VeHU 212 - Medication Reconciliation The Good, The Bad, and The Ugly

1. VeHU 212 - Medication Reconciliation (The Good, The Bad, and The Ugly) Jennifer M. Blanchard, PharmD, BCPS Blake Lesselroth, MD, MBI Rob Silverman, PharmD John W. Triplett, RPh, PhD

2. 2 Objectives Background data on medication errors Review IHI 100,000 Lives Campaign Review Joint Commission Safety Goal 8 Define medication reconciliation Technology and its limitations Regional software development Lessons learned Solution strategies and future interventions

3. 3 Frequency of Medication Errors Incomplete histories can undermine our ability to deliver comprehensive care Inaccuracies in medication documentation lead to prescribing errors, clinical harm, and measurable adverse outcomes Medication errors are the most common type of healthcare error The Institute of Medicine reports that a hospitalized patient can expect on average to be subjected to more than one medication error each day. Preventable hospital-based ADEs add an estimated $8,700 (2006 dollars) to the cost of a hospital stay. Institute of Medicine, Preventing Medication Errors Pronovost et al., J of Crit Care, 2003 Forster et al., Ann Int Med, 2003

4. 4 When Errors Occur Transition points and interfaces in care are common areas where clinical errors occur When patients are moved from one care setting to another or from one provider to another, they are particularly vulnerable to medication errors Joint Commission International Center for Patient Safety reports that communication of medical information at transition points of care have been cited as a major cause of medication errors. It has been estimated that 46% of medication errors occur during a patient�s admission to or discharge from a clinical unit and/or hospital. Rozich et al. Jt Comm J Qual Patient Saf, 2004 Vira et al. Qual Saf Health Care, 2006

5. 5 100,000 Lives Campaign Institute for Healthcare Improvement announced the 100,000 Lives Campaign in December of 2004, a national initiative to involve thousands of US hospitals in an effort to prevent 100,000 needless inpatient deaths through improvements in care. IOM estimates as many as 98,000 people die each year in US Hospitals due to medical injuries. Institute for Healthcare Improvement �Between the health care we have and the care we could have lies not just a gap, but a chasm.� Health care does not yet reliably transfer best-known science into action, and processes frequently fail, despite the best intentions of a dedicated and highly skilled workforce.� Our system, which intends to heal, too often does just the opposite � leading to unintended harm and unnecessary deaths at alarming rates. The 100,000 Lives Campaign is a nationwide initiative�launched by�the Institute for Healthcare Improvement (IHI) to significantly reduce morbidity and mortality in American health care. Building on the successful work of health care providers all over the world, we are introducing proven best practices across the country to help participating hospitals extend or save as many as 100,000 lives. With your help, IHI and its partners in this work believe it�s possible to achieve this in 18 months (January 2005 through June 2006) and in every year thereafter. Motto: Some is not a number, Soon is not a time ��Between the health care we have and the care we could have lies not just a gap, but a chasm.� Health care does not yet reliably transfer best-known science into action, and processes frequently fail, despite the best intentions of a dedicated and highly skilled workforce.� Our system, which intends to heal, too often does just the opposite � leading to unintended harm and unnecessary deaths at alarming rates. The 100,000 Lives Campaign is a nationwide initiative�launched by�the Institute for Healthcare Improvement (IHI) to significantly reduce morbidity and mortality in American health care. Building on the successful work of health care providers all over the world, we are introducing proven best practices across the country to help participating hospitals extend or save as many as 100,000 lives. With your help, IHI and its partners in this work believe it�s possible to achieve this in 18 months (January 2005 through June 2006) and in every year thereafter. Motto: Some is not a number, Soon is not a time �

