electronic Medication Management (emm) Innovation and Systems Research
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1 electronic Medication Management (emm) Innovation and Systems Research Presented by Stephen Kalyniuk Senior Project Manager 1
2 Australian Commission on Safety and Quality in Health Care (ACSQHC) Implementing an Electronic Medication Management (emm) system within a hospital is a major transformational project that substantially affects clinical service delivery, hospital departments and the work of clinicians. A Guide to Safe implementation of an emm system reports that there are elements of hospitals medication management processes that have not been implemented as part of a comprehensive emm system in Australia including: Infusions and monitoring of fluid balance Chemotherapy Renal dialysis Paediatrics Interfaces between the emm system and hospital pharmacy stock control systems Electronic Medication Management Systems A Guide to Safe Implementation, 2nd edition, content/uploads/2011/01/emms-a-guide-to-safe-implementation-2nd- Edition-web-version.pdf 2
3 The Children's Hospital at Westmead (CHW) is one of the facilities managed by The Sydney Children's Hospitals Network (SCHN). 3
4 High level Scope of the emm project at CHW Paediatrics A fully integrated EMM solution Infusions and monitoring of fluid balance Oncology protocols / trials Chemotherapy Renal dialysis Interfaces between the emm system and hospital pharmacy stock control systems Clinical Documentation including integration to Welch Allyn and Phillips vital signs Mobile devices Wi-Fi Single Sign On 4
5 Background One of three electronic Medication Management (emm) pilot sites in NSW Health. Concord and Prince of Wales This Project was the basis for research, conducted by the University of Western Sydney into the implementation and benefits of electronic medication management systems. Phased in implementation with sequence of clinical areas randomised. A period of heightened support for each area and conversion of medication charts being research requirements. Observers on site in the hospital as each location / service was implemented. Research expected to be published in
6 Background Characteristics of Medications in an acute Paediatric care setting: Mostly ordered intravenously. Almost all weight based. Medication filtering by age in days. Frequencies such as BD, TDS, Q4H but with patient specific administration times. Medications are prepared in a medication room Parents encouraged to take active role in child s care and provide advice. 6
7 Background: Hospital Pharmacy Product List (HPPL) A single list of pharmaceutical products used by hospital pharmacies across NSW. Products descriptions are based on the Australian Medicines Terminology (AMT) Provides the foundation for linking Medication Orders and Pharmacy dispensed product via the AMT Identifiers NSW Health specific ipharmacy interface business rules process these identifiers 7
8 Why? Medication errors - leading causes of preventable adverse events. - linked to drug-related morbidity, mortality, and prolonged length of stay. emm Improves legibility, accuracy, and accessibility of medication orders and enables monitoring of medication related activities. Strategy to reduce medication errors and inappropriate prescribing, improve decision support, workflow and productivity. A local study found that emm systems were associated with a 55% reduction in total prescribing errors, and a 44% decrease in serious prescribing errors. 8
9 Key elements for a Safe and Successful emm implementation 1. Medication safety awareness, tracking and governance 2. Top management team engagement, leadership and commitment 3. Sufficient funding to fully implement emm within realistic timeframes 4. Robust governance structures 5. Senior medical staff who will use emm and will champion it s use to others 6. An experienced project manager and an appropriately resourced project team 7. Clearly defined clinical scope for emm 8. Clearly defined relationships between the emm system and other clinical and administrative systems. 9. Definition of the minimum level of clinical decision support that will be implemented 10. Bedside or Wi-Fi point-of-care access 11. Robust technical infrastructure supporting emm 24/7 12. Integration with pharmacy dispensing systems 13. Business continuity plans that are tested and implemented. 9
10 Software PowerChart - Medication ordering Pharmnet - Pharmacy order review, product assignment and dispensing ipharmacy - Stock control Citrix - Application Delivery Imprivata - Enterprise Single Sign-On Linux - Server OS and Windows 8.1 Primary Client OS 10
11 Impact Patient Journey Medication history / reconciliation Conversion (Admission / Discharge) ED/CF/Middleton/Pre-admission Clinical Pharmacy Review emm to Paper to emm Transfer (ED/PICU/OT/wards) Transfer (CAPAC/oncology) Procedural transfer External transfers (Bear Cottage/another hospital/respite/home) Discharge summary/rx output Intraop Recovery - Ward Gatepass CAPAC Clinical Pharmacy dispensing (IP/OP/asap) Cytotoxic/hazardous admin. Continuous IV order/admin. Standing orders Elimination of Phone orders Clinical protocols - DKA Order actions Tapering/patches TPN/Insulin/Warfarin CAPAC/Surgical/Electronic IP Allergies and ADR/Ht and Wt Weight based dosage calculator Medication Administration Specialised Clinical Procedural clinics Haemodialysis/renal Orthopaedics Metabolic meds Heparin Chemo/oncology protocols Home continuous IV Patient Friendly list Patient Controlled Analgesia Resus Turner Intermittent/Future orders Downtime procedures 11
12 Impact Medical Staff Medication Reconciliation, Prescribing, Discharge Summaries with context links to Pathology results and Medications orders Anaesthetists Nurses Medication Administration Nurse Practitioners prescribing Observations Fluid Balance Hospital in the Home Pharmacists Transitioning from imprest based system Product assignment Performing Pharmacy Clinical Consults that were recorded in the system 12
13 Conversion of the National Inpatient Medication Chart (NIMC) Medical officers transcribe the medications under the direct supervision of Project Team members Transcription double-checked by the ward pharmacist If a patient was due to be discharged during the conversion period or transferred to a non-emm ward - stay on paper If a patient was admitted to the ward on the day of conversion then the admitting medical team would order the patient s medications in the emm system STAT or once only medications that were previously administered were not converted. Ceased medications were not be converted Paper medication charts remained on the ward with patient notes and were scanned on discharge as per current process.
14 Heparin IV Order 14
15 Potassium Continuous IV Fluid 15
16 Medication Administration Record 16
17 The Computers on Wheels (CoWS) 17
18 Qualities of Innovation that make it acceptable / spread 1. Relative advantage 2. Compatibility with existing values and practices 3. Simplicity / ease of use 4. Trialability (Pilot sites) 5. Observable results 18
19 emm Statistics Reporting Period (46 days) Monday 11-Apr-2016 TO Thursday 26-May-2016 Deployment Overview Number of Beds now live = 131 Number of Patients with medication orders = 654 Wards Live Mon 11-Apr to Sun 17-Apr - Hall / Clancy / RTC Mon 18-Apr to Sun 24-Apr Bed-in period Mon 25-Apr to Sun 1-May Bed-in period Mon 2-May to Sun 8-May - Commercial Traveller Mon 9-May to Sun 15-May - Ortho / Surgical Mon 16-May to Sun 22-May - Edgar Stephen Mon 23-May to Sun 29-May - Wade Metric Total New patients with one or more medication orders 654 placed Medication Orders placed 7502 Occurrences of Medication Administration Prescription Orders 280 Total Medication Alerts Fired Total Medication Alerts Overridden Height / weight / allergy (prescribing) forms 879 documented Nursing Admission Assessments documented Nursing Initial Assessments documented 841 Discharge Summaries Signed 371 Duplicate medication tasks cleaned up 39 Potential Hot Key Errors Checked 37 Medication and PRN Response Tasks created Total Discern Alerts Overridden 280 Allergies Documented 852 Results Signed via IView IV Infusion Events Documented Intermittent Med Events Documented 76 Meds Uncharted as In Error 339 emar Opened Pharmacy Clinical Interventions Documented 10 19
20 The SCHN emm Team at CHW 20
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