Pharmacy Automation & Informatics Kirby N. Connolly, PharmD, BCPS Pharmacy Informatics Analyst and Clinical Pharmacist Baycare Health System [email protected] Objectives
Define informatics, EHR/EMR, BCMA, MAR and eMAR
Compare and contrast medication errors via written vs. electronic methods
Review methods to reduce errors in healthcare
Analyze the medication dispensing process
Determine challenges related to BCMA
List the five rights of medication administration
Differentiate between what is and is not a medical device Informatics Overview1
Informatics: The use of computers to manage data and information
Pharmacy Informatics: the use and integration of data, knowledge, and technology involved with the medication use process to improve outcomes
Automation/technology for safe and efficient medication management
Information technology to inform and improve information management and decision making Why the need for informatics? Outpatients: “The old way” Why the need for informatics?8
Inpatients: “The old way” Old healthcare ways
Lack of communication between providers Primary MD, Covering MDs, Consulting MDs, RPhs, nursing, dietary, RT, PT, OT, etc… Lack of information Missing pages/incomplete documentation Historical procedures, lab draws, etc. Too much information Often hundreds of pages
Hard to find desired information Therapeutic Duplication Duplicate BP meds, pain meds, drug interactions, etc. Lack of follow-up Referrals and results may take a long time No system to remind patient or MD to follow-up Errors Many different methods and levels of severity Error Reduction Methods
Improving safety, cost, and efficiency
Electronic Medical Records (EMR, EHR)
Barcoding (BCMA)
Electronic Prescribing/Computerized Physician Order Entry (CPOE)
Alerts/Clinical Decision Support (CDS)
Reporting and Accountability Electronic Medical and Health Records
Electronic Medical Record (EMR): Digital version of a paper chart from one practice
Electronic Health Record (EHR): Digital version of all patient’s health records across a health care organization
Demographic Information
Problem Lists
Information from both Outpatient and Inpatient visits
Progress Notes and Consultations
Laboratory and Diagnostic Results
Inpatient Medication Administration Record (MAR)
EMR Types “EMR” and “EHR" are basically interchangeable Infographic Electronic Medical Record (EMR) Example EHR/EMR benefits
Information sharing between disciplines
All (most) patient information in one place
Searchable information
History of testing, MD visits, compliance; a holistic view of patient
E.g. Problem list may provide more information than list of medication therapy
Drug tolerance, effectiveness, history of use
What therapy to consider at what dose
Better long-term monitoring
Monitor Parameters Long-term (BP, Blood Sugar)
Identify Needs (Vaccinations, Health Screenings) Electronic Health Records pitfalls
Order entry errors Wrong patient “Didn’t mean” to enter it like that Polypharmacy “Don’t call me” med list Too much information How to find the information you need/where to look Electronic documentation resistance Usually older practitioners Interface problems Compatibility & downtimes Unforeseen issues “Sticky notes” Sometimes hard to follow the “narrative” of a patient’s visit
“7 AM - patient fine, 8 AM - patient fine, 9 AM - patient deceased” Bar Code Medication Administration (BCMA)6
BCMA is designed to make sure that the right drug is given to the right patient via the right route at the right dose and at the right time The "Five Rights“
Each drug in the hospital is labeled with a unique barcode When a patient is prescribed medication, it is sent electronically to the hospital's pharmacy verified by a pharmacist The pharmacist dispenses the barcoded dose of the drug to the patient's floor When administering the medication, the RN uses a scanner to scan barcodes Identification badge*, the patient's wristband, and drug If the barcode system cannot match the drug to the order in the system, it alerts the clinician visually Can be overridden Streamlines billing and reduces errors BCMA and the Medication Dispensing Process
