Transcript
Page 1: Moving From Paper To Electronic Medication Reconciliation

www.saferhealthcarenow.ca

Moving from Paper to Electronic

Medication Reconciliation

November 12, 2013

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Welcome to our francophone

attendees

Bienvenue à nos participants

francophones

Hélène RiverinConseillère en sécurité et en amélioration

Safety Improvement Advisor

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Pour nos participants francophones..

Pour accéder aux diapositives

français:

-Cliquez sur l'onglet "FRENCH"

OU

-Envoyer un courriel à

[email protected]

Suivre la boîte «Chat» pour les

commentaires du conférencière

traduit en français

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Next Webinar: December 10, 2013 at 12 noon ET

MedRec Quality Audit Month Results

Join us to hear about the results and how your organization should be involved.

2235patients

28%

40%

• 1906 Acute Care

• 329 Long Term Care

• Met all 5 quality criteria

• 3 - 4 met quality criteria

99Organizations

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Call Overview

1. Discuss the results of the pan-Canadian survey of existing

practices with respect to the use of technology to support

Medication Reconciliation (MedRec)

2. Describe the steps and considerations for transitioning to

electronic MedRec (eMedRec)

3. Identify factors that support and impede successful migration of

paper MedRec to eMedRec.

4. Discuss the lessons learned from research and other organizations.

Introduce the toolkit to support healthcare providers in making a safe and effective

transition from paper MedRec to eMedRec.

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Today’s Speakers

Dr. Elizabeth Borycki

Dr. Borycki is an Associate Professor at the University of Victoria, Victoria,

British Columbia Canada.

Dr. Borycki has worked in numerous roles among them as a Clinical

Informatics Specialist, Disease Management Specialist, Consultant and

Researcher. Elizabeth teaches organizational behaviour and change

management, systems evaluation, quality improvement,

information/information technology management and research methods in

the undergraduate and graduate programs in the School of Health

Information Science.

Elizabeth has co-authored many health informatics articles. More recently,

she has edited two books: The Human, Social and Organizational Aspects of

Health Information Systems and Comprehensive Management of Chronic

Obstructive Pulmonary Disease. She was the Academic Representative for

Canada’s Health Informatics Association (COACH) to the International

Medical Informatics Association (IMIA).

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Today’s Speakers

Dr. Andre Kushniruk

Dr. Kushniruk is a Professor of the School of Health Information Science at the University of

Victoria and he previously served as the Director of the School of Health Information Science

at the University of Victoria.

Dr. Kushniruk conducts research in a number of areas including evaluation of the effects of

technology, human-computer interaction in health care and other domains as well as usability

engineering. His work is known internationally and he has published widely in the area of

health informatics and testing of healthcare IT (including work in the area of decision support

for medication reconciliation).

He focuses on developing new methods for the design and evaluation of information

technology and studying human-computer interaction in health care and he has been a key

researcher on a number of national and international collaborative projects. His work includes

the development of novel methods for conducting video analysis of computer users.

Dr. Kushniruk has held academic positions at a number of Canadian universities. He was

elected as a Fellow of the American Medical Information Association (FACMI) in 2009 and

also served on the COACH (Canada's Organization for Health Informatics) board of directors.

He holds undergraduate degrees in Psychology and Biology, as well as a M.Sc. in Computer

Science from McMaster University and a Ph.D. in Cognitive Psychology from McGill

University.

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Moving from Paper to Electronic Medication

Reconciliation (eMedRec)

9

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Moving from Paper to Electronic Medication Reconciliation

(eMedRec)

Andre Kushniruk

Elizabeth Borycki

Helen Monkman

Alex Kuo

University of Victoria

Margaret Colquhoun

Alice Watt

ISMP Canada

Marie Owen

CPSI

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Medication Reconciliation (MedRec)

• A process in which providers work with patients and other providers to ensure accurate medication information is communicated across transitions of care– Admission, transfer, discharge

– Intended to prevent harm from ineffective communication

– Is challenging!

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What is eMedRec?

• Electronic MedRec (eMedRec) uses Health Information Systems (HIS) to access and integrate electronically stored patient medication data

• To support the development of the electronic Best Possible Medication History (eBPMH) and the detection and resolution of discrepancies

• Can be integrated with other systems such as computerized provider order entry (CPOE)

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eMedRec: Two Unreconciled

Medication Lists for Comparison

(adapted from Markowitz, 2011)

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eMedRec: Matching Two Medication Lists

(adapted from Markowitz, 2011)

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eMedRec: Final Reconciled Medication Record

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eMedRec Process Flow Map

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Idealized Overview of eMedRec

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What is the Current State of eMedRec?

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eMedRec: A Review of the Literature

• Conducted a literature review

• searched PubMed and CINAHL for the term “medication

reconciliation”.

• 218 unique articles, published between 2003 and

October 2012

– reviewed by title, abstract (where possible) and/or full article

to exclude studies that did not include original research (e.g.,

editorials) or that lacked reference to MedRec.

