Electronic Medication Management (EMM) Program

State and local

implementation lessons

Play EMM Video

Introduction by Dr Peter Kennedy

Deputy Chief Executive Officer – CEC

Chair of NSW EMM Steering Committee

Session agenda

• The role of eHealth in Supporting

Patient Safety

• The Clinical Perspective

• EMM Program Update

• Updates from our initial EMM sites

• Questions for the Panel

E-health NSW: Changing Patient Trajectories

The Role of e-health in Supporting Patient Safety

Dr Peter Kennedy Deputy Chief Executive Officer Clinical Excellence Commission

25 March 2014 3rd Annual Electronic Medication Management Conference

Data from HIMSS AnalyticsTM Database 2011 HIMSS Analytics

HIMSS Analytics Asia EMR Adoption Model

Stage 2

Stage 3

Stage 4

Stage 5

Stage 6

Stage 7

Stage 1

Stage 0

CDR, Controlled Medical Vocabulary,

CDS, may have Document Imaging; HIE capable

Nursing/clinical documentation (flow sheets), CDSS

(error checking), PACS available outside Radiology

CPOE, Clinical Decision Support (clinical protocols)

Full Complement of Radiology PACS

Physician documentation (structured templates), full

CDSS (variance & compliance), Closed Loop Med Admin

Complete EMR; CCD transactions to share data; Data

warehousing; Data continuity with ED, ambulatory, OP

Ancillaries – Lab, Rad, Pharmacy – All Installed

All Three Ancillaries Not Installed

EM

RA

M A

ve

rage

S

tage

Sco

re

0

1

2

3

4

5

6

7Local Health District (n=17) average EMRAM* Scores

Mean

^The Healthcare Information and Management Systems Society

*EMR Adoption Model

• Overall low average (1.41) comparable when

very small / MPS sites excluded

• Goal NOT to get all hospitals to Level 6,

however HIMMS assessed 40 hospitals have

fulfilled the majority of pre-requisites

• EMRAM is acute care focused – handover to

and from Primary and Community Care important

Maturity

The most mature EMR in the country. Usage growing

100 orders placed and results viewed per minute

Electronic Medical Record

January 2014 activity Mar-12 Jan-14 Mar-12 Jan-14 Mar-12 Jan-14 % change

Orders 127,000 131,000 3,861,000 4,000,000 46,000,000 48,000,000 4

Patient Charts Opened 180,000 206,000 5,462,000 6,200,000 65,544,000 75,000,000 14

Clinical documents created 16,500 21,000 502,000 640,000 6,024,000 7,700,000 28

Decision support alerts 6,900 10,600 211,000 323,000 2,532,000 3,900,000 54

Mar-12 Jan-14 % change

Average transaction time 0.95 0.52 45

Transactions (Millions) 139 233 68

Monthly AnnualDaily

Reduction is due to hardware and system upgrades

Growth in system use

Improved Performance: Growth in system use: Up 65% sine March 2012 Average transaction time: Down 45% since March 2012

Key activity per day: Orders: 131,000 up 4% since March 2012 Chart opens: 206,000 up 14% since March 2012 Clinical Documents Created: 23,000 up 28% since March 2012 Decision Support Alerts: 10,600 up 54% since March 2012

Communication

Leadership Team Work

TeamSTEPPS

Courtesy of the Agency for Healthcare Research and Quality

Situational Awareness

Shared Mental Model

Mutual Support

TeamSTEPPS

Five Dysfunctions

of a Team

1

Absence of trust

2

Fear of conflict

3

Lack of commitment

4

Unwillingness to hold one

another accountable

5

Inattention to results

Patrick Lencioni

Executive Sponsorship

Clinical Leadership

Technical Expertise

Equity

Principles for EMR Rollout

Policy Ministry

Governance

Strategy and Architecture

Local Networks / Bandwidth

Central Infrastructure (Data Centres) and Operations (EMR)

eHealth NSW

Local Project Management, Implementation and Training

Program Management, Procurement

End User Computing (PCs, Mobile Devices, TeleHealth Endpoints, Wireless Networks, Phones)

Ownership

Work Practice Review

Standardisation and Content Knowledge

Education

Clinician Support

Benefits Realisation

ACI / CEC / HETI / NSW Kids and Families

Local Health Districts

Enab

lers

C

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ge M

anag

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t Risk Category Owner

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IT Platform

eMR & eMM

Clinician led and data driven

HIE Patient Portal

Clinical Analytics Value added

Outcome measures Drives change

Validates process measures, projects & priorities

Business applications

Infrastructure

Standardisation

Technovigilance

Interoperability Is key to success

It has to work for both Clinicians and Patients in

improving patient care and safety.

