Implementing Shared Formulary and E-based Medication Order Review to Create "Closed Loop" Medication Process in Critical Access Hospitals (Text Version)

Slide presentation from the AHRQ 2009 conference.

On September 16, 2009, Douglas Wakefield made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (1.37 MB).

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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
Douglas S. Wakefield, PhD.

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This work was supported in part by AHRQ grant #UC1HS016156—"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 O'Brien, Douglas S. Wakefield

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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

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Errors in the Medication Cycle

Medication Management Processes

E R R O R S

Ordering
Wrong Dose
Wrong Drug
Wrong Route/Form
Allergy, Drug Interaction

Transcribing
Wrong Dose
Wrong Route
Wrong Patient
Wrong Time
Wrong Drug

Dispensing
Wrong Dose
Wrong Route
Wrong Patient
Wrong Time
Incorrect Labeling/ Drug ID
Primary catch for Allergy, Drug Interaction,

Administering
Wrong Patient
Wrong Dose
Wrong Drug,
Wrong Time/ Omitted
Wrong Route
Frequently Involves Infusion Pump

Percent of Errors 39%
Intercept Rate 19%
True Error Rate 20%

Lucian Leape, et.al., JAMA, Volume 274, 1995

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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

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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

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Open vs. Closed Loop Processes to Improve Safety

Open Loop Processes:
- Traditional process
- Sequential tasks
- +/- Asymmetry in access to information
- +/- Monitoring & Feedback

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

Image: A chart depicts the "open loop": An arrow labeled "Is Access to Patient Information Adequate?" points to a box captioned "Evaluating Patient Status and Care Needs"; another arrow labeled "Is Access to Patient Information Adequate?" points from this box to one captioned "Prescribing"; a third arrow labeled "Is Access to Patient Information Adequate?" points from this box to a blank gap; a fourth arrow labeled "Is Access to Patient Information Adequate?" points from this box to another blank gap; the first arrow labeled "Is Access to Patient Information Adequate?" points from this gap, completing the cycle. At the center of the chart is the caption "Key Process Steps Lack Information Continuity, Monitoring and Control." At the four corners of the figure, within the circle of the "Is Access to Patient Information Adequate?" arrows are four larger boxes captioned "Are the Changing Paper Records Accurate? Complete? Timely? Available? Legible?"

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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

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"Open Loop"—Continuously Links Information to Process and Automatically Provides Automatic Monitoring

Image: A chart depicts the "closed loop": An arrow labeled "Information Linked to Process" points to a box captioned "Evaluating Patient Status and Care Needs"; another arrow labeled "Information Linked to Process" points from this box to one captioned "Prescribing"; a third arrow labeled "Information Linked to Process" points from this box to one captioned "Dispensing"; a fourth arrow labeled "Information Linked to Process" points from this box to one captioned "Administration"; the first arrow labeled "Information Linked to Process" points from this box, completing the cycle. At the center of the chart is a bin captioned "EHR, Lab, Radiology, Rx Standardized Formulary, E-MAR, SSOS, CPOE, ADC, BCMA"; arrows point back and forth from this bin to the four boxes. At the four corners of the figure, within the circle of the "Information Linked to Process" arrows are four blue clouds captioned "Enables Continuous Data Access and Monitoring."

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Case Study of Seven CAHs and a Rural Referral Hospital's Collaboration to Implement "Closed Loop" Medication Processes

Methodology:

Document Reviews
Interviews
Collaborative Planning Began Late 2006
Collaborative Implementation s 2008 & 2009

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Trinity System

Image: A map of the United States is shown with an arrow pointing from Texas to Iowa.

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Mercy Health Network—North Iowa

Image: A chart depicting the Mercy Health Network is shown.

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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

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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

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Shared Formulary Proces Steps

Image: A diagram of the Shared Formulary Proces Steps is shown.

