Transcript Integration of Information - Sharing a Train of Thought

Canadian Hospital Pharmacy Leadership Conference
June 6, 2015
HIMSS Analytics Adoption Model
 Integrated Pharmacy, eMAR and CPOE
Systems
 Regional Data Repositories for Drug
Information
 Medication Reconciliation Notes
 Patient Access to Information
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Healthcare Information and Management Systems
Society – 52,000 members
Global, cause-based, not-for-profit organization
focused on better health through IT
Leads efforts to optimize health engagements and
care outcomes using IT
Vision:
◦ Better health through information technology
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Mission:
◦ Globally, lead endeavors optimizing health engagements
and care outcomes through information technology
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Wholly-owned, not-for-profit subsidiary of
HIMSS
Collects and analyzes healthcare information:
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IT adoption and environments
IT department composition and costs
healthcare trends
purchase-related decisions past and near term future
Gather data for:
◦ Every hospital in the US and Canada
◦ Europe, Middle East, Asia on a country sample basis
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HIMSS Analytics’ EMR Adoption
Model℠ (EMRAM) tracks the adoption of
EMR applications within hospitals and health
systems
First created in 2005
Institutions work to complete the 8 stages
Each level of maturity is a score derived from
a comprehensive survey of the hospital’s IT
environment
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Progressively sophisticated steps track the
accessibility of information within an EMR
◦ Ensures critical clinical information and Clinical Decision
Support guidance are available to the clinician at the
point of care
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Gated model - all technologies in a stage must
be accomplished before hospital can move up
Goal of reaching Stage 7 - an environment
where paper charts are no longer used
Order Sets
Pre CPOE
114
Post CPOE
380
Medication Order Sets
20
94
Medical Directives
14
11
Total Order Sets
148
485
Overall % of Visits with
Order Sets
67%
97%
Overall Average Sets/Visit
0.95
2.1
Pre-CPOE
PostCPOE
%Change
TEGH - Turnaround time
all meds
3.3 h
1.3 h
60%
(decrease)
TEGH - Turnaround time
Antibiotics
3.8 h
1.2 h
67%
(decrease)
St. Michael’s Turnaround time
Antibiotics
5.6 h
3.1 h
46%
(decrease)
3h
2h
33%
(decrease)
1.8 h
1.4 h
23%
(decrease)
UHN – Turnaround time
all meds
UHN – Now dose
turnaround time
Total Medication Incidents
600
538
508
500
490
489
470
398
400
# Incidents
352
352
337
308
300
200
100
0
2005/06
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
• Transcription
errors
decreased to
virtually zero
• Omission
errors
decreased by
60%
• Wrong dose
decreased by
40%
• Wrong patient
decreased by
75%
• Over time,
60% decrease
in Moderate
Severity
incidents
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200 Hospitals have ascended to the top of HIMSS
EMRAM (Stage 7)
Secret to success – Single Clinical Data
Repository
◦ Enterprise-wide with core clinical system
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152 Epic
41 Cerner
5 Meditech
1 Allscripts
◦ Best of breed hospitals are not achieving Stage 7
 Clinical Decision support hard to achieve
Software to support hospital’s core
business is from a core vendor
 Single source of truth without interfaces
 Single vendor solution for Pharmacy,
CPOE and eMAR
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◦ Medication reconciliation software is integrated
with CPOE and Pharmacy systems
◦ Tracking Allergies in a single database
◦ Integration with Smart IV pumps
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“Dissent and foot-dragging can’t be an option. It’s
critical to embrace these enterprise-wide projects
with the attitude that “there is no alternative”…And
we’re going to use this as a clinical transformation
and not an IT project.”
 John Hoyt HIMSS Analytics
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Need advanced analytics for Stage 7 – hard to
achieve with Best of Breed
 Difficult technically
 Data quality issues with disparate systems
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Reasons for not using alert functionality in
Pharmacy Information Systems (PIS):
◦ Use of a CPOE system for this functionality
◦ Lack of a database in PIS to drive functionality
◦ Lack of integration with other modules, such as Labs for
renal function
◦ Lack of patient demographic information such as patient
weight, age, etc.