6. 6 Campaign cont. The core of the campaign involved participating hospitals committing to make changes that have been proven to prevent death. These changes included the following: Deploy Rapid Response Teams Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction Prevent Adverse Drug Events Prevent Central Line Infections Prevent Surgical Site infections Prevent Ventilator-Associated Pneumonia It think it is important to note, that the initial results of the 18 month challenge have been reported and the IHI is pleased to report that it has exceed it goal of saving 100,000 lives, thanks in part to such a huge response from US hospitals. It is estimated that 80% on all US inpatients, now receive there care from a facility willingly participating in this campaign. As a result, the estimated # of needless deaths prevented as a result of the implementation of the above changes is 122,300.It think it is important to note, that the initial results of the 18 month challenge have been reported and the IHI is pleased to report that it has exceed it goal of saving 100,000 lives, thanks in part to such a huge response from US hospitals. It is estimated that 80% on all US inpatients, now receive there care from a facility willingly participating in this campaign. As a result, the estimated # of needless deaths prevented as a result of the implementation of the above changes is 122,300.

7. 7 Campaign cont. The prevention of adverse drug events (ADE�s) involved the implementation of a Medication Reconciliation system for inpatients. Reconciliation must occur not only at admission or discharge, but also during any transition point in care (Example: transfer from MICU to the floor).

8. 8 Campaign cont. Poor communication of medical information and information gaps at transition points-in-care may account for up to 50 percent of all medication errors Errors of omission and information gaps in the medication history may account for up to 20 percent of adverse drug events in the hospital Several studies have shown that the implementation of simple standardized reconciliation forms can have a five-fold reduction in errors Each time a patient moves from one setting to another, clinicians should review previous medication orders alongside new orders and plans for care, and reconcile any differences Institute for Healthcare Improvement

9. 9 Campaign cont. Institute for Healthcare Improvement has progressed from 100,000 Lives Campaign to the 5,000,000 Lives Campaign, which officially started December of 2006. 5,000,000 Lives Campaign challenges participating hospitals to adopt 12 changes in care that save lives and reduce patient injuries One of the changes advocated was medication reconciliation across the continuum of care to prevent adverse drug events Institute for Healthcare Improvement

10. 10 The Joint Commission Safety Goal The Joint Commission in keeping with the times and all the attention being focused on the prevention of medication errors, officially added Medication Reconciliation to the patient safety goals in 2005. It remained on the list in 2006 and is included in the 2007 and 2008 lists. ( It�s not going to go away!). The goals highlight problematic areas in health care and describe evidence and expert-based consensus to solutions to these problems. Recognizing that sound system design is intrinsic to the delivery of safe, high quality health care, the goals generally focus on system-wide solutions, wherever possible. -from the 2007 patient safety goal manual, critical access The goals highlight problematic areas in health care and describe evidence and expert-based consensus to solutions to these problems. Recognizing that sound system design is intrinsic to the delivery of safe, high quality health care, the goals generally focus on system-wide solutions, wherever possible. -from the 2007 patient safety goal manual, critical access

11. 11 Joint Commission Safety Goal 8 Accurately and completely reconcile medications across the continuum of care. 8A Implement a process for obtaining and documenting a complete list of the patients current medications upon the patient�s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. Joint Commission International Center for Patient Safety

12. 12 Joint Commission Safety Goal 8 cont. 8B A complete list of the patients medications is communicated to the next provider of service when it refers or transfers a patient to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility. Joint Commission International Center for Patient Safety

13. 13 Medication Reconciliation - Steps Engage the patient Assemble a medication and allergy history Compare against any recorded lists Compare medications with new orders anticipated in next care context Reconcile discrepancies Update changes throughout episodes of care Document the reconciled list and distribute to patient and/or caregiver Unfortunately with electronic records, many health care providers, including ourselves, miss this step. I have spoken to many of the inpatient medical staff and asked them point blank how they get there med list for inpatients. The majority of the time, the answer is �I transfer the outpatient meds to inpatient�. They do not talk to the patient and often times they don�t even read the medications, which is why we some times end up with rx�s for vardenafil upon admission. While I will be the first to admit that, I love the computer and couldn�t imagine going without it, I also feel that it has effectively removed the patient from the picture in some cases, namely at admission and discharge. My guess is this is also a problem in the outpatient setting as well.Unfortunately with electronic records, many health care providers, including ourselves, miss this step. I have spoken to many of the inpatient medical staff and asked them point blank how they get there med list for inpatients. The majority of the time, the answer is �I transfer the outpatient meds to inpatient�. They do not talk to the patient and often times they don�t even read the medications, which is why we some times end up with rx�s for vardenafil upon admission. While I will be the first to admit that, I love the computer and couldn�t imagine going without it, I also feel that it has effectively removed the patient from the picture in some cases, namely at admission and discharge. My guess is this is also a problem in the outpatient setting as well.

