Electronic Health Record and Smart Pump Interoperability

Electronic Health Record

and Smart Pump

Interoperability

A Work in Progress

Learning ObjectivesAt the completion of this presentation, the participant will be able to:

• Explain the general concept of Electronic Health Record (EHR) and Smart Infusion Pump Integration • Identify requirements for the process of EHR/Pump Integration

o Staff – IT (EHR team, networking, BioMed), Pharmacy (admin and staff), Nursing (admin and staff), Administration (approve and support $$$) and Education (for nursing, pharmacy and EVS)

o Equipment – computers, Smart Pumps (buy vs. lease), interfaces (cables, connectors, etc.)o Infrastructure – Electronic Health Record (EHR), network (Wi-Fi), software and servers

• Describe the difference in Smart Pump use with and without integration• Identify benefits EHR/Smart Pump Integration has on patient safety• List at least three challenges of EHR/Smart Pump Integration• Discuss the roles pharmacists have in helping maintain a medication library and data set guardrails

for smart pumps• Outline how pharmacy technicians can play a vital part in the success of EHR/Smart Pump

Integration

Texas Health ResourcesThis presentation will reference certain proprietary brands of Electronic Health Record (EHR) software and Smart Infusion Pumps and software and in no way is to promote or recommend

certain brands and/or types of application. All references, description of and photos are for demonstration and example purposes only.

• Electronic Health Record software used at THR is Care Connect which is THR’s branded version of Epic Systems®

o Texas Health Resources utilizes Care Connect/Epic ® in 17 wholly owned hospitals and 5 jointventure hospitals

• The Smart Infusion pumps are BD Alaris™o The number of smart infusion pumps maintained for production at Texas Health Resources (actual patient

administration use) is greater than 3,000o Pumps for testing and training are also maintained but with separate environmentso The software for maintain the smart infusion pumps are:

Guardrails Editor® and Alaris™ Systems Manager

Guidelines° ISMP (Institute for Safe Medication

Practices)• Resources• Publications• Alerts• News

° Register for FREEISMPhttps://www.ismp.org

° Guidelines for Optimizing Safe Implementation and Use of Smart infusion Pumpshttps://www.ismp.org/system/files/resources/2020-10/ISMP176C-Smart%20Infusion%20Pumps-100620.pdf

EHR / Smart Pump Integration1

° What does this mean?• Orders are input and verified in the EHR• Nursing prepares product for administration• The medication/fluid is selected/verified by barcode

scanning. The pump module is also selected by barcode scanning

• Infusion pumps are “auto” programmed from the EHR• IF ALL criteria are met the nurse will NOT need to select

the product from the menu screen of the pump• Two-way communication between the EHR and the

smart pump – both environments confirm administration

• The Medication Administration Record (MAR) and flowsheets are auto populated

ceFAZolin 1 gm IVPB infused over 30 minutes and documentation

was completed by the pump (exception: infusion completion)

1. Ubanyionwu S. Beyer J. "Revolutionize Medication Safety with Smart Pump-Electronic Health Record Interoperability." 2019 American Society of Health-System Pharmacists (ASHP) Summer Meetings & Exhibition; June 8-12, 2019 in Boston, MA.

EHR / Smart Pump Integration – What does it take?° Do you just plug in everything and it’s ready to go?

• IT Staffo EHR Team (Willow) – drug library & guardrailso Biomed – quality assurance and performance,

maintenanceo Networking – connectivity with Wi-Fi

• Pharmacy Departmento Pharmacy administration for allocation of staff time for

support and troubleshooting o Staff – assistance with infusion products (formulary)

and troubleshooting errors (this can be pharmacist, technician or both)

• Nursingo Administration – support needed in every area for end

user nursing. FTE allocation for education and trainingo Staff – the end user (the bedside nurse) is where it ALL

happens. Without two-way support the pump/EHR interoperability cannot happen

EHR / Smart Pump Integration – What does it take?° Do you just plug in everything and it’s ready to go?

