10 Things Every CIO Should Know About MEDICATION MANAGEMENT TECHNOLOGIES

(1)

10 Things Every CIO Should Know

About M

EDICATION

M

ANAGEMENT

T

ECHNOLOGIES

(2)

Conflict of Interest Disclosure

Allen Flynn, Pharmacist

•

Solutions Designer for

Health Practice Innovators,

LLC

•

Volunteer Section Chair,

Section on Pharmacy Informatics &

Technology, American Society of Health-System

Pharmacists

(3)

Learning Objectives

1. Explain why medication management

technologies overwhelm organizations

2. Describe interoperability gaps

3. Describe roles and responsibilities of

medication system stakeholders

4. Assess how to position pharmacists well

in your healthcare IT organization

(4)

Pharmacy‟s „Top 10‟ for CIOs

1 Scope

Oversized Footprint

2 Architecture

Like Building a Cathedral

3 Practice change

Patient-Side Pharmacists

4 Drug Supply Chain

Difficult Problems

5 Safety & Efficiency

To Do but Not To Benefit?

6 Pharmacy Staffing

Not Exactly a Pipeline

7 Redundant Work

Disparate Databases

8 Saving Money

Cost Control Pioneers

9 Complexity

Increasing Steadily

(5)

Oversized Footprint

Medication functions in the EHR contribute mightily to care process throughput and quality.

(6)

Scope of Meds’ Data Requirements

1st

Hospital

Meaningful Use, Stage 1

0 7 14 Menu Set Core 5 9 5 5

(7)

Scope of Med List Workflow

– High Level

1st

Medication List Management

Admit H&P List Home Meds Admit H&P List Allergies Order Initial Hospital Meds Nurse FHPA confirms Home Meds, Allergies Reconcile Hospital & Home Meds Order, Change & Cancel Meds Create Discharge Meds List Nurse reviews new home med list with patient Reconcile new home meds list Prescribe meds for home use Major Surgery Reconcile Pre & Post

Surgery Meds Order, Change & Cancel Meds Transfer from ICU to Acute Care Reconcile

Pre & Post Transfer Meds Order, Change & Cancel Meds

(8)

Meds’ Oversized Footprint in the EHR

1st

Overwhelmed?

Trying to maintain accurate list of

active medications?

Keeping up with order sets for

best practices with medications?

Responding to drug shortages?

Configuring and maintaining the

configuration of CDS?

(9)

Like Building A Cathedral

Demand for a more intelligent medication-use system will not cease for a generation.

(10)

First stone 1907

Last stone 1990

A Med Use System Architecture?

2nd

(11)

A Hospital Med Use System Architecture?

2nd

Automated Product Selection CDS DOSE, TIMING SMART IV PUMPS ADE SURVEILLANCE RULES ENGINE

CPOE

PHARMACY SYSTEM LABELS AUTOMATED DISPENSING CABINETS (ADCs) eMAR _{HX, DX}LABS EHR AUTOMATED DOSE PICKING SYSTEMS AUTOMATED ADC PICK-N-REPLENISH ORDER SETS CDS BUG-DRUG, CORE MEASURES, P-KINETICS CDS INDICATION, DOSE, DDI, DFI,

UTILIZATION

BAR CODE SCANNING AT COMPOUND

& DISPENSE

BCMA

EHR FOUNDATION LAYERI LAYERII LAYERIII INHERENT ORDERING SAFETY AUTOMATED TREATMENT FAILURE IDENTIFICATION PHARMACIST PATIENT TRIAGE SYSTEM AUTOMATED COMPOUNDING ROBOTS CDS COMPATIBILITY, ADMINISTRATION LAYER IV P P P DISPENSED PRODUCT LOCATION TRACKING C

Product Supply Chain Clinical Focus C B E G IN E N D

Supply Chain Integration into M edication-Use Cycle

C

EHR

C

AUTOMATED

PRESCRIBING _TO_RACKINGUTCOME

AUTOMATED ORDER VERIFICATION PROACTIVE IV DRIP REFILLS LAYER V PATIENT-SIDE DELIVERY SYSTEMS CDS DDI/ALLERGY COMPUTER ASSISTED IV FLUID ANALYSIS EHR EHR

(12)

Clinical Decision Support

Design

2nd

CDS DOSE, TIMING CDS BUG-DRUG, CORE MEASURES, P-KINETICS CDS INDICATION, DOSE, DDI, DFI,

UTILIZATION CDS COMPATIBILITY, ADMINISTRATION CDS DDI/ALLERGY

D

OSING IBUPROFEN TABLETS

> On-screen ranges

0

800

1600

1200

Dose:

(13)

Even More Pharmacy Solutions

2nd

Controlled Substance Inventory Systems Drug Wholesaler Ordering Systems Drug Supply Management Systems Continuous Inventory Management Systems Emergency Drug Box Management Systems

Patient Pharmacy Services BILLING SYSTEMS

Clinic/Office/Unit

DRUG BILLING SYSTEMS 340B Reimbursement Management Systems Formulary Management Systems Packaging Systems

Supply Chain

Management

Financial Management

(14)

Like Building a Cathedral?

