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Moving From Paper To Electronic Medication Reconciliation


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Purpose of the Call:
1.Discuss the results of the pan-Canadian survey of existing practices with respect to the use of technology to support Medication Reconciliation (MedRec)
2.Describe the steps and considerations for transitioning to electronic MedRec (eMedRec)
3.Identify factors that support and impede successful migration of paper MedRec to eMedRec.
4.Discuss the lessons learned from research and other organizations.
5.Introduce the toolkit to support healthcare providers in making a safe and effective transition from paper MedRec to eMedRec.

Published in: Health & Medicine, Technology
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Moving From Paper To Electronic Medication Reconciliation

  1. 1. Moving from Paper to Electronic Medication Reconciliation November 12, 2013
  2. 2. Welcome to our francophone attendees Bienvenue à nos participants francophones Hélène Riverin Conseillère en sécurité et en amélioration Safety Improvement Advisor
  3. 3. Pour nos participants francophones.. Pour accéder aux diapositives français: -Cliquez sur ​l'onglet "FRENCH" OU -Envoyer un courriel à Suivre la boîte «Chat» pour les commentaires du conférencière traduit en français
  4. 4. Next Webinar: December 10, 2013 at 12 noon ET MedRec Quality Audit Month Results 2235 patients Organizations 28% • Met all 5 quality criteria 40% 99 • 1906 Acute Care • 329 Long Term Care • 3 - 4 met quality criteria Join us to hear about the results and how your organization should be involved.
  5. 5. Call Overview Introduce the toolkit to support healthcare providers in making a safe and effective transition from paper MedRec to eMedRec. 1. Discuss the results of the pan-Canadian survey of existing practices with respect to the use of technology to support Medication Reconciliation (MedRec) 2. Describe the steps and considerations for transitioning to electronic MedRec (eMedRec) 3. Identify factors that support and impede successful migration of paper MedRec to eMedRec. 4. Discuss the lessons learned from research and other organizations.
  6. 6. Today’s Speakers Dr. Elizabeth Borycki Dr. Borycki is an Associate Professor at the University of Victoria, Victoria, British Columbia Canada. Dr. Borycki has worked in numerous roles among them as a Clinical Informatics Specialist, Disease Management Specialist, Consultant and Researcher. Elizabeth teaches organizational behaviour and change management, systems evaluation, quality improvement, information/information technology management and research methods in the undergraduate and graduate programs in the School of Health Information Science. Elizabeth has co-authored many health informatics articles. More recently, she has edited two books: The Human, Social and Organizational Aspects of Health Information Systems and Comprehensive Management of Chronic Obstructive Pulmonary Disease. She was the Academic Representative for Canada’s Health Informatics Association (COACH) to the International Medical Informatics Association (IMIA).
  7. 7. Today’s Speakers Dr. Andre Kushniruk Dr. Kushniruk is a Professor of the School of Health Information Science at the University of Victoria and he previously served as the Director of the School of Health Information Science at the University of Victoria. Dr. Kushniruk conducts research in a number of areas including evaluation of the effects of technology, human-computer interaction in health care and other domains as well as usability engineering. His work is known internationally and he has published widely in the area of health informatics and testing of healthcare IT (including work in the area of decision support for medication reconciliation). He focuses on developing new methods for the design and evaluation of information technology and studying human-computer interaction in health care and he has been a key researcher on a number of national and international collaborative projects. His work includes the development of novel methods for conducting video analysis of computer users. Dr. Kushniruk has held academic positions at a number of Canadian universities. He was elected as a Fellow of the American Medical Information Association (FACMI) in 2009 and also served on the COACH (Canada's Organization for Health Informatics) board of directors. He holds undergraduate degrees in Psychology and Biology, as well as a M.Sc. in Computer Science from McMaster University and a Ph.D. in Cognitive Psychology from McGill University.
