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7/6/2016
1
Development & Maintenance of Medication Related Aspects of Electronic Health Records
2016 ANNUAL MEETING
Christina Robinson, Pharm.D., BCPS Pharmacy Clinical Informatics Coordinator
DisclosuresI do not have (nor does any immediate family member have) a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation
2016 ANNUAL MEETING
Disclosures• I have no disclosures
2016 ANNUAL MEETING
EXCEPT…
I Being in Pharmacy Clinical Informatics!!!
Objectives
• Describe the process for development and implementation of evidence based electronic order sets
• Illustrate the process for development and implementation of rules based alerts and clinical decision support (CDS) tools
• Construct examples of a process for maintaining and evaluating the effectiveness of these tools in the electronic medical record
2016 ANNUAL MEETING
Swiss Cheese Theory
2016 ANNUAL MEETING
What Defenses Can We Use to Prevent the Holes from Lining Up?
a) Optimizing the Configuration of the Clinical Informatics System (CIS)
b) Loose pieces of paper with handwritten notes passed from one shift to another
c) Effective electronic communication tools that are retained within the CIS
2016 ANNUAL MEETING
Answer: a & c
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Who’s Needs Should be Considered When Developing the CIS?a) Prescribers:CPOE, Alerts, Medication Reconciliation
b) Pharmacists: Verification, Alerts, Reminders
c) Nurses: Order & Task Summaries, Barcoding
d) Patients: Safety, Education, Accurate Documentation
e) Revenue Integrity/Finance: Accurate Charging, Meaningful Use Measures
f) Medication Safety Coordinators & Risk Management
g) All of the above
2016 ANNUAL MEETING
Answer: g
Evidence Based Order Sets –Optimization of System Configuration
• Bupivacaine Liposomal (Exparel®)
• Acetylcysteine IV Therapy
• Alteplase for Stroke and Acute Myocardial Infarction (MI)
• Pneumonia
• Enoxaparin and Fondaparinux
• Heparin Protocols
2016 ANNUAL MEETING
2016 ANNUAL MEETING
Bupivacaine 1.3% Liposomal (Exparel®)
2016 ANNUAL MEETING
Bupivacaine 1.3% Liposomal (Exparel®)
2016 ANNUAL MEETING
Bupivacaine 1.3% Liposomal (Exparel®)
Bupivacaine Liposomal Label & Kit
2016 ANNUAL MEETING
7/6/2016
3
2016 ANNUAL MEETING
Bupivacaine 1.3% Liposomal (Exparel®)
2016 ANNUAL MEETING
Bupivacaine Liposomal- Utilization of Allergy Screening
2016 ANNUAL MEETING
Bupivacaine Liposomal- Utilization of Allergy Screening
2016 ANNUAL MEETING
Bupivacaine Liposomal- Utilization of Allergy Screening
2016 ANNUAL MEETING
Bupivacaine
Liposomal -
Utilization of
Allergy
Screening
2016 ANNUAL MEETING
7/6/2016
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2016 ANNUAL MEETING
Bupivacaine Liposomal – Education by RN
2016 ANNUAL MEETING
Bupivacaine Liposomal –RN Charting x96 hrs post-op
2016 ANNUAL MEETING
2016 ANNUAL MEETING
Pharmacy SBAR – Build a Patient List
SBAR: Situation, Background, Assessment, Recommendation
2016 ANNUAL MEETING
PharmacySBARGoes to the Pharmacy Worklist
2016 ANNUAL MEETING
7/6/2016
5
2016 ANNUAL MEETING
Acetylcysteine IV Therapy v1.2
2016 ANNUAL MEETING
2016 ANNUAL MEETING
Weight-Based Medications
And Dose Caps
2016 ANNUAL MEETING
2016 ANNUAL MEETING
2016 ANNUAL MEETING
A Wise Man Once Said: ‘It always comes down to the labels.’
