tool c - workflow assessment spreadsheet feb8-2010 v0

Tool C – Workflow Assessment Spreadsheet eHealth Observatory 1

Tool C - Workflow Assessment Spreadsheet For each prescribing workflow step encountered in outpatient practice, this section itemizes the expected functionality at each stage of advancing functionality. Please note that processes not directly relevant to clinician workflow are excluded. This tool is meant to allow rapid assessment of a practice’s stage of ePrescribing. Instructions:

1. For each question, determine the current workflow stage using the descriptions provided. The Current assessed stage is how the activity is currently done in the office, if at all. Read these as statements of fact e.g “I use my EMR…”. If the same description corresponds to two or more stages, select the lowest stage. If a response is in between two stages, assign a value in the middle (e.g. 2.5).

2. Where appropriate, please record your system’s potential workflow stage given your understanding of the capabilities of your system (or record the same level as current). The Current Potential assessed stage is the highest stage the practice could be at with its current level of EMR implementation. Read these as statements of potential e.g. “I could use my EMR…”. If the same description corresponds to two or more stages, select the lowest stage. If a response is in between two stages, assign a value in the middle (e.g. 2.5). For example, a system may have the capability to do drug interaction checking. Clinicians might have disabled this functionality because this function generates too many nuisance warnings, or slows down workflow too much. Similarly, a system may be able to send prescriptions electronically directly to a pharmacy, but regional regulations may prohibit clinicians from doing this. An EMR system may offer a useful tool, but the number of mouse clicks, menus and tabs necessary to use the tool may leave it generally unused. Where there is a gap between current workflow stage, and potential workflow stage, please comment on the factors that you believe have led to the discrepancy. It is important for vendors, funding agencies, governing bodies, and researchers to be made aware of disconnects between advertised/expected workflow, and the realities of life “in the trenches”. Armed with this information, software products can be improved, usability can be enhanced, and training gaps identified.

3. Once you have completed filling in responses to each question, record the values in the corresponding cells of Tool E. The spreadsheet will automatically calculate average scores for each section and two overall scores to be recorded in Tool D.


Workflow Role A: Initiator Description: an individual or system initiates a request for a prescription or prescription change. Activity Expected workflow/functionality at stage 1. Request

Prescription or Modification

A clinician can receive a request to prescribe, renew, change, or cancel a medication, via various communication methods. How do you receive requests for new prescriptions, refills, and cancellations?

Assessed stage

Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

Current: -------------- Current Potential:

I see a patient in person, or receive a telephone call, fax, or written request.

Same Same I (could) also use Email for this purpose

My office staff (could) also input(s) requests into my EMR.

I (could) also receive requests directly into my EMR.

Comments:


Workflow Role B: Prescriber Description: clinician selects patient chart, decides whether and what to prescribe, and generates a prescription. Activity Expected workflow/functionality at stage 2. Identify

Patient

As the first step in prescribing, a prescriber needs to know that they are accessing the chart of the correct patient. This is not always possible (E.g. for out of office telephone prescriptions), yet advanced ePrescribing systems should maximize the ability to ensure that the chart of the correct patient is being used. How does your system support you in confirming the identity of the patient concerned?

Assessed stage



I recognize the patient, rely on my staff to identify the patient, or confirm patient identifying information from a paper chart.

I (could) use my electronic system (e.g. scheduling) which (can) display(s) demographic information on some patients

I (could) use my EMR which (can) display(s) demographic information on most patients

I (could) use my EMR which (can) display(s) demographic information for all patients in my practice.

I (could) use my EMR which (can) display(s) demographic information including a patient photo.

I (could) use my EMR which syncs patient demographics with a jurisdictional (province / region / state) repository.

Comments:

3. Access

Patient Record

A clinician needs access to a patient’s clinical record in order to check for existing medical information, and record a prescription entry. How are your patient records stored?

Assessed stage




In paper charts. I (could) use my electronic system, which (can) include(s) free-text information on some patients.

I (could) use my EMR which (can) contain(s) free-text or structured information for most patients.

I (could) use my EMR which (can) store(s) all my patient records, but mainly as free-text.

I (could) use my EMR which (can) store(s) all my patient information in a structured form.

As in level 4, I (could) use my EMR which (can) coordinate(s) with regional data centres.

