Implementing Shared Formulary and E-based Medication Order Review to Create

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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 OBrien, 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
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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
• http//www.ihi.org/IHI/Topics/PatientSafety/Medica
  tionSystems/Changes/ImproveCoreProcessesforOrd
  eringMedications.htm

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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!
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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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Closed Loop Continuously Links Information
Process and Automatically Provides Automatic
Monitoring
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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

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Trinity System
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Mercy Health Network North Iowa
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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 Process Steps
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Summary of Formulary Changes
Table 3 Summary of Formulary Changes Table 3 Summary of Formulary Changes Table 3 Summary of Formulary Changes Table 3 Summary of Formulary Changes Table 3 Summary of Formulary Changes Table 3 Summary of Formulary Changes Table 3 Summary of Formulary Changes Table 3 Summary of Formulary Changes Table 3 Summary of Formulary Changes
Hospitals Hospitals Hospitals Hospitals Hospitals Hospitals Hospitals
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)
() 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 702 775 685 709 767 592 786 716.6
() 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) -128.7 (-6.6)
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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
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Closed Loop Continuously Links Information to
Process and Automatically Provides Automatic
Monitoring
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CAH Case Study
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CAH Case Study
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CAH Case Study
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CAH Case Study
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CAH Case Study
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Network Pharmacist Hours Post-Remote Pharmacist
Reviews
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3-month comparison
5896
3267
1544
596
682
698
649
323
100
79
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Ongoing Journey Continuous Improvement

• Regional PT 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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HIT-Based After Hours, Weekend and Holiday
Pharmacist Review Process for CAH
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3-Month Comparison Chart