14. 14 What is a medication? Prescription medications, sample medications, and over-the-counter agents Vitamins, herbals, and neutraceuticals Vaccines, diagnostic and contrast agents, radioactive medications Parenteral nutrition, blood derivatives, IV solutions Any product designated by the FDA as a drug Joint Commission International Center for Patient Safety

15. 15 When must reconciliation occur? Whenever a patient moves to another setting, service, practitioner or level of care within or outside the organization Any time medication orders will be written or medications will be used in a treatment plan Any time the affect of a medication or the presence of a medication sensitivity may impact a treatment plan

16. 16 Where should reconciliation occur? Inpatient Outpatient Urgent care Episodic ambulatory care Imaging, procedural, and ancillary settings Home based encounters

17. 17 The Role of Technology Complex medication lists impede clinic throughput and increase likelihood of cognitive errors Electronic record systems can accurately aggregate fragmented or distributed medication lists Information technology can be used to create independent and redundant error checking systems Automation can support reconciliation by providing a structured and uniform approach to data management and workflow processes

18. 18 Current Technology Limitations within the VA System Comparable to other mature electronic health record systems Fragmentation of data across multiple views Episodic orientation may confound representation of a continuum of care May not embed well within existent processes of care Significant cognitive overhead associated with electronic health record interfaces

19. 19 Regional Software Development In light of the technological difficulties with the current software previously highlighted, many facilities have taken it upon themselves to develop regional software in order to implement new Medication Reconciliation process consistent with JCAHO safety goal #8

20. 20 Regional Software cont. 4 facilities solution strategies will be highlighted. Cincinnati VA Medical Center Hines VA Hospital Portland VA Medical Center Miami VA Healthcare System Strategies range in complexity and degree of technical support needed to implement and maintain.

21. Cincinnati VA Medication Reconciliation Tools Jennifer M. Blanchard, PharmD, BCPS

22. 22 Cincinnati VAMC Outpatient Medication Reconciliation process involves the use of Class III software that was originally developed at the Tucson, AZ VA by Donald Watkins. Creates a patient friendly large print medication calendar that can be used for Medication Reconciliation.

23. 23 Cincinnati VAMC cont. Class III software was modified locally to include the following for Medication Reconciliation purposes: Active medications that had been placed on hold by either Providers or Pharmacy Recently expired medications (90 days) Non-VA Medications

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27. 27 Cincinnati VAMC cont. Calendars are printed at the time the patient checks in for an outpatient appointment. Patients are instructed to review calendar and note any discrepancies Calendar is to be reviewed with the Healthcare provider during course of visit Provider is expected to document any changes on both the paper copy and electronically (CPRS) Patient leaves with an updated Medication Calendar (medication list) at the end of the appointment Hand annotated changes considered acceptable

28. Hines VA HospitalMedication Reconciliation Tools Robert Silverman, PharmD

29. 29 �Complete and Accurate�� In slide #12, Jennifer references the requirement for a complete and accurate list of medications How complete can we get with VistA? Locally dispensed Outpatient Prescriptions Inpatient orders Non-VA medications documented at your facility *NEW* : REMOTE medications from other VA stations and the Department of Defense

30. 30 Remote Data Interoperability (RDI) Remote Data Interoperability (RDI) allows VA providers and pharmacists at one facility to interact with patient data from other facilities. RDI retrieves outpatient medication and drug allergy data from the Health Data Repository (HDR) and does order checks against that data. Existing order checking functionality is used for this process. CHDR uses RDI to do medication and drug allergy order checks against Department of Defense data in the HDR. This data is displayed to all CPRS users but is only for patients marked as ADC at any VAMC that shares care with a DoD medical facility.

