Electronic Management System

12 Months on Experience

Austin Health Major tertiary health provider in

northeast Melbourne

Three campuses

– The Austin Hospital

– Heidelberg Repatriation Hospital

– Royal Talbot Rehabilitation Centre

Major services

– Liver & Gastro-intestinal transplantation

– Spinal Cord Injuries

– Oncology

– Vic Respiratory Services

– ONJ Centre

Organisational Statistics Measure 2012 – 2013 Year

Staff (EFT)

Medical 647

Nursing 2,098

Allied 471

IT / Informatics 50

Total 5184

Structure

Facilities 3 campuses

Beds 900+ beds

Theatres 22 theatres

Throughput

Admissions (Overnight /

Day) 99,363

WIES 70,783

Attendances 183508

Emergency Visits 68,170

Operations 24,192

2011

Radiology orders Pathology orders e-Prescribing Discharge Summaries Results & Results Endorsement

2012-13

Inpatient medications MAR Fluid balance chart 724 Access

2014

Clinical Documentation First Net Physician Handover Nursing Task Manager Referrals Allied Health

The Austin Health EMR Journey

Clinical System Chosen:

Usage

Average of 4300 users for the Month of February, 2014

Objectives

• Clinical Governance Group

• Medications Design and Build

• Customisation of Reports and Auditing

• Interfacing existing systems: Pharmacy,

Pathology, Radiology

• Single Encounter Reconfiguration

• System Down-Time Management

Governance Internal Governance:

• Medication Safety Committee: Standard Four NQSHS

• Medication Governance Group: Sub-committee of the MSC Content/Functionality Approval

• Local Steering Committee: Project Governance

• Policy Framework: Update existing policies

External Governance:

• Agency and Government Groups approval process

IP Medication Implementation

•NIMC replaced by Cerner Powerchart

•MAR administration Nursing

•Caresets / PowerPlans

•Nurse Initiated Meds

•Patient Self Administration Meds

1. Dr’s Prescribing: Pre-Built Order Sentences are commonly prescribed doses

2. Default Administration instructions: MAR

Medication Administration Record

Care Sets

Ordering: Glyceryl Trinitrate Patch

Care Sets

Nurse Initiated Medications

Patient Self Administration

•Specific Subacute wards

•Self Administration (Dosette or PRN):

Medication list on MAR

•Administration by other: Parenterals/Orals

with Doses Due on MAR

MAR: Self Administration

Has implementing an eMM system

Made a Difference?

Pharmacy Annotations (NIMC)

• A pilot review of paper drug charts showed that 61%

included appropriate pharmacy annotations:

– Medication Strength, Generic/brand Name or

administration comments ie Take with food.

– This was inconsistently applied depending on

pharmacist doing the review

• Most of the time, ‘pharmacist field’ signature/initial was

unidentifiable on NIMC.

• Electronic system allows for consistency of administration

details and legibility of name

Error Prone Abbreviations Study

It is recognised, that no matter how

accurate or complete an order is, it may

be misinterpreted if it cannot be read

Cerner eliminates this patient safety risk: electronic medication orders

are 100% legible. In addition to this, hard-coding of terminology by

use of order sentences and care sets achieves consistent prescribing

terminology and avoids use of unsafe abbreviations and symbols.

Error Prone Abbreviations Study

NSW Therapeutic Advisory Group define Unacceptable

Error-Prone Abbreviations

– Drug names, Frequencies, Dosing designations

– 100 Paper Medication charts (NIMC/M85)

compared with 100 Cerner charts

– Preliminary results show error prone

abbreviations were reduced from 37% to 2%

with the introduction of the Cerner (p<0.001).

– Further investigation is required for the clinical

significance of these results

Accreditation: NSQHS Standard 4

• To ensure Cerner incorporates the full range of National Safety

and Quality Health Service (NSQHS) Standard 4 Medication

Safety

• The analysis found that Cerner exceeded the requirements and

provided additional elements or functionality that improve clinical

workflows and patient safety.

1) Remote Access to Cerner

2) Electronic Medication orders are legible and include prescribing

terminology according to National Standards

3) Medication Order changes are tracked and can be viewed

clearly

NSQHS Standard 4 4) Clinical Decision Support with drug interaction and allergy

checking

5) Standard Administration instructions for medications

incorporated in the order and available to nursing staff

immediately

6) Include all essential prescribing requirements for an Electronic

Prescription

7) Allergy and patient specific details easily Recorded and

Retrieved

8) Easy retrievable pathology result

Other Interesting Facts

• Nursing Survey revealed

• Whilst local IV Guidelines, MIMs Online and

ward pharmacist remain the most common

medication references

• Cerner Reference Information was used in the

past by 20% of nursing staff surveyed

• This will probably increase when IV Chart

(M100 Chart) is in Cerner

Warfarin Therapy: Design

• Warfarin Therapy Careset: Initiating/Maintenance

• Daily dose checks

• Specific times for administration

• Withhold dose

• Specific Details for the order (OEF)

• INR pathology order included

Warfarin: Mandatory INR Range

Warfarin Initiation

Warfarin Maintenance

MAR

Report: Warfarin

• Identifies patients prescribed warfarin in the last 10

days

• Generated according to specific location or clinical unit.

