“But the System Let Me”

Review of eMMS Design Post-Implementation

Rosemary Richman eMR Project Manager

Connie LoeMR Clinical Application Specialist (PharmNet)

Information Management and Technology DivisionSydney and South Western Sydney LHDs

eMM Concord Hospital

� Background of eMM project

� Evolution of eMM Design

Background

� Scope limited to inpatients & to test fundamental eMM functionality

� Inpatient dispensing only & no integration with iPharmacy

� No order entry without allergy information

� Minimal clinical documentation – height, weight, pulse, BGL

� Trial different devices

� Limited decision support to assist clinicians

Background

� Integration Cerner Solutions

– Closed loop medication solution

� Electronic prescribing - PowerOrders

� Pharmacy review, verification & dispensing – PharmNet

� Charting Administration - MAR

� Drug database – Multum

� Customised Decision Support – Discern Rules

Rationale

� More benefits in electronic prescribing, basic decision support & medication administration

� Minimum decision support minimised system performance issues & delays to obtain agreement on rules

� Rationalisation of decision support for maximum patient safety: minimum workflow impact

� Eliminated patient safety risks associated with the paper NIMC

� Avoided high vendor & technical risks with pharmacy system integration

� Introduced in a manner easy for the management of issues & easy for staff to adopt

� Balance between benefits & processes

Rationale

� Decision to focus on Aged Care wards:

– Many medications & many requiring modification during admission

– No complex infusions

– No high risk ADRs

– Medical interest in prescribing, reflected in work practice

– Multidisciplinary practices in place

Initial eMM Design

� Early consultation across a range of users

� Good governance structure

� Clinical champions identified, committees established, & policies around

design & processes mapped to inform system design early in the project

� Design decisions were made by a series of committees

� Standard Cerner build

� Adhered to NSW Health recommendations

� Incorporated organisational, cultural & clinical practice changes

� Clinicians involved in decision making processes - concerns

acknowledged & addressed early on

� Advocacy & leadership by senior clinicians

� Clinicians facilitated communication between clinical & project staff

� Opportunities to change processes & practices

Design Features

� Early planning for workflow changes

� Aligned with safety features of NIMC

� Integrated with real time clinical data

� Decision support at point of prescribing

� TALLman letters for look alike sound alike pairs

� No order entry without allergy functionality

Design Features (continued)

� Reasons included in sentence for PRN medications

� Times adjusted to be appropriate for care e.g. Parkinsons

� Aligned missed doses abbreviations & codes to NIMC

� Remote access for after hours review by doctors

� Order sentences

– Based on drug references and Therapeutic Guidelines

� Order sets

– Consensus of best practice

Order Sentences

� Approximately 12000 order sentences (generics and brands)

Order Sets

� Order sets used to group corresponding orders together

– Patch & patch removal orders

– Warfarin & warfarin target range orders

Implementation

� Nov 2007 – Nov 2009 implemented in 5 Aged Care wards Concord Hospital (20% inpatients)

� Pilot identified several software limitations that restricted some basic functionality at a clinically acceptable Australian standard e.g. Continuous IV Infusion

� Some components such as reconciliation were not implemented due to the inadequacy of the current functionality

Initial Issues Post Go Live

� Prescribing errors subtle & difficult to spot immediately

� Selection Errors

� High doses

� Alert over rides

� Order modification

� No link between corresponding orders in order sets

� Potential for missed doses to go unnoticed

� Not all relevant information fitted on screen

� Difficulty to translate complex charts to electronic increased

risk of missed doses

� Transcribing errors

Initial Issues Post Go Live (continued)

� Perceived increase in workload

� Long process for medication reconciliation

� Security breeches e.g. not logging off

� Informing staff on non eMM wards

� Downtime & transfer processes

� Speciality medication charts

� Loss of staff knowledge

� Maintenance of current good work practices

� Demand on pharmacy increased significantly

Initial Issues Post Go Live (continued)

