USPHS Whiteriver Indian Hospital BCMA (PSB 3*42) Deployment Site Visit January 6 – 17, 2014

Background Meaningful Use Stage 2 Criteria for Eligible Hospitals (EHs), and Critical Access Hospitals (CAHs): – Objective: Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (eMAR). – Measure: More than 10% of medication orders created by authorized providers of the EH or CAHs inpatient or emergency department during the EHR reporting period for which all doses are tracked using eMAR.

Bar Code Medication Administration Assistive (BCMA)Technology BCMA is an Assistive Technology Software Application Developed and Used by the Veterans Health Administration (VHA) Facilities to Document Medication Administration Activities and Reduce Medication Errors The VHA Bar Code Resource Office (BCRO) provides bar code verification services to IHS for wristbands and drug products that will not scan at the point of care and provide test results to the submitting facilities The BCRO has Developed a Structured Process for Performing Usability Assessments of New Features to Assure Successful Adoption by End-Users BCMA is a Component of the RPMS-EHR Certified Electronic Health Record

Purpose of BCMA (PSB 3*42) Training BCMA is an Integral Part of Patient Safety, Nurses Administer Medications, Including IV Piggyback Medications and IV Large-volume Medications, through BCMA All Information is Documented with a Date/Time Stamp for Improved Accuracy of Clinical Information The Documented Information is Available Throughout the Facility to Any Clinician as Part of the Patient’s Health Record

Purpose of Training (cont.) Pharmacy and Nursing Staff Must Collaborate Closely with Information Technology Services Staff if the Medication Administration Arm of the System is to Work Optimally The Purpose of this Week’s Training is to Provide BCMA Training to the BCMA Super Users-Nursing, Pharmacy Staff, and BCMA Coordinators

Parallel Activities Configuration & Test of BCMA Configuration & Test to convert the IV continuous and intermittent (piggyback) and completion of drug file clean-up Load of EHR version 1.1 patch 12 Configuration and Test of wristband and IV label printers CSI of delayed order release issue Configuration and end-to-end MU2 alpha test of EHR version 1.1 patch 13 Collaborative effort for problem solving of device issues (involved IHS, VA, DataRay®)

IHS-OIT/Whiteriver/Navajo Cohort/CFT Teams

Whiteriver BCMA Team Brian Campbell, PharmD, BCPS, BCMA Project Lead Ben Berrett, PharmD, BCPS, BCMA Pharmacy Coordinator Eun Jeon, PharmD, BCPS, Inpatient Pharmacy Director Evangeline Pablo, BSN, RN, FCU Nursing Supervisor, BCMA Coordinator Paula Orzel, BSN, RN, Asst. FCU Supervisor BCMA Coordinator Dan Clonts, BSN, RN, Asst. FCU Supervisor BCMA Coordinator Janna Morris, MPA, MT(ASCP), Clinical Application Coordinator Chester Colelay, Information Technology Richard Cosen, Information Technology

VA On Site Cross Functional Team Cathi Graves, Project Manager, BCRO, OIA, VHA Kirk Fox, Clinical 1 Support Team, OIT, VA Randall Baylis, BSBA, Clinical 1 Support Team, OIT, VA Jonathan Bagby, MSN, MBA, RN-BC, Nurse Consultant, BCRO, OIA, VHA Jan Zeller, MBA, BSN, RN, Education Project Manager, VA EES Daphen Shum, BSPharm, RPh, Pharmacy Supervisor, Perry Point, MD, VAMC Stephen Corma, BSPharm, RPh, Pharmacist Consultant, BCRO, OIA, VHA Hugh Scott, MS, RNC, VHA Management & Program Analyst, Washington, DC, IHS/VHA Interagency Liaison - Remote

IHS On Site Cross Functional Team David Taylor, MHS, RPh, PA-C, RN, BCMA Federal Lead, IHS/OIT Deborah Alcorn, MSN, RN, CPC, BCMA Nurse Consultant, IHS/OIT Phil Taylor, BA, RN, BCMA Nurse Consultant, MSC Contractor Chris Saddler, RN, BCMA Information Technology Consultant, IHS/OIT on-site and via remote Adobe Connect Elvira Mosely, MSHS, BSN, RN, Phoenix Area EHR/BCMA CAC Kathy Ray, CNM, HIT-PRO CP, CIMTAC Chair, IHS Navajo Area CAC Northern Navajo Medical Center BCMA Team Gallup Indian Medical Center BCMA Team Chinle Comprehensive Health Care Center BCMA Team Pine Ridge IHS Hospital BCMA Team – Remote

VA IHS BCMA Collaboration Effort Includes BCMA Software, Hardware, and Medication Administration Process Reviews FY13 – Implementation at 2 Indian Health Care facilities FY14 – Implementation at 9 Indian Health Care facilities FY15 – Implementation at 4 Indian Health Care facilities VA IHS BCMA Cross Functional Team Kick-off March 19-21, 2013 Remote Participation for Initial Configuration/Test/End-User Training-April 8-19, 2013, Albuquerque, NM Ongoing Remote RPMS Pharmacy Drug File Cleanup – 6 week series ADT delayed orders/auto DC of orders optimized to align with CMS 2 midnight rule and Interqual® criteria Integrate ADT and BCMA implementation with the Baby Friendly Initiative including rooming-in