Comments:

4. Prescribe? Having made the decision to prescribe, physicians consider:

• patient-specific clinical factors

• Patient-specific non-clinical factors

• Drug factors of the available therapeutic choices 4.1 Evaluate Patient-Specific Clinical Factors

An advanced ePrescribing system should facilitate appropriate prescribing by including the ability to evaluate patient-specific clinical factors. These include:

1. Demographics: age, gender, weight and race 2. Pregnancy & breast-feeding status 3. Allergies & intolerances 4. Current and past medications (including reason for, and date of discontinuation) 5. Current and past medical conditions 6. Metabolic status & lab results (Renal, hepatic, respiratory and cardiac function, & relevant lab results such as

culture results, lipid values, imaging findings, etc.) 7. Clinical metrics (For example, blood pressure, heart rate, peak flow, ejection fraction) 8. Psychiatric history, mental capacity, and medication compliance (including past overdoses, and current

depression or mental instability at time of prescribing) Please describe how you consider each of the following patient-related factors i.e. where do you find the information and assess its relevance?

Assessed stage



4.1.1 Demographics (Age, gender, weight and race)


I search in the paper chart.

I (could) use my electronic system, but it displays none or only some of this information, OR does not display the information at the time of prescribing.

My EMR (can) passively display(s) most of this information at the time of prescribing.

My EMR (can) passively display(s) all of this information at the time of prescribing.

My EMR (can) actively evaluate(s) this information to assist me in making prescribing decisions.

My EMR (can) access(es) external resources to further facilitate real-time active decision-making support.

4.1.2 Pregnancy & Breast-feeding Status (including stage of pregnancy


I (could) use my electronic system, but it displays none or only some of this information, OR does not display the information at the time of prescribing. Pregnant (yes/no)

My EMR (can) passively display(s) most of this information at the time of prescribing. Pregnant (yes/no) & Breast-feeding status

My EMR (can) passively display(s) all of this information at the time of prescribing. Number of weeks pregnant & breast-feeding status

4.1.3 Allergies & Intolerances (Including fillers)



I (could) use my electronic system, but it displays none or only some information about each item, OR does not display the information at

My EMR (can) passively display(s) most information about each item at the time of prescribing.

My EMR (can) passively display(s) all the information about each item at the time of prescribing.

My EMR (can) actively evaluate(s) information about each item to assist me in making prescribing decisions.



4.1.4 Current & Past Medications


the time of prescribing.

4.1.5. Current & Past Medical Conditions


4.1.6 Metabolic Status & Lab Results (E.g. GFR, lipid status, culture results)


4.1.7 Clinical Metrics (E.g. BP, peak flow, ejection fraction)



4.1.8 Psychiatric History, Mental Capacity & Medication Compliance


Comments: 4.2 Evaluate Patient-Specific non-Clinical Factors

An advanced ePrescribing system should facilitate appropriate prescribing by including the ability to evaluate patient-specific non-clinical factors. These include the consideration of factors that may facilitate or hinder a patient’s ability to afford a medication. Such factors include:

• Patient Financial status

• Patient Insurance coverage

• Patient preferences Please describe how you consider each of the following patient-related factors: i.e. where do you find the information and assess its relevance?

Assessed stage


4.2.1 Financial Status



I (could) use my electronic system, but it displays none or only some information about each item, OR does not display the information.






4.2.2 Insurer Coverage


My EMR (can) actively evaluate(s) this information to assist me in making prescribing decisions. Can optimize if multiple insurers.

4.2.3 Patient Preferences (Examples: pre- and post-school dosing, liquid preferred vs.pill)



Comments:


4.3 Evaluate Medication-Specific Factors

An advanced ePrescribing system should facilitate appropriate prescribing by including the ability to evaluate medication-specific factors. These include:

1. Allergy information (including drug excipients like lactose, dyes, etc.) 2. Contraindications 3. Warnings 4. Precautions 5. Use in special populations including use in pregnancy, lactation, children, the elderly, specific races, and genders. 6. Drug interactions 7. Adverse reactions 8. Pharmacokinetics (e.g. wash-out times, half-life, time to reach therapeutic level) 9. Dosage selection 10. Overdose risks 11. Discontinuation risks 12. Cost

Please describe how you consider each of the following medication-related factors: i.e. where do you find the information and assess its relevance?

Assessed stage


4.3.1 Allergy Information (Including fillers)



I (could) use my electronic system, but it displays none or only some information about each item, OR does not display the information at



My EMR (can) actively use(s) information about each item to suggest and rank alternative medication options.

