The document discusses initiatives at Group Health Centre to improve patient care through health information technology innovations. It describes the implementation of an electronic medical record system (EMR XTRA) that allows pharmacists to access patient information, increasing collaboration between pharmacists and physicians. An evaluation found the program improved quality of care by identifying more drug-related problems and increasing medication management recommendations. The document also discusses preparing for electronic prescribing (ePrescribing) to further enhance coordination and safety of patient care.

1. Transforming Northern Health: Innovations Making a Difference Group Health Centre: EMR XTRA and Preparing for ePrescribing (PeP) Lucy Fronzi, Project Manager March 31, 2010

2. Group Health Centre provides primary care to 75% of Sault Ste. Marie residents Ontario’s largest and longest established ambulatory health care organization providing excellence in health care to over half the population of Sault Ste. Marie for 47 years.

3. Group Health Centre is a partnership of two organizations Sault Ste. Marie and District Group Health Association (GHA) Algoma District Medical Group (ADMG) Not-for-profit, charitable corporation Governed by volunteer, community-based Board Owns physical facility, equipment, furnishings Employs all “non-physician” staff including allied health professionals and support services Independent corporation of 67 physicians (38 GPs, 16 Specialists, 13 Associates/Visiting Specialists) Wide range of specialties, including anaesthesia, cardiology, dermatology, emergency medicine, internal medicine, neurosurgery, obstetrics & gynaecology, ophthalmology, paediatrics, psychiatry, sports medicine and surgery

4. Group Health Centre employs a multi-disciplinary, patient-focused team Unique health organization Established 1963 by Steelworker’s Union Not-for-profit Multi-disciplinary Multi-specialty Multi-site 67 Physician providers 180 other professional health care providers Over 62,000 patients on the system Electronic Medical Record since 1997

5. Group Health Centre is recognized for its Health Promotion Initiatives (HPI) HPI aims to develop and evaluate evidence-based outcomes management programs in order to improve the quality of health care for GHC patients GUIDELINES BY THEMSELVES DON’T WORK Aid the provision of Appropriate Evidence Based Care Primary Care and Patient-centric Population Health Approach Continuous Assessment and Evaluation Outcomes Based

6. HPI Example #1: Diabetes GHC providers focus on achieving evidence-based process and clinical outcomes, measured for diabetes patients using the “Good Health Outcomes in Diabetes” (“GHOD”) score Process Outcomes Clinical Outcomes BP within 6 mo HbA1c within 6mo Lipids annually Albuminuria annually Foot exam completed in past year Eye exam completed in past year On ACE-I/ARB On ASA/antiplatelet On Statins BP within 6 mo and <=130/80 mmHg HbA1c within 6 mo and <= .07 Lipids annually and LDL < 2.0

7. HPI Example #1: Composite GHOD Score

8. HPI Example #2: Anticoagulation Clinic Total number of patients in program 583 Largest community AC clinic in Canada INR results in therapeutic range (+/- 0.2) are 84% (target compliance >70%), excellent quality control “ usual care” benchmarks are in the 40-60% range Major bleeding events are rare (<1%)

9. HPI Example #3: Congestive Heart Failure Number one admission diagnosis in most hospitals in Canada High re-admission rate (>25%) High mortality rate Incidence and Prevalence Increasing Since 2000, there has been a coordinated approach to the care a patient receives after leaving the hospital. All information is tracked and viewed by all involved in the care of that patient.

10. HPI Example #3: Congestive Heart Failure Through the program, re-admission rates have dropped by 43% and have been sustained

11. Health Promotion Initiatives supported by an enterprise EMR Before EMR XTRA , pharmacists not part of the “Circle of Care ” All GHC staff share a single Electronic Medical Record (EMR) system resulting in better communication, coordination of care and patient management

12. August 2006 – February 2008

13. Source: Ontario’s eHealth Strategy 2009-2012 Preventable adverse drug events are the fourth-leading cause of death in Ontario 1 Over 10 Ontarians die every day unnecessarily because of adverse drug events

14. Medications are often not being taken safely or appropriately by Ontarians It is estimated that there will be 394,000 preventable adverse drug events resulting in: 240,000 physician office visits 36,000 hospitalizations 4,000 deaths Source: Ontario’s eHealth Strategy 2009-2012

15. EMR XTRA provides pharmacists access to GHC’s enterprise EMR system Launched in May 2007 Partnership with Canada Health Infoway, Group Health Centre, Ontario Pharmacists’ Association to expand the circle of care to include pharmacists With patient consent, pharmacists can access pertinent patient information in EMR (labs, care plan, program notes, progress notes, DI test results, allergies, etc.) **no psych, counseling, social history or OBGYN notes Development of web portal for patients to access their health information

