Medication Use Process Part Two, Lecture # 6 PHCL 498 Amar Hijazi, Majed Alameel, Mona AlMehaid

Agenda Computerized Provider Order Entry (CPOE) Pharmacy Information System (PIS) Automated Medication Dispensing Devices and Robotics Bar Code Electronic Medication Administration Record (BCMAR) Smart Intravenous Infusion Pumps Electronic Medication Reconciliation

References e-book, Chapter 18 Electronic Health Records, Chapter 15 http://jamia.bmj.com/content/4/5/364.full.pdf http://www.ismp.org/tools/guidelines/smartpumps/comments/ http://ehealthinnovation.org/wp- content/uploads/SmartMedicationDeliverySystems_FullReport1.pdf

Medication Management and Technology Medication Reconciliation LIS RIS Problem List CDSS Medication Order Formulary Inventory Selection, Preparation and Distribution Automated Dispensing Cabinets Robotics Pharmacy Processing BCMAR Monitoring and Intervention Patient Portal Medication Administration CPOE NIS PHR PIS Clinical Data Repository

Computerized Physician Order Entry Refers to any system in which clinicians directly enter medication orders (and, increasingly, tests and procedures) into a computer system, which then transmits the order directly to the pharmacy. These systems have become increasingly common in the inpatient setting as a strategy to reduce medication errors. A CPOE system, at a minimum, ensures standardized, legible, and complete orders and thus has the potential to greatly reduce errors at the ordering and transcribing stages (AHRQ) Recommended by IOM in 1991 Can decrease serious inpatient medication errors by 55 %

Doctors will enter the prescription The electronic prescription is sent to the Pharmacy RX

fluoxetine (as hydrochloride) 20mg capsules Fluoxetine belongs to SSRIs, and has the following interaction information for patient’s current mediciations: Aspirin increased risk of bleeding when SSRIs given with aspirin

Advantages of CPOE Legibility Including all order components Reduce care variation Generation of alerts Specific alerts Global alerts Drug allergy Inappropriate dosing Inappropriate route Inappropriate cumulative dose Specific alerts: Alerts generated when for e.g. the ordered medication might be contraindicated because of Allergy Global Alerts: Still specific to the patient but more general for e.g. reminders of laboratory results and/or number of medications the patient is on

Advantages of CPOE, Cont’d Age contraindications Conditions contraindication Drug-diagnosis contraindication Laboratory warning Corollary orders (monitoring) Pre-intervention orders Audits Reduction in cost e.g. of corollary orders: When the doctor orders gentamicin the system reminds the doctor to order gentamicin level Theophyllin IV and Theophyllin level Insulin and Glucose monitoring Pre-intervention orders: e.g. reminder to check creatinine level before ordering a pyelogram procedure

Challenges to CPOE Ordering delay in emergency situation Alert fatigue Substantial workflow changes The implementation process More information is required to be entered: Co-signature Clinical history Diagnosis

Factors Contributing to improved CPOE Utilization Top down commitment to mandate CPOE use in the hospital Plan for resistance Scrutinize workflow Select a champion Order sets development Training and refreshment training Measure success Manage expectation Time Computers do not take care of patients

Pharmacy Information System Is a complex computer system that has been designed to meet the needs of a pharmacy department. It will allow pharmacists to supervise and have inputs on how medication is used in a hospital

PIS Functions and Features Inpatient order entry management and dispensing Outpatient order entry management and dispensing Labels and label routing Inventory management Products differentiation Order sets and protocols Clinical monitoring Manufacturing and compounding Intervention management Connectivity with other systems Fill lists ‘cart fill’ Pricing, charging and exchange

PIS General Considerations User interface Outpatient and inpatient profile Flexibility in sorting and selection of orders Display of complete profile Security and authority Data retention

Automated Medication Dispensing Devices and Robotics Centralized Mainly for inpatient setting A large robot that has access to the most frequently used medications Performs labeling of medication Place medication in patient specific drawers Handles refills of ongoing orders http://www.youtube.com/watch?v=aq59ELdqHi8&feature=share&list=PL93A403B6D459 7A7E

Automated Medication Dispensing Devices and Robotics, Cont’d Decentralized Used for inpatient Located near the patient care area Provides a check on the person requesting medication for a specific patient Has a billing interface http://youtu.be/Ve53RgvMCq8