Key Themes for EMR Rollout

Key Themes:

I. It is an opportunity to look at work practices and clinical practice

II. Will require increasing standardisation of care

III. Will provide opportunities for much better information on what we do and also in terms of outcomes

Key Themes for EMR Rollout

Key Issues:

I. The Firewall and moving information between hospitals, General Practitioners and patients

II. Use of own devices

III. Standardisation

IV. Evaluation

Key Themes for EMR Rollout

Key to Successful Implementation of Programs:

I. Training and education at facility level

II. Ongoing support at each facility

III. Adequate infrastructure at the facility level – devices, wireless network, speech recognition etc.

Key Themes for EMR Rollout

We need to define with each project what are

the quality parameters that we want to achieve

from the implementation. We need to build

them into the development process.

Quality cannot be an afterthought,

it must be a driver.

Quality in the EMR

IT is going to be introduced in to the

performance review process for all LHDs and

LHNs in NSW. This means there will be key

performance indicators and regular review of

progress at the 3 monthly meetings.

Executive Buy-In

Associate Professor Kathy Gibson

Staff Specialist Rheumatologist

Liverpool Hospital

EMM Program Clinical Secretariat Lead

The clinical perspective

Background

• In Australia, 2-4% of all hospital admissions are

medication related.

• Includes admissions due to adverse drug

reactions and those due to medication errors

which together are termed adverse drug events

(ADEs)

• Overall, about 43% of these are deemed

preventable (1)

• Errors occur at every step of the medication

management pathway

• But most occur during prescribing

1. Runciman WB et al. (2003) Adverse drug events and

medication errors in Australia Int J Qual Health Care 15 (suppl

1): i49-i59.

• Australian research shows that

errors can be reduced by more than

55% with the introduction of

electronic systems to help manage

medication prescribing, dispensing

and administration (2)

2. Westbrook JI et al. (2012) Effects of two commercial electronic

prescribing systems on Prescribing error rates in Hospital patients:

A before and after study. PLoS Med 9 (1):e1001164.

doi:10.1371/journal.pmed.1001164

What is EMM?

• Managing tasks and documents

involved in prescribing, administering

and dispensing medications to

patients using an electronic system

• Includes automated tools to assist in

choosing medications and doses to

be prescribed (decision support)

• Includes automated checking for

allergies and other patient factors that

make certain medications unsafe to

prescribe

Why do it?

• Improve accuracy and visibility of

medication information being

communicated between professionals

and health care settings

• Improve communication with patients

about their medication

• Increase legibility of medication orders

• Reduce variance in prescribing practice

• Reduce medication errors and

associated adverse events

CASE HISTORY 1

• 64 year old male patient brought to

the ED by ambulance with fever, low

oxygen levels and coughing up black

sputum

• History of end stage lung cancer self

discharged against medical advice 3

days before this presentation

• In ED patient confused and agitated

• Seen by the ED registrar and the

Oncology registrar and admission

arranged

• ED registrar agreed to write the

medication chart because Oncology

registrar called away

• ED registrar looked up the patient’s

previous medications and recharted

them by hand

• Wrote oral Hydromorphone 20mg

• Previous dose was oral

Hydromorphone 2mg

• In ED two junior nurses checked the

chart and gave the patient oral

Morphine 20mg

• Oral Morphine 20mg =

Hydromorphone 3mg

• Patient admitted to ward and

subsequently received oral

Hydromorphone 20mg as charted

and breakthrough subcutaneous

Hydromorphone 0.5mg (equivalent

to about 1.5mg oral

Hydromorphone) overnight

• Patient died the following morning

although not necessarily as a direct

result of high dose of

Hydromorphone

So what went wrong?

• ED registrar incorrectly charted

20mg Hydromorphone instead of

2mg.

• 2 ED nurses gave Morphine 20mg

orally not Hydromorphone.

• Nobody overnight recognised the

error in the Hydromorphone dose

charted.

• Case 1, Opiate prescribing • 20mg Hydromorphone vs 2mg

Hydromorphone – transcribing error

EMM system with (existing) record of usual

medication being taken on admission plus

medication reconciliation process could help

• 20mg oral Morphine vs 20mg oral

Hydromorphone – administration error

EMM system with alerts regarding look alike/sound

alike meds and/or rules that only allow prescription

of Hydromorphone using the trade name Dilaudid

How could an EMM system

help?

• Lack of recognition of incorrect dose of

Hydromorphone overnight

EMM system could alert to high dose used

and should contain record of medications being

taken on admission for comparison/cross check

31

How could an EMM system

help?