• 139 articles remained that met the inclusion criteria

• The following characteristics were also recorded:– Type of MedRec

– Points of care

– Outcome Measures

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Type of MedRec

• Processes ranged from:

– Entirely paper-based

– hybrid (i.e. combination of paper and electronic)

– entirely electronic MedRec (eMedRec).

• The numbers of studies for each type of medication

reconciliation were similar:

– paper (35 studies)

– hybrid (40 studies)

– electronic (44 studies)– some of the papers did not explicitly state or describe what type of MedRec was used and

therefore could not be included.

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Key Findings: Points of Care• The articles collected dealt with MedRec as it occurs at different

points of care.

• most of the articles focused on hybrid processes

• few articles looked at eMedRec processes across different points of

care

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Key Findings: MedRec Investigations

at Different Points of Care

Quantitative Measures of Medication Reconciliation

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Key Findings: Information Technology

(IT) and eMedRec

• Information technology has been used in the

eMedRec process to do the following:

– Generate the best possible medication lists

(BPMHs)

– Electronically support human MedRec processes

• providing electronic sources of data

• providing electronic tools for comparing lists and

detecting and resolving medication discrepancies

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Examples of eMedRec Studies

Boockvar et. al (2011). “Medication Reconciliation: Barriers

and Facilitators from Perspectives of Resident Physicians and

Pharmacists” (J. of Hospital Medicine)

• Focus groups and observation of VA eMedRec tool

• Participants agreed about central goal of eMedRec to prevent

errors, but disagreed if it achieved goal

• Participants varied in how they sequenced the task using the

tool

• When time was limited, physicians considered other

responsibilities higher priority

• Barriers included: competing tasks, unreliable sources of

information and need for education

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Schnipper et al. (2009). “Effect of an Electronic

Medication Reconciliation Application and Process

Redesign on Potential Adverse Drug Events” (Arch

Int Med)– Performed a controlled randomized trial

– Intervention was an eMedRec tool and process redesign

involving physicians, nurses and pharmacists

– Main outcome was unintended discrepancies between

preadmission meds and admission or discharge meds that had

potential for harm (PADEs)

– Found that the eMedRec tool and process redesign was

associated with a significant decrease in PADEs

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Kushniruk et al. (2011). “Cognitive Analysis of a

Medication Reconciliation Tool”

– conducted “think aloud” usability tests and clinical

simulations of use of an eMedRec tool

– Both artificial cases and real cases observed

– Found

• Pharmacists and physicians approached cognitive process of

using eMedRec tool differently

• Significant differences found in accuracy of task and time

spent by pharmacists as compared to physicians

• Led to implications for redesign, customization and training

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What is the Current State of eMedRec in

Canada?

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There is a move from paper to eMedRec• to improve efficiency and safety

• to integrate MedRec with information

systems

�+

Paper Based MedRec Hybrid MedRec eMedRec

eMedRec in Canada

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eMedRec in Canada

• We conducted an online survey of eMedRec practices in Canada to assess the current state of eMedRec

• Method:• online survey • conducted in spring 2013

• Participants:• 2799 people were invited to participate• 212 people responded

• included physicians, nurses, pharmacists, administrators, QI professionals, and health IT professionals

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Where is eMedRec Implemented

in Canada?

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Type of eMedRec in Canada

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Perceived Success of eMedRec in Canada

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Ranked Reported Motivators for eMedRec

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Factors that Led to Successful eMedRec

Implementation

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eMedRec in Canada

• eMedRec functionality was highly variable, with not all functions used

• Most respondents indicated no additional resources (e.g., human, financial) were allocated to sustaining eMedRec (61%)

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What are the Advantages of eMedRec?

• Potential Advantages of eMedRec include:

– Improved standardization of documentation

– Improved legibility of information

– Improved communication between providers

– Improved accessibility of documentation

– Potentially improved eMedRec compliance through

implementing:

• Soft stops - reminders that eMedRec needs to be completed for a patient)

• Hard stops - orders cannot be placed until eMedRec is completed

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What are the Advantages of eMedRec?

• Decision support tools

– assist in comparing medication lists

– identifying discrepancies

– providing warnings for drug interactions or allergies

• Integration with computerized provider order entry (CPOE) to facilitate improved ordering processes

• Improved efficiency of many medication-related processes in health care organizations (Poon et al.,

2006).

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Key Aspects of Implementing eMedRec

Senior leadership support is important

• The transition to eMedRec will require sustained

resources, perseverance, clear accountability,

preparation and dedication to achieve success

Understand the current state of an organization’s HIS

• is critical to implementing eMedRec

• Example: In planning to implement CPOE, it is

valuable to pair eMedRec implementation with

CPOE implementation because efficacy is improved

when they are implemented together

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Assessment of Organizational Readiness

Before implementation, organizations should determine the

following:

• What HIS they currently have in their organization

• What they plan to implement in terms of eMedRec tools

• The HIS inputs and outputs eMedRec

All involved must be aware of the type of HIS already in place

• (e.g., electronic health records)

Have a common understanding of the definition of eMedRec and

the components of eMedRec

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Workflow Standardization, Organizational

Policy and Procedures

• Implementing eMedRec usually requires changes in

workflow

• Important to communicate critical aspects of the

process such as:

– The overall plan for implementing and sustaining eMedRec

across the organization

– Health professional roles and responsibilities for each task

– Clear time expectations for tasks to be completed

– How the changes will affect all health professional tasks and

roles.

