Moving From Paper To Electronic Medication Reconciliation

Moving from Paper to Electronic
Medication Reconciliation
November 12, 2013

www.saferhealthcarenow.ca

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Hélène Riverin
Conseillère en sécurité et en amélioration
Safety Improvement Advisor

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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.

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.


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).


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.


Please complete our poll

8


Moving from Paper to
Electronic Medication
Reconciliation (eMedRec)

9


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

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!

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)


eMedRec: Two Unreconciled
Medication Lists for Comparison

(adapted from Markowitz, 2011)

eMedRec: Matching Two Medication Lists


eMedRec: Final Reconciled Medication Record


eMedRec Process Flow Map


Idealized Overview of eMedRec


What is the Current State of eMedRec?


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


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.


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


Key Findings: MedRec Investigations
at Different Points of Care

Quantitative Measures of Medication Reconciliation


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


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


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


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


What is the Current State of eMedRec in
Canada?


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

+


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


Where is eMedRec Implemented
in Canada?


Type of eMedRec in Canada


Perceived Success of eMedRec in Canada


Ranked Reported Motivators for eMedRec


Factors that Led to Successful eMedRec
Implementation


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%)


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


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).


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


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


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


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


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


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


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


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


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


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


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


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

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


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


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

Toolkit: Checklists and Tips


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: andrek@uvic.ca

Thank-you!


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


Please complete our poll

59


Moving From Paper To Electronic Medication Reconciliation

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