Pharmacy Informatics reference handbook
And now, on to my list of recommendations for BCMA implementation:
Pick a strong person to lead your implementation team. They’ll have to shoulder quite a bit and they need to be able to make decisions, stick to them, and hold others accountable.
Create an empowered multi-disciplinary team to work on the project.
Create an empowered multi-disciplinary team to work through issues following implementation.
Only meet when you have to. I hate meeting to decide when you’re going to meet.
Involve nursing early and often.
Make sure you have enough resources assigned to the project. I believe this is one of the most common mistakes that leads to project failure. If you don’t assign the proper resources to a project people will get spread too thin and things will get missed.
Remember: you’ve added something to your healthcare system and it will require maintenance and optimization. You need to have resources assigned and available to handle these two things. Don’t short change the BCMA system.
Identify key people to take ownership of the system once things start flying. In other words figure out who can help troubleshoot something once you go live.
Assign someone to analyze data coming from the BCMA system. If you chose not to have the data analyzed don’t even bother collecting it.
Only speak positively about the system in public. If you have to complain about something do it behind closed doors. People believe what they hear and a positive attitude goes a long way.
Be aggressive with your implementation timeline. Don’t sit on a project too long; it costs money and people get board.
Don’t “over plan”. You can’t plan for every possibility. Some people think you can, but I don’t think that’s realistic. Do what you can and implement. You’ll learn more during the first 3 months after implementation then you could ever learn by sitting around a table talking about what could go wrong. We agonized over our pharmacy automation much longer than we should have. A few months after implementation we ended up scrapping our original workflow in favor of a better one. Two years later and we’re still tweaking things. Be diligent in your preparation, but don’t go overboard. All you’ll do is make everyone uptight and drive yourself crazy.
Don’t be afraid to scrap something and start over. Not every idea translates well from paper to practice.
Don’t marry yourself to an idea. Just because someone else is doing something a certain way, doesn’t mean you have to. It’s always a good idea to get opinions from other facilities, but don’t force it into your system if it doesn’t makes sense for you.
Train nurses and pharmacists together prior to go-live, but not too far in advance. People tend to forget things soon after being taught when the lessons aren’t reinforced; out-of-sight, out-of-mind. I think it’s important for the pharmacists to see how the system works from the nurses point of view; it helps when barcode issues come up.
Create a list of FAQ for end users. These are typical questions that come up during training. It’s basically a list of “what ifs”.
Have lots and lots of “super users” available to help nursing during the initial implementation phase. This prevents people from getting frustrated with the system before they’ve had the change to use it correctly and efficiently.
Have a good downtime plan including a way to generate a paper MAR that isn’t too far out of date. We print a MAR to a holding queue every 60 minutes. Each time the MAR is generated it overwrites the previously stored version. If the system goes down we can print the MARs from the holding queue and the oldest they can be is 60 minutes.
Decide how to best use clinical prompting in the BCMA system, if available. There’s no need to give nurses alert fatigue with a new system. If you currently use a system to define sound-alike-look-alike meds, black box warnings, etc then consider not forcing the nurse to deal with it again in the BCMA system. For example: we use our ADCs to alert nurses of drugs with black box warning. When the nurse removes a black box med from an ADC they receive a pop-up window alerting them of what to look for. They acknowledge the alert and chose to remove the drug or not based on the information presented. It makes no sense to add the same pop-up message to the BCMA system. All you’ve accomplished by duplicating the waring is ensure that nurses will start ignoring the warnings.
Decide if you will chart in the BCMA system or elsewhere, not both. I’m talking about blood pressures, HR, finger sticks, etc. If your nurses already use a separate system to chart vitals don’t force duplicate documentation somewhere else. For example: our blood glucose monitors synch to our clinical nursing system. It makes no sense to have nurses enter the same blood sugar value in the BCMA system prior to administering insulin.
Don’t let just anyone re-print patient wristbands. If anyone can re-print a wristbands, then you’ll find them attached to clipboards, IV polls, guardrails on the beds, etc. Make it hard to do the wrong thing.
BCMA Hardware for nursing
I’m not a big fan of “hardware fairs”. Put a thousand nurses in an area with 20 different vendors and you’ll get 500 opinions on what hardware configurations should be used. On the other hand, use a small group of nurses to select a few vendors to evaluate and you’ve got something to work with.
Look at various solutions, i.e. in room devices mounted on the wall, laptops, tablets, computers on wheels (COWs), etc.