– Changes in organizational policies and procedures

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Workflow Standardization, Organizational Policy and

Procedures

• Observation of workflow and clinical simulations

• are increasingly being used around the world to assess the impact of

new information systems upon workflow

• best undertaken in a setting similar to, or in the actual setting where

eMedRec takes place.

• Observation and clinical simulations can be used to:

• diagram workflows,

• Assess the impact of the technology upon care processes

• Identify potential sources of technology-induced errors

• Design the eMedRec interface

• Design policies, procedures and training

• Address cumbersome workflows and potential pitfalls of workflows

prior to implementation

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Selection and Procurement of eMedRec

Solutions

• Organizations must carefully weigh a number of considerations related

to the selection and procurement of eMedRec technology:

– What information technology is currently available in the

organization?

– What features and functions of an eMedRec solution will be:

• mandatory for an implementation

• nice to have (but not required)

• will be implemented at a later date

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Selection of eMedRec Solutions

• Ideally the features and functions of eMedRec allow for

the following:• Display of current medications and eBPMH lists side-by-side.

• Complete information on: current, previous, active and

discontinued medications, to facilitate comparison

• Flagging of discrepancies in medications

• Medication display on a timeline so that the user understands

what medication is to be/was given and when

• Modification of medications from the same screen

– e.g. continue, discontinue, hold, or change

• Integration with CPOE (if applicable) so that new medications

can be easily prescribed

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System Reliability

• Assessment of system reliability and the creation of

reliability targets is an essential aspect of

implementing eMedRec.

• A back-up plan if eMedRec fails or goes down

– i.e., downtime policies and procedures

• Electronic or paper back- up available in the event that

there are technical difficulties that prevent MedRec

from being done electronically

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Usability

• A usable eMedRec system will lead to:

– Higher rates of compliance

– Fewer workarounds

– Less training

– More efficient eMedRec processes

– Fewer technology-induced errors

• be better for infrequent users or users with lower

levels of computer literacy

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Cost• For any implementation to be a success it is important

to identify project and long term maintenance costs.

– Ensure commitment and support of senior management through

an executive sponsor dedicated to this project

– Ensure that sufficient financial resources are available to

implement and sustain eMedRec

– Determine the impacts of using new eMedRec processes upon

physicians, nurses and pharmacists

– Ensure that there is sufficient staff with enough time to be able

to conduct eMedRec on an ongoing basis

– Conduct periodic evaluations to ensure that all health

professionals are complying with eMedRec processes

– Budget for evaluation and follow-up

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Safety

• eMedRec has the potential to:

– reduce errors

– introduce errors into the MedRec process.

• To fully benefit from eMedRec’s ability to decrease errors:

– Ensure that health professionals are educated in and aware of their

role in all aspects of eMedRec processes

– Encourage health professionals and patients to report near misses

and errors that arise, in order to refine eMedRec processes to

ensure system reliability and maximize the benefits of eMedRec

– Ensure a well defined evaluation plan is in place to track the

compliance with and outcomes of implementing eMedRec

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Issues and Challenges in Moving to eMedRec

– From Survey and Literature

• Inadvertently increasing workload by

requiring electronic entry of

medications

• Integration issues

• Changing the way users communicate

• Resistance to adopting new technology

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Recommendations

• Understand current workflow before implementing

• Understand how eMedRec can integratewith existing and planned health

information system infrastructure

• Obtain management and financial support (including ongoing for sustainability)

• Need to carefully stage eMedRec

implementation

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Need for Evaluation Throughout the

Implementation Process

• Workflow evaluation and usability testing

• Integration with existing infrastructure

• Adequacy of training

• Evaluation of Error and Performance

– Number and % of patients reconciled

– accuracy of reconciliation

– frequency of use

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Development of a New Paper to eMedRec

Toolkit

• To support managers and health care professionals

who are considering or moving to eMedRec

• Funded by Canada Health Infoway

• Work conducted by AE Informatics, University of Victoria professors, ISMP Canada and CPSI

• Will be made available through ISMP Canada and

CPSI

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Toolkit: Table of Contents

• What is the current state of eMedRec?

• What are the stages in implementing eMedRec?

• What should be considered after eMedRec is

implemented?

• How should eMedRec be evaluated?

• Lessons Learned

• Checklists

– Ideal features

– procurement and pre-implementation

– Evaluation

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Toolkit: Checklists and Tips

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Conclusions

• eMedRec can be an important tool for safety and lead to a range of benefits

• There are number of factors that influence success of eMedRec implementations

• Work based on national survey, literature review and interviews has lead to development of the:

“Electronic MedRec Implementation

Planning Kit”

Further information: [email protected]

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Thank-you!

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Upcoming MedRec Webinars

58

Dec 10, 2013 Canadian Quality Audit Month Results

Jan 14, 2014 The Marquis Project - Dr. Jeffrey Schnipper

Feb 11, 2014 Engaging Patients in MedRec

March 25, 2014 MedRec in Home Care

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