Lea Dias – EMR Business Architect

EMR Business Architect/Senior Pharmacist for PCH

HIMSS Conference in Sept 2012

PCH opens Nov 2015

Health in WA has lagged behind introducing automation and ICT

Reasons to automate:

◦ Dramatic reduction in human error

◦ Standardisation of process

◦ Reduction in variation and improved efficiency

◦ PATIENT SAFETY AND PREVENT HARM

Evidence gathered by PCH includes:

◦ Sg2 report (commissioned by Strategic Projects)

◦ Interviews with leading global hospitals

◦ Churchill Fellowship

Recommendations from Sg2 report ◦ Pharmacy Automation, Business Case for Electronic Medical Record (EMR)

Australian Commission for Safety and Quality in Healthcare

(ACSQHC) Electronic Medication Management Guidelines

Other Australian states well advanced

Investigate CLMMS

Evaluate and review implementation of an eMMS

Interview and selection process of candidates

Organising the Fellowship

Contacting the hospitals

Writing the report - humbug!!

Disseminating information to the wider Australian public

United States

UCSF Benioff Children’s Hospital (UCSF)

Boston Children’s Hospital (BCH)

Children’s Hospital of Wisconsin CHW)

Phoenix Children’s Hospital (PhCH)

United Kingdom

Great Ormond Street Hospital (GOSH)

Cambridge NHS Trust

Petach Tikva – Israel

Schneider Children’s Medical Centre

Governance

◦ Driven by patient safety, not ROI

◦ Strong executive leadership driving change

Role of Pharmacy Department

◦ Dynamic and innovative

◦ Differences in Pharmacy services internationally

Enabling technology and automation

◦ Differences in adoption of automation and technology systems

◦ Complex paediatric specific dosing

“Closing the loop”

Implementation of EMR

PMH UCSF BCH CHW PhCH GOSH Cambridge Schneider

No of paediatric beds 220 180 368 157 355 320 >1000 250

No of neonatal beds 30 50 28 110

No of ICU beds 139

Total 250 230 396 296 465 320 >1000 250

Number of pharmacist 30 40 55 40 40 50 >75 10

Number of technicians 10 >50 120 60 >70 >60 >90 >15

Ward based rounds ✖ Y Y Y Y Y Y ✖

Satellite pharmacies ✖ 2 3 6 ? Y A lot 1

24 hour / 7day service ✖ Y Y Y Y ✖ ✖ ✖

Unit dosing ✖ Y Y Y Y ✖

✖ ✖

PMH UCSF BCH CHW PhCH GOSH Cambridge Schneider

System ✖ Epic Cerner Epic AllRx JAC Epic Chameleon

E-prescribing ✖ ✔ ✔ ✔ GE ✔ ✔ ✔

Clinical documentation ✖ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Pharmacy Info System ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

EMAR* ✖ ✔ ✔ ✔ ✔ ✖ ✔ ✖

LIS/PIS integration ✖ ✔ ✔ ✔ ✔ ✖ ✔ ✔

Oncology Info System ✖ ✔

HG ✔ ✖ Chemocare

✔ ✖

ICU Information System ✖ ✔ IMDsoft ✔ ✔ IMDsoft ✔ IMDsoft

Anaesthesia Info System ✖ ✔ IMDsoft ✔ ✔ ✔ ✔ IMDsoft

Patient Admin System ✖ ✔ AllRx ✔ ? IPM ✔ ?

Billing and scheduling ✖ ✔ Epic ✔ ? ? ✔ ?

EMR ✖ ✔ ✔ ✔ ✔ ✖ ✔ ✖

*EMAR – Electronic Medication Administration Record

PMH UCSF BCH CHW PhCH GOSH Cambridge Schneider

System ✖ Epic Cerner Epic AllRx JAC Epic Chameleon

Dispensary robots ✖ ✔ ✔ N/A N/A ✔ ✔ ✖

Pharmacy carousel ✖ N/A N/A ✔ ✔ N/A N/A ✖

IV Robotics ✖ ✔ ✖ ✔ ✖ ✖ ✖ ✖

TPN compounder ✖ O ✔ ✔ ✔ ✔ ✖ O

Automated Dispensing

Machines ✖ ✔ ✔ ✔ ✔ ✖ Pilot ✖

Bar coding technology ✖ ✔ ✔ ✔ ✔ ✖ ✖ ✖

Smart pumps ✖ ✔ ✔ ✔ ✖ ✖ Post GOLIVE ✖

Unit Dose Packaging ✖ ✔ ✔ ✔ ✔ ✖ ✖ ✖

Computer On Wheels ✖ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Bedside BCMA