� Devices not charged, infection control, proximity, peak use access

� Double documentation

� Mostly minor bugs minimal time to rectify

� Some cumbersome workarounds

� Relief staff not able to use system

� Some training issues

Review of Go Live Issues

� Daily ward meetings to address issues as arose/give feedback

� Review of design in consultation with clinicians

� Immediate resolution of issues /rapid design changes

� Mostly minor bugs minimal time to rectify

� Areas of poor compliance or misinterpretation addressed quickly

� Ward/business issues managed by ward staff

� Changes to policies & procedures

� Change management & tweaking of processes/design e.g. warfarin

� After hours managers trained to respond to issues

� Rationalisation of decision support

� Audits – improve compliance or highlight problem areas

Evolution of System Design

� Tweaking initial design

– Update existing functionality

– Addition of medication safety features

� Developing custom rules

– Enforce workflows

– Provide decision support

– Address issues introduced by the system

� New functionality required from vendor

– IV fluids

– Medication reconciliation

Order Modification

� But the system let me ... change the route

� Prescribers could modify all order details including the route

resulting in some ambiguous medication orders

Order Modification

� Route is locked on order modification, prescribers have to

place a new order when changing the route

Warfarin

� But the system let me ... give the warfarin dose

� Administration prompts for warfarin dose dropped independently

of the INR check task

� Warfarin dose could be given prior to INR check task completion

Warfarin

� Five rules which evaluate warfarin/INR check parameters

(date/time, prescriber’s update instructions etc.)

� Control the availability of warfarin MAR task (for administration)

based on the INR check parameters

Paired Order Sets

� But the system let me ... just cancel warfarin/GTN patch

� Despite the grouping of the orders within an order set, orders

are not linked. Cancelling one order does not cancel the other.

Linked Cancellation for Paired Orders

� When one order within the order set is updated, rule checks

the status of corresponding order in the order set

� Corresponding order is updated with appropriate order action

where necessary

Paracetamol

� But the system let me ... order and give the Panadol

� Sometimes difficult to determine the cumulative daily dose of

paracetamol when multiple orders are prescribed

– Different routes, combination products, nurse initiated orders

Paracetamol – 24 Hour Cumulative Dose

� The cumulative doses of paracetamol within the last 24 hours

is checked upon paracetamol prescription and administration

� Prescribers receive pop-up alert at 3g/24 hours and 4g/24

hours upon placing a new order and administering a dose

Paracetamol – 24 Hour Cumulative Dose

First Dose of Antimicrobials

� But the system didn’t tell me ... the first dose starts tomorrow

� Daily frequency associated with default 8am administration time

� If ordered at 9am today � default start time 8am tomorrow

Default Antimicrobial Start Date/Time

� Start date/time for antimicrobial orders are checked and the

prescriber is alerted if the order starts the next day (after 12

midnight)

� Prescriber receives a pop-up alert to review and modify start

date/time as required

Default Antibiotic Start Date/Time

Building Medication Safety into eMM

� Mandatory Indication Documentation

� Patches

� Insulins

� Restricted Antimicrobials Prompt Upon Drug Selection

� Digoxin ADE Alerts

� IV Phenytoin Administration Alert

Mandatory Indication Documentation

GTN Patches

Fentanyl Patches

Insulins

Restricted Antimicrobial Prompts

� But the system let me ... select that order sentence

� By using an order sentence to provide information, prescribers

can inadvertently select it and place an order with this

information text

Restricted Antimicrobial Prompts

� Order sentence selection is checked to determine whether the

‘information only’ order sentence is selected

� Upon selection of the incorrect order sentence, prescriber

receives a pop-up alert to reselect correct order sentence

Potential digoxin Adverse Drug Events (ADEs)

� ISSUE: Administering digoxin when there are abnormal

potassium, magnesium and digoxin levels predisposes

patients to digoxin toxicity

� RULE: Checks for low potassium, low magnesium and high

digoxin levels upon order entry and checks when new

results are posted if there is an existing digoxin order

� ACTION: (New digoxin order)

– Pop-up alert to prescriber to review the use of digoxin

� ACTION: (Existing digoxin order)

– Messages are sent to attending doctor’s inbox and

pharmacists’ task list to review the use of digoxin

Digoxin Adverse Drug Events (ADEs)

Digoxin Adverse Drug Events (ADEs)

IV Phenytoin Administration

� ISSUE: Incidents with inappropriate administration of IV

phenytoin doses

� RULE: Checks whether phenytoin is prescriber as an IV

injection or IV infusion

� ACTION: Pop-up alert with LHD Policy on correct

administration procedure

Conclusion

� Continued process of implementation & evaluation

– Hospital wide rollout will identify new issues

– New functionality from code upgrades

� Development of decision support rules

– Increased clinical decision support

– Prioritisation of rule development

Questions?