Medication Reconciliation Design Challenges with 2007 Code

Advocate’s CareConnection

Medication Medication ReconciliationReconciliationDesign Challenges Design Challenges with 2007 Codewith 2007 Code

May 2nd, 200711:00 – 11:50

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Who we areWho we are Margie Hunssinger, RN

Manager Clinical Applications Group Laurie Gift

Manager PharmNet Applications

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Advocate HealthCareAdvocate HealthCare Largest not-for-profit IDN in metropolitan Chicago Founded in 1995 with merger of two health systems One of the top 10 systems in the United States

Ten hospitals (7 acute care, 1 LTC, 2 Children’s) Three medical groups Illinois’ largest home health service 200 sites of care 25,000 associates 4600 physicians

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Advocate Health Care, Oak Brook, Ill. Alegent Health, Omaha, Neb.

Aurora Health Care, Milwaukee

Avera Health, Sioux Falls, S.D.

Baptist Health South Florida, Coral Gables, Fla.

Baylor Health Care System, Dallas

Berkshire Health Systems, Pittsfield, Mass.

Beth Israel Deaconess Medical Center/CareGroup, Boston

Bridgeport Hospital, Bridgeport, Conn.

““Most Wired” status by Hospitals Most Wired” status by Hospitals and Health Networksand Health Networks past six past six yearsyears (2000-06 (2000-06))

Number 1

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Medication Reconciliation - Advocate HistoryMedication Reconciliation - Advocate HistoryPreparing our process - 2005Preparing our process - 2005 Advocate-wide effort in 2005 to develop a paper process

for documenting Medication Reconciliation Team consisted of representatives from all sites

Pharmacists Nurses Quality

Goal was to have one form to be used at all hospitals Forms already in use at Advocate Hospitals, and other

institutions used as starting point Medication Reconciliation team expressed strong desire

to use EMR – Advocate moved ahead with a solution.

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Medication Reconciliation - Advocate HistoryElectronic Medication Rec Process - 2005

Documentation: Electronic Medical Record

Printing the Report

Paper Documentation

Total Process of Medication Reconciliation

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Medication Reconciliation - Advocate HistoryMedication Reconciliation - Advocate HistoryNurse Documentation - 2005Nurse Documentation - 2005 A new Admission Order will be automatically placed

on all documenting units

The order will create a scheduled patient care task called Home Medication History

Medication History will no longer be part of the current Patient History Form

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Medication Reconciliation - Advocate HistoryMedication Reconciliation - Advocate History Documentation on this form is like all forms - Documentation on this form is like all forms - 20052005 If the box says <alpha> click in the box to see

options. If the box is empty, type in response. You can change date and time if necessary Sign with Green Check Mark Icon

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Medication Reconciliation - Advocate History Medication Reconciliation - Advocate History Documentation - 2005Documentation - 2005

New Tab Medication Reconciliation To View Home Medication Documentation and Current

Medications

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Medication Reconciliation - Advocate History Medication Reconciliation - Advocate History Med Reconciliation Screen - 2005Med Reconciliation Screen - 2005

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Medication Reconciliation - Advocate History Medication Reconciliation - Advocate History Discontinued Scheduled Medications - 2005Discontinued Scheduled Medications - 2005

Scheduled Medications that have been discontinued in the last 24 hours will be listed as well

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Medication Reconciliation - Advocate History Medication Reconciliation - Advocate History Printed Meds Rec – Page 1Printed Meds Rec – Page 1

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Medication Reconciliation - Advocate History Medication Reconciliation - Advocate History Printed Meds Rec – Final PagePrinted Meds Rec – Final Page

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Medication Reconciliation - Advocate History Medication Reconciliation - Advocate History Opportunities for improvement - 2005Opportunities for improvement - 2005 Use of free text entries will need to be eliminated. Conversion of home meds to inpatient meds. Difficult to ensure that complete history including drug,

dose, frequency, route, and last dose taken included for every entry.

Reconciliation process is not electronically captured, difficult to measure compliance.

Need for compliance audits – currently a VERY manual process.

