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“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
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eMM Concord Hospital
� Background of eMM project
� Evolution of eMM Design
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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
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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
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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
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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
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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
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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
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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
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Order Sentences
� Approximately 12000 order sentences (generics and brands)
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Order Sets
� Order sets used to group corresponding orders together
– Patch & patch removal orders
– Warfarin & warfarin target range orders
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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
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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
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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
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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
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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
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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
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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
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Order Modification
� Route is locked on order modification, prescribers have to
place a new order when changing the route
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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
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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
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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.
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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
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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
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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
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Paracetamol – 24 Hour Cumulative Dose
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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
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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
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Default Antibiotic Start Date/Time
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Building Medication Safety into eMM
� Mandatory Indication Documentation
� Patches
� Insulins
� Restricted Antimicrobials Prompt Upon Drug Selection
� Digoxin ADE Alerts
� IV Phenytoin Administration Alert
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Mandatory Indication Documentation
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GTN Patches
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Fentanyl Patches
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Insulins
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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
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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
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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
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Digoxin Adverse Drug Events (ADEs)
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Digoxin Adverse Drug Events (ADEs)
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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
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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
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Questions?