Overview and Workflow Considerations with RPMS Pharmacy 5/7 and the Electronic Health Record Brian Wren Pharm.D., BCPS Chief, Pharmacy Services W.W. Hastings Indian Hospital

Medication Reconciliation Pharmacists are best suited to provide this service Provider consistency? How far are providers willing to go?

W.W. Hastings Outpatient Medication Reconciliation The (ORX) convention is used with “dummy providers” All active, pending and hold medications are imported into the provider template The provider then reconciles medications on that list. If a patient is taking a medication that is not in the file an is sent to one of two pharmacists

Continued… The dispensing pharmacist then completes the medication reconciliation note (see example) An will also be sent if the pharmacist notices that a med the patient is taking is not in the file (most common occurrence)

Continued The medication reconciliation sheet is then printed and given to the patient Patients are encouraged to bring it back at the next visit ORX labels do print at W.W. Hastings

Talking Points What do pharmacists do when the patient is not taking a medication on the list? What is done when the patient does not know the dose? Does medication reconciliation occur on refills?

Other Examples? Carnegie Phoenix Indian Medical Center

Why Pharmacy v5/7? New patches will require V5/7 Required for AudioCare, robotic, & ADC interfaces Medication order checks Laser Labels Paperless Refills

Pharmacy 5/7 Workflow Considerations To hold or not to hold Filling from appointment to appointment Utilization of technicians Paperless refills-When and How

Paperless Refills Site Parameter Streamlines coding issues and pharmacy refill documentation Provider ordered refills-(More of an issue when E.H.R. is installed)

Paperless Refills There is no need for registration to create a visit with this system PCC/Data Entry will notice an increase in errors Tip: If a medication is taken off hold there will be a missing POV

Paperless Refills Question: What do you do when there is no appropriate diagnosis for the medication that is being refilled?

Why EHR Mandate by IHS Director More efficient access to clinical data More effective billing and coding practices Consults/referrals

IHS-EHR Benefits Patient safety focus Organized management of data Clinical reminders (In progress) Provider order entry

Terminology CPOE-Computerized Provider Order Entry CAC-Clinical Application Coordinator GUI-Graphical User Interface Vista-Veterans Health Information System & Technology Architecture

EHR Essentials Commitment Provider Acceptance Robust Network

Facility Considerations Network costs FTE costs Decrease in efficiency (may be temporary) Training Scheduled rollout is best Use of the E.H.R. initially for CPOE may be considered

EHR Workflow Education of staff (particularly providers) is extremely important New orders will be entered by providers and verified by pharmacists Accuracy of provider entry is paramount

E.H.R. Challenges for Pharmacy Difficult (time-consuming) to link individual med orders to a specific visit Continuity of pharmacy refill visits- original orders, intervals, documentation of drug monitoring Pharmacists are “tied” to computer terminals verifying orders

More Decisions and Issues Who maintains the quick orders, drug file etc. Are completed provider notes a prerequisite before meds can be filled? (Please say yes!) How will schedule II medication be processed?

Continued… How/when will pending meds be processed How/when will pharmacy be notified when orders are pending –Option 1: Checking the queue periodically –Option 2: Patients present to the pharmacy with a “routing slip” given to them when their provider visit is completed

Training Providers (Pharmacy Opportunity) Pharmacy should participate and assume an active role in this endeavor Time spent training providers will drastically improve the efficiency of order verification by pharmacists Maximize quick orders

W.W. Hastings Approach All chronic medications are 30 days with 11 refills Providers are required to reorder all medications that patients are taking at each visit-This streamlines the medication refill screening process A RX refill note is completed for all medication refills

Pharmacist Decentralization Maximizes efficiency and pharmacist interaction with physicians Increases patient satisfaction/decreases wait times Challenges –Patient counseling using “show and tell” –Space –Difficult for small sites

No Paper? Discontinuation of usage of summary labels Try to extrapolate the best paper processes to the electronic format (i.e. How did we do this on paper?) Tracking medication errors

Pitfalls Minimize the transition time between “paper” and electronic processes Pharmacy may need to negotiate a cessation date for the usage of orders written on paper Providers should not be allowed to switch from the E.H.R. back to paper (i.e. when they are busy)

Workload Distribution January 2004

Workload Distribution January 2007

Demonstration Tour of E.H.R. Processing a paperless refill Processing a pending order