fronzi (ghc)
TRANSCRIPT
Transforming Northern Health: Innovations Making a Difference
Group Health Centre: EMRXTRA and Preparing for ePrescribing (PeP)
Lucy Fronzi, Project Manager
March 31, 2010
Group Health Centre provides primary care to 75% of Sault Ste. Marie residents
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Ontario’s largest and longest established ambulatory health care organization providing excellence in health care to over half the population of Sault Ste. Marie for 47 years.
Group Health Centre is a partnership of two organizations
Sault Ste. Marie and District Group Health Association (GHA)
Algoma District Medical Group (ADMG)
Not-for-profit, charitable corporation
Governed by volunteer, community-based Board
Owns physical facility, equipment, furnishings
Employs all “non-physician” staff including allied health professionals and support services
Independent corporation of 67 physicians (38 GPs, 16 Specialists, 13 Associates/Visiting Specialists)
Wide range of specialties, including anaesthesia, cardiology, dermatology, emergency medicine, internal medicine, neurosurgery, obstetrics & gynaecology, ophthalmology, paediatrics, psychiatry, sports medicine and surgery
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Group Health Centre employs a multi-disciplinary, patient-focused team
Unique health organization Established 1963 by Steelworker’s Union Not-for-profit Multi-disciplinary Multi-specialty Multi-site 67 Physician providers 180 other professional health care providers Over 62,000 patients on the system
Electronic Medical Record since 1997
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Group Health Centre is recognized for its Health Promotion Initiatives (HPI)
• HPI aims to develop and evaluate evidence-based outcomes management programs in order to improve the quality of health care for GHC patients
• GUIDELINES BY THEMSELVES DON’T WORK– Aid the provision of Appropriate Evidence Based
Care– Primary Care and Patient-centric– Population Health Approach – Continuous Assessment and Evaluation– Outcomes Based
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HPI Example #1: Diabetes
• GHC providers focus on achieving evidence-based process and clinical outcomes, measured for diabetes patients using the “Good Health Outcomes in Diabetes” (“GHOD”) score
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Process Outcomes Clinical Outcomes
BP within 6 mo HbA1c within 6mo Lipids annually Albuminuria annually Foot exam completed in past year Eye exam completed in past year On ACE-I/ARB On ASA/antiplatelet On Statins
BP within 6 mo and <=130/80 mmHgHbA1c within 6 mo and <= .07Lipids annually and LDL < 2.0
HPI Example #1: Composite GHOD Score
HPI Example #2: Anticoagulation Clinic
• Total number of patients in program 583• Largest community AC clinic in Canada• INR results in therapeutic range (+/- 0.2) are 84% (target
compliance >70%), excellent quality control• “usual care” benchmarks are in the 40-60% range• Major bleeding events are rare (<1%)
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HPI Example #3: Congestive Heart Failure
• Number one admission diagnosis in most hospitals in Canada
• High re-admission rate (>25%)• High mortality rate• Incidence and Prevalence Increasing• Since 2000, there has been a coordinated approach to
the care a patient receives after leaving the hospital. All information is tracked and viewed by all involved in the care of that patient.
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HPI Example #3: Congestive Heart Failure• Through the program, re-admission rates have dropped by 43% and have been
sustained
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Health Promotion Initiatives supported by an enterprise EMR
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Before EMRXTRA, pharmacists not
part of the
“Circle of Care”
All GHC staff share a single Electronic Medical Record (EMR) system resulting in better communication, coordination of care and patient management
August 2006 – February 2008
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Preventable adverse drug events are the fourth-leading cause of death in Ontario1
Over 10 Ontarians die every day unnecessarily because of adverse drug events
Source: Ontario’s eHealth Strategy 2009-2012
Medications are often not being taken safely or appropriately by Ontarians
• It is estimated that there will be 394,000 preventable adverse drug events resulting in:– 240,000 physician office visits
– 36,000 hospitalizations
– 4,000 deaths
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Source: Ontario’s eHealth Strategy 2009-2012
EMRXTRA provides pharmacists access to GHC’s enterprise EMR system
• Launched in May 2007• Partnership with Canada Health Infoway, Group Health
Centre, Ontario Pharmacists’ Association to expand the circle of care to include pharmacists
• With patient consent, pharmacists can access pertinent patient information in EMR (labs, care plan, program notes, progress notes, DI test results, allergies, etc.) **no psych, counseling, social history or OBGYN notes
• Development of web portal for patients to access their health information
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Focus of EMRXTRA
• Pharmacists in Sault Ste. Marie area were the first in Canada to access lab test results, allergies and other vital data from consenting patients’ electronic medical records
• Collaboration with Primary Care Physicians (PCP) at Group Health Centre (GHC) and access to the EMR means that pharmacists have accurate and comprehensive medical data about the patients for whom they provide care
• Enhanced “circle of care” increases the opportunity to provide better, safer care to these patients and to help reduce adverse medical events
Benefits Summary
What are the benefits and IT adoption implications of including pharmacists in the circle of care?
