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Medication Use Process
Part Two, Lecture # 6
PHCL 498
Amar Hijazi, Majed Alameel, Mona AlMehaid
Agenda
Computerized Provider Order Entry (CPOE)
Pharmacy Information System (PIS)
Automated Medication Dispensing Devices and Robotics
Bar Code Electronic Medication Administration Record (BCMAR)
Smart Intravenous Infusion Pumps
Electronic Medication Reconciliation
References
e-book, Chapter 18
Electronic Health Records, Chapter 15
http://jamia.bmj.com/content/4/5/364.full.pdf
http://www.ismp.org/tools/guidelines/smartpumps/comments/
http://ehealthinnovation.org/wp-content/uploads/SmartMedicationDeliverySystems_FullReport1.pdf
Medication Management and Technology
• Medication Reconciliation
• LIS• RIS• Problem List• CDSS
Medication Order
• Formulary Inventory• Selection, Preparation and Distribution
• Automated Dispensing Cabinets
• Robotics
Pharmacy Processing • BCMAR
• Monitoring and Intervention
• Patient Portal
Medication Administratio
n
Clinical Data Repository
CPOE
PIS
NIS
PHR
Computerized Physician Order Entry
Refers to any system in which clinicians directly enter medication orders (and, increasingly, tests and procedures) into a computer system, which then transmits the order directly to the pharmacy. These systems have become increasingly common in the inpatient setting as a strategy to reduce medication errors. A CPOE system, at a minimum, ensures standardized, legible, and complete orders and thus has the potential to greatly reduce errors at the ordering and transcribing stages (AHRQ)
Recommended by IOM in 1991
Can decrease serious inpatient medication errors by 55 %
Doctors will enter the prescription
The electronic prescription is sent
to the Pharmacy RX
fluoxetine (as hydrochloride) 20mg capsulesfluoxetine (as hydrochloride) 20mg capsules
Fluoxetine belongs to SSRIs, and has the following interaction information for patient’s current mediciations:
Aspirinincreased risk of bleeding when SSRIs given with aspirin
Advantages of CPOE
Legibility
Including all order components
Reduce care variation
Generation of alerts
Specific alerts
Global alerts
Drug allergy
Inappropriate dosing
Inappropriate route
Inappropriate cumulative dose
Advantages of CPOE, Cont’d
Age contraindications
Conditions contraindication
Drug-diagnosis contraindication
Laboratory warning
Corollary orders (monitoring)
Pre-intervention orders
Audits
Reduction in cost
Challenges to CPOE
Ordering delay in emergency situation
Alert fatigue
Substantial workflow changes
The implementation process
More information is required to be entered:
Co-signature
Clinical history
Diagnosis
Factors Contributing to improved CPOE Utilization
Top down commitment to mandate CPOE use in the hospital
Plan for resistance
Scrutinize workflow
Select a champion
Order sets development
Training and refreshment training
Measure success
Manage expectation
Time
Computers do not take care of patients
Pharmacy Information System
Is a complex computer system that has been designed to meet the
needs of a pharmacy department. It will allow pharmacists to
supervise and have inputs on how medication is used in a hospital
PIS Functions and Features
Inpatient order entry management and dispensing
Outpatient order entry management and dispensing
Labels and label routing
Inventory management
Products differentiation
Order sets and protocols
Clinical monitoring
Manufacturing and compounding
Intervention management
Connectivity with other systems
Fill lists ‘cart fill’
Pricing, charging and exchange
PIS General Considerations
User interface
Outpatient and inpatient profile
Flexibility in sorting and selection of orders
Display of complete profile
Security and authority
Data retention
Automated Medication Dispensing Devices and Robotics
Centralized
Mainly for inpatient setting
A large robot that has access to the most frequently used medications
Performs labeling of medication
Place medication in patient specific drawers
Handles refills of ongoing orders
http://www.youtube.com/watch?v=aq59ELdqHi8&feature=share&list=PL93A403B6D4597A7E
Automated Medication Dispensing Devices and Robotics, Cont’d
Decentralized
Used for inpatient
Located near the patient care area
Provides a check on the person requesting medication for a specific patient
Has a billing interface
http://youtu.be/Ve53RgvMCq8
Automated PharmacyDrugs Dispensing System
It Consists of:
Software.