16. Focus of EMR XTRA Pharmacists in Sault Ste. Marie area were the first in Canada to access lab test results, allergies and other vital data from consenting patients’ electronic medical records Collaboration with Primary Care Physicians (PCP) at Group Health Centre (GHC) and access to the EMR means that pharmacists have accurate and comprehensive medical data about the patients for whom they provide care Enhanced “circle of care” increases the opportunity to provide better, safer care to these patients and to help reduce adverse medical events

17. Benefits Summary What are the benefits and IT adoption implications of including pharmacists in the circle of care? Improve clinical interactions between clinicians and with patients Improve ability to manage patients’ medications Identify workflow processes and issues of managing EMR XTRA patients Improve adoption of technology over time Improve patient access to appropriate care providers Identify ongoing costs for continued provision of EMR XTRA Evaluation Question Evaluation Indicators Key Results 97% increase in pharmacist-PCP activities 57% increase in pharmacist-patient activities Improved perceived quality of interactions 94% more drug-related problems identified 246% increase in medication management recommendations made by pharmacists to PCPs Fewer medication list discrepancies identified Poor integration of the EMR system and EMR XTRA processes into the workflows of pharmacists Over 50% of enrolled patients have not yet been assessed by pharmacists Actively participating pharmacists are regularly accessing the EMR Pharmacists and PCPs both listed as a top 3 resource more often compared to baseline Pharmacists’ compensation drives ongoing cost of EMR XTRA under current reimbursement model Program success will require significant investment in change management      - - - 

18. Pharmacist activities with PCPs and patients increased in quantity… Pharmacist-PCP activities, by type Counts per patient ↑ 97% Pharmacist-patient activities, by type Counts per patient ↑ 57%

19. … and quality PCPs’ perceptions of quality of interactions with pharmacists Percent of “Always” or “Often” responses; Baseline Post-implementation

20. Pharmacists and patients perceived improvement in quality of interactions Pharmacists’ perceptions of quality of interactions with patients Percent of “Always” or “Often” responses Pharmacists felt their ability to manage and empower patient self-management of chronic conditions improved Patients perceived an improvement in the coordination and consistency of their care Source: Post-implementation survey results Baseline Post-implementation Patients’ perceptions of quality of interactions with pharmacists Percent of “Always” or “Often” responses

21. In the first year, pharmacists provided 844 services in 353 patient encounters… Top 5 pharmacist services provided Counts Provide initial or F/U review Provide health education Provide drug information Identify DRP Resolve DRP with patient Other

22. … and were better able to manage patients’ medications Drug-related problems (DRP) identified Counts per patient ↑ 94% Medication management recommendations made by pharmacists to PCPs Counts per patient ↑ 246%

23. Preparing for ePrescribing PeP

24. The ePrescribing Demonstration Project evaluates the impact of electronic prescribing on providers and patients Goals of the ePrescribing Demonstration Project: Quickly provide and demonstrate the patient safety and quality of care benefits of electronic prescribing to Ontarians Create physician, nurse practitioner and pharmacist champions of electronic prescribing Demonstrate the full cycle of electronic prescribing through to dispensing in local settings Identify and understand the issues, challenges and opportunities of implementing electronic prescribing and apply this understanding to the provincial roll out Create tools and frameworks for process/workflow changes, adoption strategies and benefits evaluation that can be used for the overall provincial roll out The intent was not to test prototypes of the provincial solution

25. Demonstration Project sites enabled a “closed loop” prescribing and dispensing process Authorization GBFHT: Secondary PIN GHC: Keystroke Notification EMR sends message to alert pharmacist of pending prescription Pharmacy Management System (PMS) Transcription Pharmacy staff manually enter prescription information into the PMS Pharmacy staff receives / downloads prescription Patient presents to prescriber Prescriber decides to prescribe Prescriber completes prescription Pharmacy staff fills prescription Patient picks up prescription D A B C F G H I Patient requests prescription refill Pharmacy staff requests prescription refill renewal Prescriber receives renewal request E Patient visits community prescriber Community prescriber views patient’s medication profile in the EMR and consults system-integrated decision support tools as needed. Prescriber concludes that patient requires prescription drug therapy and creates a new prescription, authorizes it and posts it to the EMR. Pharmacist accesses EMR, selects the patient’s prescription and flags the prescription as “downloaded” Pharmacist or delegate fills the prescription as per usual procedures Patient presents at pharmacy to pickup medication A B C D E F ePrescribing Demonstration Project Workflow

