Implementing Shared Formulary and E-based Medication Order Review to Create “Closed Loop”

Medication Process in Critical Access Hospitals

September 16, 2009

Douglas S. Wakefield, PhD.

• This work was supported in part by AHRQ grant #UC1HS016156 – “EHR Implementation for the Continuum of Care in Rural Iowa” , University of Iowa Center for Health Policy and Research, and the University of Missouri Center for Health Care Quality.

• Research Team:– Marcia M. Ward, Jean Loes, John O’Brien,

Douglas S. Wakefield

Agenda

• CAH Challenges in Improving Medication Processes

• CAH Network Approach to Implementing Shared Formulary and 24x7 Pharmacist Review of Medication Orders

• Open vs. Closed Loop Medication Processes … Theory to Practice

Errors in the Medication Cycle

•Wrong Patient•Wrong Dose•Wrong Drug,•Wrong Time/ Omitted

•Wrong Route•Frequently Involves Infusion Pump

•Wrong Dose•Wrong Route•Wrong Patient•Wrong Time•Wrong Drug

•Wrong Dose•Wrong Route•Wrong Patient•Wrong Time•Incorrect Labeling/ Drug ID

•Primary catch for Allergy, Drug Interaction,

•Wrong Dose•Wrong Drug•Wrong Route/Form

•Allergy, Drug Interaction

ERRORS

Percent of Errors 39% 12% 11% 38%

Intercept Rate 19% 3% 4% 1%

True Error Rate 20% 9% 7% 37%

Ordering Transcribing Dispensing AdministeringMedicationManagementProcesses

Lucian Leape, et.al., JAMA, Volume 274, 1995

IHI Suggestion for Improving Medication Processes are

Challenges for All Hospitals

• Ensure allergy information accompanies patients

• Use Drug Interaction Software • Pharmacists review of all medication orders• Provide reference materials at point of care• Make allergy information available• Place pharmacists in patient care units• Connect medication orders to lab resultshttp://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Changes/Improve+Core+Processes+for+Ordering+Medications.htm

Additional Challenges facing Critical Access Hospitals’

• Availability of Pharmacists– Pharmaceutical Expertise– Order Review Prior to Administration– Nurse Must Dispense Medications

• Access to Patient-Specific Information when needed (Ordering, Dispensing, Administration)

• Fragmented / Disconnected Workflow Processes• Reliance on Paper / Handwritten Documentation• Financial Resources• Information Technology Expertise & Resources

Open vs. Closed Loop Processes to Improve Safety

• Open Loop Processes:– Traditional process– Sequential tasks– +/- Asymmetry in access to information– +/- Monitoring & Feedback

Key Process Steps Lack Information Continuity, Monitoring & Control

“Open Loop” Information Handoffs Create Uncertainty and Opportunity for Poor Quality and Error!

Closed Loop Processes to Improve Safety

• Closed Loop Processes:– Goal is connected and non-fragmented

processes – Sequential tasks – Symmetry in access to needed information– Built in monitoring and feedback – Information technology integrated into

workflow

Enables Continuous Data Access

& Monitoring

Enables Continuous Data Access

& Monitoring

Enables Continuous Data Access

& Monitoring

Enables Continuous Data Access

& Monitoring

EHR, Lab, Radiology, Rx Standardized Formulary,

E-MAR, SSOS, CPOE,ADC, BCMA

“Closed Loop” Continuously Links Information Process and Automatically Provides Automatic Monitoring

Case Study of Seven CAHs and a Rural Referral Hospital’s Collaboration to Implement

“Closed Loop” Medication Processes

Methodology:• Document Reviews• Interviews• Collaborative Planning Began Late 2006• Collaborative Implementation s 2008 & 2009

Trinity System

Buffalo Center

April 8, 2008

Affiliated and Contract Managed Hospitals with Mercy - North Iowa

Mercy Clinics

Physician-Hospital Organizations

Algona

Bancroft

Kossuth

Worth

Northwood

GraettingerHoward

Lime Springs

Cresco

MitchellSt. Ansgar

OsageRiceville

Stacyville

Garner

Kanawha

WesleyPalo Alto

Emmetsburg

Wright

Hancock

Britt

Winnebago

Lake Mills

Forest City

Mason City

Clear LakeCerro Gordo

11

FranklinSheffield

Hampton

Hardin

Iowa Falls

Ackley

Floyd

Rockford

Dumont

Butler

Chickasaw

New Hampton

West Bend

Dows

Latimer

PHO Affiliated Clinics

2

Rockwell

GreeneBelmond

Mercy Health Network – North Iowa

Coordinated Planning & Implementation

• Cohort Approach to Planning & Implementation

• EHR, CPOE, Lab, Radiology, Pharmacy Systems

• Technology Enabled Devices:– Automated Dispensing, BCMA

• Shared Formulary• 24x7 Pharmacist Medication Order Reviews

Rationale for Shared Formulary

• Expand evidence-based formulary content

• Create shared knowledge base and formulary content for subsequent HIT implementation