Hardware.
And it interfaces with Hospital Information System to get Patients and orders Data
Automated PharmacyDrugs Dispensing SystemAutomated PharmacyDrugs Dispensing System
Replace manual distribution with: A Fully Pharmacy Automated System
HIS
Console
Interface
IV Preparation ROBOT
Packaging Machines ATDPS Integrated packaging machines with all software and devices in the
pharmacy.
Billing From all Stations on a regular basis
Bar- code generated automatically for every backed tablet.
Bar Code Medication Administration
BCMA is a clinical information module residing within each facility’s health
information system. The module is accessible from computer work
stations and mobile computers on each nursing unit. From work station
computers staff may view medication order reports and look up
medication administration information. The module is accessed via
wireless connectivity from a laptop computer mounted on a wheeled
medication cart. Each cart has either a wireless or tethered handheld
scanner. The carts have a number of individual patient medication
drawers, corresponding to the number of patients served per cart
BCMAR DiagramPhysician
order CPOE
Pharmacy Verification
Medication Dispensing
Nurse Verification
Nurse Confirms
patient’s ID
Patient’s med list displays
Due med is selected and
scanned
Nurse Administers
med
Bar-Code
Unique key for every drug
Eliminates Medication errors
BCMAR Advantages
Legible recording of meds
Guidance of medication administration
Positive patient identification
Assessment reminder
High alert medication verification
Discrepancies reporting
5 and 8 Rights
BCMAR Challenges
Cost associated with Bar Code arm bands or RFID
The ability to have Bar Coded unit-dose available
Workflow changes
Adhering to procedures
Portability of equipment
workarounds
Factors Contributing to improved BCMAR Utilization
Consider nursing workflow and medication management process
Analyze the product design i.e. human-computer interface to prevent work around
Scrutinize the software to ensure the system is simple to use
Device must be ubiquitous
Assess integration
Communication
EMR Bar Code Reader
Medication Dispensing
Machine
Physician Pharmacist Nurse
Smart Intravenous Infusion Pumps
Intravenous (IV) infusions have been identified as frequent contributors to
medication errors, and the injuries that result from them. This is not
surprising given that approximately 90% of patients receive medications via
the IV route, and IV pumps are responsible for the majority of medication
deliveries
General infusion pumps were designed to improve accuracy and continuity
of IV infusions by allowing nurses to program an hourly rate and volume.
However, studies have shown that these devices are involved in 35-60% of
the estimated 770,000 Adverse Drug Events (ADEs) that occur each year in
the US
Smart Intravenous Infusion Pumps
More specifically, the Institute of Medicine estimated that two-thirds
of preventable deaths are due to infusion therapy and are
attributable to manual programming errors when using infusion
pumps
Smart Intravenous Infusion Pumps
To address high incidence of infusion errors, manufacturers have
developed smart pumps. Smart pumps have Dose Error Reduction
Systems (DERS), which include hospital-defined drug libraries with
dosing limits and other clinical advisories integrated into the system
(i.e., smart pumps)
Smart Pumps Advantages
Detect and correct infusion programming errors
Comparing entered dosage values with predefined libraries set by the institution
“Soft” or “Hard” limit warning
Reduce errors associated with miscalculated doses
Smart Pumps Challenges
Longer process
Selecting clinical area
Selecting drug name and concentration (if not Bar Coded)
Staying up-to-date with emerging devices
Correctly maintaining and updating the devices
Requires a complex implementation process
Requires integration with the medication administration process
Bar Coded Smart Pumps Workflow
Electronic Medication Reconciliation
Another type of medication error that occurs is at the transition of care
JCI has mandated that all healthcare organizations that prescribe medication must “accurately and completely reconcile medications across the continuum of care
Electronic MedRec (eMedRec) uses Health formation 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)
eMedRec Advantages
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
Improved standardization of documentation
Improved legibility of information
Improved communication between providers
Improved accessibility of documentation