• Health System/Hospital Administrationo Show me the $$$$

• 2015 Pump Cost Estimationo It has been shown the listed prices can easily double

when networked for interoperability o Decrease in IV medication administration errorso Increase in proper documentation o Increase in capture of mediation/fluid billing o Increase in caregiver (physician, nurse and pharmacist)

satisfaction

2

2. Laskaris J. Purchasing Insight: Watch infusion pump prices as market surges for intravenous therapy. Healthcare Finance website. January 23, 2015 Accessed March 14, 2021 https://www.healthcarefinancenews.com/blog/purchasing-insight-infusion-pump-prices-market-surges-intraveneous-drug-therapy#:~:text=The%20cost%20of%20these%20devices,cost%20will%20more%20than%20double.

EHR / Smart Pump Integration – What does it take?° Equipment and Infrastructure

• Computers/Laptopso Staff will need for pump and EHR softwareo Cables and ports, interfaces for pump BiOS flash

(production, training and testing)

• Smart Infusion Pumpso Buy v. Lease – very subjective o Service maintenance contracts or in-house clinical

engineering (BioMed)o Software licensing – per pump and timeframe

(monthly, quarterly or yearly)

• Software/Hardwareo Electronic Health Record (EHR) capable of smart

infusion pump interoperabilityo Wi-Fi – routers, wireless access points, securityo Servers – support software of the smart infusion

pumps (THR has three separate servers for the environments of production, testing and training)

Smart Pump Use With and Without Integration° With Integration

• Pump is preprogrammedo Drug/fluid library is in the software of the pumpo Drug/fluid parameters are loaded to the pump with

software (drug/fluid database)

• Drug/Fluid Verificationo Pump and drug/fluid are both scanned o Two-way communication (EHR/pump) is confirmedo Pump “loads” the drug/fluid then is visually

confirmed and compared to EHR screeno Components such as dose, volume, rate and

duration are automatically sent to the EHR

• Chartingo Upon verification and starting of the pump, auto

documentation of the MAR and flowsheet has occurred

o Still need to verify correct dose and/or volume and time of start and time of infusion

° Without Integration• Pump is preprogrammed

o Drug/fluid library is in the software of the pumpo Drug/fluid parameters are loaded to the pump with

software (drug/fluid database)• Drug/Fluid Verification, BUT…

o Only drug/fluid is scanned into the EHR o NO two-way communication of EHR/pump

(NOTHING is auto selected by communication)o Pump library must be searched via the pump screen

and the drug/fluid selected by the nurseo Some components must still be manually entered

on the pump screen by the nurse prior to admin• Charting

o Verification of drug/fluid on the pump (after manual selection) and starting of the pump does NOT send information back to the EHR, no documentation

o The nurse must verify everything on the screen of the pump to the MAR, they must also document the start time on the MAR and document the dose and/or rate on the flowsheet

Smart Pump Use With and Without Integration° Basic Infusion (CAN BE chosen regardless)

• Pump is programmed completely by the user at the bedside

o NO drug/fluid library is usedo Information is taken from the label and/or MARo NO guardrails or limits (dose, duration,

concentration, etc.)• How does this happen?

o EHR and smart pump interoperability not available (Wi-Fi issues, patient location out-of-scope (OOS), drug/fluid OOS

o Latest drug/fluid library not loaded on the pumpo Pump is set to incorrect environment (PRD v. TST)o Drug/fluid not in the drug libraryo Drug/fluid incorrect or difficult to understando Emergent situation/timeo User has not been trained on the use of Smart

Pumpso Attempt of drug diversion or “covering up”

mistakes

EHR and Smart Pump Interoperability Benefits° Automation is the Key

• But not without checks, checks and more checkso What benefit is seen and how?

a) Decrease of infusion related dose-errors

Preprogrammed infusions

Interoperability assures 100% compliance of vetted and approved infusions

Decrease of human input errors

Decrease of pump alerts

Reduction of alert overrides

Decrease in reprogramming, cancelling or delay of administration

Decrease in keystrokes needed for infusion administration

Decreased time for bedside caregiver for administration (time spent elsewhere or less time in isolation areas)

Prevention of missed revenue from improper or absent documentation

Improved delivery of medication/fluid (eliminate differences in order and manually programmed rate or dose)

Improved nursing and pharmacist satisfaction

Smart Pump Dose-Error Reduction Software (DERS)° BD Alaris™

• Guardrails®

o Master Listsa) Drugs – items in black font are preloaded (part of the

software) and cannot be deleted. Blue font entries are created by the user and can be named anything (must be 20 characters or less)