Current report process lends to non-standardized procedures, site to site and unit to unit.

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Medication Reconciliation2007 CodeChallenges

• Hmmm

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Medication Reconciliation 2007 Code Medication Reconciliation 2007 Code ChallengesChallenges Cerner 2007 code upgrade presented options to explore a

complete EMR solution to the medication reconciliation process.

Cerner Design This was designed such that the nurse will capture the

medication history in the new window and the physician will have the privilege to perform medication reconciliation. It is a CPOE design and is not designed to support an alternative workflow.

For non-CPOE sites, they will need to maintain and use their current processes or the Cerner recommended processes and reports.

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Medication Reconciliation 2007 Code Medication Reconciliation 2007 Code ChallengesChallenges

Is your site 100% CPOE enabled?Every Physician?

Who will do reconciliation online?

• Nursing • Pharmacist • Physician

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Medication Reconciliation 2007 Code Medication Reconciliation 2007 Code ChallengesChallenges Each Advocate hospital has varying % of CPOE adoption. All clinicians perceive online processes as additional work. Advocate’s eight hospitals include

Large teaching sites with residents Mid-size hospitals Small community hospitals

Site Nursing and Pharmacist resources vary FTE numbers Shift staffing Medication order entry access

Process outliers Emergency Bedded Outpatients

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Medication reconciliation – 2007Medication reconciliation – 2007Advocate ApproachAdvocate Approach Implement medication reconciliation, make available to

all CPOE physicians and residents at all sites. All sites will utilize codified documented medications. Current medication reconciliation reports and genviews

will be re-created incorporating 2007 code design. They will reflect any electronic reconciliation done.

Reconciliation workflow can be site specific Sites may choose to have nursing and/or pharmacists complete

electronic reconciliation processes if no CPOE physician is available.

Sites may choose to continue reconciliation process utilizing re-created reports and genviews.

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Medication reconciliation – 2007Medication reconciliation – 2007Why Now??Why Now?? Solutions are available in 2007 code Prescription Writing “Carrot” Increased CPOE Adoption Current Process is not working. Candidates are a “Base” to move forward for Next Steps

2007 Base Functions• Enhanced View• Enhanced orders• Medication Reconciliation

Next Steps - 2008• House-wide Discharge Planning• Continued CPOE Rollout• CareConnection ED Solution – (FirstNet)

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Workflow Diagram – Admission / TransferWorkflow Diagram – Admission / Transfer

#1APatient

Admitted

#1APatient

Admitted

#2ANurse

Documents Meds Taken at Home

#2ANurse

Documents Meds Taken at Home

#3CPOE

Physician?

#3CPOE

Physician?

#8Med Rec Paper Report from CC

#8Med Rec Paper Report from CC

#7Med Rec paper report

printed from CC


printed from CC

#5Physician Completes

Admission Med Reconciliation in CareConnection


Admission Med Reconciliation in CareConnection

#9Physician

Completes Med Rec on Paper

#9Physician

Completes Med Rec on Paper

#11Paper Med Rec report

is reconciled in CareConnection by

Clinician



Clinician

#12Newly written paper

Med Orders are sent to pharmacy per the

usual process

#12Newly written paper

Med Orders are sent to pharmacy per the

usual process

YES

NO

Med Rec Admission / Transfer 2007 Code Upgrade

DRAFT Workflow Proposal

Med Rec Admission / Transfer 2007 Code Upgrade

DRAFT Workflow Proposal

#6Med Reconciliation

Completed on Admission / Transfer in

CareConnection

#6Med Reconciliation

Completed on Admission / Transfer in

CareConnection

#13Paper Med Orders to

Pharmacy

#13Paper Med Orders to

Pharmacy

#4Available to

Perform Med Rec in CC?

#4Available to


NO

YES

#10Completed Med Rec Paper Rpt Filed in Pt

Chart

#10Completed Med Rec Paper Rpt Filed in Pt

Chart

#1BPatient

Transferred

#1BPatient

Transferred

#2BNurse / Physician

Review Meds at time of patient transfer

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Workflow Diagram - DischargeWorkflow Diagram - Discharge

#14Patient ready for

Discharge

#15CPOE

Physician?