CASE HISTORY 2

• 66 year old female admitted to

investigate acute blurring of vision in

her left eye and headache

• On warfarin to thin her blood

because of chronic atrial fibrillation

• At admission changed to clexane

(short acting anticoagulant)

• Found to have a tumour in her brain

• Clexane correctly witheld 24 hours

before surgery

• Clexane restarted 48 hours after

surgery at full dose

• A few hours after second Clexane dose

given patient acutely deteriorated due

to a large bleed into her brain

• Bleed drained in theatre and patient

sent to ICU but made no recovery and

died 12 days later

• The senior neurosurgeons consulted

stated that full dose anticoagulation

after this kind of brain surgery is

contraindicated for several weeks post-

op

So what happened? • No clear verbal or written orders given to

junior staff regarding peri-op anticoagulant

management

• Policy to guide junior staff found to be

ambiguous

• The medication order for Clexane expired on

the day of surgery

• It was recharted on a new chart that day but

only the dose 24 hours after surgery was

marked to be witheld

• Therefore restarted the next day

How could an EMM

system help?

• Case 2

• Full dose Clexane restarted 24 hours

after brain surgery

EMM can contain links to specific policy

on anticoagulation and could have rule

to prevent anticoagulation prescription

within specific time frame from surgery

• Clexane recharted by hand on day of

surgery

As above

Will EMM prevent all errors?

• No! E-systems can introduce new errors

• Everybody (administrators, IT staff,

clinicians, trainers etc) needs to be

involved in testing, reviewing,

implementing and refining these

systems

• Everybody who prescribes, dispenses,

administers or takes a medication in a

hospital is a stakeholder as is everybody

involved in managing hospital care

The Physician/Clinician

Champion

• What are they?

• Who are they?

• Why do we need them?

The physician/clinician

champion can provide expert

input to project team

• Clinical expertise assists the team in

planning phases

• Knowledge of clinical process helps

define/change plan

• Risk anticipation and remedies can

be quickly identified

The physician/clinician

champion can communicate to

and from physician colleagues

• Physicians and other clinicians may

“tune out” non-clinical experts

• Nobody carries more authority than

a respected colleague

• Physician/clinician champion can

listen, assess and translate

colleagues concerns

The physician/clinician

champion can help make

critical decisions

• The effective clinician leader is a

highly-skilled decision maker

• Informed decisions require

background on the entire project

• Formal decisions should include

clinician input

Are physician and IT project

leaders ready for this change?

Of course I will

be involved!

I’d love to have

physician input

and leadership!

Are physician and IT project

leaders ready for this change?

I will tell you

exactly what you

need to do for

me!

We don’t need to brief

the physicians on

every problem…

Are physician and IT project

leaders ready for this change?

My partners can

be so

unreasonable!

He needs to fix

those

demanding

physicians.

Are physician and IT project

leaders ready for this change?

This needs to be

fixed by Friday

or we cancel the

project!

I don’t do surgery, I wish

he would stop trying to

be my project manager!

Clinical IT projects:

A fork in the road for work

processes

Improve! Worsen!

It is never neutral!

Recommendation: Appoint

clinical champions for all clinical

IT projects and especially EMM!

• Effective clinician input into clinical IT projects is necessary

• The clinician champion role can assist in the two most important factors in project success: – Executive leadership

– User involvement

• Clinician champion education for clinical IT project leadership needs to be developed

Dr Robin Mann

EMM Program Director

Program progress and plans

EMM Challenges

• Readiness

• Capacity and capability

– LHDs and vendors

• Product maturity

• Integration with existing architecture

• Federated delivery model

• Standardisation and reuse

EMM Maturity

Hospital

Administer

Review

Prescribe

Check

Dispense

Discharge Reconcile

GP

Community

pharmacy

Community

services

Outpatient

care Su

pp

ort

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Le

ve

l 1

EM

M

Su

pp

ort

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y

Le

ve

l 2

EM

M

Su

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na

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Consumer

EMM Program

Dr Angus Ritchie

Silvia Fazekas

Cheryl McCullagh

Update from initial sites

Dr Angus Ritchie

Renal Physician and EMM Clinical Lead

Concord Repatriation General Hospital, Sydney LHD

Initial site update

Concord Update

• EMM Phase 1

• EMM Phase 2

• Enhanced IV functionality

IV Enhancements

• What is an IV?

