REMOTE MEDICATION ORDER ENTRY in Rural Minnesota by: Mike Dudzik RPh, MHA

1. REMOTE MEDICATION ORDER ENTRYinRural Minnesotaby: Mike Dudzik RPh, MHA Minnesota Rural Health Conference Smart Health 2006: Focus on Technology

2. OUR PARTNERS SISU MEDICAL SYSTEMS • A consortium of 14 rural healthcare facilities • They work together as non-profits to share IT resources

3. OUR PARTNERS

4. OUR PARTNERS

5. WILDERNESS HOSPITALS • Mercy Hospital in Moose Lake • Riverwood Healthcare Center in Aitkin • Community Memorial Hospital in Cloquet • Lakeview Memorial Hospital in Two Harbors • Cook Hospital in Cook • Deer River Health Center in Deer River • Big Fork Valley Hospital in Big Fork • Ely-Bloomenson Hospital in Ely

6. GOALS • Learning about our partners • To discuss the AHRQ grant process • To explain the components of the grant • To understand the difference between telepharmacy and After Hours Order Entry • To explain the Board of Pharmacy’s position

7. GOALS • For hospital administration to better understand why this is not just “another” expense • To understand the nuts and bolts of this service • How after hours and telepharmacy do improve patient safety while reducing medication errors • How will we measure this improvement in safety

8. GOALS • Are After Hours OE and/or telepharmacy needed in LTC settings also?

9. THE GRANT PROCESS • AHRQ: Planning and an IT Grant • A grant writer from Health Planning and Management Resources was hired • Administrators from the Wilderness Hospitals, St Luke’s, UMD and SISU met many times • The grant provided $1.5 Million to be matched by the participating hospitals and partners

10. COMPONENTS OF THE GRANT • After Hours Order Entry • Telepharmacy video cameras • Vacation replacement for pharmacists • CEU’s via videoconferencing • POS bedside barcode scanning • A QA tool to measure improvement in safety

11. TELEPHARMACY VS AFTER HOURS • Telepharmacy involves the use of video cameras to verify medication orders, drug package sizes, strength correctness, to identify a dosage form or to fill “retail” prescriptions at remote sites Example: No Dakota College of Pharmacy • After Hours Remote Order Entryis the process where a “hub” hospital pharmacy department enter medication orders directly into the remote hospital’s PIS

12. BOARD OF PHARMACY • The current pharmacist shortage is severe nationally and most severe in rural communities • Many rural hospitals do not have a FT pharmacist • Some have coverage from several hours, up to 12 or more hours daily, no coverage on weekends, nights or holidays • Pharmacy Boards see After Hours and telepharmacy as a means to address a dangerous lack of pharmacist manpower and to improve the safety of patients

13. BOARD OF PHARMACY REQUIRES: • Annual variance • HIPPA Business Associates agreement • Hub and remote sites policies and procedures • Copy of each sites drug formulary • Pharmacist final review of order and patientprofile • Measurement of quality provided • Not a replacement for vacations or sick time • Hours of operation

14. ASHP AND JCAHO PROPOSAL States: That when a health care facility’s on-site pharmacy is open less than 24 hours a day, the hospital makes arrangements for a pharmacist review of all medication orders when their pharmacy is closed. Currently the requirement specifies that a “qualified” health care professional review the orders in the pharmacists absence.

15. NUTS AND BOLTS OF AFTER HOURS • Utilizing the same Meditech IT platform- advantages • Performing the service out of a 24/7 hospital pharmacy • Specially trained certified pharmacy OE technicians • Additional pharmacist staff added during critical hours • Cross utilization of all pharmacy staff for productivity • “Emergency” use of pharmacists at home for OE

16. NUTS AND BOLTS • Keep the service affordable and flexible for members $8-12.00 per hour based on volume • Currently After Hours enters: 90-300 orders per day 4000 orders per month • St Luke’s keeps a notebook for each hospital with order sets, preferences, etc for reference • Currently testing telepharmacy video equipment • Developing website for all hospitals to share

17. MEDICATION SAFETY IMPROVED • A pharmacist reviews/approves all medication orders when the remote pharmacy is closed • Nursing has direct access to a hospital trained pharmacist 24/7 • 5 R’s of medication administration are verified • Allergies checked against patient’s current meds

18. MEDICATION SAFETY IMPROVED • Food drug allergies are checked • Elimination of drug class duplications of therapy • Drug appropriateness verified • Medication and IV labels can be printed by hub • Automatic printing of computerized MARs by hub • Timely review of orders prior to administration Goal= 15-45 minutes • Use of “clinical messages” for communication and QA measurement

19. QUALITY MEASUREMENT BY UMD “Quality Assurance” survey will measure: • Any change in medication error rate • Any time lag between orders written and administered • The level of staff satisfaction with after hours service versus normal hours of operation • The quantitative and qualitative measurement of clinical interventions • Any change in appropriate drug use and dosing • Any change in “first doses” given before RPh review

20. OTHER OPPORTUNITIES • Is there a need telepharmacy for small towns with limited drug stores and/or hours of operation? • Is After Hours OE only needed during certain hours? • Is After Hours OE needed for LTC facilities? • Should we combine our resources to create a Minnesota “hub OE center” for telepharmacy and After Hours OE for all of Minnesota? • Can pharmacists work with the BOP to allow After Hours OE from pharmacists at home?

21. OTHER OPPORTUNITIES • Keep the service fees affordable without losing money • Keep our services housed in Minnesota • Standardize the definition and measurement of “quality”

22. OTHER PROVIDERS • Rx e-source by Cardinal Health- 4 regional hubs in the USA (non-hospital based) • Fairview Northland Hospital currently does OE for Fairview Red Wing (hospital based) Bruce Thompson, RPh,MS bthomps4@fairview.org 763-389-6625 • E-PharmPro,Inc currently recruiting and advertising in Minnesota www.pharmPro-Inc.com 800-659-7440

23. FOR MORE INFORMATION Mike Dudzik, RPh, MHA, Dir of Pharmacy St Luke’s Hospital Duluth, MN 55811 mdudzik@slhduluth.com 218-249-5621

24. THANK YOU!

25. TelePharmacy in Minnesota Many Models

26. After hours order entry is a good thing for a small hospital Pharmacist • Medication orders are reviewed and entered into our patient care system • Allergies are entered, MAR’s are printed, problems orders are handled if necessary • Morning “clean up” is much quicker • Patients get morning meds sooner

27. Pharmacy Automation makes it better • We don’t have Acudose/Pyxis/Omnicell cabinets • With cabinets nurses rarely needs to enter Pharmacy at night • New JCAHO medication standard July 1 2006 • Only Pharmacists may enter Pharmacy

28. Accurate MARs • Computer generated Medication Administration Records are priceless to Nursing after hours • Clinical notes appear on MARs to get problem orders clarified

29. TelePharmacy models in MN • Mostly retail Pharmacies • Technician at remote site with drugs • Audio and Video connection to main Pharmacy • Usually share computer system with main Pharmacy • Pharmacist does drug use review and checks med and label

30. TelePharmacy models in MN • Usually low volume remote sites • Some remote sites have prepacked med that are released from cabinet by main Pharmacy • Drop stations where prescriptions are picked up and patients counseled face to face or by phone

31. TelePharmacy models in MN • Prepacked meds are taken to remote clinic sites and dispensed by Physicain/provider • Instymed machines in ERs and clinics are considered Physician dispensing

32. Board of Pharmacy Our primary role is to protect the public Telepharmacy should not replace the face to face interactions of a Pharmacist and patient. Technology and the marketplace change much faster than legislation and regulation

33. Thank You