#21Med Rec Paper

Report Printed from CC


printed from CC


Discharge Med Reconciliation in CareConnection

#22Physician Completes Med Rec on Paper



clinician

NO

Med Rec on Discharge – 2007 Code UpgradeDRAFT Workflow Proposal

#19Med Reconciliation Completed

on Discharge in CareConnection

#18Pt Prescriptions generated from CareConnection

#23Physician writes

patient prescriptions

How will paper prescriptions hand written for the patient be captured in CareConnection? Or will they be?

#24Process

Hole

YES#16

Available to Perform Med Rec in CC?

#16Available to


YES

#26Completed Med Rec

Paper Report Filed in Pt Chart

Process DecisionPaper Document

End of ProcessKEY =

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Medication Reconciliation – 2007 Medication Reconciliation – 2007 FunctionalityFunctionalityNavigationNavigation

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Medication Reconciliation – 2007 Medication Reconciliation – 2007 Functionality Functionality Overall med History – all med ordersOverall med History – all med orders

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Medication Reconciliation – 2007 Medication Reconciliation – 2007 Functionality Functionality Document Medication by History Document Medication by History

• Active Home Meds

• Compliance Information

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Medication Reconciliation – 2007 Medication Reconciliation – 2007 Functionality Functionality Document Medication HistoryDocument Medication History

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Medication Reconciliation – 2007 Medication Reconciliation – 2007 Functionality Functionality Addition of a new Documented MedAddition of a new Documented Med

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Medication Reconciliation – 2007 Medication Reconciliation – 2007 Functionality Reconciliation choicesFunctionality Reconciliation choices

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Medication Reconciliation – 2007 Medication Reconciliation – 2007 Functionality Admission Reconciliation Functionality Admission Reconciliation ScreenScreen

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Medication Reconciliation – 2007 Medication Reconciliation – 2007 Functionality Admission Reconciliation Functionality Admission Reconciliation ScreenScreen

• Actions complete ready to sign

• Documented Meds NOT converted to inpatient orders - still active Home meds

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Medication Reconciliation – 2007 Medication Reconciliation – 2007 Functionality Reconciliation History Functionality Reconciliation History displaydisplay

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Medication Reconciliation – 2007 Medication Reconciliation – 2007 Functionality Functionality Discharge ReconciliationDischarge Reconciliation

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Medication Reconciliation Issues – Medication Reconciliation Issues – 20072007Advocate Listing / PrioritizationAdvocate Listing / Prioritization

• Killing Bugs !

• Issue Spreadsheet

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Advocate Issue Resolution Advocate Issue Resolution ProcessProcess Go-Live issues have been approved by Nursing,

Pharmacy and Physician liaisons. Go-Live issues are escalated to Cerner via Midwest

escalation form as well as Cerner requested information. Issue status is discussed at weekly meetings with Cerner.

Cerner defines CSP release that will contain fix CSP 2007.07 is the LAST CSP Advocate will install Exception packages will be requested for Go-Live issues post

2007.07 CSP release. Issue owners track daily activity in change control.

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Medication reconciliation – 2007Medication reconciliation – 2007Advocate Approach - TimelineAdvocate Approach - Timeline Cerner 2007.01 code delivered – 12/06 Cerner recommended 2007.02 CSP installed – 01/07 Functional candidates defined – 01/07

Meds reconciliation Enhanced View Enhanced Orders

Functional Analysis/Assessment/POC 01/07 – 03/07 Build to 2007 domain 03/07 – 04/07 2007 design complete 5/1/07 Functional/Integration Testing 05/07 – 06/07 6/18/07 – Go / No-Go decision for meds reconciliation MOCKS – 05/07 – 08/07 Last CSP 2007.07 – Cerner release 6/15/07 User verification testing – 07/07 Training begins – 08/07 Implementation 09/15/07

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Questions?Questions?

Medication Reconciliation Design Challenges with 2007 Code

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