Improve clinical interactions between clinicians and with patients
Improve ability to manage patients’ medications
Identify workflow processes and issues of managing EMRXTRA patients
Improve adoption of technology over time
Improve patient access to appropriate care providers
Identify ongoing costs for continued provision of EMRXTRA
Evaluation Question
Evaluation Indicators Key Results
• 97% increase in pharmacist-PCP activities • 57% increase in pharmacist-patient activities• Improved perceived quality of interactions
• 94% more drug-related problems identified• 246% increase in medication management
recommendations made by pharmacists to PCPs• Fewer medication list discrepancies identified
• Poor integration of the EMR system and EMRXTRA processes into the workflows of pharmacists
• Over 50% of enrolled patients have not yet been assessed by pharmacists
• Actively participating pharmacists are regularly accessing the EMR
• Pharmacists and PCPs both listed as a top 3 resource more often compared to baseline
• Pharmacists’ compensation drives ongoing cost of EMRXTRA under current reimbursement model
• Program success will require significant investment in change management
-
--
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Pharmacist activities with PCPs and patients increased in quantity…
Pharmacist-PCP activities, by typeCounts per patient
↑ 97%
1.0
1.9
Baseline Post-implementation
Pharmacist-patient activities, by typeCounts per patient
↑ 57%
3.7
5.8
Baseline Post-implementation
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PCPs’ perceptions of quality of interactions with pharmacistsPercent of “Always” or “Often” responses;
Initiated by pharmacist
Initiated by PCP
Conducted throughassistant/tech
Mutually respectful
Focused on patient caremgmt
Related to info PCP providespharmacist
Related to info pharmacistprovides PCP
Clinically related
Related to administrativeissues
Timely
Helpful
Good use of my time
Professionally satisfying
Baseline
Post-implementation
…and quality
Pharmacists’ perceptions of quality of interactions with patientsPercent of “Always” or “Often” responses
Pharmacists felt their ability to manage and empower patient self-management of chronic conditions improved
Patients perceived an improvement in the coordination and consistency of their care
Source: Post-implementation survey results
Baseline
Post-implementation
Mutually respectful
Based on informed decisions
Clinically related
Related to administrative issues
Related to managing
chronic conditions
Coordinated & complementary
with other clinicians
Related to issues that
can be better handled by
others
Professionally satisfying
My interactions with patients are:
Focused on empowering self-mgmt
Patients’ perceptions of quality of interactions with pharmacistsPercent of “Always” or “Often” responses
My interactions with pharmacists are:
Mutually respectful
Timely
Focused on most urgent problem
Coordinated and consistent
with other care
Focused on helping me with
all my medical conditions
Pharmacists and patients perceived improvement in quality of interactions
In the first year, pharmacists provided 844 services in 353 patient encounters…
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Top 5 pharmacist services providedCounts
353
230
177
59
5
25
Provide initial or F/U review
Provide health education
Provide drug information
Identify DRP
Resolve DRP with patient
Other
…and were better able to manage patients’ medications
Drug-related problems (DRP) identifiedCounts per patient
↑ 94%
0.62
1.20
Baseline Post-implementation
Medication management recommendations made by pharmacists to PCPsCounts per patient
↑ 246%
0.26
0.90
Baseline Post-implementation
Preparing for ePrescribing
PeP
The ePrescribing Demonstration Project evaluates the impact of electronic prescribing on providers and patients
Goals of the ePrescribing Demonstration Project:• Quickly provide and demonstrate the patient safety and quality of care benefits of
electronic prescribing to Ontarians• Create physician, nurse practitioner and pharmacist champions of electronic
prescribing • Demonstrate the full cycle of electronic prescribing through to dispensing in local
settings• Identify and understand the issues, challenges and opportunities of implementing
electronic prescribing and apply this understanding to the provincial roll out• Create tools and frameworks for process/workflow changes, adoption strategies and
benefits evaluation that can be used for the overall provincial roll out
The intent was not to test prototypes of the
provincial solution
Pharmacy staff receives / downloads
prescription
Patient presents to prescriber
Prescriber decides to prescribe
Prescriber completes
prescription
Pharmacy staff fills
prescriptionPatient picks
up prescription
DDAA BB CC FF
GGHH
II
Patient requests
prescription refill
Pharmacy staff requests
prescription refill renewal
Prescriber receives renewal request
EE
AuthorizationGBFHT: Secondary PINGHC: Keystroke
NotificationEMR sends message to alert pharmacist of pending prescription
Pharmacy Management System (PMS) TranscriptionPharmacy staff manually enter prescription information into the PMS
Patient visits community prescriber
Community prescriber views patient’s medication profile in the EMR and consults system-integrated decision support tools as needed. Prescriber concludes that patient requires prescription drug therapy and creates a new prescription, authorizes it and posts it to the EMR.