Configuration & Test Lessons Learned Printers – You Don't Always Get What You Order – Make Sure You Have Enough of the Recommended Labels – What look alike aren’t alike – Created Terminal Types for Pediatric and Infant for Barcode Wristbands – Implemented New Device File entries for 6 New Zebra Wristband Printers We Are Dependent on the Site's and Area's IT Staff – RPMS Configuration includes (a) BCMA; (b) Taskman; (c) New Routines for Printing, Reports, IHS Patient Chart; (d) ADT; (e) Delayed orders/Auto-discontinue rules; (f) User set-up – Sites using printers outside of VA experience should expect to have their vendor on-site for BCMA Configuration & Test Assigned does not necessarily equal completion Regardless of work and planning unanticipated problems will occur – Discharge of patients – Communication to nurses to not pass medications – Each site has unique strengths and unique problems

Training Activities Saturday – Training Preparation and Practice Session (11 Hours) Sunday - Morning and Afternoon Super User Training Sessions (4 hours each) Monday – Morning and Afternoon Super User Training Sessions (4 hours each), Evening BCMA Pharmacy Training Session (4 hours) Tuesday – Morning and Afternoon Super User Training Sessions (4 hours each) Wednesday – Morning BCMA Pharmacy Training (4 hours), Afternoon BCMA Coordinator Training (4 hours) – Go Live Wednesday afternoon – Troubleshooting Thursday – Debriefing, Go Live and Troubleshooting Continues Throughout Thursday and Friday Major Medication Passes (9:00 AM & 9:00 PM) 14 hours on Wednesday and 14 hours on Thursday A Total of 73 – Includes Whiteriver nursing and pharmacy staff and VA/HIS remote attendees. This also includes remote representatives from Chicksaw, Pine Ridge, Chinle, Gallup, Shiprock and Alaska area (SEARHC). There are 37 (90.2%) Whiteriver nurses who participated in the training that will administer medications. Close to Two-Thirds of Students Attended all Multiple Classes Students trained as BCMA Coordinator’s will continue Troubleshooting and Continue Monitoring

BCMA Training

BCMA Training Lessons Learned When we are training we are also verifying assignment of new keys and menus Four hours of training is information intense to accommodate patient care activities A Scanner does not have to accompany each BCMA GUI Client; only those that will be used in Point of Care requires a scanner Involvement of HIM BCMA Team Member for guidance to document “High Acuity” situations i.e. “Comments” for late medication Provide End-User Access to the VA BCMA Training Module in preparation for on-site BCMA Training and for Refresher and New Hire Training Plan to Continue to Train all Inpatient Nurses and Inpatient Pharmacists BCMA character sizes are hard coded, the only way to increase text size is to adjust the resolution

BCMA Training Lessons Learned Consider Placing the “Comment” Bar Code Sheet on the Medication Cart for Convenient Access Create Policies & Procedures to Align with New BCMA Processes: – Using the CPRS Med Order Button – Timely Medication Administration – Update Omnicell Medication Override Policy/Procedure –Each Nurse to View Missed Med & PRN Effectiveness Reports Often –BCMA Competency Evaluation periodically (annual, bi-annual, etc.) –Documentation for All PRN Effectiveness –Consider Realistic PRN Documentation Time Frame –Independent Nurse Verification for 5 Rights Medication Administration when Over- riding Scanning Process

BCMA Training Nursing & Pharmacy

Go Live Lessons Learned Identify BCMA Competency Forms & Perform for Nursing Post Go Live Expand Pharmacy Roles and Responsibilities to include BCMA training and orientation Incorporate BCMA Reports in Medication Error Review Committee and Root Cause Analysis Meetings Whiteriver BCMA Team to Meet Weekly to Discuss Scanning Failures/Troubleshooting and Provide Feedback to All Clinical Staff Pharmacists to Shadow Nurse Medication Administration Periodically and Nurse shadow Pharmacists

Go Live Lessons Learned RN’s View Assigned Patient’s PRN Effectiveness Report Several Times Per Shift Each RN and Med Nurse View Missed Med Report Beginning Shift, After Every Major Pass, and End of Each Shift Prior to Discharge, Complete or Stop all IV Infusions, if Ordered Remove Patient Med Patches and Document as Removed in BCMA Continue to Implement & Monitor the Observation to Full Admit Process for both ADT and Pharmacy Medical Staff to Review the 2-Midnight Rule CMS requirements and Interqual® criteria

Post Implementation Statistics Medications Wednesday PM – 83% scanned Thursday AM – 88% Wristbands Wednesday PM – 81% scanned Thursday AM – 86%

Thank You