My EMR (can) access(es) external resources to provide real-time active decision-making support.


4.3.2 Contraindications


the time of prescribing. Or I use a standalone application to check info (e.g. ePocrates or UpToDate)

4.3.3 Warnings


4.3.4 Use in Special Populations


4.3.5 Drug Interactions



4.3.6 Adverse Reactions


4.3.7 Pharmacokinetics


4.3.8. Dosage Selection


4.3.9 Overdose Risks



4.3.10 Discontinuation Risks


4.3.11 Cost


Comments: 4.4 Evaluate

Options

Having considered the patient-specific factors, and medication-specific factors, how do you rank the available therapeutic options for treating a condition, and then select a drug?

Assessed stage



I evaluate options manually.

I (could) use my electronic system, but it cannot display a list of treatment options for a given diagnosis.

I (could) use my EMR which (can) display(s) a list of medication options if I enter a diagnosis or drug class. The EMR does not help me choose one.

I (could) use my EMR which (can) include(s) some patient and medication-related factors when displaying a list of drug options.

I (could) use my EMR which (can) actively evaluate(s) patient-specific and drug-specific factors and present(s) a ranked list of drug options.

I (could) use my EMR which (can) include(s) all of level 4 functionality, and integrate(s) information with external EHR systems.


Comments:

5. Document Prescription

Having decided to prescribe a medication, how do you document it in your patient’s medical record?

Assessed stage



I write a note in the patient’s paper chart, or include a copy of the faxed prescription request.

I (could) write a free-text note in my electronic system each time that I write a prescription, and scan in faxed prescription requests.

I (could) write the medication in my EMR (free text), which (can) also allow(s) me to use an existing medication entry.

I (could) document prescriptions in structured fields in my EMR.

Same External regional data repositories are (or can be) automatically updated with the newest medication information.

Comments:

6. Transmit Prescription

Having decided to prescribe a medication, how do you transmit it to a pharmacy?

Assessed stage



I write my prescriptions by hand, and give it to the patient. I also use fax and telephone.

Even though I (could) record prescription information in my electronic system, prescriptions still need to be written by hand.

I (could) use my EMR to print prescriptions, but I (would) still sign them manually.

I (could) use my EMR to digitally sign prescriptions, but governance restrictions prohibit me from using this function.

I (could) digitally send and sign prescriptions to a specific pharmacy or chain.

I (could) send prescriptions digitally to a regional data centre, so that patients can pick up their prescription at any pharmacy.

Comments:


6.1 Transmit a Prescription Securely

Having decided to prescribe a medication, how do you transmit it securely?

Assessed stage



I write prescriptions by hand.

Same. I (could) use my EMR to print prescriptions, For enhanced protection, I (would) still sign them manually.

I (could) use my EMR which (can) print(s) on security-enhanced prescription paper, or otherwise prints prescriptions in a form that makes them difficult to modify.

Prescriptions are (or could be) sent digitally to pharmacies via a secure connection.

The receiving pharmacy does (or can do) “hand-shaking” with my EMR to directly confirm the validity of the prescription.

Comments:

7. Initiate

Prescribing-Related Activities

Having written a prescription, there is often the need to initiate related activities. How do you do the following?: 1. Initiate Monitoring Investigations – decide what baseline lab and follow-up testing is appropriate (E.g. baseline and

follow-up lab work, eye exams, imaging, etc.) 2. Flag Refill – flag a recall when a prescription will be due for a refill. 3. Request Insurer Coverage - by a third-party payer 4. Reconcile Insurer Response - reconcile the insurer’s response with the initial request 5. Broadcast Warnings - warn pharmacies and/or clinicians if your patient is drug-seeking, is a suicide risk, or should

only receive prescriptions from you alone: a. How could you notify all pharmacies and clinicians in your community? b. How could you notify all pharmacies and clinicians at a regional or national level?

6. Notify Initiator - if another clinician (for example, a consultant), had initially recommended a medication that you then prescribed:

a. How would you notify the originating clinician, that the medication had been prescribed?, including the medication name, dose, and quantity.

b. How would you associate a consultant’s letter (that contained information about the medication advice), with the event of medication prescribing?


7.1 Initiate Monitoring Investigations

While you are prescribing, how do you decide what baseline lab and follow-up testing is appropriate (E.g. baseline and follow-up lab work, eye exams, imaging, etc.)

Assessed stage



I use my judgment and experience to decide.