  8. 8. Please complete our poll 8
  9. 9. Moving from Paper to Electronic Medication Reconciliation (eMedRec) 9
  10. 10. Moving from Paper to Electronic Medication Reconciliation (eMedRec) Andre Kushniruk Elizabeth Borycki Helen Monkman Alex Kuo University of Victoria Margaret Colquhoun Alice Watt ISMP Canada Marie Owen CPSI
  11. 11. Medication Reconciliation (MedRec) • A process in which providers work with patients and other providers to ensure accurate medication information is communicated across transitions of care – Admission, transfer, discharge – Intended to prevent harm from ineffective communication – Is challenging!
  12. 12. What is eMedRec? • Electronic MedRec (eMedRec) uses Health Information Systems (HIS) to access and integrate electronically stored patient medication data • To support the development of the electronic Best Possible Medication History (eBPMH) and the detection and resolution of discrepancies • Can be integrated with other systems such as computerized provider order entry (CPOE)
  13. 13. eMedRec: Two Unreconciled Medication Lists for Comparison (adapted from Markowitz, 2011)
  14. 14. eMedRec: Matching Two Medication Lists (adapted from Markowitz, 2011)
  15. 15. eMedRec: Final Reconciled Medication Record (adapted from Markowitz, 2011)
  16. 16. eMedRec Process Flow Map
  17. 17. Idealized Overview of eMedRec
  18. 18. What is the Current State of eMedRec?
  19. 19. eMedRec: A Review of the Literature • Conducted a literature review • searched PubMed and CINAHL for the term “medication reconciliation”. • 218 unique articles, published between 2003 and October 2012 – reviewed by title, abstract (where possible) and/or full article to exclude studies that did not include original research (e.g., editorials) or that lacked reference to MedRec. • 139 articles remained that met the inclusion criteria • The following characteristics were also recorded: – Type of MedRec – Points of care – Outcome Measures
  20. 20. Type of MedRec • Processes ranged from: – Entirely paper-based – hybrid (i.e. combination of paper and electronic) – entirely electronic MedRec (eMedRec). • The numbers of studies for each type of medication reconciliation were similar: – paper (35 studies) – hybrid (40 studies) – electronic (44 studies) – some of the papers did not explicitly state or describe what type of MedRec was used and therefore could not be included.
  21. 21. Key Findings: Points of Care • The articles collected dealt with MedRec as it occurs at different points of care. • most of the articles focused on hybrid processes • few articles looked at eMedRec processes across different points of care
  22. 22. Key Findings: MedRec Investigations at Different Points of Care Quantitative Measures of Medication Reconciliation
  23. 23. Key Findings: Information Technology (IT) and eMedRec • Information technology has been used in the eMedRec process to do the following: – Generate the best possible medication lists (BPMHs) – Electronically support human MedRec processes • providing electronic sources of data • providing electronic tools for comparing lists and detecting and resolving medication discrepancies
  24. 24. Examples of eMedRec Studies Boockvar et. al (2011). “Medication Reconciliation: Barriers and Facilitators from Perspectives of Resident Physicians and Pharmacists” (J. of Hospital Medicine) • Focus groups and observation of VA eMedRec tool • Participants agreed about central goal of eMedRec to prevent errors, but disagreed if it achieved goal • Participants varied in how they sequenced the task using the tool • When time was limited, physicians considered other responsibilities higher priority • Barriers included: competing tasks, unreliable sources of information and need for education
  25. 25. Schnipper et al. (2009). “Effect of an Electronic Medication Reconciliation Application and Process Redesign on Potential Adverse Drug Events” (Arch Int Med) – Performed a controlled randomized trial – Intervention was an eMedRec tool and process redesign involving physicians, nurses and pharmacists – Main outcome was unintended discrepancies between preadmission meds and admission or discharge meds that had potential for harm (PADEs) – Found that the eMedRec tool and process redesign was associated with a significant decrease in PADEs
  26. 26. Kushniruk et al. (2011). “Cognitive Analysis of a Medication Reconciliation Tool” – conducted “think aloud” usability tests and clinical simulations of use of an eMedRec tool – Both artificial cases and real cases observed – Found • Pharmacists and physicians approached cognitive process of using eMedRec tool differently • Significant differences found in accuracy of task and time spent by pharmacists as compared to physicians • Led to implications for redesign, customization and training
  27. 27. What is the Current State of eMedRec in Canada?
