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Patients Support a Pharmacist-led
Best Possible Medication
Discharge Plan (BPMDP) via Tele-
robot in a Remote and Rural
Community Hospital
PAULA NEWMAN
CADTH SYMPOSIUM APRIL 2019
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Disclosure
I have the following relevant financial relationships to
disclose:
I am employed by Northwest Telepharmacy Solutions
I received research support from the Ontario Branch
Canadian Society of Hospital Pharmacists to conduct
this study
I do not have any actual or potential non-financial
relationships to disclose
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Outline
Health care in rural & remote communities
Medication Reconciliation or MedRec
Videoconferencing
Ontario Telemedicine Network (OTN),
Robotic Telepresence
Our research
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Remote and Rural Communities
Fewer visits to primary care provider- decreased preventative
services and disease management
Sparsely populated, northern Ontario presents challenges to the health care system
87% of Ontario land is populated by 6% of the population
Northern and rural hospitals struggle to recruit healthcare providers
Results in difficulty in providing the same level of care offered in
larger, urban centres
http://www.health.gov.on.ca/en/pro/programs/ecfa/action/primary/pri_telemedecine.aspx
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Remote and rural residents
People living in Northern Ontario, lag behind provincial averages in the
quality of health and healthcare
Report poorer health, more chronic conditions, more likely to smoke,
increased morbidity and mortality from heart disease and diabetes.
Life expectancy 2.9 years less, dying prematurely due to suicide, circulatory
disease and respiratory disease
In young First Nations population 76% of men and 87% of women will
develop diabetes in their lifetime
Highest burden of disease, worst quality of health, least access to health care
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To conduct medication counselling
To answer questions from patients and their families about their
medications prior to leaving hospital
Formalize communication between the hospital pharmacist and the
community pharmacist and patient’s other health care providers
Provide post-hospital follow-up and support
Provide discharge/transfer medication reconciliation
Remote and Rural Communities
Gap in healthcare includes access to a pharmacist
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Medication Reconciliation in Hospital
Reduces the risk of preventable medication-related adverse events
Pharmacists have demonstrated invaluable in the process:
Improvement in health outcomes
Reduction in health care costs and utilization,
Reduction in mortality, 30 day re-admission, and ER visits
Significant ROI
E.A. Wright et al. / Journal of the American Pharmacists Association 59 (2019) 178e186The Journal of Rural Health 00 (2016) 1–8c 2016 National Rural Health Association
`A formal process in which healthcare providers work together with patients and care
providers to ensure accurate and comprehensive medication information is communicated consistently across ALL transitions of care.’
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Medication Reconciliation
MedRec on
Transfer BPMH
HOSPITAL ADMISSION
*BPMDP
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Despite Canada having a publicly
funded universal healthcare
system there is an inequality in healthcare access
Many small and rural hospitals do not have on-site pharmacists to support medication reconciliation upon
hospital discharge
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Medication Reconciliation in Hospital-
BPMDP- Opportunity
For pharmacists to review patient’s discharge medications:
provide medication management at discharge
counsel patients and coach patients in disease prevention
Communicate with other health care providers and prescribers
For patients and their caregivers to ask questions about their medications
Medication dosing changes, medications discontinued
New medications initiated in hospital
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Provincial Telemedicine- Ontario
Telemedicine Network (OTN)
49% conducted in Northern Ontario
Has enabled increased access to healthcare
Rural and remote, aboriginal, underserviced, official language minorities
Significantly decreases travel (245 M km of travel since 2002):
