Transcript Discharge - Hospital Pharmacy in Canada

Crossing the Transitions of Care
through Information Integration
Canadian Hospital Pharmacy Leadership Conference
June 6, 2015
Robyn Tamblyn
James McGill Chair, Professor McGill University
Department of Medicine and Department of Epidemiology,
Biostatistics & Occupational Health
Scientific Director of the Institute of Health Services and
Policy Research
Care Transitions and Medication Errors
• 67% of inpatients have at least 1 error in their
medication history at admission
• 12% of medication discrepancies are unintentional,
but have potential for harm. Of these, 72% were due
to admission errors, while 26% were due to lack of
reconciliation at discharge
• 19% to 23% of patients will have an adverse drug
event within 30 days of hospital discharge and
14.3% will be readmitted
• Adverse drug events are preventable in 58% of the
cases
• Adverse drug events are the 6th leading cause of
death at a cost over $5.6 million per hospital per year
Pippens JE et al. Classifying and Predicting Errors of Inpatient Medication reconciliation. J Gen Intern Med. 2008. 23(9):1414-22
Forster AJ et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170:345-349.
Forster AJ et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-167.
Coleman EA et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165:1842-1847.
Leape LL et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274:35-43.
Bates DW et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997;277:307-311.
Cost of Adverse Drug Events in Canada
2.5 million hospitalizations in Canada each year
19% - 23% of discharged patients will have an
adverse event within 30 days
14.3% will be readmitted to the hospital
•
•
70% of events are related to prescribed medications
58% of events are preventable
Average cost per
hospitalization = $10,500
Cost of ADEs/year = $2.62B
Bates DW et al. The Costs of Adverse Drug Events in Hospitalized Patients. JAMA. 1997
Medication Reconciliation is a Hospital
Accreditation Requirement
Accreditation Canada has a 2 phase approach:
• 2014 – 2017 medrec should be implemented in ONE service
• 2018  medrec should be implemented in ALL services
2016 Required Organizational Practice:
Required Actions to Reduce Medication Errors and
Preventable Adverse Drug Events
Complete community and hospital dug lists
Reconciliation of community and hospital
drugs for each patient at discharge
Communication to community
providers
Action by community
providers
Data entry and/or automated
medication information feeds
User adoption
Who are the providers?
Connect to their coordinates
Patient compliance
Avoided
medication errors
and adverse drug
events
Reduce
readmission
Follow-up information on drug
prescriptions and dispensing
Follow-up on ED visits and
hospitalizations
The Current Medication
Reconciliation Process is Time Intensive
Need to
search for
pharmacy
coordinates
… Google,
Canada 411
Admitted Patients Have Multiple Medications,
Pharmacies, and Prescribing Physicians
Pharmacy
Medications
4.6%
3.4%
15.5%
9.8%
9.9%
32.3%
0 pharmacy
0 drugs
1-10 drugs
1 pharmacy
53.3%
2 pharmacies
71.3%
21+ drugs
3+ pharmacies
Prescribers
0.8%
12.9%
9.8%
0 MD
1-3 MDs
4-7 MDs
76.5%
11-20 drugs
8+ MDs
Time Required for Medication Reconciliation
at Admission and Discharge
45
Geriatrics
Internal Medicine
40.8
40
Time (minutes)
35
30
29.0
29.0
25
20
18.9
16.3
13.4
15
10
13.0
5.2
5
19.4
6.2
0
Prior to meeting the
patient
Discussion with
patient
External research on Reconciliation of
medication history medications and
documentation
Meguerditchian AN et al. Medication reconciliation at admission and discharge: a time and motion study. BMC Health Serv Res. 2013
Preparing the
discharge
prescription
90
80.9
41.5%
75.3
80
68.6
70
of medications were not
documented in hospital chart
60
46.2
50
44
43.4
41.3
40
33.7
32.8
26.1
30
19.8
20
10
Cardiovascular Drugs
Hormones and Synthetic
Substitutes
Blood Formation, Coagulation
and Thrombosis Agents
Medications by
Therapeutic Class
Electrolytic, Caloric and Water
Balance
OTHERS
Autonomic Drugs
Gastrointestinal Drugs
Central Nervous System Agents
Eye, Ear, Nose and Throat
Preparations
Anti-Infective Agents
0
Skin and Mucous Membrane
Agents
Percent Not Documented in the Hospital Chart
Discrepancies in Hospital Charts
Compared to Community Pharmacy Records
Tamblyn R et al. Estimating the information gap between emergency department records of community medication compared to on-line access to the community-based
pharmacy records. JAMIA. 2014
E-MedRec + Communication
at Transitions in Care
Partners Group: The Pre-Admission
Medication List “PAML”
Turchin A et al. Evaluation of an Inpatient Computerized Medication Reconciliation System. JAMIA. 2008
Poon EG et al. Design and Implementation of an Application and Associated Services to Support Interdisciplinary Medication Reconciliation Efforts at an Integrated Healthcare
Delivery Network. JAMIA 2006
PAML Clinical Trial:
Potential Adverse Drug Events
Outcome
PADEs No (per patient)
Control Arm
(n=160)
