1. Canadian Hospital Pharmacy Leadership Conference June 6, 2015

2.  HIMSS Analytics Adoption Model  Integrated Pharmacy, eMAR and CPOE Systems  Regional Data Repositories for Drug Information  Medication Reconciliation Notes  Patient Access to Information

4.  Healthcare Information and Management Systems Society – 52,000 members  Global, cause-based, not-for-profit organization focused on better health through IT  Leads efforts to optimize health engagements and care outcomes using IT  Vision: ◦ Better health through information technology  Mission: ◦ Globally, lead endeavors optimizing health engagements and care outcomes through information technology

5.  Wholly-owned, not-for-profit subsidiary of HIMSS  Collects and analyzes healthcare information: ◦ IT adoption and environments ◦ IT department composition and costs ◦ healthcare trends ◦ purchase-related decisions past and near term future  Gather data for: ◦ Every hospital in the US and Canada ◦ Europe, Middle East, Asia on a country sample basis

6.  HIMSS Analytics’ EMR Adoption Model ℠ (EMRAM) tracks the adoption of EMR applications within hospitals and health systems  First created in 2005  Institutions work to complete the 8 stages  Each level of maturity is a score derived from a comprehensive survey of the hospital’s IT environment

7.  Progressively sophisticated steps track the accessibility of information within an EMR ◦ Ensures critical clinical information and Clinical Decision Support guidance are available to the clinician at the point of care  Gated model - all technologies in a stage must be accomplished before hospital can move up  Goal of reaching Stage 7 - an environment where paper charts are no longer used

13. Pre CPOEPost CPOE Order Sets114380 Medication Order Sets2094 Medical Directives1411 Total Order Sets148485 Overall % of Visits with Order Sets 67%97% Overall Average Sets/Visit0.952.1

14. Pre-CPOEPost- CPOE %Change TEGH - Turnaround time all meds 3.3 h1.3 h60% (decrease) TEGH - Turnaround time Antibiotics 3.8 h1.2 h67% (decrease) St. Michael’s - Turnaround time Antibiotics 5.6 h3.1 h46% (decrease) UHN – Turnaround time all meds 3 h2 h33% (decrease) UHN – Now dose turnaround time 1.8 h1.4 h23% (decrease)

15. Transcription errors decreased to virtually zero Omission errors decreased by 60% Wrong dose decreased by 40% Wrong patient decreased by 75% Over time, 60% decrease in Moderate Severity incidents

17.  200 Hospitals have ascended to the top of HIMSS EMRAM (Stage 7)  Secret to success – Single Clinical Data Repository ◦ Enterprise-wide with core clinical system  152 Epic  41 Cerner  5 Meditech  1 Allscripts ◦ Best of breed hospitals are not achieving Stage 7  Clinical Decision support hard to achieve

18.  Software to support hospital’s core business is from a core vendor  Single source of truth without interfaces  Single vendor solution for Pharmacy, CPOE and eMAR ◦ Medication reconciliation software is integrated with CPOE and Pharmacy systems ◦ Tracking Allergies in a single database ◦ Integration with Smart IV pumps

19.  “Dissent and foot-dragging can’t be an option. It’s critical to embrace these enterprise-wide projects with the attitude that “there is no alternative”…And we’re going to use this as a clinical transformation and not an IT project.”  John Hoyt HIMSS Analytics  Need advanced analytics for Stage 7 – hard to achieve with Best of Breed  Difficult technically  Data quality issues with disparate systems

20.  Reasons for not using alert functionality in Pharmacy Information Systems (PIS): ◦ Use of a CPOE system for this functionality ◦ Lack of a database in PIS to drive functionality ◦ Lack of integration with other modules, such as Labs for renal function ◦ Lack of patient demographic information such as patient weight, age, etc.  Consistent, comprehensive decision support for all clinicians is only possible with core clinical systems

22.  Defined in many segments of the IT world  Allow data from disparate systems to populate a single repository  Interface standards for Healthcare, real time  HL7 – various versions  IHE for Document sharing  Terminology standards for inter-operability  Snomed CT – clinical terminology  UCUM – unified codes for unit of measure  HCDPD – Health Canada Drug Product Database  GTIN – Global Trade Item Number