Automated Pharmacy Drugs Dispensing System It Consists of: Software. Hardware. And it interfaces with Hospital Information System to get Patients and orders Data It Consists of Tow major Parts: Software and Hardware Interface with Hospital Information System to get Patients and orders data

Automated Pharmacy Drugs Dispensing System Replace manual distribution with: A Fully Pharmacy Automated System Automated Pharmacy Drugs Dispensing System HIS: Hospital Information System HIS Console Interface

OPP Robotics http://youtu.be/i4A-HbjQp70

IV Preparation ROBOT

Packaging Machines ATDPS Integrated packaging machines with all software and devices in the pharmacy. Billing From all Stations on a regular basis Bar- code generated automatically for every backed tablet.

Bar Code Medication Administration BCMA is a clinical information module residing within each facility’s health information system. The module is accessible from computer work stations and mobile computers on each nursing unit. From work station computers staff may view medication order reports and look up medication administration information. The module is accessed via wireless connectivity from a laptop computer mounted on a wheeled medication cart. Each cart has either a wireless or tethered handheld scanner. The carts have a number of individual patient medication drawers, corresponding to the number of patients served per cart

BCMAR Diagram Physician order CPOE Nurse Administers med Pharmacy Verification Due med is selected and scanned Medication Dispensing Patient’s med list displays Nurse Verification Nurse Confirms patient’s ID

Bar-Code Unique key for every drug Eliminates Medication errors

BCMAR Advantages Legible recording of meds Guidance of medication administration Positive patient identification Assessment reminder High alert medication verification Discrepancies reporting 5 and 8 Rights

BCMAR Challenges Cost associated with Bar Code arm bands or RFID The ability to have Bar Coded unit-dose available Workflow changes Adhering to procedures Portability of equipment workarounds

Factors Contributing to improved BCMAR Utilization Consider nursing workflow and medication management process Analyze the product design i.e. human-computer interface to prevent work around Scrutinize the software to ensure the system is simple to use Device must be ubiquitous Assess integration Communication EMR Bar Code Reader Medication Dispensing Machine Physician Pharmacist Nurse

Smart Intravenous Infusion Pumps Intravenous (IV) infusions have been identified as frequent contributors to medication errors, and the injuries that result from them. This is not surprising given that approximately 90% of patients receive medications via the IV route, and IV pumps are responsible for the majority of medication deliveries General infusion pumps were designed to improve accuracy and continuity of IV infusions by allowing nurses to program an hourly rate and volume. However, studies have shown that these devices are involved in 35-60% of the estimated 770,000 Adverse Drug Events (ADEs) that occur each year in the US

Smart Intravenous Infusion Pumps More specifically, the Institute of Medicine estimated that two-thirds of preventable deaths are due to infusion therapy and are attributable to manual programming errors when using infusion pumps

Smart Intravenous Infusion Pumps To address high incidence of infusion errors, manufacturers have developed smart pumps. Smart pumps have Dose Error Reduction Systems (DERS), which include hospital-defined drug libraries with dosing limits and other clinical advisories integrated into the system (i.e., smart pumps)

Smart Pumps Advantages Detect and correct infusion programming errors Comparing entered dosage values with predefined libraries set by the institution “Soft” or “Hard” limit warning Reduce errors associated with miscalculated doses

Smart Pumps Challenges Longer process Selecting clinical area Selecting drug name and concentration (if not Bar Coded) Staying up-to-date with emerging devices Correctly maintaining and updating the devices Requires a complex implementation process Requires integration with the medication administration process

Bar Coded Smart Pumps Workflow

Electronic Medication Reconciliation Another type of medication error that occurs is at the transition of care JCI has mandated that all healthcare organizations that prescribe medication must “accurately and completely reconcile medications across the continuum of care Electronic MedRec (eMedRec) uses Health formation Systems (HIS) to access and integrate electronically stored patient medication data To support the development of the electronic Best Possible Medication History (eBPMH) and the detection and resolution of discrepancies Can be integrated with other systems such as computerized provider order entry (CPOE)

eMedRec Advantages Generate the best possible medication lists (BPMHs) Electronically support human MedRec processes providing electronic sources of data Providing electronic tools for comparing lists and Detecting and resolving medication discrepancies Improved standardization of documentation Improved legibility of information Improved communication between providers Improved accessibility of documentation