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2016 ANNUAL MEETING
Nursing Worklist
2016 ANNUAL MEETING
Alteplase Bolus and Infusion for Stroke
2016 ANNUAL MEETING
Alteplase Bolus for Ischemic Stroke
2016 ANNUAL MEETING
AlteplaseInfusion for Ischemic Stroke
2016 ANNUAL MEETING
NS Order to run post
Alteplase
2016 ANNUAL MEETING
Alteplase Bolus and Infusion for Stroke: Room for Improvement
7/6/2016
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2016 ANNUAL MEETING
New NS Plain Order
for post-Alteplase
2016 ANNUAL MEETING
NS Rate to be
Added by
RPh
2016 ANNUAL MEETING
Frien
dly R
emin
der
2016 ANNUAL MEETING
Safety Issue: Development of
Smart ‘No ____’ orders
2016 ANNUAL MEETING
No Antiplatelets x 24 Hrs Post Alteplase
2016 ANNUAL MEETING
No Anticoagulants x 24 Hrs Post Alteplase
7/6/2016
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2016 ANNUAL MEETING
“No ____” Orders Actively Screen for Contraindicated Meds x24hrs Post Alteplase
2016 ANNUAL MEETING
New Additions to Alteplase Order Set
2016 ANNUAL MEETING
Alteplase Configuration in Acute MI Set
Evidence Based Order Sets –Optimization of System Configuration PLUSMLM’s (Medical Logic Modules)
• Antibiotic Selection in Pneumonia • Recommendations Based on Risk Factors
• Enoxaparin and Fondaparinux • Automation of Lab Monitoring Based on Indication
• Heparin Protocols• Weight based Automation of Protocols
2016 ANNUAL MEETING
2016 ANNUAL MEETING
Web Link
Select Risk
Factors
2016 ANNUAL MEETING
Antibiotic Recommendations
7/6/2016
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2016 ANNUAL MEETING
Enoxaparin Order Set
2016 ANNUAL MEETING
Enoxaparin – Labs Based on Indication
VTE ProphylaxisTherapeutic
Anticoagulation
2016 ANNUAL MEETING
Enoxaparin – Labs Selection
MLM edits needed for system to
recognize that a SCr is included in
a BMP & CMP
2016 ANNUAL MEETING
New Oral Anticoagulants
2016 ANNUAL MEETING
Rivaroxaban – Taper Dose Orders
2016 ANNUAL MEETING
Rivaroxaban – Taper Dose Orders
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2016 ANNUAL MEETING
Rivaroxaban – Taper Dose Orders
2016 ANNUAL MEETING
Rivaroxaban – Taper Dose Orders
2016 ANNUAL MEETING
Rivaroxaban – Taper Dose Orders
2016 ANNUAL MEETING
New Oral Anticoagulants: Home Medication Reconciliation
HEPARIN PROTOCOLS
2016 ANNUAL MEETING
Heparin Weight Based Protocols
2016 ANNUAL MEETING
7/6/2016
11
2016 ANNUAL MEETING
Heparin Weight Based Protocols
2016 ANNUAL MEETING
Heparin Protocols – RN Worklist
2016 ANNUAL MEETING
Heparin Protocols – Task Form
2016 ANNUAL MEETING
Heparin Bolus q6h PRN – Max Dose
2016 ANNUAL MEETING
CDS Based on Specialty Areas
2016 ANNUAL MEETING
CDS Based on Specialty Areas
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2016 ANNUAL MEETING
Insulin Soft Stop MLM
2016 ANNUAL MEETING
Additional CDS Based on Reported Med Errors
Hypoglycemia
2016 ANNUAL MEETING
Insulin Hard Stop MLM
2016 ANNUAL MEETING
Insulin Hard Stop MLM
SYSTEM MAINTENANCE
2016 ANNUAL MEETING
• Maintain integrity of hyperlinks
• Each site must add allergy codes to new items built for ADM’s
• Update automation (MLM’s) when guidelines are updated
• Order set configuration and MLM updates when lab monitoring changes are needed
• Clinical Informatics Order Set Team!!! • Mandatory Order Set Review by Pharmacy – on any order set with
medications
• Alert fatigue – use configuration options as much as possible to utilize alerts to help avoid medication errors but also be proactive in reducing unnecessary ‘nuisance’ alerts
• Pharmacy Clinical Workgroup (CW)
Reducing Alert Fatigue
2016 ANNUAL MEETING
7/6/2016
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2016 ANNUAL MEETING