I (could) use my electronic system, but it displays none or only some of this information, OR does not display the information at the time of prescribing.

I (could) use my EMR which (can) passively display(s) most of the appropriate monitoring advice at the time of prescribing.

I (could) use my EMR which (can) passively suggest(s) comprehensive monitoring advice at the time of prescribing.

I (could) use my EMR which (can) actively recommend(s) appropriate baseline and monitoring investigations, and generate(s) requisitions and automated reminders.

I (could) use my EMR which includes all of level 4 functionality, and (can) integrate(s) information with external EHR systems.

Comments: 7.2 Flag for Refill Having generated a prescription, how do you flag a recall when a prescription will be due for a refill?

Assessed stage



I could do this manually.

I have an electronic system, but this feature is not present.

I (could) use my EMR to write a note about this, but the note is just passively displayed when the chart is viewed.

I (could) use my EMR to generate timed reminders for renewals, but I (would) have to create the reminder myself.

I (could) use my EMR which (can) actively generate(s) automated refill reminders.

I (could) use my EMR which (can) integrate(s) information with external EHR systems. If a prescription is refilled elsewhere, my EMR (can) adjusts the refill reminder date.


Comments: 7.3 Request Insurer Coverage

Having generated a prescription, how do you submit a request for coverage by a third-party payer?

Assessed stage



I phone or complete a paper form and then mail or fax it.

I (could) complete some forms electronically, but then mail or fax them.

I (could) use my EMR which (can) print(s) the forms for me, but the information is not stored in my EMR unless I scan it.

I (could) complete the forms from within my EMR, and the EMR saves it. I (would) then still need to mail or fax the form.

I (could) use my EMR which (can) lets me do real-time coverage checking. Approval/rejection result is received directly to my EMR.

The coverage process is (or could be) integrated with a jurisdictional (province / region) ePrescribing system.

Comments: 7.4 Reconcile Insurer Response

Having requested insurer coverage for a medication, how do you reconcile the insurer`s response with the original request for coverage?

Assessed stage



When I send a coverage request to an insurer, they fax or mail a response.

I have an electronic system, and (could) scan the insurer response into the system

I (could) scan the insurer response into my EMR.

I (could) scan the insurer’s written response, and (can) link the response document to the original request.

The insurer’s approval/ rejection result is (or can be) received directly by my EMR, and automatically linked to the original request. It (can) also reconcile(s) coverage by

The coverage process is (or can be) integrated with a region-wide ePrescribing system.


multiple insurers.

Comments: 7.5 Broadcast Warnings

When prescribing, a clinician may want to caution other care providers about a patient’s drug allergies, risk of suicide, drug-seeking behaviour, multi-doctoring, etc. A clinician may also want to be notified if a patient seeks to multi-doctor. How are these processes done in your office?

Assessed stage



We have a telephone/fax-based “fan-out” protocol in our community.

I have an electronic system, and (could) document concerns in free text. Colleagues with access to my EMR could view the warnings when they access the chart.

I (could) use my EMR which has a field dedicated to this function that I view. Colleagues with access to my EMR could view the warnings when they access the chart.

I (could) use my EMR to write a reminder note associated with the specific medication of concern. Colleagues with access to my EMR could view the warnings when they access the chart.

I (could) use my EMR to broadcast a “fan-out” warning to pharmacies and other selected care providers.

I (could) use my EMR which integrates with a regional prescription broadcast system and can both broadcast and receive alerts. My EMR (can) actively alert(s) me if my patient seeks to refill the prescription of concern via another provider.

Comments: 7.6 Notify Initiator If another clinician (for example, a consultant), had initially recommended a medication that you then prescribed:

• How do you notify the originating clinician, that the medication had been prescribed?

• How do you associate a consultant’s letter (that contained information about the medication advice), with the event of medication prescribing?

Assessed stage




I could write a note and fax it.

Same Same

Same

I have an EMR that I (could) use to create a “link” between the Rx and the source document.

My EMR (can) automatically send(s) a note to the consultant.

Comments:

8. Ongoing Monitoring

After generating a prescription, there is a need for ongoing monitoring of prescription-related issues over both the short-term and long-term:

1. Revise Prescription - notification of the patient or pharmacist, when a clinician wants to revise a prescription based on supplementary information. What processes care in place to facilitate this process for you? E.g. If on completing your charting later in the day, you realized that a patient was allergic to the medication you had prescribed.