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Consistent, comprehensive decision support for all
clinicians is only possible with core clinical
systems
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Defined in many segments of the IT world
Allow data from disparate systems to populate a
single repository
Interface standards for Healthcare, real time
 HL7 – various versions
 IHE for Document sharing
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Terminology standards for inter-operability
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Snomed CT – clinical terminology
UCUM – unified codes for unit of measure
HCDPD – Health Canada Drug Product Database
GTIN – Global Trade Item Number
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Purpose is to build a patient medication profile
across the continuum of care
Support the following business functions
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ePrescribing
Dispensing & Managing Rx status
Adding OTC or samples information
Drug queries
Patient Medication queries
Contra-indications e.g. drug-drug, drug-allergy, dose checks
No standards for Medication Reconciliation
process at this time
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Quality
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Reduced ADEs
Decreased medication abuse
Increased medication compliance
Increased patient and provider satisfaction
Increased timely access to information
Productivity
 Enhanced provider communications
 Increased provider efficiency
 Enhanced drug cost management
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Very slow progress compared to Labs, XRay
Majority of in-use repositories obtain data from Rx
dispensing in retail pharmacy only
◦ PEI exception and includes MD samples, hospital Rx,
OTC/herbal
◦ Western Provinces 100% for retail Rx
◦ Rest of Canada is 0%-80% of Rx
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Access/adoption is partial
◦ Western jurisdictions is mainly pharmacists and ER
◦ Very little access/adoption by Community MDs
◦ Hospital adoption rates vary from 50% for ER and low of
30% for Inpatients (CHI)
Availability of EHR information by jurisdiction
PE
AB
BC
SK
MB
NL
NS
NB
NT
QC
ON
NU
YT
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
80%
100%
100%
100%
100%
100%
100%
38%
25%
20%
0%
80%
27%
80%
0%
Clinical Reports/
Immunizations
Lab Test
Results
Dispensed
Drugs
Diagnostic
Images
Provider
Demographics
Client
Demographics
(December 31, 2014)
100%
100%
100%
99%
100%
100%
100%
100%
100%
77%
75%
90%
50%*
100%
100%
100%
100%
100%
100%
100%
100%
100%
95%
100%
80%
100%
* An additional 45% of Yukon’s lab tests are performed in BC and digitally stored in BC’s Provincial
Laboratory Information System
©Canada Health Infoway 2015
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Typically would be only on discharge
Hospital EMRs with CPOE already have ePrescribing
function with printed / signed Rx
 Legibility benefit already realized
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Technically more difficult since you need trigger events
 Theoretically could be medication reconciliation at discharge if
performed 100% of the time [7x24]
 All clinicians have to use the same tool/process
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Need to consider Data Quality and Single Source of
Truth (Core systems)
Likely one of the last items in jurisdictional EPRs
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Accreditation Canada
◦ Medication reconciliation is a required organizational
practice
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Need to support the reconciliation task with
Clinical Documentation
 Describes medication-related decisions to start, stop, hold
therapy
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Complementary to a drug profile
Needs to be electronic to share with regional
electronic patient record repositories
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“One Good Note”, CJHP 67(3) May/June 2014, p 250
◦ Advocates for documenting more in the patient record
and less on monitoring forms
◦ “If you’re going to spend the time performing a detailed
workup, why not share that information with your
colleagues in the form of a concise and clearly written
chart note?”
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For continuity of care in the ideal world, on
discharge, goes to:
 Family Physician
 Pharmacy of Record
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For Health Professionals, generally a single point
of access in a Jurisdiction
Includes information such as:
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Visits/encounters, demographics
Lab tests (hospital and community)
Diagnostic test results and Images (hospital and community)
Immunizations
Allergies and Intolerances
Medications
Transcribed Reports / Discharge Summaries
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Relatively easy technical effort if there is a core
clinical system since triggers are available
If have a shared Clinical Documentation system,
the notes are available internally as well to the full
care team (in a Core Clinical System)
Measurement of extent of medication
reconciliation should also evaluate % of
medication reconciliation notes
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Medications I need to take
 What to keep taking
 New medications
 What to stop taking
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How I might feel and what to do
Changes to my routine
Appointments I have to go to
Where to go for more information
Technically difficult to prepare if have a
Pharmacy system separate from core system
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Personal Health Records eg. Alberta Netcare,
Sunnybrook MyChart, myUHN
Continuity of care record, particularly with chronic
disease; can share with family, MDs
Information patients can enter
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How much you exercise, what you eat
How you are feeling – symptom scales
Medications including OTC and herbal medications
Your health care team and emergency contact information
In Alberta some data downloaded to Portal
 Netcare electronic health record
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Can include educational material
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Very appropriate to add to downloaded information
in a Patient Portal
May want to consider standard email contact
information for further questions
Language in notes needs to be appropriate for
patient audience so it can serve a dual purpose
◦ UHN has very well-written guidelines
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Author will usually be clear in the report
Pegi Rappaport
[email protected]
416-469-6580 Ext 6032
Toronto East General Hospital, 825 Coxwell Avenue, Toronto, Ontario, M4C 3E7
Tel: (416) 461-8272 Fax: (416) 469-6106
www.tegh.on.ca
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Setting a New Standard in Quality and Value
Laboratory and Pharmacy, and Radiology
Management Systems are all Live and Operational
in the inpatient hospital and the laboratory system
produces discrete data
 Cerner for Pharmacy, Radiology
 Soft (SCC) for Labs and Blood Bank
 CoPath for Pathology (shared service)
 Meditech for Microbiology (shared service)
 Agfa for PACS
Major ancillary clinical systems feed data to a clinical data
repository (CDR) that provides physician access for retrieving and
reviewing results. The CDR contains a controlled medical vocabulary
between the interfaced systems, and the clinical decision support/rules
engine (CDS) for rudimentary conflict checking. Information from
document imaging systems may be linked to the CDR at this stage.