23.  Purpose is to build a patient medication profile across the continuum of care  Support the following business functions  ePrescribing  Dispensing & Managing Rx status  Adding OTC or samples information  Drug queries  Patient Medication queries  Contra-indications e.g. drug-drug, drug-allergy, dose checks  No standards for Medication Reconciliation process at this time

24.  Quality  Reduced ADEs  Decreased medication abuse  Increased medication compliance  Increased patient and provider satisfaction  Increased timely access to information  Productivity  Enhanced provider communications  Increased provider efficiency  Enhanced drug cost management

25.  Very slow progress compared to Labs, XRay  Majority of in-use repositories obtain data from Rx dispensing in retail pharmacy only ◦ PEI exception and includes MD samples, hospital Rx, OTC/herbal ◦ Western Provinces 100% for retail Rx ◦ Rest of Canada is 0%-80% of Rx  Access/adoption is partial ◦ Western jurisdictions is mainly pharmacists and ER ◦ Very little access/adoption by Community MDs ◦ Hospital adoption rates vary from 50% for ER and low of 30% for Inpatients (CHI)

26. ©Canada Health Infoway 2015 26 Availability of EHR information by jurisdiction (December 31, 2014) Client Demographics Provider Demographics Diagnostic Images Dispensed Drugs Lab Test Results Clinical Reports / Immunizations PE100% AB100% BC100% SK100% 99%100% MB100% NL100% 38%100% NS100% 25%100% NB100% 20%100% NT100% 0%100% QC100% 80%77%95% ON100% 27%75%100% NU100% 80% 90%80% YT0% 100%0%50%*100% * An additional 45% of Yukon’s lab tests are performed in BC and digitally stored in BC’s Provincial Laboratory Information System

30.  Typically would be only on discharge  Hospital EMRs with CPOE already have ePrescribing function with printed / signed Rx  Legibility benefit already realized  Technically more difficult since you need trigger events  Theoretically could be medication reconciliation at discharge if performed 100% of the time [7x24]  All clinicians have to use the same tool/process  Need to consider Data Quality and Single Source of Truth (Core systems)  Likely one of the last items in jurisdictional EPRs

32.  Accreditation Canada ◦ Medication reconciliation is a required organizational practice  Need to support the reconciliation task with Clinical Documentation  Describes medication-related decisions to start, stop, hold therapy  Complementary to a drug profile  Needs to be electronic to share with regional electronic patient record repositories

33.  “One Good Note”, CJHP 67(3) May/June 2014, p 250 ◦ Advocates for documenting more in the patient record and less on monitoring forms ◦ “If you’re going to spend the time performing a detailed workup, why not share that information with your colleagues in the form of a concise and clearly written chart note?”  For continuity of care in the ideal world, on discharge, goes to:  Family Physician  Pharmacy of Record

34.  For Health Professionals, generally a single point of access in a Jurisdiction  Includes information such as:  Visits/encounters, demographics  Lab tests (hospital and community)  Diagnostic test results and Images (hospital and community)  Immunizations  Allergies and Intolerances  Medications  Transcribed Reports / Discharge Summaries

35.  Relatively easy technical effort if there is a core clinical system since triggers are available  If have a shared Clinical Documentation system, the notes are available internally as well to the full care team (in a Core Clinical System)  Measurement of extent of medication reconciliation should also evaluate % of medication reconciliation notes

37.  Medications I need to take  What to keep taking  New medications  What to stop taking  How I might feel and what to do  Changes to my routine  Appointments I have to go to  Where to go for more information  Technically difficult to prepare if have a Pharmacy system separate from core system

38.  Personal Health Records eg. Alberta Netcare, Sunnybrook MyChart, myUHN  Continuity of care record, particularly with chronic disease; can share with family, MDs  Information patients can enter  How much you exercise, what you eat  How you are feeling – symptom scales  Medications including OTC and herbal medications  Your health care team and emergency contact information  In Alberta some data downloaded to Portal  Netcare electronic health record  Can include educational material

39.  Very appropriate to add to downloaded information in a Patient Portal  May want to consider standard email contact information for further questions  Language in notes needs to be appropriate for patient audience so it can serve a dual purpose ◦ UHN has very well-written guidelines  Author will usually be clear in the report