26. Prescribers strongly believe that knowing prescription status helps them manage compliance Source: Prescriber Post-Implementation Survey data Observations Over 80% of prescribers, both pre and post Go-Live, believe knowing prescription status (e.g., prescription has been received by the pharmacy) can help them manage patient medication compliance Over three-fourths of patients surveyed feel that electronic prescribing has helped their doctor, nurse practitioner, and pharmacist better manage their medications Discussion ePrescribing supports prescribers with access to updated prescription status information in shared medication profiles to manage patient medication compliance

27. The most commonly reported reasons pharmacists access patient medication histories are directly related to patient care Source: Pharmacist Post-Implementation Survey data Observations 87% of pharmacists feel they access medication histories to verify past doses for appropriateness of the current prescriptions The main reasons pharmacists access patient medication history are directly related to patient care and medication management Discussion Pharmacists access medication histories for patient care purposes; while this may improve workflow efficiencies ( e.g. through reduced need to verify instructions with prescribers), it may be recognized more for benefits to patient care than for workflow improvements

28. Paper prescriptions may lead to clinically significant adverse events often flagged by alerts in electronic systems Prescriptions where paper (vs. EMR or ePrescribing) was first used to create a prescription in scenarios with drug interactions Prescriptions where the prescriber changed their prescription decision after viewing clinical alerts in EMR By Medication Scenario: A2: 0% B3: 40% A4: 75% Source: Time-Motion Study Implications and Discussion Handwriting prescriptions may lead to avoidable medication errors that may be systematically flagged by electronic systems In addition to the patient safety issue, medication errors can impact workflow adversely – prescribers and/or pharmacists require additional time to make any necessary prescription changes No. of Paper Prescriptions with Interactions A No. of Paper Prescriptions where the Interaction was Identified by Prescriber No. of Paper Prescriptions with Interactions Deemed Clinically Significant B Observations Only 1 of 14 prescribers creating paper prescriptions identified drug interaction Subsequently creating same prescription via EMR generated several clinical alerts; 5 prescribers deemed interactions sufficiently clinically significant to warrant change in prescribing decision 75% of prescribers changed their prescriptions as a result of clinical alerts during the A4 scenarios

29. Sharing medication histories does not reduce the need for prescriber-pharmacist interactions Providers Who Think Access to Patient Medication Histories Reduces Need for Interactions In percent n=51 n=36 n=29 n=45 Source: Prescriber & Pharmacist Pre- & Post-Implementation Survey data 46 36 Observations Prior to the ePrescribing Project, about 60% and 80% of prescribers and pharmacists respectively thought greater access to patient medication histories would reduce the need for interactions After the Project, about 30% fewer prescribers and 30% fewer pharmacists think greater access to medication histories reduces the need for interactions with each other Implications and Discussion Sharing clinical information, such as patient medication histories, enhances, not eliminates prescriber-pharmacist interactions Sharing information decreases avoidable interactions, but increases clinically relevant ones,; thus little total change in interactions However, quality, timeliness and clinical relevance of these interactions seems to increase Prescribers and pharmacies in both communities serve stable, consistent, and known patient populations, thus existing medication records already fairly complete prior to ePrescribing project

30. A ‘how to’ guide has been developed outlining lessons learned and experiences gathered along GHC’s 12 year journey for a fully electronic medical record.

31. Key takeaways from EMR XTRA and ePrescribing evaluation Benefits of extending EMR access to the complete circle of care team on improving clinical interactions, medication management and patient safety are clear Patients understand the value pharmacists bring to their care Systematic, concerted change management efforts are required to drive adoption, even for the most “technologically advanced” clinicians – money by itself is not enough!

32. Engaging and leveraging early adopters as project champions is an effective strategy to achieve results Despite adoption challenges, primary care providers, pharmacists and patients all recognize the benefits of extending clinical histories to community providers Continuing and expanding EMR XTRA will require a sustainable pharmacist reimbursement model, a structured change management strategy, and an investment in technology infrastructure Continuing eprescribing requires changes in regulatory college requirements and legislation changes Key takeaways from EMR XTRA and ePrescribing evaluation

33. Key Messages Silos that exist with in health care sector act as barriers to better health outcomes and work to increase costs while decreasing services 1 Integration of technology and interaction between health care providers improve patient safety Expected results of Implementation of medication management systems will help prevent – each year – 217,000 adverse drug events, 132,000 physician office visits, 20,000 hospitalizations and 2,200 deaths due to adverse events 2 Source 1: 2004 Pharmacist and Primary Health Care Canadian Pharmacists Association Source 2: Ontario’s eHealth Strategy 2009-2012

34. Questions? Lucy Fronzi [email_address]