Concentration the suitable dose/volume--- dose / --- volume indicates a WildCard (more on this)

Used As indicates the profile type

Aliases is the naming tool to link the EHR and the Smart Infusion Pump

b) Fluids – very limited setup. Mainly for Aliases and if it will support a secondary infusion

c) Therapies – an option to split items from one order into more than one use. Example – vasopressin for hypotension or for esophageal bleeding

d) Clinical Advisories – FYI type information on the pump screen for the end user

e) Syringes – suitable and used syringes for use on the syringe module (primary for neonatal infusion)

f) PCA Syringe – suitable and used syringes for the PCA module

g) Channel Labels – electronic scrolling information for the pump module

Smart Pump Dose-Error Reduction Software° BD Alaris™

• Guardrails®

o Drugs- Drug Name: The name of the drug can be no longer

than 20 characters (this has caused issues when there is a need to be specific in naming such as with neonatal products)

- Drug Units: The dropdown list cannot be edited. Cannot add to or take away. Challenges here can be needing a unit take is built into the orderable of the EHR (such as million units (MU) with PCN, vial as a unit such as with snake antivenom)

- Aliases: The naming tool to link the EHR and the Smart Infusion Pump. Problems that can arise here; no more than 12 characters in length are allowed. The same alias cannot exist in more than one drug name (example: if ceFAZolin is a drug name and you create ceFAZolin PED but you want the alias CEFAZOLININT to be for both because the guardrail is the same, it is not allowed. A separate alias with a separate record must be created.) – difficulty with IMS, IPS in EHR


• Guardrails®

o Fluids- Fluids: The name of the fluid can be no longer than 20

characters (this has caused issues when there is a need to be specific in naming such as with neonatal products)

- Supports Secondary: Does the fluid support a secondary infusion (set above the primary line, clamped)

- Aliases: The naming tool to link the EHR and the Smart Infusion Pump. Problems that can arise here; no more than 12 characters in length are allowed. The same alias cannot exist in more than one fluid name


• Guardrails®

o Therapies- Therapy Name: The name of the therapy can be no

longer than 20 characters AND the total entries are limited to 250


• Guardrails®

o Clinical Advisory- Advisory Name: The name of the therapy can be no

longer than 20 characters AND the total entries are limited to 100

Drug Units: Challenges here can be needing a unit take is built into the orderable of the EHR (such as million units (MU) with PCN, vial as a unit such as with snake antivenom)


• Guardrails®

o Syringes and PCA Syringes- Many questions surrounding syringes.

Recommend looking into the vendors information (FAQ) for syringes


• Guardrails®

o Profiles- Adult- Inhalation – came into play during COVID- NICU (neonatal)- Pediatrics – many guardrails are the same and

changes may come within the EHR in age-based contexts

- Create New Profile- Total Entries – limited to 2500- Hard Limits – always a max or always a min???


• Guardrails®

o Libraries- Each profile has four libraries

- Continuous/Bolus- Intermittent- Fluids- PCA

° ceFAZolin• Adult Profile

o Intermittent Library- Pump/Syringe – which (or both) can infusion

occur on- Primary/Secondary – which (or both) type of

infusion can it support (using one module)- Duration Limits – initial, max and min- Soft Limit – warning only (yellow)- Hard Limit – warning and cannot continue

(red)- Hard Limits – always a max or always a min???

Smart Pump Dose-Error Reduction Software° ceFAZolin

• Adult Profileo Intermittent Library

- Pump/Syringe – which (or both) can infusion occur on

- Primary/Secondary – which (or both) type of infusion can it support (using one module)

- Duration Limits – initial, max and min- Soft Limit – warning only (yellow)- Hard Limit – warning and cannot continue (red)- Hard Limits – always a max or always a min???

Smart Pump Dose-Error Reduction Software° ceFAZolin

• Adult Profileo Continuous/Bolus Library

- Continuous Infusion Dosing Range- Concentration Limits – WILDCARD

--- dose / --- volume: WHAT DOES THIS MEAN????(essentially the sky is the limit is not configured correctly)

- Bolus Dose?- Soft Limit – warning only (yellow)- Hard Limit – warning and cannot continue (red)- Hard Limits – always a max or always a min???