31. 31 New Medication Reconciliation Tools using RDI Components TIU Data Object �Remote Active Medications� Health Summary �Medication Reconciliation Profile + Remote�

32. 32 Remote Active MedicationsTIU Data Object

33. 33 Medication Reconciliation Profile+Remote

34. 34 Potential Future Tools Remote Allergies TIU Data Object Addition of Pending/Held medications to other available Med Rec tools �Med-Chart�

35. 35 New Service Request Interim Solution Distribute the Hines Class III Medication Reconciliation Tools as Class I IDMC has accepted this issue and prioritized it as mandated work for FY08 Funding not yet approved Long Term Solution Will be incorporated as one of the enhancements of CPRS v29

36. 36 References What is RDI? http://vaww1.va.gov/netsix-ric-cprs/docs/RDI.doc VistA University RDI Training Materials http://vaww.vistau.med.va.gov/VistaU/rdi/ New Service Request for Medication Reconciliation (Interim Solution) http://vista.med.va.gov/pas/ViewTrackingRecord.asp?RequestID=20070108

37. Portland VA Medical CenterMedication Reconciliation Tools Blake Lesselroth, MD, MBI

38. 38 Portland VA - Strategic Plan Every healthcare provider and hospital administrator expressed an investment in medication reconciliation However, process improvement is a multidisciplinary endeavor that is resource intensive. It was, therefore, important to solicit sponsors with sufficient political capital and some governance over patient care and IT Discussion of EO, TIMS, and PSC Assembled a multidisciplinary work team comprised of representative stakeholders � physicians, pharmacists, informaticists, nurses, QP specialists Made the somewhat arbitrary decision to break apart our work into a series of modules that when assembled would meet needs across a continuum of care � each module is designed to address a specific interface in care The rationale was that some 46-70% of medication errors occur at a care interface. We established hypotheses about error production based on prior quality and informatics research. We hypothesized that some errors were related to the availability of reliable information at the point of care. This should be reparable through appropriate use of electronic records and information retrieval. We also hypothesized that some errors might result from provincial business or workflow constraints which may not be analogous in every care setting. However, we also hypothesized that some errors might persist in spite of (or perhaps because of) information technology. For example, we were concerned that the fragmentation of information across the record might enhance errors (e.g. it can be challenging to identify recently expired medications). We also were concerned about the cognitive overhead associated with information technology. Trainees must learn the patient and efficient information retrieval at the same time. Finally, we were concerned about the distribution of tasks. That is to say, that a user may be expected to complete not one but 10 or 20 separate tasks to complete a process such as discharge or transfer. Task distribution contributes to cognitive overhead, errors of omission, and process heterogeneity. Industrial engineering literature founded on Demming principles suggest that variability in process can translate to variability in outcomes. Statistical variability tends to increase the probability of crossing the threshold for failure. If tasks could be consolidated into a single supply chain or cascade, it might reduce errors of omission and errors of comission. Every healthcare provider and hospital administrator expressed an investment in medication reconciliation However, process improvement is a multidisciplinary endeavor that is resource intensive. It was, therefore, important to solicit sponsors with sufficient political capital and some governance over patient care and IT Discussion of EO, TIMS, and PSC Assembled a multidisciplinary work team comprised of representative stakeholders � physicians, pharmacists, informaticists, nurses, QP specialists Made the somewhat arbitrary decision to break apart our work into a series of modules that when assembled would meet needs across a continuum of care � each module is designed to address a specific interface in care The rationale was that some 46-70% of medication errors occur at a care interface. We established hypotheses about error production based on prior quality and informatics research. We hypothesized that some errors were related to the availability of reliable information at the point of care. This should be reparable through appropriate use of electronic records and information retrieval. We also hypothesized that some errors might result from provincial business or workflow constraints which may not be analogous in every care setting. However, we also hypothesized that some errors might persist in spite of (or perhaps because of) information technology. For example, we were concerned that the fragmentation of information across the record might enhance errors (e.g. it can be challenging to identify recently expired medications). We also were concerned about the cognitive overhead associated with information technology. Trainees must learn the patient and efficient information retrieval at the same time. Finally, we were concerned about the distribution of tasks. That is to say, that a user may be expected to complete not one but 10 or 20 separate tasks to complete a process such as discharge or transfer. Task distribution contributes to cognitive overhead, errors of omission, and process heterogeneity. Industrial engineering literature founded on Demming principles suggest that variability in process can translate to variability in outcomes. Statistical variability tends to increase the probability of crossing the threshold for failure. If tasks could be consolidated into a single supply chain or cascade, it might reduce errors of omission and errors of comission.

