Successfully Achieving a Closed Loop Medication System

A Canadian Perspective

Russ Swaga BSc (Pharm), MBA, CPHIMS-CA

Overview of the Canadian Healthcare Environment

Funding Model

Who is the Greatest Canadian?

Sir Frederick Banting

Wayne Gretzky Alexander Graham Bell

Tommy Douglas

"Who is The Greatest Canadian? CBC viewers respond". The Canadian Broadcasting Corporation. 2010

eMM in Canada

Insert HIMSS EMR Adoption Model

Community teaching hospital affiliated with the University of Toronto

Catchment area: 400,000

Three Sites:General, Branson, Seniors’ Health

Beds: 413 acute care 200 long-term care

Volume per year:110,000 ED visits

28,000 inpatient cases5,800 births

Phase 2 System Components:

• Computerized Provider Order Entry (CPOE)

• Evidence-Based Order Sets & Clinical Workflows

• Closed-Loop Medication Administration

• Medication Reconciliation, Depart Process

• Advanced Clinical Decision Support andPhysician Documentation

The NYGH eCare Project is unique in Canada:

– First Canadian deployment of CPOE with regularly-updated evidence integrated into the physician decision-making workflow

– First Canadian hospital to roll out closed-loop barcode medication administration in all Medical, Surgical and Critical Care units

– First HIMSS Stage 6 community teaching hospital in Canada(only 4 hospitals in Canada overall)

Evidence Based Order

Set

Dose Range Checking

Adverse Drug Event

Rules

Med ReconciliationHIMSS 4

HIMSS 5

DVT Rule

HIMSS 6

Transcribing

Ordering

and

Dispensing

Administration

Medication Integration Process

Metrics

And Improved Patient

Outcomes

12

Improvement in Medication Turnaround Time

0

50

100

150

200

250

300

Pre Go-Live

Post CPOE

291 Minutes

50 Minutes

Average Turnaround Time from Antibiotic Ordering

to First Dose Administration

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

% of BPMH Performed for all eCare units

Overall

TARGET

2011-2012

90%

Best Possible Medication History (BPMH)

TARGET

2011-2012

70%

Post-eCare

Before Alert

47%

Pre-eCare

Telemetry only

7%

Admission Medication Reconciliation

Alert Introduced

TARGET

2011-2012

70%

Pre-eCare

Telemetry only

9%

Length of Stay and Inpatient Volumes:Pre-CPOE (2009) vs Post-CPOE (2011)

28-day readmission rate in Medicine: 363 (5.08%) 401 (5.28%)

Pre-CPOE vs Post-CPOE: Hospital Standardized Mortality Ratio (HSMR)

19

111 deaths prevented in 9 months(11 from pneumonia, 7 from COPD)

\Metro Edition Thursday Dec 13, 2012

In-Hospital Death Rates Down Across Greater Toronto Area

• Annual CIHI Report demonstrated that preventable in-hospital deaths were reduced

• NYGH – top performer in Greater Toronto and second best in all of Canada

• CEO Tim Rutledge: “health information technology has hard-wired quality and safety into the hospital”

eCare: Key Success Factors

1. Organizational Vision, Readiness and Commitment

2. Engagement of front-line clinicians:– Change management more important than system design!

– Respected local clinician champions for peer-driven change

– Clinicians have direct input into design of system ownership

3. Effective communication plan:– Understand reasons and impetus for change

– Recognize unique adoption characteristics of each clinician group

4. Clinical Integration: Clinicians, Evidence, Workflows

5. Robust and reliable Technical Infrastructure

6. Continuous Measurement, Learning and Improvement

Challenges of Implementing a U.S. Vendor CIS

• Philosophical

• Legislative and Administrative

• Technical

• Practical

• Clinical

Philosophical

• Not predicated on a publically funded, single payer system

– Focus on billing, charge on administration, phachargecredit, Patient’s Own Medications

Challenges of Implementing a U.S. Vendor CIS

Legislative and Administrative

• Encounter Strategy (ED vs Inpatient)

• Privacy Laws

– Cloud Technology

• JCAHO requirements

• Meaningful Use

• PAL’s containing U.S. Brand Names

Challenges of Implementing a U.S. Vendor CIS

Technical

• Multum Drug Database, Order Catalogue, Multum Outpatient Order Sentences, Obsoleted Medications

• NDC’s vs GTIN’s

Challenges of Implementing a U.S. Vendor CIS

Practical

• Availability of functionality

– KDMO (Knowledge Driven Medication Ordering)

– mCDS (Medication Clinical Decision Support)

• Support (Global Support Desk)

Challenges of Implementing a U.S. Vendor CIS

Clinical

• Workflows – “Cerner Standard”

• Clinical Pharmacist Documentation

• Staffing

– 24/7 Pharmacy

– Nurse Witness

• Non SI Units of Measure

Challenges of Implementing a U.S. Vendor CIS

Take Away

Adapt your system to meet the needs of your clinicians and your patients

Thank You