September 16, 2009 Douglas S. Wakefield, PhD.

1. Implementing Shared Formulary and E-based Medication Order Review to Create “Closed Loop” Medication Process in Critical Access Hospitals September 16, 2009 Douglas S. Wakefield, PhD.

2. This work was supported in part by AHRQ grant #UC1HS016156 – “EHR Implementation for the Continuum of Care in Rural Iowa” , University of Iowa Center for Health Policy and Research, and the University of Missouri Center for Health Care Quality. • Research Team: • Marcia M. Ward, Jean Loes, John O’Brien, Douglas S. Wakefield

3. Agenda • CAH Challenges in Improving Medication Processes • CAH Network Approach to Implementing Shared Formulary and 24x7 Pharmacist Review of Medication Orders • Open vs. Closed Loop Medication Processes … Theory to Practice

4. Errors in the Medication Cycle Ordering Transcribing Dispensing Administering Medication Management Processes • Wrong Dose • Wrong Route • Wrong Patient • Wrong Time • Incorrect Labeling/ Drug ID • Primary catch for Allergy, Drug Interaction, • Wrong Patient • Wrong Dose • Wrong Drug, • Wrong Time/ Omitted • Wrong Route • Frequently Involves Infusion Pump • Wrong Dose • Wrong Drug • Wrong Route/Form • Allergy, Drug Interaction E R R O R S • WrongDose • Wrong Route • Wrong Patient • Wrong Time • Wrong Drug Percent of Errors 39% 12% 11% 38% Intercept Rate19%3%4% 1% True Error Rate 20% 9% 7% 37% Lucian Leape, et.al., JAMA, Volume 274, 1995

5. IHI Suggestion for Improving Medication Processes are Challenges for All Hospitals • Ensure allergy information accompanies patients • Use Drug Interaction Software • Pharmacists review of all medication orders • Provide reference materials at point of care • Make allergy information available • Place pharmacists in patient care units • Connect medication orders to lab results http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Changes/Improve+Core+Processes+for+Ordering+Medications.htm

6. Additional Challenges facing Critical Access Hospitals’ • Availability of Pharmacists • Pharmaceutical Expertise • Order Review Prior to Administration • Nurse Must Dispense Medications • Access to Patient-Specific Information when needed (Ordering, Dispensing, Administration) • Fragmented / Disconnected Workflow Processes • Reliance on Paper / Handwritten Documentation • Financial Resources • Information Technology Expertise & Resources

7. Open vs. Closed Loop Processes to Improve Safety • Open Loop Processes: • Traditional process • Sequential tasks • +/- Asymmetry in access to information • +/- Monitoring & Feedback

8. “Open Loop” Information Handoffs Create Uncertainty and Opportunity for Poor Quality and Error!

9. Closed Loop Processes to Improve Safety • Closed Loop Processes: • Goal is connected and non-fragmented processes • Sequential tasks • Symmetry in access to needed information • Built in monitoring and feedback • Information technology integrated into workflow

10. “Closed Loop” Continuously Links Information Process and Automatically Provides Automatic Monitoring Enables Continuous Data Access & Monitoring Enables Continuous Data Access & Monitoring Enables Continuous Data Access & Monitoring Enables Continuous Data Access & Monitoring

11. Case Study of Seven CAHs and a Rural Referral Hospital’s Collaboration to Implement “Closed Loop” Medication Processes • Methodology: • Document Reviews • Interviews • Collaborative Planning Began Late 2006 • Collaborative Implementation s 2008 & 2009

12. Trinity System

13. Mercy Health Network – North Iowa Buffalo Center Lake Mills Stacyville Kossuth Lime Northwood Winnebago Springs Mitchell St. Bancroft Riceville Forest City Ansgar Worth Cresco Osage Howard Graettinger Cerro Gordo Hancock Floyd Chickasaw Wesley Clear Lake Garner Palo Alto 2 11 Mason City Emmetsburg Britt Rockford New Hampton Algona Rockwell Kanawha West Bend Sheffield Belmond Greene Franklin Wright Latimer Dumont Hampton Dows Butler Hardin Ackley Affiliated and Contract Managed Hospitals with Mercy - North Iowa Iowa Falls Mercy Clinics Physician-Hospital Organizations April 8, 2008 PHO Affiliated Clinics

14. Coordinated Planning & Implementation • Cohort Approach to Planning & Implementation • EHR, CPOE, Lab, Radiology, Pharmacy Systems • Technology Enabled Devices: • Automated Dispensing, BCMA • Shared Formulary • 24x7 Pharmacist Medication Order Reviews

15. Rationale for Shared Formulary • Expand evidence-based formulary content • Create shared knowledge base and formulary content for subsequent HIT implementation • Standardize the pharmacy system IT build • Facilitate remote pharmacist reviews

16. Shared Formulary Process Steps

17. Summary of Formulary Changes

18. Rationale for 24x7 Pharmacist Medication Order Review • Medication orders not reviewed • Rural pharmacist supply constrained • Nurses dispensing medications from pharmacy

19. Network Pharmacy Hours 2007

20. “Closed Loop” Continuously Links Information to Process and Automatically Provides Automatic Monitoring Enables Continuous Data Access & Monitoring Closed Loop Requires Integration of HIT within Workflow … How was this Done? Enables Continuous Data Access & Monitoring Enables Continuous Data Access & Monitoring Enables Continuous Data Access & Monitoring

21. CAH Case Study

22. CAH Case Study

23. CAH Case Study

24. CAH Case Study

25. CAH Case Study

26. Network Pharmacist Hours: Post-Remote Pharmacist Reviews

27. 3-month comparison 5896 3267 1544 596 698 649 682 323 100 79

28. Ongoing Journey Continuous Improvement • Regional P&T Committee • Remote Rx Order Review Costs & Performance • ADC Transition to full “Profile Mode” • Process Monitoring: • CPOE Order Rates • ADC Overrides • BCMA Scanning Rates • HIT Updating and Integration with Workflow

29. Questions?

30. HIT-Based After Hours, Weekend and Holiday Pharmacist Review Process for CAH

31. 3-Month Comparison Chart 1544 649 5896 596 3267 323 682