2. Identify Unfilled Prescriptions – notification if a patient does not fill their prescription within an expected time period. 3. Identify Delayed Refills – notification if a patient does not receive a refill when it is due. 4. Identify Patients Affected by a Drug Recall - identifying and then notifying affected patients If a medication or a

specific lot number was later recalled. 5. Identify Need for Prescription Modification - identifying situations where a prescription needs to be changed because

of a change in patient or drug-specific factors: a. Your patient’s eGFR dropped below 40 while they were on Metformin. b. A patient became pregnant, and they had a prn prescription for Cipro for UTI. c. A change in a drug product monograph mandated a change in dose for your patients with CHF.

8.1 Revise Prescription

Having prescribed a medication, what processes are in place to maintain contact information for notification of the patient or pharmacist, if you need to revise a prescription based on supplementary information? E.g. If on completing your charting later in the day, you realized that a patient was allergic to the medication you had prescribed, or you received a lab result that a patient was pregnant.

Assessed stage


Current:

There is no or minimal

I have an electronic

I have an EMR, and (can) record

I have an EMR, and (can) record

I have an EMR that I (could)

My EMR (can) integrate(s) with


-------------- Current Potential:

provision for recording information about a patient’s preferred pharmacy.

system, and (can) record basic patient contact information. There is no or minimal provision for recording information about a patient’s preferred pharmacy.

most patient contact information. I (can) record most information about a patient’s preferred pharmacies.

comprehensive patient contact information including their Email addresses, and phone numbers. I (can) record comprehensive information about a patient’s preferred pharmacies.

use to send a notification to each of the patient’s preferred pharmacies about the need for a prescription modification.

a regional pharmacy system, allowing requests for prescription modifications to be accessible by all pharmacies.

Comments: 8.2 Identify Unfilled Prescriptions

Having prescribed a medication, how do you know if a patient does or does not fill their prescription within an expected time period?

Assessed stage



I don’t usually know if a prescription is unfilled, unless the patient tells me.

I have an electronic system, but it does not have this capability.

I (could) use my EMR to write a note to remind me to ask about this, but the note is (or would be) just passively displayed when

Same My EMR (can) obtain(s) dispensing information from pharmacies, to reconcile prescriptions.

My EMR (can) integrate(s) with a pharmacy system that notifies me when a prescription is filled. My EMR (can)


the chart is viewed.

generate(s) a warning for unfilled prescriptions.

Comments:

8.3 Identify Delayed Refills

Having prescribed a medication, how do you know if a patient does not get a refill on-time?

Assessed stage



I don’t usually know, unless I ask the patient.

Same.

I (could) use my EMR to write a reminder note, but the note is (or would be) just passively displayed when the chart is viewed.


My EMR (can) actively generate(s) automated refill reminders.

My EMR (can) integrate(s) with a regional pharmacy system, and (can) notify me when refills occur.

Comments: 8.4 Identify Patients Affected by a Drug Recall

Having prescribed a medication, how do you identify and then notify patients affected if a medication or a specific lot number is later recalled?

Assessed stage



I could do this by chart review, or notify patients during encounters.

I have an electronic system and (could) identify some patients, based on a free-text search for the drug.

I have an EMR and (could) identify most patients, based on free-text or structured searching of medication list.

I have an EMR and (could) identify all patients using a given drug, by brand or generic name.

I have an EMR and (could) identify all patients who are, or have previously used a given drug, by brand or generic name.

My EMR (can) receive(s) recall notices automatically, and (can) do(es) ongoing active surveillance and notification if a patient is at risk.


Comments:

8.5 Identify Need for Medication Modification

Having prescribed a medication, how do you identify situations where a prescription needs to be changed because of a change in patient or drug-specific factors? For example:

a. Your patient’s eGFR dropped below 40 while they were on Metformin. b. A patient became pregnant, and they had a prn prescription for Cipro for UTI. c. A change in a drug product monograph mandated a change in dose for your patients with CHF.

Assessed stage



I do this manually.

I have an electronic system. During a patient encounter, it (can) display(s) a patient summary sheet. It’s solely up to me to identify the need for medication modifications.

I have an EMR. During a patient encounter, it (can) display(s) a patient summary sheet. It’s solely up to me to identify the need for medication modifications.

I have an EMR. During a patient encounter, it (can) generate(s) some basic suggestions for medication modifications if clinical information changes. (E.g. patient becomes pregnant).