PADEs No (per patient)
Intervention Arm
(n=162)
Adjusted and
Clustered RR
(95% CI)
230 (1.44)
170 (1.05)
0.72 (0.52-0.99)
153 (0.96)
125 (0.77)
0.80 (0.55-1.15)
80 (0.5)
52 (0.32)
0.62 (0.29-1.34)
PADEs at admission
49 (0.31)
44 (0.27)
0.87 (0.51-1.52)
PADEs at discharge
181 (1.13)
126 (0.78)
0.67 (0.49-0.98)
All Potential Adverse Drug Events (PADEs)
PADEs by type of error
History errors
Reconciliation errors
PADEs by time of occurrence
The rate of hospital readmission or
emergency department visit within 30 days
reduced by 4% in the intervention group
Schnipper JL et al. Effect of an Electronic Medication Reconciliation Application and Process Redesign on Potential Adverse Drug Events. Arch Intern Med. 2009
E-MEDREC:
User Centered Design is Critical to Adoption
The graveyard of
adoption failures
Workflow
complexity and
value for use
requires agile
development
Saving Time and Reducing Errors
15 years of
Provincial
experience using
Drug Repository
this process
& Master
US Patent :
Provider Registry US8010379B2
Harmonizing
hospital drugs to
a common
standard
Hospital
Pharmacy System
2011/08/30
Side by side view
of community and
hospital medications
Standardized, printable,
barcoded forms across
institutions
Alignment of matching
medications
Meets all Accreditation
Canada requirements
Access Medication Reconciliation
Module from Hospital EMR
RightRx:
Community
Medication List
 User enters dose
 Users enters whether or
not the patient is taking
the medication as
prescribed
 Hovering over a
medication allows user to
see more details
(prescribing physician and
dispensing pharmacy)
 Access to drug
monograph
RightRx:
Validated
Community
Medication List
 Patient information listed
 Pharmacy where each
medication was dispensed
 Any notes entered by user
 Barcoded for proper
hospital archiving
Community Medication List:
Issues Encountered
1. Role of users
• Pharmacist vs pharmacy technician
• Who is responsible for what
aspect of medrec?
• Policy defined for role-based rights
2. Retrieving the identity of prescribing
physicians and dispensing pharmacies
• Linking to coordinates via regulatory body
database
Community Medication List:
Issues Encountered
3. Lack of standardized directives
• Lack of structured directives for hospital & population
health data
• Requires users to enter
more data
4. The consent process for
external data access
• Consent-in vs opt-out for
accessing community medications
• The incompetent patient
Aude Motulsky et al. Challenges to the implementation of a nationwide electronic
prescribing network in primary care: a qualitative study of users' perceptions. J Am
Med Inform Assoc. 2015
RightRx:
Admission /
Transfer / Med Review
 Mapping to a common
standard to create side by
side alignment of
community and hospital
medications
 Medications ordered by
AFHS class
 1 click action to continue,
stop, or modify each
medication
 Recommended order
summary
RightRx:
Pharmacy
Recommendation Order
 Standardized form for
pharmacists
recommendations
 Printed with the
pharmacist’s name
 Reason for stopped or
modified medications
printed
 Notes for physician
printed under each
medication
RightRx:
Admission Prescription
 Physician can
electronically accept
pharmacist
recommendation
 Admission prescription
printed with physician’s
name and license number
Admission / Transfer / Med Review:
Issues Encountered
1. Medication reconciliation process
differs in hospitals
• Idiosyncratic process unit by unit,
service by service
2. Hospital drug sentences
• Customized concoctions
• Data clean up required
Admission / Transfer / Med Review:
Issues Encountered
3. Alignment of community and
hospital medications
• Knowledge base and process
used to match
community and
hospital
medications
• Exact match vs
soft match to
manage missing
directives
RightRx:
Discharge
 Clear community
medication list
available for
discharge
prescription
 Alignment of
medications
 User forced to
act on each
medication
Standardized Stop and Change
Reasons Appear on All Forms
RightRx:
Discharge
 Legible discharge
prescription, including
all medications to be
stopped
 Reasons for changes
displayed under each
medication
 Number of renewals
can be pre-set to user’s
choice
 Discharge physician’s
name and license
number printed
Prescribing
Community
Physician
Pharmacy
RightRx:
Discharge
Communication
 Automatic documents
printed for prescribing
community physicians
and community
pharmacies
 Faxed from the unit after
patient is discharged
Discharge:
Issues Encountered
1. Community physicians do not know why new
medications were started
• Indications documented for new medications &
included in faxes to community physicians and
pharmacists
2. Number of prescription repeats needed to be
customized by unit
Discharge:
Issues Encountered
3. Lack of consensus on the responsibility of the
discharging physician to re-prescribe
community medications
• Relates to pre-admission medications that the
discharging physician does not want to deal
with
• Does ‘continue as prior to
admission’ relieve
physicians of legal liability?