39. 39 Select �Med Recon� View

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41. 41 Select �Discharge Med Review� View

42. 42 Patient Education Handout

43. 43 Discharge - Unified Action Profile Aggregate distributed information by assembling medication couplets associated with ordering and dispensing information Reduce cognitive overhead by creating actionable tools within CPRS that approximate traditional clinical activities and support reconciliation decisions Enforces a process-standardization step in the discharge cascade Automate creation of an auditable �snapshot� of the medication dispense list to consolidate supply chain activities and reduce duplicative work Basic medication reconciliation tools used at the time of discharge can reduce clinically significant medication variances by up to 75% (Vira et al 2006) To reduce data fragmentation and errors of omission � all inpatient and outpatient medications are assembled into paired couplets in a single electronic record user view � it is therefore easier for the user to identify all prescribed medications, discrepancies between medication lists, and recently expired or discontinued medications. Every medication requires an action � some passive and some active � in order for a pharmacists to dispense medications correctly. Hence, the provider is required to designate an order for each medication. The orders (continue, discontinue, change, renew) approximate expectations of a paper-based world and the way a provider thinks. This reduces cognitive overhead and errors of omission. After every medication has been reviewed, the pharmacists processes the medications and a final dispense list is documented. The document includes boilerplated text designed for the consumer. Basic medication reconciliation tools used at the time of discharge can reduce clinically significant medication variances by up to 75% (Vira et al 2006) To reduce data fragmentation and errors of omission � all inpatient and outpatient medications are assembled into paired couplets in a single electronic record user view � it is therefore easier for the user to identify all prescribed medications, discrepancies between medication lists, and recently expired or discontinued medications. Every medication requires an action � some passive and some active � in order for a pharmacists to dispense medications correctly. Hence, the provider is required to designate an order for each medication. The orders (continue, discontinue, change, renew) approximate expectations of a paper-based world and the way a provider thinks. This reduces cognitive overhead and errors of omission. After every medication has been reviewed, the pharmacists processes the medications and a final dispense list is documented. The document includes boilerplated text designed for the consumer.

44. 44 Preliminary Outcome Data Compared medication lists to plans outlined during staff rounds Medication discrepancies were reduced but not eradicated Most minor errors included inconsequential documentation omissions (e.g. missing topical ointments or failure to list OTC meds on DC summary) Less clinically significant variances were identified than anticipated based on prior studies (7% vs 18-20%) There were no documented cases of clinical harm Our work reflects work published in quality literature � there seems to be relatively little impact on clinically insignificant discrepancies but we appear to have had a marked impact on the incidence of clinically relevant variances Vira and colleagues had a similar outcome using a clinical pharmacist to conduct a medication recon review of the medication lists of every patient and review with a provider prior to discharge. (they reduced their clinically significant error rate by half)Our work reflects work published in quality literature � there seems to be relatively little impact on clinically insignificant discrepancies but we appear to have had a marked impact on the incidence of clinically relevant variances Vira and colleagues had a similar outcome using a clinical pharmacist to conduct a medication recon review of the medication lists of every patient and review with a provider prior to discharge. (they reduced their clinically significant error rate by half)