My EMR (can) actively and regularly monitor(s) patient clinical information and incoming results, and automatically suggest(s) medication modifications.

My EMR (can) access(es) external resources to further enhance automated decision support re medications.

Comments:


Workflow Role C: Patient Description: Patient receives prescription and optionally reviews it. Activity Expected workflow/functionality at stage 9. Review Prescription

Having generated a prescription, how does a patient have an opportunity to review it and contact you if they have questions or concerns about the prescription?

Assessed stage



I write my prescriptions by hand, and give it to the patient. Patients can telephone me if they have questions about a prescription.

I have an electronic system that (can) print(s) out prescriptions that I give to my patients. Patients can telephone me if they have questions about a prescription.

I have an EMR that (can) print(s) out prescriptions that I give to my patients. Patients can telephone or email me if they have questions about a prescription.

Same I (can) digitally send and sign prescriptions, and print a copy if the patient wants one.

I (can) send prescriptions digitally, and (can) also send a digital copy to the patient for their review.

Comments:


Workflow Role D: Dispenser Description: Physician workflow includes dispensing medication samples. Activity Expected workflow/functionality at stage 10. Dispense? If you dispense medication samples to a patient, how do you check that the drug sample had not expired and that the lot

number had not been recalled?

Assessed stage



I manually check the sample’s expiry date. We manually check our samples when a lot is recalled.

Same Same Same I have an EMR, and (could) scan the sample (for example, bar-code, RFID). The EMR (can) warn(s) me if the sample is expired.

I have an EMR, and (could) scan the sample (for example, bar-code, RFID). The EMR (can) warn(s) me if the sample is expired, and does real-time checking for recalls.

Comments:

11. Document (Dispense)

Having dispensed medication samples, how do you document having dispensed the samples, including dose, quantity, lot number, and expiry date? E.g. done by hand, bar-code scanner, RFID, etc.

Assessed stage



I write a note in the patient’s chart.

I have an electronic system, and (could) document this information in free-text.

I have an EMR, and (could) document some of this information in structured fields.

I have an EMR, and (could) document all of this information in structured fields.

I (could) scan sample information directly into structured fields in my EMR, using for example, bar-code, RFID.

I have an EMR that (can) do(es) the preceding and automatically request(s) re-stocking when a sample supply is low.


Comments:

12. Initiate Dispensing-Related Activities

After a medication has been dispensed, several ancillary workflow tasks can be triggered:

1. Review Medication – After dispensing medication samples, what resources do you use to review use and side effects of a medication with a patient?

2. Flag for Refill – Having dispensed a medication, how would you flag that that it should be renewed when it runs out?

3. Notify Clinician – If a pharmacist dispensed a medication, how would you know details of the transaction?: a. The fact that the medication had been dispensed b. Whether the pharmacist had substituted a generic version of the medication c. Details about which pharmacy was used, what was dispensed, including dose, quantity, lot number, and

expiry date? 4. Notify Patient – After you have dispensed a medication sample, what mechanisms are in place to update any

personal health record that your patient might have? 5. Reconcile Dispensing with Prescription – If you were the prescriber, how would you reconcile the original

prescription with the dispensed medication?

12.1 Review Medication

After dispensing medication samples, how do you review use and side effects of a medication with a patient?

Assessed stage



I do this manually.

I have an electronic system, but it displays none or only some of this information. I (could) use a stand-alone electronic resource to provide information.

My EMR (can) print(s) some of this information.

My EMR (can) print(s) most or all of this information.

My EMR (can) actively analyz(es) my patient’s situation to provide customized patient advice.

My EMR (can) do(e)s the former, and electronically transmit(s) the advice to the patient.

Comments:


12.2 Flag for Refill Having documented the dispensed medication, how do you flag that the sample should be renewed when it runs out?

Assessed stage



I do this manually.

Same

I (could) use my EMR to write a note about this, but the note is (or would be) just passively displayed when the chart is viewed.


My EMR (can) actively generate(s) automated refill reminders.

My EMR (can) integrate(s) information with external EHR systems. If a prescription is refilled elsewhere, my EMR (can) adjust(s) the refill reminder date.

Comments: 12.3 Notify Clinician

After a pharmacist has dispensed medication, how do you become aware of the dispensing details? 1. The fact that the medication had been dispensed 2. Whether the pharmacist had substituted a generic version of the medication 3. Details about which pharmacy was used, what was dispensed, including dose, quantity, lot number, and

expiry date?

