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,