• Benefit

– Clinical Staff can instantly identify warfarin patients

– Prioritise higher risk patients

– Usage report shows Warfarin Report is used daily

by Pharmacy and HMO on Cardiac Ward and CCU

Warfarin Report

• Division of work with Gen Med & Endocrine Units

• Patients identified

– Undiagnosed and/or Uncontrolled Diabetes

• Automated ordering of HbA1c

– Rule to order automatically for Patients over 54

» Inpatients LOS > 1 day

» Who have not had an HbA1c result in last 90 days

Mental Health Patients over 29 yrs

Identifying Patients- Diabetes

HbA1c Results

• Alerts auto applied based on result value of HbA1c% test.

–Result value 6.5% - 8.0% »Apply Medical – ‘Possible Diagnosis of Diabetes’ alert

»Send a message to generic Diabetes – New Patient Inbox

»Monitored by General Med Unit as Inpatients

–Result value >8.1% »Apply Medical – ‘Possible Poorly Controlled Diabetes’ alert

»Monitored by Endocrine Unit -utilise existing Alerts report

Communication to GP - Discharge Summary

Normal Hb A1c result

Abnormal Result > 6.4%

No comment will populate if there is no result in Cerner with the previous 3 months

Inpatient Management of Diabetes

BMJ Diabetes Action Set = PowerPlan in Cerner

Austin Health’s ‘Good Antimicrobial Prescribing Practice (GAPP)’ policy required custom build in to Cerner.

Currently using an online approval system (IDEA3S) to generate approval numbers based on selection criteria

On paper

- Approval number is written on the drug chart

- Required before administration but not always followed

In Cerner

- Creative use of Discern Alert

- Cannot proceed with order unless approval number is documented in appropriate field

Antimicrobial Stewardship

Antimicrobial Stewardship

Entering an

Approval

Number is

Mandatory

Antimicrobial Stewardship

In ICU, compliance with the GAPP alert has dramatically

improved from 45% in October 2012 to 87% in August 2013

ID Reports

• Powerful reporting in real time

– Infectious Diseases utilise reports for their daily reviews

– Report looks at all antimicrobials that are currently – in real time- being ordered for patients

– Allows Infectious Diseases unit to be proactive in monitoring antimicrobial use at the Austin

– Report analyses all wards at the Austin Hospital but can filtered down to a specific ward or unit

Real time reports on medications ordered

Medication Administration Reports

Using Discern Analytics

– Ability to do reports on Medication Administration events

– All information pertaining to medication administrations such as who gave it, what was given, how much was given, when it was given

– Which specific medications are currently ordered within the hospital?

– Incredible advantage due to speed of access to information

Medication Administration Reports

• Examples:

– Usage vs. Supply

– Recently Panadeine Forte & Tramadol taken off imprest

VTE and Allergy Recording

Allergy Recording in Cerner

Integration

Cerner integrates with

•Pharmacy dispensing system (Inpatient

Meds>Merlin)

•Pathology system (Pathology orders and

results>Kestrel)

•Radiology (Radiology>RIS)

Single Encounter Issue • ED> WARD Two Drug Charts!

– New drug chart requires copying medications from ED to transferred ward.

• Redesign integration of Patient Administrative System (Trakcare) HL7 messaging to Cerner.

• Ignoring HL7 message allowed the ED encounter to update the MAR to the new ward location

• SINGLE ENCOUNTER LOGIC SOLVED! ONE Drug Chart!

• Intercampus transfers or transfers from Acute to Subacute, are separate encounters/Drug Charts.

Managing Downtime

Planned/Unplanned

- Down Time is pre-scheduled

- Unplanned is not!

- Notification to Clinical Areas

- Additional Cerner staffing requirements for support

- Printing the MAR to NIMC prior to downtime

- Pathology Orders Report printed and sent to Pathology

- Pathology/Radiology on Paper

- Post Downtime

Conclusion • 12 Months post roll-out of IP medications powerful data is being generated

that is real-time and otherwise could not be obtained on paper

• Reports can assist with

– identifying patients

– Determine medication usage/appropriateness

• Helped improved compliance with National Safety and Quality Health Service

(NSQHS) Standard 4:Medication Safety

• Standardising Patient Care through medication design, use of order

sentence/CareSets/PowerPlan/Nursing orders/ Patient self administering

• Lesson’s learnt from our experience. Obtain baseline data of current workflow

on paper before comparison can be made using EMM.

• Regularly review update medication catalogue accordingly

Questions?