The hospital is health information exchange (HIE) capable at this stage
and can share whatever information it has in the CDR with other patient
care stakeholders.
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Cerner Powerchart; exchange data with 8 external
systems, e.g. OLIS, PRO, eCHN, HRM, HDIRS, ENITS,
EMPI, IAR
Can have disparate systems, but need a single CDR
Nursing documentation (e.g. vital signs, flow sheets,
nursing tasks/orders and electronic medication
administration record (eMAR) are required; nursing notes,
care plan charting, and are implemented and integrated with the
CDR for at least one service in the hospital. The first level of
clinical decision support is implemented to conduct error
checking with order entry (i.e., drug/drug, drug/food, drug/lab
conflict checking normally found in the pharmacy). Some level of
medical image access from picture archive and communication
systems (PACS) is available for access by physicians outside the
Radiology department via the organization’s intranet.
 Cerner for CDR and Clinical Decision support with integrated
Multum; Agfa for PACS viewing internally and via VPN
Computerized Practitioner Order Entry (CPOE) for use by any
clinician authorized to create orders in your state(s) is added to
the nursing and CDR environment along with the second level of
clinical decision support capabilities related to evidence based
medicine protocols. If one patient service area has implemented
CPOE with physicians entering orders and completed the previous
stages, then this stage has been achieved. Need % of total physician
orders entered by physicians, such as 1-25% etc.
 Cerner Powerchart with 100% electronic orders for Day Surgery
and Inpatients
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57% orders entered by MDs directly
4% by telephone/verbal
17% from pre-authorized conditional and multi-phase orders
10% from approved medical directives
10% direct entry as per scope of practice (mainly pharmacists)
The closed loop medication administration environment is fully
implemented. The eMAR and bar coding or other auto identification
technology, such as radio frequency identification (RFID), are implemented
and integrated with CPOE and pharmacy to maximize point of care patient
safety processes for medication administration. You are satisfying the 5
rights of patient safety at the bedside and there is an override management
process in place to review overrides that occur.
 Cerner Powerchart; One nursing unit – Mental Health (40 beds) 2015
 A big change in processes for Pharmacy – Unit dose, bar code labeling
of all medications including paediatrics
 Stage 7 requires:
◦ 95% of patients and 95% of medications have closed loop process for
medications (includes ER admitted patients)
◦ Closed loop required for Blood Products and Breast milk
Physician Documentation- What percent of physicians use the
physician documentation system? AND What percent of physician
documentation in the inpatient setting (excluding ED) is captured
from structured template physician documentation that generates
discrete data and triggers an immediate electronic alert from the
Clinical Decision Support application that produces clinical
guidance real-time for the provider? NEED TO STATE THE RULEGUIDANCE that is built into the application and if possible send a
screen shot.
 Cerner Powerchart Powernotes, Clinical Notes for direct entry
◦ 43% of physicians use the system
◦ 28% of the notes are structured documentation
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Real time guidance example is Allergy documentation – back
checking against the medication profile and BPMH
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Document resuscitation medications after the fact on eMAR
Anaesthesia medications documented on eMAR
Full Dose Range Checking for medications - adults and paediatrics
Diagnostic Imaging discrete results, e.g. abnormal, malignant as separate
data fields
ER MDs use structured documentation to produce their notes
Cataract Surgery Order entry and MAR documentation
ECT documentation - replace current check sheet
Business Intelligence to support Quality Improvement for patient care
Patient Portal
Clinically relevant paper documentation must be scanned within 24 hours of
creation