  28. 28. eMedRec in Canada There is a move from paper to eMedRec • to improve efficiency and safety • to integrate MedRec with information systems Paper Based MedRec Hybrid MedRec eMedRec +
  29. 29. eMedRec in Canada • We conducted an online survey of eMedRec practices in Canada to assess the current state of eMedRec • Method: • online survey • conducted in spring 2013 • Participants: • 2799 people were invited to participate • 212 people responded • included physicians, nurses, pharmacists, administrators, QI professionals, and health IT professionals
  30. 30. Where is eMedRec Implemented in Canada?
  31. 31. Type of eMedRec in Canada
  32. 32. Perceived Success of eMedRec in Canada
  33. 33. Ranked Reported Motivators for eMedRec
  34. 34. Factors that Led to Successful eMedRec Implementation
  35. 35. eMedRec in Canada • eMedRec functionality was highly variable, with not all functions used • Most respondents indicated no additional resources (e.g., human, financial) were allocated to sustaining eMedRec (61%)
  36. 36. What are the Advantages of eMedRec? • Potential Advantages of eMedRec include: – – – – Improved standardization of documentation Improved legibility of information Improved communication between providers Improved accessibility of documentation – Potentially improved eMedRec compliance through implementing: • Soft stops - reminders that eMedRec needs to be completed for a patient) • Hard stops - orders cannot be placed until eMedRec is completed
  37. 37. What are the Advantages of eMedRec? • Decision support tools – assist in comparing medication lists – identifying discrepancies – providing warnings for drug interactions or allergies • Integration with computerized provider order entry (CPOE) to facilitate improved ordering processes • Improved efficiency of many medication-related processes in health care organizations (Poon et al., 2006).
  38. 38. Key Aspects of Implementing eMedRec Senior leadership support is important • The transition to eMedRec will require sustained resources, perseverance, clear accountability, preparation and dedication to achieve success Understand the current state of an organization’s HIS • is critical to implementing eMedRec • Example: In planning to implement CPOE, it is valuable to pair eMedRec implementation with CPOE implementation because efficacy is improved when they are implemented together
  39. 39. Assessment of Organizational Readiness Before implementation, organizations should determine the following: • What HIS they currently have in their organization • What they plan to implement in terms of eMedRec tools • The HIS inputs and outputs eMedRec All involved must be aware of the type of HIS already in place • (e.g., electronic health records) Have a common understanding of the definition of eMedRec and the components of eMedRec
  40. 40. Workflow Standardization, Organizational Policy and Procedures • Implementing eMedRec usually requires changes in workflow • Important to communicate critical aspects of the process such as: – The overall plan for implementing and sustaining eMedRec across the organization – Health professional roles and responsibilities for each task – Clear time expectations for tasks to be completed – How the changes will affect all health professional tasks and roles. – Changes in organizational policies and procedures
  41. 41. Workflow Standardization, Organizational Policy and Procedures • Observation of workflow and clinical simulations • are increasingly being used around the world to assess the impact of new information systems upon workflow • best undertaken in a setting similar to, or in the actual setting where eMedRec takes place. • Observation and clinical simulations can be used to: • • • • • • diagram workflows, Assess the impact of the technology upon care processes Identify potential sources of technology-induced errors Design the eMedRec interface Design policies, procedures and training Address cumbersome workflows and potential pitfalls of workflows prior to implementation
  42. 42. Selection and Procurement of eMedRec Solutions • Organizations must carefully weigh a number of considerations related to the selection and procurement of eMedRec technology: – What information technology is currently available in the organization? – What features and functions of an eMedRec solution will be: • mandatory for an implementation • nice to have (but not required) • will be implemented at a later date