If you decide to go with COWs or tablet PCs consider: 1) your storage needs for the devices, 2) battery life and replacement, 3) your protocol for cleaning the devices that go from one room to another, and how to handle patients in isolation
Evaluate several types of barcode scanners, i.e. wireless, bluetooth, tethered. Look at different manufacturers. I’m a fan of Code Corp scanners myself, but would also recommend Honeywell.
Don’t skimp on the barcode scanners; this is the center piece of the barcode scanning workflow after all.
I still believe that the scanner you chose should be the same as the one
used in pharmacy. I’ve received some negative feedback regarding this opinion, but I’m sticking with the recommendation. A single vendor means one support system to deal with, one set of hardware configurations, fewer questions trying to decide if it’s the hardware or the barcode and the ability to instantly pick up a scanner and use it anywhere in the hospital.
Evaluate your wireless coverage throughout the hospital if you chose to go with wireless devices. Nothing is worse than pushing a wireless COW into a patient care area only to find out you can’t connect to the hospital network. I don’t care how great the system is, at that point the COW becomes a doorstop.
Make sure you have enough electrical outlets and network access points.
Take the opportunity to clean up your pharmacy formulary
Standardize the nomenclature in your pharmacy system, i.e. tablet, capsule, etc
Take a long hard look at your latin sig file. Pharmacists tend to use a lot of unnecessary latin sigs. Create a standard list along with standardized administration times. You should already have standardized sigs and administration times, but if you don’t get it done now.
Get rid of as many non-formulary items as you can.
Consider how you’re going to handle the following:
pediatric syringes. are you going to use dose specific barcoding or drug identification only.
insulin. patient specific vials or pens or a third option
premixed IVs. Are you going to have nursing scan the product barcode or the pharmacy generated barcode
chemotherapy
Get everything in the pharmacy barcoded. This is key. You may have to use a combination of systems. You will need a way to barcode everything from bulk tablets to injectable vials to pediatric syringes. We use a complete automated packaging and labeling solution from Talyst, but there are others out there that offer similar services. Medical Packaging Inc offers a simple label solution; m:Print bar code label software from PearsonMedical is another. Even with all of our high-tech labeling equipment we ended up using Microsoft Word, a bunch of Avery return address labels and a free on-line linear barcode image creator at IDAutomation.com, Inc for certain items. That simple solution actually worked better than our multi-thousand dollar system in a couple of situations where we needed a barcode image without the lot and expiration data on the label. Go figure.
Think about oddball medication in the pharmacy that may require a unique solution like unit dosed respiratory therapy drugs, levalbuterol, budesonide, etc, ampules, bulk tablets, etc.
Scan everything in the pharmacy to make sure they are in your system. In fact, I recommend you do it twice.
Scan everything in the automated dispensing cabinets on the pilot unit a few days before you go live. I thought we had everything well in hand until I scanned the items in our ADCs and found a couple of meds by manufacturers we hadn’t purchased in several months. The meds were still in date, but not in the system.
Develop a system to deal with medications that have no barcode, won’t scan or scan as the wrong drug. No matter how diligent you are items will slip through the cracks; better to have a system in place than to be caught with your pants down.
Cross train everyone in the pharmacy to troubleshoot barcoding issues. Trust me, you’ll regret it if you don’t.
Creation and adherence to workflows make the transition to a new pharmacy information system easier. Workflows clearly define steps related to verification, preparation, dispensing and sometimes administration of medications.
Some examples include (in no specific order):
1. Conditional medication ordering
2. Discharge medication ordering and dispensing
3. Dispensing extra or missed doses
4. Dispensing inpatient chemotherapy medications
5. Dispensing variable rate and bulk products
6. Documenting medications administered in the past
7. Expiring medication orders
8. Clinical monitoring and documentation
9. Patient transfers
10. Investigational medications
11. Managing medication charges
12. Multi-route medication ordering
13. Nursing communication to pharmacy
14. Pended and held medications
15. Prior to discharge orders
16. Pharmacist documentation and communication
17. Pharmacy interventions
18. Taper order entry and administration
19. Ambulatory infusion orders
20. Charging for bulk medications
21. Crediting medication charges
22. Dispensing first doses
23. Therapeutic substitutions
24. Pharmacist documentation of height and weight
25. Allergy documentation
26. Medication reconciliation at admission, discharge, and transfer
27. Non-formulary ordering
28. Adjusting administration times
29. Cart fill/batch printing
30. General and prn medications
31. Order verification
32. Patient supplied medications
33. Advanced preparation of medications
34. Bolus medication ordering
35. Compounding medications
36. Dispensing home health medications
37. Dispensing respiratory medications
38. Dispensing TPNs
39. Medication list management
40. FDB/Medispan/Multum update maintenance
41. Medication build
42. NDC replacement maintenance
43. Pharmacist order resolution
44. Overriding medication charges
45. Pharmacist in Training (order entry, no verification)
46. Ordering titratable medication
47. Ordering stat medication
48. Pharmacist rounding
49. Pharmacist to physician communication
50. Pharmacist to pharmacist communication
51. Pharmacy consult orders
52. Protocol medication ordering
53. Repackaging medications
54. Reprinting labels
The Pharmacist’s Guide to Meaningful Use
What is Meaningful Use?
