patients support a pharmacist-led best possible medication … · anatomical main group alimentary...

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

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

Outline

Health care in rural & remote communities

Medication Reconciliation or MedRec

Videoconferencing

Ontario Telemedicine Network (OTN),

Robotic Telepresence

Our research

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

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

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

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.’

Medication Reconciliation

MedRec on

Transfer BPMH

HOSPITAL ADMISSION

*BPMDP

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

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

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

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

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

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

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

TELEROBOT

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

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)

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

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).

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

Unintentional Discharge Medication

List Discrepancy- TYPE

71%

14%

14%

TYPE OF UNINTENTIONAL MEDICATION DISCREPANCY

Omission

Addition

Other



List Discrepancy - CAUSES

13%

88%

DISCREPANCY CAUSE(S)

Patient level

Med system level



List Discrepancy Causes - MED LEVEL Rate=0.78


14%

43% 14%

14%

14%

SYSTEM LEVEL CAUSE(S) Conflicting information from different informationalsources

BPMH incomplete/inaccurate

Rx error

Administrative problems

Other

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



Discrepancy-Pharmacist Intervention

50%

17%

33%

INTERVENTION, MEDICATION LEVEL

Drug changed (cancelled or started)

Dose changed

Other

Rate=0.67



Discrepancies-Pharmacist Interventions

67%

33%

HEALTH CARE PROFESSIONAL (HCP) LEVEL

(Prescriber, Nurse, Pharmacist)

Requested information

from HCP

Intervention

suggested to HCP

Rate=0.33


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

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.

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

Thank you for giving us the

opportunity to share our research

Robot video

patients support a pharmacist-led best possible medication … · anatomical main group alimentary...

Documents