“closing the loop” ✖ ✔ ✔ ✔ ✔ ✖ ✖ ✖

Teaching hospital affiliated UCSF Medical Centre Campus

180 paediatric/50 neonatal beds

Unit dosing in the mid-70’s

Oct 2010 Mission Bay, Robotic Manufacturing Pharmacy

Bar code unit doses:

◦ tablets, capsules, liquid syringes, IV syringes and IV infusions

◦ full bar coding capability

Early 2011, Benioff went live with an EMR

EMR - Epic

Integration with PAS

Electronic Prescribing with Clinical Decision Support

Integrated Pathology and Diagnostic Imaging

Pharmacist verification queue

Full BCMA

Medication reconciliation

Integrated with automation

Mar/ April 2010

May to July 2010

July to Oct 2010

Oct 2010 to (Mar*) Oct*

2011

Sept to Dec

2011

Dec to Mar 2012

Mar-Jun

2012

Epic sign off

Training & certification Training in Basics of Epic Capabilities of system

Validation Epic facilitate workflow sessions with subject matter experts. Big picture decision with pharmacy and nursing (3 x3hr sessions).

Build Phase Decision made through validations configured by doctors, pharmacists, nurses. *Timeline blowout

Training Super user training

Training End user training

Testing of system 6 months

Phase 1- Mar 12 GO LIVE

Pharmacy, EMAR, BCMA, Nurse documentation

Phase 2 – Jun 12

CPOE, Clinical documentation, scheduling, billing etc

*Initial date

GO LIVE Oct 11

Mar/April

2012

Jan to Apr 2013

May to Aug 2013

Sept to Jan 2014

Jan - Mar

2014

Mar – Oct 2014

Oct 2014

Epic sign off

Training & certification Training in Basics of Epic Capabilities of system

Validation Epic facilitate workflow sessions with subject matter experts. Big picture decision with pharmacy and nursing

Build Phase Decision made through validations configured by doctors, pharmacists, nurses. *Timeline blowout

Training Super user training

Training End user training

Testing of system 6 months

Team workflows Clinical documentation Radiology Ordering Pharmacy Med rec Discharge Bloods Meds mgt

Epic training Definitions Multiple choice 5 weeks validation 2-3 months training or more

GO LIVE Oct 14

Example Inventory Ordering meds from ward Swimlane visio Documenation and validation Epic training and exams

1.5 million doses – no medication errors

Building COG protocols into oncology system (integration with Apex)

Building interface with IV robotics and Smart Pumps into Apex

MB facility studying molecular gene therapy

Affiliated with Harvard Medical school

396 paediatric/28 neonatal beds

In late 90’s, BCH were pioneers in introducing technologies with

three main functions:

Basic science research

Direct clinical applied research

Continued research and to enable benchmarking against other paediatric

hospitals in the US

HIMSS Level 7 hospital

Upgrade Cerner clinical system in 2004 (introduced late 90’s)

Allscripts for bed management

Epic for billing and scheduling

Epic - MY CHART, Online Patient Portal

IMDsoft – ICU and anaesthesia

ALICE for patient tracking

Home grown system for oncology COG protocols (integrated with IHS)

Homegrown cardiology and ophthalmology systems

Vecna – Infectious Diseases (2.5 years in development)

Integration with automation and smart pump technology

Scan in timeline

PMH UCSF BCH CHW PhCH GOSH Cambridge Schneider

System ✖ Epic Cerner Epic AllRx JAC Epic Chameleon

E-prescribing ✖ ✔ ✔ ✔ GE ✔ ✔ ✔

Clinical documentation ✖ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Pharmacy Info System ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