• Intermittent

• Continuous

• Sequenced

IV Enhancements

After eMAR

documentation

IV Enhancements

Proposed Display

Current Display

Phase 1

• 2005 Project begins

• 2007 EMM two Aged Care wards

• 2010 EMM three more wards

• Road blocks

– iPharmacy-Pharmnet interface

– Functional deficits

Phase 2

• Inpatient EMM – all wards

• Outpatient prescribing

• Medication history & reconciliation

Phase 2

Sep 2012 Nov 2013

Project kick-off Conversion target

Phase 2

Sep 2012 Nov 2013 Mar 2014

Project kick-off Conversion target New conversion target

Phase 2

Sep 2012 Nov 2013

Mar 2014

TBC

Project kick-off Conversion target New conversion target

Changes

• Bigger team

• Comprehensive scope

• Change management

• Timeline replanning

Clinical Leadership

Usual Practice New Model

Paid for another role Dedicated funding

Specialty-specific view Big-picture view

Clinical work prioritised Clinical work balanced

Learn by experience Specific training

Slow, consultative decisions Rapid decision-making

Vague lines of reporting Clear lines of reporting

Reluctant to take ownership

Clinical Leadership

Usual Practice New Model

Paid for another role Dedicated $

Specialty-specific view Big-picture view

Clinical work prioritised Clinical work balanced

Learn by experience Specific training

Slow, consultative decisions Rapid decision-making

Vague lines of reporting Clear lines of reporting

Reluctant to take ownership Take ownership of problems

Clinical Leadership

Usual Practice New Model

Paid for another role Dedicated $

Specialty-specific view Big-picture view

Clinical work prioritised Clinical work balanced

Learn by experience Specific training

Slow, consultative decisions Authority to make decisions

Vague lines of reporting Clear lines of reporting

Reluctant to take ownership Take ownership of problems

Current priorities

• IV Project leadership

• Change Control Board

• Medication reconciliation

– Admission conversion

– Discharge documentation

• “Form wars”

• Compliance (legal, regulatory)

• Evaluation

Silvia Fazekas

eMEDS Project Manager

South Eastern Sydney Local Health District

Initial site update

Cheryl McCullagh

Director Clinical Integration

Sydney Children’s Hospitals Network

Initial site update

The MEMORY strategy describes the plan for implementation of a fully integrated health record across SCHN; it involves more than 20 projects in the next three years. Aims include:

safer care

better access, for multiple users

current complete records

reduced risk around missing or incomplete information

reduced errors

accessible to all from anywhere

improved reporting

SINGLE EMR

CHW

SCH

2013 2014 2015 2016 2017

EMM + EMRP

Westmead

Clin-docs

build

Move to SurgiNet

PathNet c/compass

Move off iPM to SCHN stack

Voice Rec in ED

PAS: add Facility ID

PAS feed To CHW

EMM across Randwick

FirstNet Surginet

SCHN EMR Strategic Roadmap- 4 years

70

EIR

SCH scanning

PCEHR

Voice Rec in ED

EMR CHW

EMR SCHN

Backscanning lanier

END

END VR lanier

VR lanier

Email, Reports, Lync, MRD, Scanning, Coding, IT support, PCs, Printing, BYOD, PAS, shared patients

NAP forms

CCIS

CCIS TBA

NAP forms

EMR SCHN

Implementation Process

EMM/EMRP Project Milestones

End-User Training

Go Live Aug 2015

Project Kick-off

10/03/14

System Review

12/03/14

Design Review

23/06/14

System Validation Sessions

29/09/14 8/12/14

Trainer & Conversion

Prep

16/02/15

Maintenance Training

6/04/15

Integration Testing 1

18/05/15

Post Conversion Assessment

16/11/15

Client Executive Session

10/3/14

Integration Testing 2

29/06/15

Policy

Governance

Strategy and Architecture

Local Networks / Bandwidth

Central Infrastructure (Data Centres) and Operations (EMR)

Local Project Management, Implementation and Training

Program Management, Procurement

End User Computing (PCs, Mobile Devices, TeleHealth Endpoints, Wireless Networks, Phones)

Ownership

Work Practice Review

Standardisation and Content Knowledge

Education

Clinician Support

Benefits Realisation

Local Health Districts need to focus on all of these

EMM-the biggest leap in the EMR

Enab

lers

C

han

ge M

anag

emen

t Risk Category Owner

72

What we have worked out so far

•Who reads email

•Face to face needs senior support

•Surgeons are hard to find

•Coherent, consistent and real reasons for change

•Champions need support too

•Little EMR changes are big clinical changes

•Only users can defend the decisions we make

•Long term credibility is more important that short term change

The MEMORY strategy needs everyone

Addressing old risks adds different risks

Champion responsibilities

Communication, vigilance, feedback

Support

Sharing the messages

Keep the momentum forward

Eyes on the end goal

Focus on the journey

MEMORY Strategy Stories

•Critical mass- 80%

•Story for each project

•Story for each site

•Lead with safety quality access

branding

video /E-learning ++++++

Professional group visits

Support from exec down

Champion Visibility

MEMORY strategy outcomes

•HIMMS level 6

•The first implementation of paediatric

EMM in Australia

•The first implementation of full

documentation in paediatric oncology

•Electronically accessible records for all

patients

•Summary information available to GPs

and Families

•Lifetime e-record for all

children going forward

Questions ?

Questions for the panel?

Chaired by Dr Peter Kennedy

Electronic Medication Management (EMM) Program

State and local

implementation lessons