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Table 3: Summary of Formulary Changes

Formulary Changes	Hospitals
Formulary Changes	Franklin	Hancock	Kossuth	Mitchell	New Hampton	Palo Alto	Ellsworth	Average
# in Original CAH Formulary	829	868	667	746	706	750	1351	845.3
# in New Shared Formulary	803	803	803	803	803	803	803	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%)

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Rationale for 24x7 Pharmacist Medication Order Review

Medication orders not reviewed
Rural pharmacist supply constrained
Nurses dispensing medications from pharmacy

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Network Pharmacy Hours 2007

Image: A sample chart of the Network Pharmacy Hours in 2007 is shown.

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"Closed Loop" Continuously Links Information to Process and Automatically Provides Automatic Monitoring

Image: Chart depicting the "closed loop," as shown in Slide 10, is covered by a red block containing the following text:

Closed Loop Requires Integration of HIT within Workflow... How was this Done?

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CAH Case Study "Closed Loop" Medication Process Workflow and HIT Framework

Image: Chart displays the following:

Workflow Tasks & Information Flow	People to People ———	System to System — — —	People to System —-—-—-
CAH Physician
CAH Nurse
Information Technology	Images, from left to right: A circle captioned "CPOE"; a bin captioned "Electronic Health Record (EHR)"; a square captioned "Pharmacy Information System (RxIS)"; a square captioned "Automated Dispensing Cabinet (ADC)"; a square captioned "Bar Code Medication Admin (BCMA)"; two small rectangles, one captioned "Billing" atop the other, captioned "E-MAR."
Remote Pharmacist

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CAH Case Study "Closed Loop" Medication Ordering Process and Information Flow

Image: Flow chart displays the following:

Workflow Tasks & Information Flow	People to People ———	System to System — — —	People to System —-—-—-
CAH Physician	First section of flowchart: Decision to Order Medication Based on Available Information -> Order Entered by CPOE (Yes/No) -> Writes or Gives Verbal Order
CAH Nurse	Second section of flowchart: Fax Written to Order Pharmacist
Information Technology	Images, from left to right: A circle captioned "CPOE"; a bin captioned "Electronic Health Record (EHR)"; a square captioned "Pharmacy Information System (RxIS)"; a square captioned "Automated Dispensing Cabinet (ADC)"; a square captioned "Bar Code Medication Admin (BCMA)"; two small rectangles, one captioned "Billing" atop the other, captioned "E-MAR."
Remote Pharmacist	Final section of flowchart: Receives Notication of Medication Order for Review

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CAH Case Study "Closed Loop" Medication Order Verification Process and Information Flow

Image: Flow chart displays the following:

Workflow Tasks & Information Flow	People to People ———	System to System — — —	People to System —-—-—-
CAH Physician	First section of flowchart: Decision to Order Medication Based on Available Information -> Order Entered by CPOE (Yes/No) -> Writes or Gives Verbal Order. Physician Contacted by Pharmacist.
CAH Nurse	Second section of flowchart: Fax Written to Order Pharmacist. Nurse Contacted by Pharmacist.
Information Technology	Images, from left to right: A circle captioned "CPOE"; a bin captioned "Electronic Health Record (EHR)"; a square captioned "Pharmacy Information System (RxIS)"; a square captioned "Automated Dispensing Cabinet (ADC)"; a square captioned "Bar Code Medication Admin (BCMA)"; two small rectangles, one captioned "Billing" atop the other, captioned "E-MAR."
Remote Pharmacist	Final section of flowchart: [Image: Red Star] Receives Notication of Medication Order for Review -> Reviews Order -> Additional Information Needed (Yes/No) -> Verifies Order (arrows point to "Physician/Nurse Contacted by Pharmacist" above.

