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Implementing Shared Formulary and E-based Medication Order Review to Create Closed Loop Medication Process in Critical Access Hospitals September 16, 2009.

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Presentation on theme: "Implementing Shared Formulary and E-based Medication Order Review to Create Closed Loop Medication Process in Critical Access Hospitals September 16, 2009."— Presentation transcript:

1 Implementing Shared Formulary and E-based Medication Order Review to Create Closed Loop Medication Process in Critical Access Hospitals September 16, 2009 Douglas S. Wakefield, PhD.

2 This work was supported in part by AHRQ grant #UC1HS – EHR Implementation for the Continuum of Care in Rural Iowa, University of Iowa Center for Health Policy and Research, and the University of Missouri Center for Health Care Quality. Research Team: –Marcia M. Ward, Jean Loes, John OBrien, Douglas S. Wakefield

3 Agenda CAH Challenges in Improving Medication Processes CAH Network Approach to Implementing Shared Formulary and 24x7 Pharmacist Review of Medication Orders Open vs. Closed Loop Medication Processes … Theory to Practice

4 Errors in the Medication Cycle Wrong Patient Wrong Dose Wrong Drug, Wrong Time/ Omitted Wrong Route Frequently Involves Infusion Pump Wrong Dose Wrong Route Wrong Patient Wrong Time Wrong Drug Wrong Dose Wrong Route Wrong Patient Wrong Time Incorrect Labeling/ Drug ID Primary catch for Allergy, Drug Interaction, Wrong Dose Wrong Drug Wrong Route/Form Allergy, Drug Interaction ERRORSERRORS Percent of Errors 39% 12% 11% 38% Intercept Rate 19% 3% 4% 1% True Error Rate 20% 9% 7% 37% Ordering TranscribingDispensing Administering Medication Management Processes Lucian Leape, et.al., JAMA, Volume 274, 1995

5 IHI Suggestion for Improving Medication Processes are Challenges for All Hospitals Ensure allergy information accompanies patients Use Drug Interaction Software Pharmacists review of all medication orders Provide reference materials at point of care Make allergy information available Place pharmacists in patient care units Connect medication orders to lab results ve+Core+Processes+for+Ordering+Medications.htm

6 Additional Challenges facing Critical Access Hospitals Availability of Pharmacists –Pharmaceutical Expertise –Order Review Prior to Administration –Nurse Must Dispense Medications Access to Patient-Specific Information when needed (Ordering, Dispensing, Administration) Fragmented / Disconnected Workflow Processes Reliance on Paper / Handwritten Documentation Financial Resources Information Technology Expertise & Resources

7 Open vs. Closed Loop Processes to Improve Safety Open Loop Processes: –Traditional process –Sequential tasks –+/- Asymmetry in access to information –+/- Monitoring & Feedback

8 Open Loop Information Handoffs Create Uncertainty and Opportunity for Poor Quality and Error!

9 Closed Loop Processes to Improve Safety Closed Loop Processes: –Goal is connected and non-fragmented processes –Sequential tasks –Symmetry in access to needed information –Built in monitoring and feedback –Information technology integrated into workflow

10 Enables Continuous Data Access & Monitoring Closed Loop Continuously Links Information Process and Automatically Provides Automatic Monitoring

11 Case Study of Seven CAHs and a Rural Referral Hospitals Collaboration to Implement Closed Loop Medication Processes Methodology: Document Reviews Interviews Collaborative Planning Began Late 2006 Collaborative Implementation s 2008 & 2009

12 Trinity System

13 Buffalo Center April 8, 2008 Affiliated and Contract Managed Hospitals with Mercy - North Iowa Mercy Clinics Physician-Hospital Organizations Algona Bancroft Kossuth Worth Northwood Graettinger Howard Lime Springs Cresco Mitchell St. Ansgar Osage Riceville Stacyville Garner Kanawha Wesley Palo Alto Emmetsburg Wright Hancock Britt Winnebago Lake Mills Forest City Mason City Clear Lake Cerro Gordo 11 Franklin Sheffield Hampton Hardin Iowa Falls Ackley Floyd Rockford Dumont Butler Chickasaw New Hampton West Bend Dows Latimer PHO Affiliated Clinics 2 Rockwell Greene Belmond Mercy Health Network – North Iowa

14 Coordinated Planning & Implementation Cohort Approach to Planning & Implementation EHR, CPOE, Lab, Radiology, Pharmacy Systems Technology Enabled Devices: –Automated Dispensing, BCMA Shared Formulary 24x7 Pharmacist Medication Order Reviews

15 Rationale for Shared Formulary Expand evidence-based formulary content Create shared knowledge base and formulary content for subsequent HIT implementation Standardize the pharmacy system IT build Facilitate remote pharmacist reviews

16 Shared Formulary Process Steps

17 Table 3: Summary of Formulary Changes Hospitals FranklinHancockKossuthMitchell New Hampton Palo AltoEllsworth Average # in Original CAH Formulary # in New Shared Formulary 803 # (%) Do Not Stock Taken Out of New CAH Formulary 119 (14.8%) 33 (4.1%) 124 (15.4%) 117 (14.6%) 37 (4.6%) 257 (32.0%) 34 (4.2%) 103 (12.8%) # (%) Selected From New Shared Formulary 684 (85.2%) 770 (95.9%) 679 (84.6%) 686 (85.4%) 766 (95.4) 546 (68.0%) 769 (95.8%) 700 (87.2%) # (%) Items Added to New Shared Formulary 18 (2.2%) 5 (0.6%) 6 (0.7%) 23 (2.9%) 1 (0.1%) 46 (5.7%) 17 (2.2%) 16.6 (1.0%) # in Final Revised CAH Formulary # (%) Change from Original to Final CAH Formulary -127 (-15.3%) -93 (-10.7%) +18 (2%) -37 (-5.0%) +61 (8.6%) -158 (-21.1%) -565 (-41.8%) (-6.6%) Summary of Formulary Changes

18 Rationale for 24x7 Pharmacist Medication Order Review Medication orders not reviewed Rural pharmacist supply constrained Nurses dispensing medications from pharmacy

19 Network Pharmacy Hours 2007

20 Enables Continuous Data Access & Monitoring Closed Loop Requires Integration of HIT within Workflow … How was this Done? Closed Loop Continuously Links Information to Process and Automatically Provides Automatic Monitoring

21 CAH Case Study

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26 Network Pharmacist Hours: Post-Remote Pharmacist Reviews

27 month comparison

28 Ongoing Journey Continuous Improvement Regional P&T Committee Remote Rx Order Review Costs & Performance ADC Transition to full Profile Mode Process Monitoring: –CPOE Order Rates –ADC Overrides –BCMA Scanning Rates HIT Updating and Integration with Workflow

29 Questions?

30 HIT-Based After Hours, Weekend and Holiday Pharmacist Review Process for CAH

31 Month Comparison Chart


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