Drug is stored within the pharmacy and Drug is received into retrieved once an order for it is placed pharmacy via barcode Drug is checked and placed in a medication storage cabinet (or a patient label is attached)
RN removes medication RN scans patient wristband and medication from storage barcode and administers medication to patient cabinet BCMA and the Medication Dispensing Process1
1. Medication Received and Stored Barcoding assists with inventory management 2. Medication Ordered and Retrieved Pharmacist verifies order on computer Label prints to alert technician to fill Technician scans medication and patient label 3. Medication Verified by Pharmacist Correct product on label 4. Medication Delivered Added to automatic dispensing cabinet OR tubed to floor via pneumatic tubes Much of the delivery process is still on paper 5. Medication Administered RN scans medication and patient bracelet Bulk vs. Unit-dose packaging
Hospitalized patients need a unique method of dispensing medication
Short stays
Several medication dose/freq/type changes
Solution: unit-dosed medications Unit-dosed oral liquids
Patient-specific (label added) Commercially available Medication Prepacking Process
Pills are packaged Drug is delivered to individually pharmacy in “bulk” and heat- bottle wrapped
Medications are now labeled for individual use BCMA up-keep and challenges
Barcodes must be constantly updated
Different manufacturers
New products
Shortages
Non-formulary medications Electronic Medical Record (EMR) Example: adding orders electronically Computerized Physician Order entry (CPOE) Computerized Physician Order entry (CPOE) Computerized Physician Order entry (CPOE) Computerized Physician Order Entry (CPOE)1
Has been shown to markedly decrease prescribing errors
Excludes many errors from poor handwriting/transcription
Drug product selection according to pharmacy formulary
Non-formulary medications are not orderable (Pro vs con)
Dose standardization
Commonly ordered route, dose, and frequencies are shown (Pro vs con)
Errors or confusion can occur when desired order sentences are not available
“Core measure” and “Meaningful use” requirements
Plans can be built to enable practitioners to order required items
Decreases “fall outs” which can decrease reimbursement
Clinical Decision Support (CDS) can help direct prescribing Pharmacist Prescription Review1
Analyses and assessment
Allergies
Indication
Dose
Route of administration
Instructions
Drug interactions
Side effects
Lab results
Intolerance
Clinical objectives
Duration
Expected outcome Medication order pitfalls1
Written orders
Illegible handwriting
Look alike/sound alike drugs
Unit of measure errors (mcg vs. mg)
Pharmacist lack of background knowledge
Physician education Electronic orders
Wrong patient
Polypharmacy Pharmacy Verification System Electronic Medical Record (EMR) Review Interfaces
Pharmacy Electronic Order Health Entry Record System
Medication inventory management system
Medication storage/dispensing cabinets Clinical Decision Support (CDS) Alerts
Based on Pharmacy Drug References
Lexi-comp, Clinical Pharmacology, etc.
Reduces prescribing errors
Allergies, Duplicates, Drug interactions, Lab interactions, Incorrect dose/freq, etc.
Allows documentation for physician or pharmacist override
All alerts and overrides can be reviewed and assessed
Effectiveness
Error review and prevention CDS Alert Optimization: Alert Fatigue
Alert fatigue aka “information overload”
An unintended consequence of CDS
A systematic review2 of computerized reminders found only minor improvements in process of care
Found alerts to be only modestly effective at best
Very common
Clinicians override the vast majority of CPOE warnings, including “critical” ones
Increases with heavier use of CPOE/increased exposure to alerts
Implication: without system redesign, the safety consequences will likely become more serious CDS Alert Optimization: Alert Fatigue
Alert Fatigue has be implicated as a significant cause in several high-profile errors
Reports of a hospitalized teenager receiving a 38-fold overdose of an antibiotic
The ordering physician has been advised by colleagues to “just ignore the alerts” CDS Alert Optimization
How can we reduce the number of “nuisance” alerts?
Does the alert improve safety?
How can we improve?
Is it always overridden?
Is it clinically useful?