• Standardize the pharmacy system IT build

• Facilitate remote pharmacist reviews

Shared Formulary Process Steps

Table 3: Summary of Formulary Changes Hospitals

Franklin Hancock Kossuth MitchellNew

HamptonPalo Alto Ellsworth Average

# in Original CAH Formulary

829 868 667 746 706 750 1351 845.3# in New Shared Formulary

803 803 803 803 803 803 803 803# (%) Do Not Stock Taken Out of New CAH Formulary

119 (14.8%)

33 (4.1%)

124 (15.4%)

117 (14.6%)

37 (4.6%)

257 (32.0%)

34 (4.2%)

103 (12.8%)

# (%) Selected From New Shared Formulary

684 (85.2%)

770 (95.9%)

679 (84.6%)

686 (85.4%)

766 (95.4)

546 (68.0%)

769 (95.8%)

700 (87.2%)

# (%) Items Added to New Shared Formulary

18 (2.2%)

5 (0.6%)

6 (0.7%)

23 (2.9%)

1 (0.1%)

46 (5.7%)

17 (2.2%)

16.6 (1.0%)

# in Final Revised CAH Formulary

702 775 685 709 767 592 786 716.6

# (%) Change from Original to Final CAH Formulary

-127 (-15.3%)

-93 (-10.7%)

+18 (2%)

-37 (-5.0%)

+61 (8.6%)

-158 (-21.1%)

-565 (-41.8%)

-128.7 (-6.6%)

Summary of Formulary Changes

Rationale for 24x7 Pharmacist Medication Order Review

• Medication orders not reviewed

• Rural pharmacist supply constrained

• Nurses dispensing medications from pharmacy

Network Pharmacy Hours 2007S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T F S

00:00 0:59

1:00 1:59

2:00 2:59

3:00 3:59

4:00 4:59

5:00 5:59

6:00 6:59

7:00 7:59

8:00 8:59

9:00 9:59

10:00 10:59

11:00 11:59

12:00 12:59

13:00 13:59

14:00 14:59

15:00 15:59

16:30 16:59

17:00 17:59

18:00 18:59

19:00 19:59

20:00 20:59

21:00 21:59

22:00 22:59

23:00 23:59

Network Pharmacist CoverageTechnicain Coverage

Hour of Day

Enables Continuous Data Access

& Monitoring

Enables Continuous Data Access

& Monitoring

Enables Continuous Data Access

& Monitoring

Enables Continuous Data Access

& Monitoring

EHR, Lab, Radiology, Rx Standardized Formulary,

E-MAR, SSOS, CPOE,ADC, BCMA

Closed Loop Requires Integration of HIT within Workflow …

How was this Done?

“Closed Loop” Continuously Links Information to Process and Automatically Provides Automatic Monitoring

CAH Case Study

CAH Case Study

CAH Case Study

CAH Case Study

CAH Case Study

Network Pharmacist Hours: Post-Remote Pharmacist Reviews

S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T F S

00:00 0:59

1:00 1:59

2:00 2:59

3:00 3:59

4:00 4:59

5:00 5:59

6:00 6:59

7:00 7:59

8:00 8:59

9:00 9:59

10:00 10:59

11:00 11:59

12:00 12:59

13:00 13:59

14:00 14:59

15:00 15:59

16:30 16:59

17:00 17:59

18:00 18:59

19:00 19:59

20:00 20:59

21:00 21:59

22:00 22:59

23:00 23:59

Network Pharmacist Coverage

Technicain Coverage

Remote Coverage by Remote Pharmacy Service

Remote Coverage by Network Pharmacist

Hour of Day

3267

5896

1544

682 596 698323

649100 79

3-month comparison

Ongoing Journey Continuous Improvement

• Regional P&T Committee• Remote Rx Order Review Costs & Performance• ADC Transition to full “Profile Mode”• Process Monitoring:

– CPOE Order Rates– ADC Overrides– BCMA Scanning Rates

• HIT Updating and Integration with Workflow

Questions?

HIT-Based After Hours, Weekend and Holiday Pharmacist Review Process for CAH

5896

3267

1544

682 323

649

596

3-Month Comparison Chart