At the legislative level, Meaningful Use(MU) is a proposed rule created by CMS to implement the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA). It establishes criteria to promote the adoption of meaningful use of technology in healthcare. The primary goals are to improve the quality and value of healthcare in the United States through the use of technology such as electronic health records (EHR), computerized provider order entry (CPOE), medication reconciliation tools, and clinical decision support (CDS). It should be noted that as of 3/8/2010, the rule is not final. In addition, there may be incentives from CMS if your organization chooses to implement these criteria. More information on Health Information Technology is available at the CMS website (http://www.cms.hhs.gov/Recovery/11_HealthIT.asp).
Improving quality, safety, efficiency, and reduce health disparities
Objective: Use of CPOE for orders (any type) directly entered by authorizing provider (for example, MD, DO, RN, PA, NP)
Measure: CPOE is used for at least 10 percent of all orders
The RPh: Implementation of CPOE, building and maintenance of medication orders and order sets to support its use by physicians. This can require a significant number of pharmacy resources that are trained to configure the EHR for use.
Objective: Implement drug-drug, drug-allergy, drug- formulary checks
Measure: The eligible hospital has enabled this functionality.
The RPh: Pharmacy plays a critical role in management and analysis of medication alerts in the EHR. This objective only requires that it be turned on. However, most institutions choose to make the information truly meaningful to physicians and pharmacists by analyzing and fine tuning the alerts. Various studies have shown over 50% of the severe interactions shown to providers are not clinically significant. The numbers are higher for moderate and mild alerts. Consequently you may want to design a process to review overridden alerts on a monthly/quarterly basis to eliminate the unwanted alerts from firing. This requires resources to review the data.
Hospital Objective: Maintain active medication list.
Measure: At least 80 percent of all unique patients admitted by the eligible hospital have at least one entry (or an indication of “none” if the patient is not currently prescribed any medication) recorded as structured data.
The Rph: Medication Reconciliation processes vary widely per institution. Some use nurses, physicians, patient care technicians, pharmacy technicians, or pharmacists to perform reconciliation. This objective requires medication reconciliation on admission, and does not address transfers or discharges. The Joint Commission requires medication reconciliation in all areas. As stewards of medication use, the pharmacy is often involved the design and workflow processes for medication reconciliation.
Objective: Maintain active medication allergy list.
Measure: At least 80 percent of all unique patients admitted to the eligible hospital have at least one entry (or an indication of “none” if the patient has no medication allergies) recorded as structured data.
The RPh: Maintenance of medication allergies varies with institution. Some have separate pharmacy, eMAR, or EHR systems resulting in separate databases. This can create synchronization issues if different data types are used in each (“high” in one system might be “severe” in another). Identifying these challenges can help design and reconfigure existing systems to ensure compliance. In addition, pharmacists may want to consider mandatory allergy review, but this is not a requirement for MU.
Objective: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach
Measure: Generate at least one report listing patients of the eligible hospital with a specific condition.
The RPh: This may or may not involve pharmacy, depending on what conditions and quality measures are chosen. If they are medication use related, the pharmacy may need to provide resources to help design and develop the reports.
Objective: Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules
Measure: Implement five clinical decision support rules relevant to the clinical quality metrics the Eligible Hospital is responsible for as described further in section II.A.3.
The RPh: Clinical decision support is considered by many Informatics professionals to be one of the biggest benefits of implementing an EHR. These rules do not have to be medication based, but many great examples include medication-lab or medication-disease rules. An example might be to design an alert that warns a physician if they order warfarin with no accompanying INR on file in the last 24 hours. If medication use rules are chosen, the pharmacist will play a pivotal role in their design and implementation.
Engage patients and families in their healthcare
Objective: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, allergies, discharge summary, and procedures), upon request.
Measure: At least 80 percent of all patients who request an electronic copy of their health information are provided it within 48 hours.
The RPh: This objective implies the use of the internet or similar electronic tools to provide the patient online access to their medical information. Many EHR vendors provide these patient portals as part of their system. The Pharmacist might be involved in the design and policy review process anytime medication information is shown to patients.