Continue As Prior To Admission
Proposed Solution
for Discharge Prescription
The Right-Rx Trial
Can e-MEDREC + inbound/outbound
communication module
Reduce time for medrec &
communication
Increase medrec adoption
Reduce medication errors
Reduce adverse drug events,
ED visits & readmissions in 30 days
Cluster Randomized Trial Design
Internal
Medicine
MGH: 15
RVH: M6 + M10
Intervention Control
Cardiac/Thoracic
Surgery
RVH: S08E-W &
S09W
MGH: 11E
Intervention
General
Surgery
MGH: 18E-W
RVH: SO9W &
R05
Control Intervention
Control
Specialized
Surgery
MGH: 11E & 12E
& 18E
RVH: R05 & S09W
Intervention
Follow up Interview – 30 days (post discharge)
RAMQ
Feed
ER Visit & Hospitalization
30 days, 90 days (post discharge)
*The top unit listed is the intervention unit for each pair
Control
Time for Medication Reconciliation
Time for Medication Reconciliation
Form Completion in Medicine
3.5
3.33
3
2.43
Minutes
2.5
2.37
2
1.63
1.5
1
0.5
0
CDL
Discharge
PDF Form
RightRx
Adoption of Right-Rx
Adoption in Internal Medicine
Proportion of Admitted Patients with Medication
30
No data entered in RightRx
Data entered but not finalized (death, transferred units)
25
RightRx electronic discharge
Number of discharges
20
15
10
5
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Weeks
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Adoption in Cardiac Surgery
Proportion of Admitted Patients with Medication
30
No data entered in RightRx
With no
pharmacists!
Data entered but not finalized (death, transferred units)
Number of discharges
25
RightRx electronic discharge
20
15
10
5
0
1
2
3
4
5
6
7
8
9
10
11
12
13
Weeks
14
15
16
17
18
19
20
21
22
23
24
25
Cumulative Number of Users
118
120
105
98
100
80
80
68
60
56
52
46
41
40
40
33
31
29
25
24
21
20
17
15
6
8
4 4
11
4
8
7
1
17
14
13
11
5
4
1
17
16
15
11
2
5
6
2
7
6
2
2
0
October
November
Nursing student
December
Nurse
January
Pharmacy student
February
Pharmacist
March
April
Medical student
May
Physician
Post-Discharge Medication Errors
Medications at Transitions of Care:
Discharge - Control Unit
1,934 prescriptions
at discharge
New Start
22.2%
(430 medications)
NOT DISPENSED
42.1%
(181 medications)
Continued
60.7%
(1,174 medications)
149 Patients
12.98 prescriptions per patient
Modified
8.0%
(155 medications)
NOT DISPENSED
34.3%
(456 medications)
Stopped
9.1%
(175 medications)
DISPENSED
16.5%
(29 medications)
Medications at Transitions of Care:
Discharge – Intervention Unit
1,707 prescriptions
at discharge
New Start
28.7%
(489 medications)
NOT DISPENSED
48.1%
(235 medications)
Continued
45.5%
(777 medications)
Modified
9.1%
(156 medications)
NOT DISPENSED
46.7%
(235 medications)
112 Patients
15.2 prescriptions per patient
Stopped
16.7%
(285 medications)
DISPENSED
1.1%
(3 medications)
Failure to Stop
Percentage of Stopped Medications
Being Dispensed in the Community
18
16.5%
Percentage of Stopped
Medication Dispensed
16
14
12
10
8
6
4
2
1.1%
0
Control
Intervention
Stop Order Errors
Discharge Prescription: Control Unit
RAMQ Dispensed Drugs
(same day as discharge)
Acetaminophen
Furosemide
Metoprolol
Midazolam
Pantoprazole
Hydromorphone
Stop Order Errors
Discharge Prescription: Intervention Unit
Summing Up
• Strategic Directions
– Escalate interface to community pharmacy data
(DIS or Claims) to increase safety and efficiency
– Standardize drug and directive data-NLP in the
short term
– Monitor and establish best practices for
ethical/legal grey zones
• Clinical and System Issues
– High variability in current processes
– High Risk Patients and Transitions are the Norm
– Failed Stop Orders and Medication noncompliance-may be an important cause of
potentially preventable admissions
Thank you
Robyn Tamblyn
James McGill Chair, Professor McGill University
Department of Medicine and Department of Epidemiology,
Biostatistics & Occupational Health
Scientific Director of the Institute of Health Services and
Policy Research
[email protected]