Pharmacist accesses EMR, selects the patient’s prescription and flags the prescription as “downloaded”
Pharmacist or delegate fills the prescription as per usual procedures
Patient presents at pharmacy to pickup medication
AA
BB CC
DD
EE
FF
ePrescribing Demonstration Project Workflow
Demonstration Project sites enabled a “closed loop” prescribing and dispensing process
Observations
• Over 80% of prescribers, both pre and post Go-Live, believe knowing prescription status (e.g., prescription has been received by the pharmacy) can help them manage patient medication compliance
• Over three-fourths of patients surveyed feel that electronic prescribing has helped their doctor, nurse practitioner, and pharmacist better manage their medications
Prescribers strongly believe that knowing prescription status helps them manage compliance
Discussion
• ePrescribing supports prescribers with access to updated prescription status information in shared medication profiles to manage patient medication compliance
Source: Prescriber Post-Implementation Survey data
The most commonly reported reasons pharmacists access patient medication histories are directly related to patient care
87
45
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Verify past doses and/or instructions to determine the
appropriateness of the current prescription
Address a question from a patient or his/her delegate
Prepare for patient counselling of prescriptions
Reasons pharmacists report they access patient medication historyn= 29; In percent
Observations
• 87% of pharmacists feel they access medication histories to verify past doses for appropriateness of the current prescriptions
• The main reasons pharmacists access patient medication history are directly related to patient care and medication management
Discussion
• Pharmacists access medication histories for patient care purposes; while this may improve workflow efficiencies (e.g. through reduced need to verify instructions with prescribers), it may be recognized more for benefits to patient care than for workflow improvements
Source: Pharmacist Post-Implementation Survey data
A. Prescriptions where paper (vs. EMR or ePrescribing) was first used to create a prescription in scenarios with drug interactionsB. Prescriptions where the prescriber changed their prescription decision after viewing clinical alerts in EMR
Implications and Discussion
• Handwriting prescriptions may lead to avoidable medication errors that may be systematically flagged by electronic systems
• In addition to the patient safety issue, medication errors can impact workflow adversely – prescribers and/or pharmacists require additional time to make any necessary prescription changes
No. of Paper Prescriptions with Interactions A
No. of Paper Prescriptions where the Interaction was Identified by
Prescriber
No. of Paper Prescriptions with Interactions Deemed Clinically
Significant B
By Medication Scenario:• A2: 0%• B3: 40%• A4: 75%
Observations
• Only 1 of 14 prescribers creating paper prescriptions identified drug interaction
• Subsequently creating same prescription via EMR generated several clinical alerts; 5 prescribers deemed interactions sufficiently clinically significant to warrant change in prescribing decision
• 75% of prescribers changed their prescriptions as a result of clinical alerts during the A4 scenarios
Paper prescriptions may lead to clinically significant adverse events often flagged by alerts in electronic systems
Source: Time-Motion Study
63
78
36 46
Prescribers Pharmacists
Pre Post
Observations
• Prior to the ePrescribing Project, about 60% and 80% of prescribers and pharmacists respectively thought greater access to patient medication histories would reduce the need for interactions
• After the Project, about 30% fewer prescribers and 30% fewer pharmacists think greater access to medication histories reduces the need for interactions with each other
Implications and Discussion
• Sharing clinical information, such as patient medication histories, enhances, not eliminates prescriber-pharmacist interactions
• Sharing information decreases avoidable interactions, but increases clinically relevant ones,; thus little total change in interactions
• However, quality, timeliness and clinical relevance of these interactions seems to increase
• Prescribers and pharmacies in both communities serve stable, consistent, and known patient populations, thus existing medication records already fairly complete prior to ePrescribing project
Providers Who Think Access to Patient Medication Histories Reduces Need for InteractionsIn percent
n=51
n=36
n=29
n=45
Sharing medication histories does not reduce the need for prescriber-pharmacist interactions
Source: Prescriber & Pharmacist Pre- & Post-Implementation Survey data
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A ‘how to’ guide has been developed outlining lessons learned and experiences gathered along GHC’s 12 year journey for a fully electronic medical record.
Key takeaways from EMRXTRA and ePrescribing evaluation
• Benefits of extending EMR access to the complete circle of care team on improving clinical interactions, medication management and patient safety are clear
• Patients understand the value pharmacists bring to their care
• Systematic, concerted change management efforts are required to drive adoption, even for the most “technologically advanced” clinicians – money by itself is not enough!
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• Engaging and leveraging early adopters as project champions is an effective strategy to achieve results
• Despite adoption challenges, primary care providers, pharmacists and patients all recognize the benefits of extending clinical histories to community providers
• Continuing and expanding EMRXTRA will require a sustainable pharmacist reimbursement model, a structured change management strategy, and an investment in technology infrastructure
• Continuing eprescribing requires changes in regulatory college requirements and legislation changes
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Key takeaways from EMRXTRA and ePrescribing evaluation
Key Messages
• Silos that exist with in health care sector act as barriers to better health outcomes and work to increase costs while decreasing services1
• Integration of technology and interaction between health care providers improve patient safety
• Expected results of Implementation of medication management systems will help prevent – each year – 217,000 adverse drug events, 132,000 physician office visits, 20,000 hospitalizations and 2,200 deaths due to adverse events2
Source 1: 2004 Pharmacist and Primary Health Care Canadian Pharmacists Association
Source 2: Ontario’s eHealth Strategy 2009-2012