45. 45 Portland VA - APHID As stated before, each interface is characterized by different pressures and constraints. Each ambulatory care visit (primary care or otherwise) can make med recon challenging for different reasons. In general, it is less crucial to assemble multiple medication lists (although this can be an issue for patients receiving co-managed care). It is difficult, however, to ensure the accuracy of the list endorsed by the patient. An accurate history can be difficult to ascertain for several reasons. Patients may not know or recognize the names of their medications. Patients may be confused by the complexity of their regimen. Patients may continue to take expired or discontinued medications. Patients may consume medications dispensed from outside providers or purchased from outside suppliers. The provider also must be expected to gather, validate, update, and document this history during the episode in care. Cycle time studies indicate that taking a valid history requires between 10 and 30 minutes. Most care encounters are allotted 15 minutes. Our developers realized that we had to think outside the box. We therefore, looked to industry to inform our next device, the Automated Patient History Intake Device As stated before, each interface is characterized by different pressures and constraints. Each ambulatory care visit (primary care or otherwise) can make med recon challenging for different reasons. In general, it is less crucial to assemble multiple medication lists (although this can be an issue for patients receiving co-managed care). It is difficult, however, to ensure the accuracy of the list endorsed by the patient. An accurate history can be difficult to ascertain for several reasons. Patients may not know or recognize the names of their medications. Patients may be confused by the complexity of their regimen. Patients may continue to take expired or discontinued medications. Patients may consume medications dispensed from outside providers or purchased from outside suppliers. The provider also must be expected to gather, validate, update, and document this history during the episode in care. Cycle time studies indicate that taking a valid history requires between 10 and 30 minutes. Most care encounters are allotted 15 minutes. Our developers realized that we had to think outside the box. We therefore, looked to industry to inform our next device, the Automated Patient History Intake Device

46. 46 Ambulatory Care - APHID Electronic kiosk accessed by veteran prior to clinic appointment Security ensured by allowing access only via Veterans Identification Card Deliver a structured and automated history form Distribute data to members of health care team for action Adopted a hybrid of traditional medical informatics and consumer informatics Modeled after consumer-driven kiosks used in other types of industry including travel and retail � the patient is the primary user Patient checks in for a clinic appointment using the kiosk appliance The program then interacts with multiple Vista packages including the appointment manager and the medication file. As the patient checks in, medications and allergies are reviewed. Information gathered is then available during the appointment. The goal was to validate data and narrow information gaps without disrupting clinic workflow.Adopted a hybrid of traditional medical informatics and consumer informatics Modeled after consumer-driven kiosks used in other types of industry including travel and retail � the patient is the primary user Patient checks in for a clinic appointment using the kiosk appliance The program then interacts with multiple Vista packages including the appointment manager and the medication file. As the patient checks in, medications and allergies are reviewed. Information gathered is then available during the appointment. The goal was to validate data and narrow information gaps without disrupting clinic workflow.

47. 47 The Interface - Login Why did we take this approach Why did we take this approach

48. 48 Check-In

49. 49 Patient Allergies

50. 50 Medication Reconciliation

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52. 52 Data Utilization � Convenient and Efficient Information gathered at kiosk can be printed or retrieved using Patient Data Objects Universal access to information at any point during the workflow Medication reviews may be used for med recon documentation or patient education

53. 53 AfterClinic Summary Uses TIU package to generate a concluding document Designed for patient consumption May be used by any member of care team

54. 54 APHID Data Approximately 85% of patients are capable of using the kiosk Most patients take an average of 7 minutes but it is important to allow up to 25 minutes for check-in Most providers reported the process was transparent to workflow and improved the medication history Studies being conducted to assess accuracy, efficacy, and cost effectiveness This model meets current security and privacy standards for a healthcare enterprise

55. 55 Portland VA Med ReconAdditional Information

56. Miami VA Healthcare System John Triplett, RPh, PhD

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58. 58 Ambulatory & Preadmission Process Clerk generates form Patient/Caregiver completes form VA Medications Non-VA medications Allergies Medication List Updated by: PC Provider in clinic Provider ordering admission

59. 59 Admission to Inpatient Admitting clerk assures that patient or care giver has completed the Ambulatory worksheet. Provider writing admission orders is responsible for medication reconciliation. The CPRS based Medication Reconciliation tool MUST be utilized for all admissions.

