connie lo, sydney & south western sydney local health districts: “but the system let me” -...
DESCRIPTION
Connie Lo, eMR Clinical Application Specialist, Sydney & South Western Sydney Local Health Districts, NSW delivered this presentation at the 2013 Electronic Medication Management conference. It is Australia’s only conference to look solely at electronic prescribing and electronic medication management systems. For more information on the annual event, please visit the conference website: http://www.healthcareconferences.com.au/emedmanagementTRANSCRIPT
“But the System Let Me”
Review of eMMS Design Post-Implementation
Rosemary Richman eMR Project Manager
Connie LoeMR Clinical Application Specialist (PharmNet)
Information Management and Technology DivisionSydney and South Western Sydney LHDs
eMM Concord Hospital
� Background of eMM project
� Evolution of eMM Design
Background
� Scope limited to inpatients & to test fundamental eMM functionality
� Inpatient dispensing only & no integration with iPharmacy
� No order entry without allergy information
� Minimal clinical documentation – height, weight, pulse, BGL
� Trial different devices
� Limited decision support to assist clinicians
Background
� Integration Cerner Solutions
– Closed loop medication solution
� Electronic prescribing - PowerOrders
� Pharmacy review, verification & dispensing – PharmNet
� Charting Administration - MAR
� Drug database – Multum
� Customised Decision Support – Discern Rules
Rationale
� More benefits in electronic prescribing, basic decision support & medication administration
� Minimum decision support minimised system performance issues & delays to obtain agreement on rules
� Rationalisation of decision support for maximum patient safety: minimum workflow impact
� Eliminated patient safety risks associated with the paper NIMC
� Avoided high vendor & technical risks with pharmacy system integration
� Introduced in a manner easy for the management of issues & easy for staff to adopt
� Balance between benefits & processes
Rationale
� Decision to focus on Aged Care wards:
– Many medications & many requiring modification during admission
– No complex infusions
– No high risk ADRs
– Medical interest in prescribing, reflected in work practice
– Multidisciplinary practices in place
Initial eMM Design
� Early consultation across a range of users
� Good governance structure
� Clinical champions identified, committees established, & policies around
design & processes mapped to inform system design early in the project
� Design decisions were made by a series of committees
� Standard Cerner build
� Adhered to NSW Health recommendations
� Incorporated organisational, cultural & clinical practice changes
� Clinicians involved in decision making processes - concerns
acknowledged & addressed early on
� Advocacy & leadership by senior clinicians
� Clinicians facilitated communication between clinical & project staff
� Opportunities to change processes & practices
Design Features
� Early planning for workflow changes
� Aligned with safety features of NIMC
� Integrated with real time clinical data
� Decision support at point of prescribing
� TALLman letters for look alike sound alike pairs
� No order entry without allergy functionality
Design Features (continued)
� Reasons included in sentence for PRN medications
� Times adjusted to be appropriate for care e.g. Parkinsons
� Aligned missed doses abbreviations & codes to NIMC
� Remote access for after hours review by doctors
� Order sentences
– Based on drug references and Therapeutic Guidelines
� Order sets
– Consensus of best practice
Order Sentences
� Approximately 12000 order sentences (generics and brands)
Order Sets
� Order sets used to group corresponding orders together
– Patch & patch removal orders
– Warfarin & warfarin target range orders
Implementation
� Nov 2007 – Nov 2009 implemented in 5 Aged Care wards Concord Hospital (20% inpatients)
� Pilot identified several software limitations that restricted some basic functionality at a clinically acceptable Australian standard e.g. Continuous IV Infusion
� Some components such as reconciliation were not implemented due to the inadequacy of the current functionality
Initial Issues Post Go Live
� Prescribing errors subtle & difficult to spot immediately
� Selection Errors
� High doses
� Alert over rides
� Order modification
� No link between corresponding orders in order sets
� Potential for missed doses to go unnoticed
� Not all relevant information fitted on screen
� Difficulty to translate complex charts to electronic increased
risk of missed doses
� Transcribing errors
Initial Issues Post Go Live (continued)
� Perceived increase in workload
� Long process for medication reconciliation
� Security breeches e.g. not logging off
� Informing staff on non eMM wards
� Downtime & transfer processes
� Speciality medication charts
� Loss of staff knowledge
� Maintenance of current good work practices
� Demand on pharmacy increased significantly
Initial Issues Post Go Live (continued)
� Devices not charged, infection control, proximity, peak use access
� Double documentation
� Mostly minor bugs minimal time to rectify
� Some cumbersome workarounds
� Relief staff not able to use system
� Some training issues
Review of Go Live Issues
� Daily ward meetings to address issues as arose/give feedback
� Review of design in consultation with clinicians
� Immediate resolution of issues /rapid design changes
� Mostly minor bugs minimal time to rectify
� Areas of poor compliance or misinterpretation addressed quickly
� Ward/business issues managed by ward staff
� Changes to policies & procedures
� Change management & tweaking of processes/design e.g. warfarin
� After hours managers trained to respond to issues
� Rationalisation of decision support
� Audits – improve compliance or highlight problem areas
Evolution of System Design
� Tweaking initial design
– Update existing functionality
– Addition of medication safety features
� Developing custom rules
– Enforce workflows
– Provide decision support
– Address issues introduced by the system
� New functionality required from vendor
– IV fluids
– Medication reconciliation
Order Modification
� But the system let me ... change the route
� Prescribers could modify all order details including the route
resulting in some ambiguous medication orders
Order Modification
� Route is locked on order modification, prescribers have to
place a new order when changing the route
Warfarin
� But the system let me ... give the warfarin dose
� Administration prompts for warfarin dose dropped independently
of the INR check task
� Warfarin dose could be given prior to INR check task completion
Warfarin
� Five rules which evaluate warfarin/INR check parameters
(date/time, prescriber’s update instructions etc.)