Can we add color, additional reference information, etc? Healthcare shift5
Healthcare organizations (HCOs) invest a significant amount of resources in health information technology (HIT) initiatives
Considerable demand for HIT workers with training and skills to create a successful and safe interface between HIT and the healthcare delivery system
Pharmacists’ professional identity, education, training, and experience make them ideal candidates to fill a critical need in pharmacy informatics
Understanding of core pharmacy operations, clinical practice, the medication-use process, standards, and regulations
Path and skills required have varied considerably
Need to build core competencies and grow number of available programs Pharmacy Informaticists’ Role5
Acquiring professional perspective Ensuring that data, information, and knowledge are:
Accurate, accessible, complete, consistent, current, timely, precise, reliable, relevant, and understandable
Readily and rapidly understood and accessed within the workflow
Validated, integrated, and optimized
Centrally managed, collaboratively developed, and easily communicated
Audited, measured, and evaluated for effectiveness Analyzing problems
Evaluation and communication of the potential risks of a newly implemented technology
Innovating and producing solutions
Articulating rationale
Implementing, evaluating, and refining solutions
Translating user requirements into safe and effective system designs Completing maintenance
Corrective, Customized, Enhancements and Preventive Medication Administration Record (MAR)7
A report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional
A part of a patient's permanent record on their medical chart
The health care professional signs off at the time that the drug or device is administered
MARs can be referred to as drug charts
Electronic versions are called e-MARs 5 rights of medication administration
Right med
Right patient
Right dose
Right route
Right time
(*6- Right documentation)
Electronic Medication Administration Record (eMAR) Implementation
Medication errors4
Hospitalized patients: 1 error per patient per day
Patient harm results from 450,000 medication errors every year
Barcode Scanning (BCMA)
Significant reduction in medication errors
Downfall: Can be overridden Electronic Medication Administration Record (eMAR) Electronic Medication Administration Record (eMAR) Electronic Medication Administration Record (eMAR) Electronic Medication Administration Record (eMAR) Electronic Medication Administration Record (eMAR) Electronic Medication Administration Record (eMAR) Medical Device or not?3 TPN Compounding Machine TPN ordering FDA oversight
TPN compounder/order entry software is regulated
Many “sentinel” events
Clinical Decision Support is also regulated
Not currently enforced
Legal implications of manipulating CDS alerts Computerized Pumps aka “Smart Pumps”
Pumps can be used in a variety of ways
IV infusions, PCA, TPN, Epidurals, Intermittent infusions
Pumps have medication libraries
Drug product concentrations for formulary medications
Intended to reduce complexity and improve safety
Issues in the event of shortage or product changes
Standard infusion concentrations and rates
Titration ability
Dose/rate alerts
Different warning limits depending on level of acuity
Continual updates
Detailed data can be obtained
Reporting and assessment of use Error reduction: continuing processes
Patient Labels
Is it clear enough?
Shands 2007 Error
Patient charges
Automatic billing pitfalls
Reporting
Med errors
Sentinel events References
1. Brent I. Fox et al. Knowledge, Skills, and Resources for Pharmacy Informatics Education. Am J Pharm Educ. 2011 Jun 10; 75(5): 93. PMCID: PMC3142977. 2. Shojania KG et al. Effect of point-of-care computer reminders on physician behaviour: a systematic review. CMAJ. 2010 Mar 23;182(5):E216-25. doi: 10.1503/cmaj.090578. Epub 2010 Mar 8. 3. Course textbook. Chapter 15 Managing Pharmacy Automation and Informatics. Tribble DA and Ho M. 4. Siebert et al. The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. J Am Med Inform Assoc. 2008 Sep-Oct;15(5):585-600. Epub 2008 Jun 25. 5. American Society of Health-System Pharmacists. ASHP statement on the pharmacist’s role in informactics. Am J Health-Syst Pharm. 2007;64(2):200-203. 6. Rouse, Margaret. Bar Coded Medication Administration (BCMA). http://searchhealthit.techtarget.com/definition/Bar-Coded-Medication-Administration 7. Medication Administration Record. https://en.wikipedia.org/wiki/Medication_Administration_Record 8. Overview of eMAR Electronic Medication Administration Record. http://crrtonline.com/prespdfs/winter_emar.pdf. March 2006.