1. Chickasaw Nation Medical Center BCMA (PSB 3*42) Deployment Site Visit January 27 – February 7, 2014

2. IHS-VA BCMA Deep Look Cherokee NC 2008

3. VA-IHS-ITU Choctaw

4. 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.

5. 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) will verify Indian Healthcare facilities wristbands, as well as drug products that will not scan at the point of care, and provide test results 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

6. What is BCMA? 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 Pharmacy and Nursing Staff Must Collaborate Closely with Information Technology Services Staff if the Medication Administration Arm of the System is to Work Optimally

7. Chickasaw Nation Medical Center BCMA Team Travis Freeze, PharmD, BCMA Project Lead Jesse Anderson, CPHIT, EHR Sr. CAC Melissa Kennedy, BSN, RN, BCMA Coordinator Landon Trimble, BSN, RN EHR CAC Patrick Simpson, Programmer Robert Carlile, RPh, PhC, Pharmacy Informaticist

8. VA Remote 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

9. IHS On Site/Remote 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 via Remote Adobe Connect Kathy Ray, CNM, HIT-PRO CP, CIMTAC Chair, IHS Navajo Area CAC Northern Navajo Medical Center BCMA Team – Remote Gallup Indian Medical Center BCMA Team – Remote Chinle Comprehensive Health Care Center BCMA Team – Remote Pine Ridge IHS Hospital BCMA Team – Remote

10. 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

11. Configuration & Test Lessons Learned BCMA Deployment Required Updating Current Patch Level PIMS Patch 1016 is Required for PIMS Patch 1017 Routines for Patient Wristband Printing Patch Installation Brought to Light a Pre-existing but Unrecognized Issue by CNMC BCMA Installation by Script Did Not Complete on All Workstations (20 out of 80 failed) Recommended for Script Installs That Each Installation is Verified Verify Correct Path for BCMA Application Target Wristbands Printed Prior to Launch through Pre-Admission Process Failed to Scan The Extensive Preparation Done by Travis and Melissa Enabled an Outstanding Configuration and Go-Live

12. Training Activities Friday – Training Preparation and Practice Session (11 Hours) Sunday – Afternoon Super User Training Sessions (4 hours) 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 – Super User 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 (10:00 AM & 10:00 PM) 14 hours on Wednesday and 14 hours on Thursday A Total of 241 – Includes Chickasaw nursing, pharmacy, and respiratory therapy staff and VA/IHS remote attendees. This also includes remote representatives from Pine Ridge, Chinle, Gallup, Shiprock and Alaska area (SEARHC). Students trained as BCMA Coordinator’s will continue Troubleshooting and Continue Monitoring

13. Training Encounters ParticipantsSunday Super User 2/2/14 2 Sessions Monday Super User 2/3/14 2 Sessions Monday Pharmacy 2/3/14 Evening Tuesday Super User 2/4/14 2 Sessions Wednesday 2/5/14 Super User & BCMA Coord Total Chickasaw Nation 91711202885 Claremore IHS 3427521 Cherokee Nation 27918 OKC Area168823 OIT37271029 VHA/VA114311837 I/T/U Remote 816327 Total1756207671240

14. BCMA Training

15. BCMA Training Lessons Learned Respiratory Therapy and ICU – May Benefit From CPRS Med Order Button Respiratory Treatments – Administration Times “Now” Administration Time Involvement of HIM BCMA Team Member for guidance to document “High Acuity” situations i.e. “Comments” for late medication Provide New Hire, Agency Nurses & Students Access to the VA BCMA Training Module in preparation for BCMA Training Plan to Continue to Train all Inpatient Nurses and Inpatient Pharmacists

16. BCMA Training Lessons Learned Consider Placing the “Comment” Bar Code Sheet in the Medication Notebook for Convenient Access Create Policies & Procedures to Align with New BCMA Processes: – Each Nurse to View Missed Med & PRN Effectiveness Reports at Specified Shift Intervals – Timely Medication Administration – Update Pyxis Medication Override Policy/Procedure –BCMA Competency Evaluation periodically (annual, bi-annual, etc.) –Documentation for All PRN Effectiveness –Consider Realistic PRN Documentation Time Frame –Accurate Medication Order Verification Process –Independent Nurse Verification for 5 Rights Medication Administration when Over- riding Scanning Process Each Nurse Manager to Generate Missed Med & PRN Effectiveness Reports at Specified Shift Intervals Nurse Managers Will Need to be Trained for Manual Medication Entry to Reconcile Missed Medication Report

17. BCMA Training Nursing & Pharmacy

18. Go Live Lessons Learned Nursing to Use EHR and BCMA to determine Medications Due, Dosages, and Administration Times Nursing to Keep Virtual Due List Time Parameter Narrow Each Nurse and Charge Nurse to View Missed Medications and PRN Effectiveness Reports at Specified Shift Intervals 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

19. Go Live Lessons Learned Incorporate BCMA Reports in Medication Error Review Committee and Root Cause Analysis Meetings Chickasaw Nation BCMA Team to Continue 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 Continue to Implement & Monitor the Observation to Full Admit Process for both ADT and Pharmacy

20. Post Implementation Statistics TOTAL MED EVENTSMEDICATIONSWRISTBANDS Feb 5 Go Live Shift19993.5 %97.2 % Feb 7 Go Live Shift17197.1 %100 % Total Go Live130095.2 %96.6 %

21. Thank You