architecture • Federated delivery model • Standardisation and reuse
  • 49. EMM Maturity Hospital Administer Review Prescribe Check Dispense DischargeReconcile GP Community pharmacy Community services Outpatient care Supportedby Level1EMM Supportedby Level2EMM Supportedby nationalservices Consumer
  • 50. EMM Program
  • 51. Dr Angus Ritchie Silvia Fazekas Cheryl McCullagh Update from initial sites
  • 52. Dr Angus Ritchie Renal Physician and EMM Clinical Lead Concord Repatriation General Hospital, Sydney LHD Initial site update
  • 53. Concord Update • EMM Phase 1 • EMM Phase 2 • Enhanced IV functionality
  • 54. IV Enhancements • What is an IV? • Intermittent • Continuous • Sequenced
  • 55. IV Enhancements After eMAR documentation
  • 56. IV Enhancements Proposed Display Current Display
  • 57. Phase 1 • 2005 Project begins • 2007 EMM two Aged Care wards • 2010 EMM three more wards • Road blocks – iPharmacy-Pharmnet interface – Functional deficits
  • 58. Phase 2 • Inpatient EMM – all wards • Outpatient prescribing • Medication history & reconciliation
  • 59. Phase 2 Sep 2012 Nov 2013 Project kick-off Conversion target
  • 60. Phase 2 Sep 2012 Nov 2013 Mar 2014 Project kick-off Conversion target New conversion target
  • 61. Phase 2 Sep 2012 Nov 2013 Mar 2014 TBC Project kick-off Conversion target New conversion target
  • 62. Changes • Bigger team • Comprehensive scope • Change management • Timeline replanning
  • 63. Clinical Leadership Usual Practice New Model Paid for another role Dedicated funding Specialty-specific view Big-picture view Clinical work prioritised Clinical work balanced Learn by experience Specific training Slow, consultative decisions Rapid decision-making Vague lines of reporting Clear lines of reporting Reluctant to take ownership
  • 64. Clinical Leadership Usual Practice New Model Paid for another role Dedicated $ Specialty-specific view Big-picture view Clinical work prioritised Clinical work balanced Learn by experience Specific training Slow, consultative decisions Rapid decision-making Vague lines of reporting Clear lines of reporting Reluctant to take ownership Take ownership of problems
  • 65. Clinical Leadership Usual Practice New Model Paid for another role Dedicated $ Specialty-specific view Big-picture view Clinical work prioritised Clinical work balanced Learn by experience Specific training Slow, consultative decisions Authority to make decisions Vague lines of reporting Clear lines of reporting Reluctant to take ownership Take ownership of problems
  • 66. Current priorities • IV Project leadership • Change Control Board • Medication reconciliation – Admission conversion – Discharge documentation • “Form wars” • Compliance (legal, regulatory) • Evaluation
  • 67. Silvia Fazekas eMEDS Project Manager South Eastern Sydney Local Health District Initial site update
  • 68. Cheryl McCullagh Director Clinical Integration Sydney Children’s Hospitals Network Initial site update
  • 69. The MEMORY strategy describes the plan for implementation of a fully integrated health record across SCHN; it involves more than 20 projects in the next three years. Aims include:  safer care  better access, for multiple users  current complete records  reduced risk around missing or incomplete information  reduced errors  accessible to all from anywhere  improved reporting
  • 70. SINGLE EMR CHW SCH 2013 2014 2015 2016 2017 EMM + EMRP Westmead Clin-docs build Move to SurgiNet PathNet c/compass Move off iPM to SCHN stack Voice Rec in ED PAS: add Facility ID PAS feed To CHW EMM across Randwick FirstNet Surginet SCHN EMR Strategic Roadmap- 4 years 70 EIR SCH scanning PCEHR Voice Rec in ED EMR CHW EMR SCHN Backscanning lanier END ENDVR lanier VR lanier Email, Reports, Lync, MRD, Scanning, Coding, IT support, PCs, Printing, BYOD, PAS, shared patients NAP forms CCIS CCIS TBA NAP forms EMR SCHN
  • 71. Implementation Process EMM/EMRP Project Milestones End-User Training Go Live Aug 2015 Project Kick- off 10/03/14 System Review 12/03/14 Design Review 23/06/14 System Validation Sessions 29/09/14 8/12/14 Trainer & Conversion Prep 16/02/15 Maintenance Training 6/04/15 Integration Testing 1 18/05/15 Post Conversion Assessment 16/11/15 Client Executive Session 10/3/14 Integration Testing 2 29/06/15
  • 72. Policy Governance Strategy and Architecture Local Networks / Bandwidth Central Infrastructure (Data Centres) and Operations (EMR) Local Project Management, Implementation and Training Program Management, Procurement End User Computing (PCs, Mobile Devices, TeleHealth Endpoints, Wireless Networks, Phones) Ownership Work Practice Review Standardisation and Content Knowledge Education Clinician Support Benefits Realisation Local Health Districts need to focus on all of these EMM-the biggest leap in the EMR EnablersChangeManagement Risk Category Owner 72
  • 73. What we have worked out so far •Who reads email •Face to face needs senior support •Surgeons are hard to find •Coherent, consistent and real reasons for change •Champions need support too •Little EMR changes are big clinical changes •Only users can defend the decisions we make •Long term credibility is more important that short term change
  • 74. The MEMORY strategy needs everyone Addressing old risks adds different risks  Champion responsibilities  Communication, vigilance, feedback  Support  Sharing the messages  Keep the momentum forward  Eyes on the end goal  Focus on the journey
  • 75. MEMORY Strategy Stories •Critical mass- 80% •Story for each project •Story for each site •Lead with safety quality access branding video /E-learning ++++++ Professional group visits Support from exec down Champion Visibility
  • 76. MEMORY strategy outcomes •HIMMS level 6 •The first implementation of paediatric EMM in Australia •The first implementation of full documentation in paediatric oncology •Electronically accessible records for all patients •Summary information available to GPs and Families •Lifetime e-record for all children going forward
  • 77. Questions ?
  • 78. Questions for the panel? Chaired by Dr Peter Kennedy
  • 79. Electronic Medication Management (EMM) Program State and local implementation lessons