Time and cost ($ 25 million annually in northern travel) for patients and
providers
Carbon footprint (67 M kg of pollutant load and > 27 M L of fuel saved)
Facilitation of education and skills transfer for HCP
http://www.health.gov.on.ca/en/pro/programs/ecfa/action/primary/pri_telemedecine.aspx
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Robotic Telepresence
Care-giver’s physical presence virtually extended via a mobile robotic
platform with real-time audio-visual equipment
Study in a remote Inuit northern community found deploying a remote
presence robot
Feasible
had a high degree of satisfaction by patients and caregivers
Health care providers deemed it improved patient care, workload and job
satisfaction
Ivar M, Jong M, Keays-White D, Turner G. The Use of Remote Presence for Health Care Delivery in a Northern Inuit Community: a Feasibility Study. Int J Circumpolar Health
2013,72:21112
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Lady Dunn Health Centre
North shore of Lake Superior, ON
Population 4,300-
Dubreuville, Hawk Junction, Michipicoten First Nation, Michipicoten Township-Wawa, Missanabie and White River
10 acute care, two respite and 16 long-term beds, 24 h ER
1 remote pharmacist 8-4 M-F
1 community pharmacy
Nearest tertiary care hospital is 225 km
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Study Objectives
Primary
To assess how patients in a remote and rural community hospital, who are
at high risk for preventable adverse drug events, perceive a pharmacist-
led real-time BPMDP utilizing telerobot technology
Secondary
To determine interview time requirements – prep, interview, discrepancy
resolution
To describe unintentional discharge medication discrepancies (type, cause,
intervention)
To describe facilitators, inefficiencies and barriers in completing interviews
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Methodology
Patients were provided a letter of information BPMDP interview by the RN
Pharmacists created a BPMDP and documented:
all unintended discharge medication list discrepancies by class, type, cause and intervention
Inefficiencies, barriers and facilitators for conducting interviews.
Pharmacist conducted interview via telerobot
Provided patient counselling and health literature
Encouraged patients and caregivers to ask questions regarding their medications
Patients completed anonymous satisfaction survey via kiosk on a computer tablet or paper copy with RN assistance if required
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TELEROBOT
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Inclusion Criteria- Patients at
High Risk of Adverse Drug Events
Eligibility Criteria
Age > 18 AND
Admitted to the hospital for >72 h AND
High risk for ADE, one of:
> 5 medications for chronic conditions OR
High risk medications OR
Principle diagnosis, one of:
Cancer
COPD
Stroke
Heart failure
Diabetes
Depression, OR
Prior unplanned hospitalization within the
last 6 months
High Risk Medications
Categories: antiretrovirals, chemotherapeutic, oral hypoglycemic, immunosuppressant
agents, insulins, opioids, pediatric liquids, pregnancy category X
Drugs: Carbamazepine, Heparin, Metformin, Methotrexate, Propylthiouracil, Warfarin
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Study Flow Chart
Patients assessed for eligibility
(n=202)
Interviews completed
(n=9)
Analysis
Eligible
(n=47)
Contacted
(n=24)
Satisfaction Surveys completed
(n=8)
Allocation
Review completed interview
(n=9)
Completed Surveys
(n=8)
Excluded (n=23)
No longer eligible (n=9)
Logistic problem (n=5)
Language barrier (n=5)
Enrollment
Excluded (n=15)
Technical problems (n=6)
oAbsence of internet (n=2)
oConnectivity to the robot (n=4)
Declined to participate (n=6)
Language barrier (n=2)
Could not be reached (n=1)
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Study Population
Characteristics Value
Gender
Males, % 55
Females, % 45
Age, years (median, IQR) 76 (7)
Location
Wawa, ON , % 100
Primary reason for hospitalization
Cardiovascular, % 44
Respiratory,% 22
Musculoskeletal, % 11
Gastrointestinal, % 11
Other, % 11
Rate of eligible patient participation, % 37.5
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Survey
Responses
Negative 7%
Undecided 13%
POSITIVE 80%
N=8
Becevic, Mirna; Clarke, Martina A; Alnijoumi, Mohammed M; Sohal, Harjyot S; Boren, Suzanne A; Kim, Min S; Mutrux, Rachel. "Robotic Telepresence in a Medical Intensive Care Unit—Clinicians’ Perceptions" Perspectives in Health Information Management (Summer, July 2015).