Improve coordination of care
Eligible Hospital Objective: Capability to exchange key clinical information (for example, discharge summary, procedures, problem list, medication list, allergies, diagnostic test results), among providers of care and patient authorized entities electronically.
Measure: Performed at least one test of certified EHR technology's capacity to electronically exchange key clinical information.
The RPh: This objective implies your institution can electronically transmit a medication list to another hospital or provider if requested. Some EHR vendors provide this functionality in their systems already. Consequently, pharmacist involvement may be required to design and develop medication related communication to other systems.
Objective: Perform medication reconciliation at relevant encounters and each transition of care.
Measure: Perform medication reconciliation for at least 80 percent of relevant encounters and transitions of care.
The RPh: Similar to medication reconciliation on admission, this objective requires reconciliation if the patient is transferred to a different level of care (e.g. medicine ward to ICU). As stewards of medication use, the pharmacy is often involved the design and workflow processes for medication reconciliation. Transfer reconciliation differs from admission, because it only involves hospital ordered medications. The pharmacist may need to consider this when designing the transfer workflow.
Improve population and public health
Objective: Capability to submit electronic data to immunization registries and actual submission where required and accepted.
Measure: Performed at least one test of certified EHR technology's capacity to submit electronic data to immunization registries.
The RPh: Depending on governance at your institution, immunizations may fall under partial responsibility of the pharmacy for because they are often maintained as medication orders. However, this objective addresses the “immunization administration log” in the system. The pharmacy may need to be involved in its design if they maintain the drug records in the EHR.
Ensure adequate privacy and security for personal health information
Objective: Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.
The RPh: This is often controlled by the HIPAA security officer at your facility, representing an important reminder to pharmacists for protection of patient information. Please remain diligent, following applicable standards and policies set forth by your institution. In addition the pharmacist may want to consider privacy when designing any of the objectives of Meaningful Use.
Reporting of provider clinical quality measures electronically to CMS from your EHR
These clinical quality measures encompass a wide range of medical specialties, including Endocrinology, Primary Care, Cardiology, Pulmonology, Oncology, Obstetrics and Gynecology, Psychiatry, Radiology, Ophthalmology, Procedures/Surgery, Neurology, Pediatrics, Nephrology, Gastroenterology, Podiatry, and core measures (Blood pressure for example).
These proposed clinical quality measures include criteria such as “Percentage of patients aged 18-75 years with DM who had most recent HbA1c >9.0%”. An complete list can be viewed at http://www.cms.hhs.gov/PQRI/20_AlternativeReportingMechanisms.asp#TopOfPage.
Your EHR would need to capture this information and submit it to CMS at the interval required. In order to qualify, the Electronic Provider would need to submit information on just two of the core measure groups (inquiry for tobacco use, blood pressure, etc) and just one of the specialty measure groups (cardiology, endocrinology, etc). You can review these in detail on page 142 of the proposed rule.
Depending on which measures your organization chooses, the Pharmacy may or may not be involved in the process.
The RPh: The pharmacist may be involved in development of medication related reports or electronic communications to CMS. Identification of specific medication records in the EHR for report generation is an area where pharmacist may be required to provide resources. The pharmacy may also be involved in committees that implement and monitor clinical quality measures (e.g. Pharmacy and Therapeutics, Medication Use Safety).
Reporting of hospital clinical quality measures electronically to CMS from your EHR
Unlike provider measures, ALL of the measures for hospitals must be submitted electronically for payment year 2012. They must be attested to (provide data if they ask) by the end of the 2011 payment year. These are proposed on page 153 of the proposed rule, with “Emergency Department Throughput; median time from ED arrival to time of departure from the emergency room for patients admitted to the facility via the ED”. The method of electronic submission has not been finalized.
Many of these hospital measures were adopted from The Joint Commission, such as “Ischemic Stroke - Thrombolytic therapy for patients arriving within 2 hours of symptom onset” or “Platelet monitoring on unfractionated heparin.”
Specific classes of medications included in the measurements are: antithrombotics, anticoagulants, thrombolytics, antihyperlipidemics, antiplatelets, ACEI/ARBs, Beta-blockers, and antibiotics.
The RPh: Like provider measures, the pharmacist may be involved in hospital quality reporting to CMS. Because all of these measures are required, it is more likely the pharmacist will be involved in the process.
Remember MU as proposed pertains to Medicare and Medicaid. It is not currently required for private insurers. However, interoperability of electronic personal health information in the US may push legislation into all healthcare sectors.