Smart Pump Dose-Error Reduction Software

EHR/Smart Pump Interoperability – Continuous Care Connect Order:

0.9% NaCl 1000 mL IV continuous at 75 mL/hr• The nurse chooses the drug/fluid from the MAR for admin

• The MAR is auto completed at the time of acknowledgement by the pump

• The flowsheet is auto completed with rate (volume will be based on time)

• The EHR sends info to the pump and awaits action at the pump then verifies that information

EHR/Smart Pump Interoperability – Intermittent Care Connect Order:

alteplase 0.81 mg/kg x 85 kg patient• The nurse chooses the drug/fluid from the MAR for admin

• The MAR is auto completed at the time of acknowledgement by the pump

• The flowsheet is auto completed with rate (volume will be based on time)

• The EHR sends info to the pump and awaits action at the pump then verifies that information

EHR/Smart Pump Interoperability – We Have a Problem! Care Connect Order:

0.9 % NaCl 1000 mL at 75 mL/hr• The nurse chooses the drug/fluid from the MAR for admin

• The EHR sends info to the pump and awaits action at the pump, BUT something went wrong:

• Pump is off• Pump is not connected (Wi-Fi)• Primary v. Secondary issue – what was chosen by the nurse• Info being sent by the EHR does not match ALL the

information in the pump library (volume, dose, rate, etc.)• Many things could cause an error…the take home point is

the nurse is able to correct any issues and resend, manually program (does NOT mean basic infusion – STILL need to use the DERS drug data library with guardrails).

Pharmacy Department Roles in EHR / Pump Interoperability° Pharmacist

• Drug Data Librariano Develop and maintain the drug/fluid library for the

software of the pumpo Establish standards and consistency for CSPs/fluids

• Education / Reports / Safety / QIo End user (nurse) education for proper useo Monitor compliance, opportunities for

improvemento Wide range of reporting available internally and with

the pump and EHR vendorso Monitor and manage errors and near-misses for

opportunity to improve

• EHR Management / Revenueo Work with different teams withing the EHR team for

improvement of workflow o Missed revenue through documentation or other

errors

° Technician• Maintaining Software Integrity & Updates

o Verify updates are installed (drug library has been “pushed” to the appropriate pumps)

o Drug database software is updated and working appropriately

• Troubleshooting Errors or Discrepancieso Why did something fail? EHR or pump issue?o Pull and review data from pumps and/or HERo Review logs, orders audit trails, chart review

• BCMA Maintenanceo Is barcoding changing? (NDC, custom barcodes,

etc.)o Work with Biomed (clinical engineering) to assure

scanners and barcodes are in working order

• Reportso Wide range of reporting available internally and with

the pump and EHR vendors

References1. Ubanyionwu S. Beyer J. "Revolutionize Medication Safety with Smart Pump-Electronic Health Record Interoperability." 2019 American Society of Health-

System Pharmacists (ASHP) Summer Meetings & Exhibition; June 8-12, 2019 in Boston, MA.

2. Laskaris J. Purchasing Insight: Watch infusion pump prices as market surges for intravenous therapy. Healthcare Finance website. January 23, 2015 Accessed March 14, 2021 https://www.healthcarefinancenews.com/blog/purchasing-insight-infusion-pump-prices-market-surges-intraveneous-drug-therapy#:~:text=The%20cost%20of%20these%20devices,cost%20will%20more%20than%20double.

3. Biltoft J, Finneman L. Clinical and financial effects of smart pump-electronic medical record interoperability at a hospital in a regional health system. Am J Health Syst Pharm. 2018 Jul 15;75(14):1064-1068.

4. Joseph R, Lee SW, Anderson SV, Morrisette MJ. Impact of interoperability of smart infusion pumps and an electronic medical record in critical care. Am J Health Syst Pharm. 2020 Jul 23;77(15):1231-1236

5. Guidelines for Optimizing Safe Implementation and Use of Smart infusion Pumps https://www.ismp.org/system/files/resources/2020-10/ISMP176C-Smart%20Infusion%20Pumps-100620.pdf

6. Epic Systems – 1979 Milky Way, Verona, WI 53593

7. Becton, Dickinson and Company (BD) and Subsidiary of CareFusion – Franklin Lakes, New Jersey

8. Texas Health Resources – 612 E Lamar Blvd., Arlington, TX 76011

Electronic Health Record and Smart Pump Interoperability

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