40. Setting a New Standard in Quality and Value 40 Toronto East General Hospital, 825 Coxwell Avenue, Toronto, Ontario, M4C 3E7 Tel: (416) 461-8272 Fax: (416) 469-6106 www.tegh.on.ca Pegi Rappaport prapp@tegh.on.ca 416-469-6580 Ext 6032

41. Laboratory and Pharmacy, and Radiology Management Systems are all Live and Operational in the inpatient hospital and the laboratory system produces discrete data  Cerner for Pharmacy, Radiology  Soft (SCC) for Labs and Blood Bank  CoPath for Pathology (shared service)  Meditech for Microbiology (shared service)  Agfa for PACS

42. Major ancillary clinical systems feed data to a clinical data repository (CDR) that provides physician access for retrieving and reviewing results. The CDR contains a controlled medical vocabulary between the interfaced systems, and the clinical decision support/rules engine (CDS) for rudimentary conflict checking. Information from document imaging systems may be linked to the CDR at this stage. The hospital is health information exchange (HIE) capable at this stage and can share whatever information it has in the CDR with other patient care stakeholders.  Cerner Powerchart; exchange data with 8 external systems, e.g. OLIS, PRO, eCHN, HRM, HDIRS, ENITS, EMPI, IAR  Can have disparate systems, but need a single CDR

43. Nursing documentation (e.g. vital signs, flow sheets, nursing tasks/orders and electronic medication administration record (eMAR) are required; nursing notes, care plan charting, and are implemented and integrated with the CDR for at least one service in the hospital. The first level of clinical decision support is implemented to conduct error checking with order entry (i.e., drug/drug, drug/food, drug/lab conflict checking normally found in the pharmacy). Some level of medical image access from picture archive and communication systems (PACS) is available for access by physicians outside the Radiology department via the organization’s intranet.  Cerner for CDR and Clinical Decision support with integrated Multum; Agfa for PACS viewing internally and via VPN

44. Computerized Practitioner Order Entry (CPOE) for use by any clinician authorized to create orders in your state(s) is added to the nursing and CDR environment along with the second level of clinical decision support capabilities related to evidence based medicine protocols. If one patient service area has implemented CPOE with physicians entering orders and completed the previous stages, then this stage has been achieved. Need % of total physician orders entered by physicians, such as 1-25% etc.  Cerner Powerchart with 100% electronic orders for Day Surgery and Inpatients ◦ 57% orders entered by MDs directly ◦ 4% by telephone/verbal ◦ 17% from pre-authorized conditional and multi-phase orders ◦ 10% from approved medical directives ◦ 10% direct entry as per scope of practice (mainly pharmacists)

45. The closed loop medication administration environment is fully implemented. The eMAR and bar coding or other auto identification technology, such as radio frequency identification (RFID), are implemented and integrated with CPOE and pharmacy to maximize point of care patient safety processes for medication administration. You are satisfying the 5 rights of patient safety at the bedside and there is an override management process in place to review overrides that occur.  Cerner Powerchart; One nursing unit – Mental Health (40 beds) 2015  A big change in processes for Pharmacy – Unit dose, bar code labeling of all medications including paediatrics  Stage 7 requires: ◦ 95% of patients and 95% of medications have closed loop process for medications (includes ER admitted patients) ◦ Closed loop required for Blood Products and Breast milk

46. Physician Documentation- What percent of physicians use the physician documentation system? AND What percent of physician documentation in the inpatient setting (excluding ED) is captured from structured template physician documentation that generates discrete data and triggers an immediate electronic alert from the Clinical Decision Support application that produces clinical guidance real-time for the provider? NEED TO STATE THE RULE- GUIDANCE that is built into the application and if possible send a screen shot.  Cerner Powerchart Powernotes, Clinical Notes for direct entry ◦ 43% of physicians use the system ◦ 28% of the notes are structured documentation  Real time guidance example is Allergy documentation – back checking against the medication profile and BPMH

47.  Document resuscitation medications after the fact on eMAR  Anaesthesia medications documented on eMAR  Full Dose Range Checking for medications - adults and paediatrics  Diagnostic Imaging discrete results, e.g. abnormal, malignant as separate data fields  ER MDs use structured documentation to produce their notes  Cataract Surgery Order entry and MAR documentation  ECT documentation - replace current check sheet  Business Intelligence to support Quality Improvement for patient care  Patient Portal  Clinically relevant paper documentation must be scanned within 24 hours of creation