60. 60 Admission to Inpatient IMPORTANT POINTS: Non-VA medications MUST be ordered prior to initiating the CPRS tool. Medications new to the patient at the time of admission MUST be ordered prior to initiating the CPRS tool. The Medication Reconciliation tool is initiated through the Notes tab.

61. 61 Medication Reconciliation Tool: Admission

62. 62 Medication Reconciliation Tool: Admission

63. 63 Medication Reconciliation Tool: Admission

64. 64 Medication Reconciliation Tool: Admission

65. 65 Medication Reconciliation Tool: Admission

66. 66 Medication Reconciliation Tool: Admission

67. 67 Medication Reconciliation Tool: Admission

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69. 69 Other Transition Points Reconciliation MUST also occur at the following inpatient transition points: Upon Transfer (when new orders are required by policy, i.e. change in level of care). Compare current inpatient orders with new inpatient orders. At Discharge The new Home Medications list MUST be compared with the pre-admission Home list, AND with the current inpatient medications.

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71. 71 Medication Reconciliation Transfer

72. 72 Medication Reconciliation Transfer

73. 73 Provider discharge piece

74. 74 Provider discharge

75. 75 Pharmacist discharge -launched by an icon on the desktop -CPRS sign in

76. 76 Pharmacist discharge

77. 77 Pharmacist discharge

78. 78 Pharmacist discharge

79. 79 Pharmacist discharge

80. 80 Pharmacist discharge

81. 81 Pharmacist discharge

82. 82 Pharmacist discharge

83. 83 Monitoring Implementation of the Process Use of Tool Not Mandatory Done by Note Titles VistA Report Developed 89% of Admissions, 60% of Transfers, 93% of Provider Discharges and 85% of Pharmacist Discharges.

84. 84 Lessons learned Retrieve and aggregate medication lists into like couplets to improve efficiency, and reduce cognitive errors Try to embed �actionable� order capabilities to facilitate user adoption and influence point-of-care behavior Study workflow carefully and recognize provincial and environmental constraints. Know the failure modes. Capitalize upon the current health record architecture and medication error checking functionality Make every member of the team a steward in medication reconciliation activities � including the patient Capture and consolidate as many data streams as possible A couple important take home points should be noted Although much of our work is provincial � there are basic themes that should translate to disparate health care settings Basic informatics commandments for decision support are relevant here � simple point-of-care devices that respect existent workflow and user expectations work best Make certain to embed devices into workflow patterns but don�t �over anticipate� when user requirements are unclear Make certain to include devices that provide a tangible �return on the investment� for the care provider � this may be in the form of automated documentation or high fidelity messaging Consolidate tools into the most simple supply chain possible and exploit the existent data repository � if it is the database RETRIEVE IT! Engage every member of the care provision team. A perfect electronic solution will not compensate for the human elements required in the processA couple important take home points should be noted Although much of our work is provincial � there are basic themes that should translate to disparate health care settings Basic informatics commandments for decision support are relevant here � simple point-of-care devices that respect existent workflow and user expectations work best Make certain to embed devices into workflow patterns but don�t �over anticipate� when user requirements are unclear Make certain to include devices that provide a tangible �return on the investment� for the care provider � this may be in the form of automated documentation or high fidelity messaging Consolidate tools into the most simple supply chain possible and exploit the existent data repository � if it is the database RETRIEVE IT! Engage every member of the care provision team. A perfect electronic solution will not compensate for the human elements required in the process

85. 85 Lessons Learned cont. Use multi-media to it�s full potential � pictures, paper, reports, and dialogs User buy-in is critical to success. Identify several clinical champions to catalyze change Process improvements should deliver a tangible return-on-investment (like automatic documentation) Expect criticism. Any effort that re-engineers a process will represent a compromise between stakeholders Regular data collection and enthusiastic feedback is essential to drive continuous quality improvement Many strategies are viable to achieve Med recon, but not all of them work to improve patient care

86. 86 Questions?