1. WW Hastings Indian Hospital BCMA (PSB 3*42) Deployment Site Visit March 24 – April 4, 2014

2. IHS RPMS EHR Deployment

3. BCMA Inpatient Deployment

4. Cherokee Nation WW Hastings Hospital BCMA Team Jamie Tapp, PharmD, Pharmacy IT Analyst, BCMA Project Lead Julie McCandless, ADN,RN, Nurse CAC, BCMA Coordinator Stacey Thornton, PharmD, Director of Inpatient Pharmacy, BCMA Co-Coordinator Krysten Knight, BSN, RN, Med/Surg Nurse Manager, BCMA Co- Coordinator Kari Barrett, PharmD, Director of Outpatient Pharmacy, BCMA Super User Tammy Schuman, BSN, ICU Nurse Manager, BCMA Super User Stefanie Walker, ADN, ICU/SD Charge Nurse, BCMA Super User Martin Goate, Information Technology Specialist Waylon Glass, Health Information System Administrator

5. 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 Wil Darwin, National Pharmacy Council Chair

6. 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 Barbara Connolly, Clinical 1 Support, OIT, VA

7. 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

8. Meaningful Use Criteria 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.

9. BCMA Configuration & Test Week One Lessons Learned Printers: current IV label printer is using an outdated print server that is no longer supported by DataRay and is generating IV labels that are not recognized by BCMA Printers: recommended that DataRay utilize standard IHS output for printing wristbands RN FINISH Configuration: required installation of routine PSIVORFB to allow nurse verification of IV orders in EHR RN FINISH Process: decided to change how this function could be better utilized to decrease burden to overnight nursing staff by only finishing medications to be given, finish orders as they are entered, and change the daily administration time from 0600 to 1000 Complex Medication Orders: identified various medication orders and order sets that may not have displayed as desired in BCMA

10. BCMA Week Two Training & Go Live Plan Friday – Training Preparation and Practice Session (10 Hours) Sunday – Afternoon Nursing Super User Training Sessions (4 hours) Monday – Morning and Afternoon Nursing Super User Training Sessions (4 hours Each), Pharmacy Evening Training Session (4 hours) Tuesday – Morning Nursing Super User Training Session (4 hours), Pharmacy Afternoon Training Session (4 hours) Wednesday – Morning Nursing Super User Training (4 hours), Afternoon BCMA Coordinator (4 hours) – Go Live Wednesday Evening – Troubleshooting Thursday – Debriefing, Go Live and Troubleshooting Continues Throughout Thursday and Friday Medication Passes (6:00 AM thru 10:00 PM): 19 hours on Wednesday and 16 hours on Thursday and Friday A Total of – 148 Training Encounters, of these 82 were Unduplicated Educational Encounters for Cherokee Nation WW Hastings Hospital

11. Cherokee Nation WW Hastings Hospital Training

12. BCMA Training

13. Cherokee Nation WW Hastings Pharmacy Session

14. BCMA Training Lessons Learned Delineate the 2 Nurse Verification Process for Insulin and address documentation concerns that will change throughout the Cherokee Nation Health System Identify Medication Orders with Multiple Administration Routes and Pharmacy to Use Comments to Show Possible Routes Identify IV Syringes prepared by pharmacy with route of SUBQ or IM and develop an alternate process of entering those orders so that they display in a safe manner in BCMA Electrolyte Replacement Orders are entered as PRN -- Nurses to Review Medication Therapy Report to View Electrolyte Replacement Doses Given

15. BCMA Training Lessons Learned Create Policies & Procedures to Align with New BCMA Processes: – Steps for using the “RN Finish Key” and second RN Order Verification in EHR – Bar code scanning and documentation for Patient Controlled Analgesia (PCA) – Each Nurse to View Missed Med & PRN Effectiveness Reports at Specified Shift Intervals – Identify Medications that Require “Comments” (e.g., “See Titration Protocol”, Insulin, Lab Values) Per Facility and Provide List for Nursing Users

16. Go Live Lessons Learned Nursing to Use Due List to Obtain Medications from Omnicell Nursing to Keep Virtual Due List Time Parameters Narrow Each Nurse and Nursing Team Lead to View Missed Medications, Due List, and PRN Effectiveness Reports at Specified Shift Intervals Nursing Team Lead to ensure that medication orders are verified prior to med pass Transfer of Outpatient to Inpatient Med Orders many times creates unable to scan situations within BCMA

17. Go Live Lessons Learned ER Medications are on Paper Resulting in Difficult Medication Reconciliation with High Risk for Errors BCMA Requires Real Time ADT to assure medication safety Incorporate BCMA Reports in Medication Error Review Committee and Root Cause Analysis Meetings and other PI activities WW Hastings BCMA Team to Meet Weekly to Discuss Scanning Failures/Troubleshooting and Provide Feedback to All Clinical Staff

18. Go Live Lessons Learned Pharmacy processes to troubleshoot scanning failures may include running various BCMA reports typically reserved for nursing Avoid configuration of electronic health software for reimbursement at the expense of patient safety and quality healthcare

19. Post Implementation Statistics Wristbands Medications Count Processed via Scanner 307 %Total Events 89.5% Scanner By-Pass 36 Keyed Entry (12) Unable to Scan Option (24) 10.5 3.5 7 Total Wristband Scan Events 343 Count Processed via Scanner 630 % Total Events 92.1% Scanner By-Pass 54 Keyed Entry (2) BCMA Unable to Scan (48) Vista Manual Med Entry (4) 7.9 0.3 7 0.6 Total Medication Label Scan Events 684

20. Thank You & Good Luck!