Assessed stage



Pharmacists will sometimes fax or phone me a notification if they have prescribed medication to a patient.

Same Same Same Pharmacists (can) securely send electronic messages to my EMR.

My EMR is integrated with pharmacy systems that automatically send information about dispensed medications.

Comments:


12.4 Notify Patient After you have dispensed a medication sample, how do you update any personal health record (PHRs) that your patient might have?

Assessed stage



I don’t usually do this, except perhaps for immunization records.

I have an electronic system and (can) print out a paper copy for the patient if needed.

I have an EMR and (can) print out a paper copy for the patient if needed.

Same Same I have an EMR that can directly communicate with digital PHRs.

Comments: 12.5 Reconcile Dispensing with Prescription

After a pharmacist has dispensed a medication, how do you reconcile the original prescription with the dispensed medication?

Assessed stage




I have an electronic system, and (could) write a free-text note to this effect.

I have an EMR, and (could) write a free-text note to this effect.

I have an EMR, and (could) enter some of this information in a structured manner.

I have an EMR that has structured fields to capture this information. I (would) have to enter the information manually.

My EMR is integrated with pharmacy systems, that automatically send information about dispensed medications, and reconcile even generic substitutions.

Comments:


Workflow Role E: Administering Authority Description: Clinicians administer medications in their offices. Activity Expected workflow/functionality at stage 13. Administer? Before administering medication to a patient, it is important to evaluate

1. Medication-specific factors 2. Patient-specific factors

This is necessary to verify the safety of administering the product to a patient.

13.1 Evaluate Medication-Specific Factors

Evaluating medication-specific factors includes checking: 1. Confirm intended patient - the medication is for the correct patient 2. Confirm intended medication - the correct medication and dose was dispensed 3. Check for Expiry or Recall - the medication has not expired and that the medication or lot number has not been

recalled 13.1.1 Confirm Intended Patient

Before administering the medication, how do you verify that the medication is for the correct patient?

Assessed stage



I manually check the patient name on the medication.

Same Same Same I have an EMR, and (could) scan the medication, (for example, using a bar-code reader, RFID reader). The EMR (can) warn(s) me if the name on the medication does not match that of the current patient.

Same

Comments: 13.1.2 Confirm Before administering a medication, how do you verify that the correct medication and dose have been dispensed?


Intended Medication

Assessed stage



I manually compare the chart notes to the medication in hand.

Same Same Same I (could) scan the medication (for example, using a bar-code, RFID). My EMR (can) warn(s) me if the medication does not match that prescribed.

Same

Comments: 13.1.3 Check for Expiry or Recall

How do you verify that the medication that you are about to administer has not expired and that the medication or lot number has not been recalled?

Assessed stage



I manually check the medication’s expiry date. We manually check our samples when a lot is recalled.

Same Same Same I (could) scan the medication (for example, using a bar-code reader, RFID reader). My EMR (can) warn(s) me if the sample has expired.

I have an EMR, and (could) scan the medication. The EMR (can) warn(s) me if the sample is expired, and do(es) real-time checking for recalls.

Comments: 13.2 Evaluate Patient-Specific Factors

Before administering a medication to a patient, it is important to evaluate patient-specific factors: 1. As there can be a delay between the time that a medication is prescribed, and the time that it is administered, how do

you verify that the medication is still safe to administer, given the patient’s current medical status at the time of


administration? (e.g. patient has a prescription for prn Cipro and becomes pregnant) 2. Medications requiring repeated administration, like vaccines and hormonal injections (E.g. Lupron) are usually given

on a scheduled basis. How do you know if a patient is on-schedule for medication administration? 13.2.1 Check Current Medical Status

How do you verify that the medication is still safe to administer, given the patient’s current medical status at the time of administration? (e.g. patient has a prescription for prn Cipro and becomes pregnant)

Assessed stage



I verify this manually.

I have an electronic system. During a patient encounter, it (can) display(s) a patient summary sheet.

I have an EMR. During a patient encounter, I (could) review patient information which I (can) search for or is passively displayed.

I have an EMR. During a patient encounter, it (can) generate(s) basic suggestions if clinical information changes.

My EMR (can) actively evaluate(s) comprehensive patient information and warn(s) me if there are medication concerns.

My EMR (can) access(es) external resources to further enhance automated decision support regarding medications.

Comments: 13.2.2 Check Medication Schedule

How do you know if a patient is on-schedule for medication administration? (e.g. vaccination series)

Assessed stage



I could record the date of administration in the paper chart and refer to this when deciding when the next dose is due.