  43. 43. Selection of eMedRec Solutions • Ideally the features and functions of eMedRec allow for the following: • Display of current medications and eBPMH lists side-by-side. • Complete information on: current, previous, active and discontinued medications, to facilitate comparison • Flagging of discrepancies in medications • Medication display on a timeline so that the user understands what medication is to be/was given and when • Modification of medications from the same screen – e.g. continue, discontinue, hold, or change • Integration with CPOE (if applicable) so that new medications can be easily prescribed
  44. 44. System Reliability • Assessment of system reliability and the creation of reliability targets is an essential aspect of implementing eMedRec. • A back-up plan if eMedRec fails or goes down – i.e., downtime policies and procedures • Electronic or paper back- up available in the event that there are technical difficulties that prevent MedRec from being done electronically
  45. 45. Usability • A usable eMedRec system will lead to: – Higher rates of compliance – Fewer workarounds – Less training – More efficient eMedRec processes – Fewer technology-induced errors • be better for infrequent users or users with lower levels of computer literacy
  46. 46. Cost • For any implementation to be a success it is important to identify project and long term maintenance costs. – Ensure commitment and support of senior management through an executive sponsor dedicated to this project – Ensure that sufficient financial resources are available to implement and sustain eMedRec – Determine the impacts of using new eMedRec processes upon physicians, nurses and pharmacists – Ensure that there is sufficient staff with enough time to be able to conduct eMedRec on an ongoing basis – Conduct periodic evaluations to ensure that all health professionals are complying with eMedRec processes – Budget for evaluation and follow-up
  47. 47. Safety • eMedRec has the potential to: – reduce errors – introduce errors into the MedRec process. • To fully benefit from eMedRec’s ability to decrease errors: – Ensure that health professionals are educated in and aware of their role in all aspects of eMedRec processes – Encourage health professionals and patients to report near misses and errors that arise, in order to refine eMedRec processes to ensure system reliability and maximize the benefits of eMedRec – Ensure a well defined evaluation plan is in place to track the compliance with and outcomes of implementing eMedRec
  48. 48. Issues and Challenges in Moving to eMedRec – From Survey and Literature • Inadvertently increasing workload by requiring electronic entry of medications • Integration issues • Changing the way users communicate • Resistance to adopting new technology
  49. 49. Recommendations • Understand current workflow before implementing • Understand how eMedRec can integrate with existing and planned health information system infrastructure • Obtain management and financial support (including ongoing for sustainability) • Need to carefully stage eMedRec implementation
  50. 50. Need for Evaluation Throughout the Implementation Process • • • • Workflow evaluation and usability testing Integration with existing infrastructure Adequacy of training Evaluation of Error and Performance – Number and % of patients reconciled – accuracy of reconciliation – frequency of use
  51. 51. Development of a New Paper to eMedRec Toolkit • To support managers and health care professionals who are considering or moving to eMedRec • Funded by Canada Health Infoway • Work conducted by AE Informatics, University of Victoria professors, ISMP Canada and CPSI • Will be made available through ISMP Canada and CPSI
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  53. 53. Toolkit: Table of Contents • What is the current state of eMedRec? • What are the stages in implementing eMedRec? • What should be considered after eMedRec is implemented? • How should eMedRec be evaluated? • Lessons Learned • Checklists – Ideal features – procurement and pre-implementation – Evaluation
  54. 54. Toolkit: Checklists and Tips
  55. 55. Conclusions • eMedRec can be an important tool for safety and lead to a range of benefits • There are number of factors that influence success of eMedRec implementations • Work based on national survey, literature review and interviews has lead to development of the: “Electronic MedRec Implementation Planning Kit” Further information:
  56. 56. Thank-you!
  57. 57. 57
  58. 58. Upcoming MedRec Webinars Dec 10, 2013 Canadian Quality Audit Month Results Jan 14, 2014 The Marquis Project - Dr. Jeffrey Schnipper Feb 11, 2014 Engaging Patients in MedRec March 25, 2014 MedRec in Home Care 58
  59. 59. Please complete our poll 59