EMAR* ✖ ✔ ✔ ✔ ✔ ✖ ✔ ✖

LIS/PIS integration ✖ ✔ ✔ ✔ ✔ ✖ ✔ ✔

Oncology Info System ✖ ✔

HG ✔ ✖ Chemocare

✔ ✖

ICU Information System ✖ ✔ IMDsoft ✔ ✔ IMDsoft ✔ IMDsoft

Anaesthesia Info System ✖ ✔ IMDsoft ✔ ✔ ✔ ✔ IMDsoft

Patient Admin System ✖ ✔ AllRx ✔ ? IPM ✔ ?

Billing and scheduling ✖ ✔ Epic ✔ ? ? ✔ ?

EMR ✖ ✔ ✔ ✔ ✔ ✖ ✔ ✖

*EMAR – Electronic Medication Administration Record

PMH UCSF BCH CHW PhCH GOSH Cambridge Schneider

System ✖ Epic Cerner Epic AllRx JAC Epic Chameleon

Dispensary robots ✖ ✔ ✔ N/A N/A ✔ ✔ ✖

Pharmacy carousel ✖ N/A N/A ✔ ✔ N/A N/A ✖

IV Robotics ✖ ✔ ✖ ✔ ✖ ✖ ✖ ✖

TPN compounder ✖ O ✔ ✔ ✔ ✔ ✖ O

Automated Dispensing

Machines ✖ ✔ ✔ ✔ ✔ ✖ Pilot ✖

Bar coding technology ✖ ✔ ✔ ✔ ✔ ✖ ✖ ✖

Smart pumps ✖ ✔ ✔ ✔ ✖ ✖ Post GOLIVE ✖

Unit Dose Packaging ✖ ✔ ✔ ✔ ✔ ✖ ✖ ✖

Computer On Wheels ✖ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Technology/automation

integration ✖ ✔ ✔ ✔ ✔ ✖ ✖ ✖

Bedside BCMA

“closing the loop” ✖ ✔ ✔ ✔ ✔ ✖ ✖ ✖

<2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

UCSF Epic May 10

‘GO LIVE’

June 12

BCH Phase 1

Phase 2A Phase 2B Phase 3

CHW Allscripts 2000

BDM centricity (GE)

Interface develop-ment

Bi-directional interface

Epic Jan 10

‘GO LIVE’

Sept 12

PhCH Allscripts 1999

‘GO LIVE’ 2002

BDM centricity (GE)

Bi-directional interface

Sunrise full integration

Rolled out to wards

PICU/ NICU/ ED

Ambulatory care

GOSH Ascribe

JAC

Cambridge Epic Jan 12

‘GO LIVE’ Oct 14

Schneider IMDsoft Chameleon

Success of CLMMS dependent on: ◦ Good EMR implementation

◦ Good automation

◦ Robust governance structure

Driven by patient safety, not ROI (all sites)

Best of breed systems - resource and time intensive and costly

Set realistic timeframes, avoid rapid implementation

Resource constraints poses a serious risk to patient safety

Do not overdo ‘alerts’ or ‘hard stops’ - ALERT FATIGUE!!

Select systems with usability by multiple users at the same time

Day 1 - Automation:

◦ Automated Dispensing Machines (limited function)

◦ Bedside medication drawers

◦ Mobile medication carts

◦ Paper medication charts

Pharmacy Automation

◦ Whole Pack Robotics

◦ Unit-Dose Robotics

EMR staged rolled out

◦ Electronic prescribing with clinical decision support

◦ Bar code medication administration = CLMMS

Dramatic reduction in medication errors

◦ Illegible prescription

◦ Transcription errors

◦ Wrong doses (decimal point error)

◦ Wrong drug selection

Improvement in Nursing workflow

Operational efficiencies for Pharmacy

Data decision support and standardised treatment sets

Accurate measuring and collection of data: errors and

outcomes

EMR and Pharmacy automation enables future improvements on a

long journey

Strong support from top down to continue to drive development

Ambitious long-term project with realistic Day 1 position

Moving towards CLMMS in Western Australia

What could the future look like with a poorly implemented EMR?