I (could) record the date of medication administration in my electronic system.

I (could) record the date of medication administration in my EMR.

Same

My EMR (can) track(s) when scheduled medications are due, and warn(s) me if it is about to be administered too early.

My EMR (can) access(es) external resources to further enhance automated decision support regarding medications.

Comments:


14. Document (Administer)

Having administered a medication, how do you document details about the medication, dose, route, site, lot number, etc in your patient’s medical record?

Assessed stage



I write a note in the patient’s paper chart.

I have an electronic system, and (could) document this information in free-text.

I have an EMR, and (could) document some of this information in structured fields.

I have an EMR, and (could) document most or all of this information in structured fields.

I (could) scan medication information directly into structured fields in my EMR, using for example, bar-code, RFID.

I have an EMR that (can) do(es) the preceding and automatically request(s) re-stocking when a sample supply is low.

Comments:

15. Initiate Administering-Related Activities

After administering medication to a patient several ancillary workflow activities may be initiated. How are the following done in your office?

1. Flag for Next Dose – How would you flag when the next dose was due, if applicable (E.g. series of vaccine doses)?

2. Notify Clinicians (Clinician to Clinician) - If another clinician (for example, a consultant), had initially prescribed a medication that you then administered:

a. How would you notify the initial prescriber, that the medication had been administered? b. How would you forward details about what was administered, including dose, quantity, lot number, and

expiry date? c. How would you associate a consultant’s letter (that contained information about the prescription), with the

event of medication administration? 3. Notify Patient – If a patient has a personal health record, how would you update their record after administering a

medication? 4. Reconcile Administration with Prescription – If you were the prescriber, how would you reconcile the original

prescription with the administered medication? 15.1 Flag for Next Dose

Having documented administering a medication, how do you flag when the next dose would be due, if applicable (E.g. series of vaccine doses)?

Assessed stage


Current: I could do this I (could) use my I (could) use my I (could) use my My EMR (can) My EMR



manually. electronic system to write a note about this, but the note is (or would be) just passively displayed when the chart is viewed.

EMR to write a note about this, but the note is (or would be) just passively displayed when the chart is viewed.

EMR to generate timed reminders, but I (would) have to create the reminder myself.

actively suggest(s) a reminder schedule based on the medication administered.

integrates information with external EHR systems.

Comments: 15.2 Notify Clinicians (Clinician to Clinician)

If another clinician (for example, a consultant), had initially prescribed a medication that you then administered, how do you notify the initial prescriber about the details of the medication administration?

Assessed stage



I could phone or write a note and fax it.

Same Same

Same

I (could) use my EMR to create a “link” between the administration event and the consultant’s letter.

My EMR (can) automatically send(s) a note to the consultant.

Comments: 15.3 Notify Patient If a patient has a personal health record (PHR), how do you update their record after administering a medication?

Assessed stage


Current:

I don’t usually do this, except perhaps for immunization

I have an electronic system and (could) print out

I have an EMR and (could) print out a paper copy for the

Same Same I have an EMR that can directly communicate with digital



records.

a paper copy for the patient.

patient. PHRs.

Comments: 15.4 Reconcile Administration with Prescription

If you were the prescriber, how do you reconcile the original prescription with the administered medication?

Assessed stage




I have an electronic system, and (could) write a free-text note to this effect.

I have an EMR, and (could) write a free-text note to this effect.

I have an EMR, and (could) enter some of this information in a structured manner

Medication information is scanned directly into my EMR, using for example, bar-code, RFID. My EMR (can) automatically reconcile(s) the prescription with the medication administration.

Same

Comments:

16. Notify Care Providers re Adverse Event

If a patient has an adverse reaction to a medication, how are care providers including pharmacists notified of the fact?

Assessed stage



I could phone, fax, or write a letter if necessary.

I have an electronic system, and (could) document this information in

I have an EMR, and (could) document this information in free-text, where it can be viewed

Same I have an EMR, and (could) document this information in a structured form, where it can be

My EMR integrates with external systems, allowing me to notify all active


free-text, where it can be viewed by colleagues using the system.

by colleagues using the system.

viewed by colleagues using the EMR.

care providers, including pharmacists.

Comments:

Workflow Summary General comments about workflow level in this practice

tool c - workflow assessment spreadsheet feb8-2010 v0

Documents