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CAH Case Study "Closed Loop" Medication Administration Process and Information Flow

Image: Flow chart displays the following:

Workflow Tasks & Information Flow	People to People ———	System to System — — —	People to System —-—-—-
CAH Physician	First section of flowchart: Decision to Order Medication Based on Available Information -> Order Entered by CPOE (Yes/No) -> Writes or Gives Verbal Order. [Image: Red Star] Physician Contacted by Pharmacist.
CAH Nurse	Second section of flowchart: Fax Written to Order Pharmacist. Nurse Contacted by Pharmacist. Nurse Confirms that Order Has Been Verfied -> Nurse Obtains Medications from ADC -> Administer Medications.
Information Technology	Images, from left to right: A circle captioned "CPOE"; a bin captioned "Electronic Health Record (EHR)"; a square captioned "Pharmacy Information System (RxIS)"; a square captioned "Automated Dispensing Cabinet (ADC)"; a square captioned "Bar Code Medication Admin (BCMA)"; two small rectangles, one captioned "Billing" atop the other, captioned "E-MAR."
Remote Pharmacist	Final section of flowchart: Receives Notication of Medication Order for Review -> Reviews Order -> Additional Information Needed (Yes/No) -> Verifies Order (arrows point to "Physician/Nurse Contacted by Pharmacist" above.

Slide 25

CAH Case Study "Closed Loop" Medication Process and Information Flow

Image: Flow chart displays the following:

Workflow Tasks & Information Flow	People to People ———	System to System — — —	People to System —-—-—-
CAH Physician	First section of flowchart: Decision to Order Medication Based on Available Information -> Order Entered by CPOE (Yes/No) -> Writes or Gives Verbal Order. Physician Contacted by Pharmacist.
CAH Nurse	Second section of flowchart: Fax Written to Order Pharmacist. Nurse Contacted by Pharmacist. Nurse Confirms that Order Has Been Verfied -> Nurse Obtains Medications from ADC -> Administer Medications.
Information Technology	Images, from left to right: A circle captioned "CPOE"; a bin captioned "Electronic Health Record (EHR)"; a square captioned "Pharmacy Information System (RxIS)"; a square captioned "Automated Dispensing Cabinet (ADC)"; a square captioned "Bar Code Medication Admin (BCMA)"; two small rectangles, one captioned "Billing" atop the other, captioned "E-MAR."
Remote Pharmacist	Final section of flowchart: Receives Notication of Medication Order for Review -> Reviews Order -> Additional Information Needed (Yes/No) -> Verifies Order (arrows point to "Physician/Nurse Contacted by Pharmacist" above.

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Network Pharmacist Hours: Post-Remote Pharmacist Reviews

Image: Color-coded chart displays the hours of Pharmacist Coverage, Remote Coverage by Network Pharmacist, and Remote Coverage by Remote Pharmacy Service in a sample month.

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3 Month Comparison of Pattern of Actions taken by Local and Remote Pharmacists for One Critical Access Hospital (February—April, 2009)

% Reviewed

3 Month Local Pharmacists' Total: 3267
3 Month Exteranl Pharmacists' Average: 5896

% Ordered

3 Month Local Pharmacists' Total: 1544
3 Month Exteranl Pharmacists' Average: 682

% Modified

3 Month Local Pharmacists' Total: 596
3 Month Exteranl Pharmacists' Average: 698

% Discontinued

3 Month Local Pharmacists' Total: 323
3 Month Exteranl Pharmacists' Average: 649

% Voided

3 Month Local Pharmacists' Total: 100
3 Month Exteranl Pharmacists' Average: 79

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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

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Questions?

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Figure 1: HIT-Based After Hours, Weekend and Holiday Pharmacist Review Process for Critical Access Hospitals (CAH)

Image: Flow chart depicts decision-making process for dealing with medication requests during off-peak hours.

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3-Month Comparison of Percent of Actions Taken by Local and Remote Pharmacists by Action Category for One Critical Access Hospital (February—April, 2009)

Reviewed

% by Local Pharmacists: 3267
% by External Pharmacists: 5896

Ordered

% by Local Pharmacists: 1544
% by External Pharmacists: 687

Modified

% by Local Pharmacists: 596
% by External Pharmacists: 698

Discontinued

% by Local Pharmacists: 323
% by External Pharmacists: 649

Voided

% by Local Pharmacists: 100
% by External Pharmacists: 79

Current as of December 2009

Internet Citation: Implementing Shared Formulary and E-based Medication Order Review to Create "Closed Loop" Medication Process in Critical Access Hospitals (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/news/events/conference/2009/wakefield/index.html