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Discharge Medication List Discrepancies:
Drug Category
14%
14%
43%
14%
14%
ANATOMICAL MAIN GROUP
Alimentary tract/metabolism
Blood and blood forming organs
Cardiovascular system
Systemic hormonal (exclude insulin, sex hormones)
Various
Rate=0.78
Claeys et al. Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies Drugs Aging 2012; 29 (7): 577-591
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Unintentional Discharge Medication
List Discrepancy- TYPE
71%
14%
14%
TYPE OF UNINTENTIONAL MEDICATION DISCREPANCY
Omission
Addition
Other
Claeys et al. Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies Drugs Aging 2012; 29 (7): 577-591
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Unintentional Discharge Medication
List Discrepancy - CAUSES
13%
88%
DISCREPANCY CAUSE(S)
Patient level
Med system level
Claeys et al. Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies Drugs Aging 2012; 29 (7): 577-591
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Unintentional Discharge Medication
List Discrepancy Causes - MED LEVEL Rate=0.78
Claeys et al. Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies Drugs Aging 2012; 29 (7): 577-591
14%
43% 14%
14%
14%
SYSTEM LEVEL CAUSE(S) Conflicting information from different informationalsources
BPMH incomplete/inaccurate
Rx error
Administrative problems
Other
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Unintentional Discharge Medication List
Discrepancies- Pharmacist Interventions
15%
25%
30%
30%
INTERVENTION(S) TO SOLVE THE UNINTENTIONAL MEDICATION DISCREPANCY
Healthcare professional level
Patient level
Medication level
Other
Claeys et al. Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies Drugs Aging 2012; 29 (7): 577-591
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Unintentional Discharge Medication List
Discrepancy-Pharmacist Intervention
50%
17%
33%
INTERVENTION, MEDICATION LEVEL
Drug changed (cancelled or started)
Dose changed
Other
Rate=0.67
Claeys et al. Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies Drugs Aging 2012; 29 (7): 577-591
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Unintentional Discharge Medication List
Discrepancies-Pharmacist Interventions
67%
33%
HEALTH CARE PROFESSIONAL (HCP) LEVEL
(Prescriber, Nurse, Pharmacist)
Requested information
from HCP
Intervention
suggested to HCP
Rate=0.33
Claeys et al. Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies Drugs Aging 2012; 29 (7): 577-591
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Inefficiencies, Barriers and Facilitators
Inefficiencies
Technical issues with the robot connectivity (Wi-Fi) and operation
Pharmacist assigned for robot interviews only (not hospital pharmacist) needed to frequently check for patient discharge list
Last minute notice of discharge and/or availability of discharge medication list
On site staff had difficulty turning on robot and computer tablet for survey, patient did not want to wait for interview
Barriers
RN selection bias for patients for interviews
Not supported as a mandatory process prior to hospital discharge
Usual charge nurse not available to set up robot
On-site pharmacy software not working to view discharge script
Facilitators
Hospital staff were supportive once interview time established
Hospital staff present during interview and to assist with robot if required
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Conclusion
Conducting BPMDP interviews via telerobot in a small, rural community
hospital is feasible and well accepted by patients
Most high risk patients have a medication discrepancy upon hospital
discharge:
Often a medication to for the management of CV disease
Usually by omission, due to an inaccurate BPMH on admission
Pharmacists are able to resolve these discrepancies by communicating with
both patients and their providers
Program barriers, and inefficiencies have been identified to increase
recruitment and timely BPMDP interviews.
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Next Steps
Larger study
Multi-centre
Include larger hospitals in urban centres
Assess healthcare provider satisfaction
Include semi-qualitative post study interviews with health care providers and patients
Assess healthcare utilization
30 day ER visits and
30-day hospital re-admissions
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Thank you for giving us the
opportunity to share our research
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Robot video