� Control the availability of warfarin MAR task (for administration)
based on the INR check parameters
Paired Order Sets
� But the system let me ... just cancel warfarin/GTN patch
� Despite the grouping of the orders within an order set, orders
are not linked. Cancelling one order does not cancel the other.
Linked Cancellation for Paired Orders
� When one order within the order set is updated, rule checks
the status of corresponding order in the order set
� Corresponding order is updated with appropriate order action
where necessary
Paracetamol
� But the system let me ... order and give the Panadol
� Sometimes difficult to determine the cumulative daily dose of
paracetamol when multiple orders are prescribed
– Different routes, combination products, nurse initiated orders
Paracetamol – 24 Hour Cumulative Dose
� The cumulative doses of paracetamol within the last 24 hours
is checked upon paracetamol prescription and administration
� Prescribers receive pop-up alert at 3g/24 hours and 4g/24
hours upon placing a new order and administering a dose
Paracetamol – 24 Hour Cumulative Dose
First Dose of Antimicrobials
� But the system didn’t tell me ... the first dose starts tomorrow
� Daily frequency associated with default 8am administration time
� If ordered at 9am today � default start time 8am tomorrow
Default Antimicrobial Start Date/Time
� Start date/time for antimicrobial orders are checked and the
prescriber is alerted if the order starts the next day (after 12
midnight)
� Prescriber receives a pop-up alert to review and modify start
date/time as required
Default Antibiotic Start Date/Time
Building Medication Safety into eMM
� Mandatory Indication Documentation
� Patches
� Insulins
� Restricted Antimicrobials Prompt Upon Drug Selection
� Digoxin ADE Alerts
� IV Phenytoin Administration Alert
Mandatory Indication Documentation
GTN Patches
Fentanyl Patches
Insulins
Restricted Antimicrobial Prompts
� But the system let me ... select that order sentence
� By using an order sentence to provide information, prescribers
can inadvertently select it and place an order with this
information text
Restricted Antimicrobial Prompts
� Order sentence selection is checked to determine whether the
‘information only’ order sentence is selected
� Upon selection of the incorrect order sentence, prescriber
receives a pop-up alert to reselect correct order sentence
Potential digoxin Adverse Drug Events (ADEs)
� ISSUE: Administering digoxin when there are abnormal
potassium, magnesium and digoxin levels predisposes
patients to digoxin toxicity
� RULE: Checks for low potassium, low magnesium and high
digoxin levels upon order entry and checks when new
results are posted if there is an existing digoxin order
� ACTION: (New digoxin order)
– Pop-up alert to prescriber to review the use of digoxin
� ACTION: (Existing digoxin order)
– Messages are sent to attending doctor’s inbox and
pharmacists’ task list to review the use of digoxin
Digoxin Adverse Drug Events (ADEs)
Digoxin Adverse Drug Events (ADEs)
IV Phenytoin Administration
� ISSUE: Incidents with inappropriate administration of IV
phenytoin doses
� RULE: Checks whether phenytoin is prescriber as an IV
injection or IV infusion
� ACTION: Pop-up alert with LHD Policy on correct
administration procedure
Conclusion
� Continued process of implementation & evaluation
– Hospital wide rollout will identify new issues
– New functionality from code upgrades
� Development of decision support rules
– Increased clinical decision support
– Prioritisation of rule development
Questions?