2nd

Need for planning

Some components integrated with

EHR (CPOE), others are not.

Components and solutions are

interrelated and interdependent.

Clinical Decision Support applies

in a variety of different ways.

Consider the role of the

(15)

The EHR must support radically transforming the pharmacist’s practice in the hospital.

(16)

Patient-Side Pharmacists?

3rd

The Making of a 21

st

Century

Hospital Pharmacist

Bachelor’s Degree in Science Pharmacy School (4 years) General Practice Residency (1 year) Specialty Residency (1 more year) Masters Degree

D

ISPENSING

↑

P

ATIENT

C

ARE

G

OAL:

?

(17)

Patient-Side Pharmacists?

3rd

ASHP Pharmacy Practice

Model Initiative

&

IT

•

Med System Safety Standards

•

Sufficient Resources

•

Telepharmacy

•

EHR Design & Innovation

•

Pharmacists as ‘

Power-users’

of IT

(18)

Patient-Side Pharmacists?

3rd

Going upstairs…

Mobility

solutions needed.

Automation and technical staff

will

displace

some current

pharmacist duties.

Documentation

components

become even more important.

Outcome tracking

for individual

(19)

Drug Supply Chain Problems

It is past time for supply chain engineers to help operate the drug supply chain.

(20)

Supply Chain Confusion & Waste

4th

1

st

Dose: Satellite

2

nd

– nth: Basement

Automated Dispensing Cabinet

(ADC)

IF None in Satellite THEN Basement Sends It

IF controlled substance AND NOT in ADC… THEN Nurse has to pick up the drug

IF refrigerated THEN

Deliver to the refrigerator and not the patient bin If out of stock THEN

Pharmacy borrows ORplaces order with wholesaler THEN wait

AND THEN deliver to the nursing unit

(21)

Supply Chain Information Gaps

4th

PHARMACY NURSE

INFORMATION TO SHARE AND RECONCILE WITH NURSING

Satellite Inventory

Main (Basement) Pharmacy Inventory

Automated Dispensing Cabinet Contents

Automated Dispensing Cabinet Inventory

Pneumatic Tube System Tracking

Tracking of Pharmacy Staff Deliveries

Controlled Substance Formulary

Refrigerated Medications List

Purchase Order Content and Status

Borrow and Loan Logs

DISPENSED PRODUCT LOCATION TRACKING PATIENT-SIDE DELIVERY SYSTEMS

(22)

Drug Supply Chain in the Hospital

4th

It is past time for supply chain engineers to help operate the drug supply chain.

Help!

Keohane et al, JONA, 2008

Nurses spend 25% of their time

managing meds

The LARGEST proportion of that

nurse time managing meds (30%)

is spent “Obtaining and Verifying

Medications”

(23)

↑

Safety

Efficiency

Gains in efficiency and gains in safety accrue unevenly amongst stakeholders.

5th

Helmet

(24)

↑

Safety

Efficiency?

5th

Physicians Nurses Pharmacists Data Consumers CPOE BCMA MEDICATION RECONCILIATION SMART IV PUMPS NA NA

(25)

↑

Safety

Efficiency?

5th

Physicians Nurses Pharmacists Data Consumers CPOE BCMA MEDICATION RECONCILIATION SMART IV PUMPS NA NA

(26)

↑

Safety

Efficiency?

5th

Medication Use System Stakeholders

DOCUMENTING TO DISTRACTION?

Physicians

Nurses

Pharmacists

BENEFICIARIES

Patients & Families

Purchasing & Billing

Medication Safety Leaders

HIM

Quality & Risk Management

Executive Management

(27)

Not Exactly A Pipeline

Anticipate acute shortages of pharmacist-analysts capable of optimizing EHRs.

(28)

6th

Workforce Development in

Pharmacy Informatics

The Pharmacist-Analyst Role

> Clinical background

Awareness of implications

> Operational knowledge

Understanding workflows

> Business analysis

Requirements & Processes

> Project management

Organized Estimator

> Systems thinking

Sequencing & Planning

> IT/Database skills (SQL)

Queries & Reports

> Leadership skills

Ethics & Invitational Vision

(29)

6th

RAND: Developing Military

Healthcare Leaders, 2011

The Pharmacist-Analyst Role

> Clinical background

>

Operational knowledge

Management experience

>

Business analysis

>

Project management

>

Systems thinking

Enterprise insights

> IT/Database skills (SQL)

>

Leadership skills

Leadership experience

(30)

–

Pharmacist-Analysts

6th

Considering Staff Development

Anticipate acute shortages of pharmacist-analysts capable of optimizing EHRs.

#

Item

1

Work Experience (Management, Enterprise insight, Leadership)

2

IT Interest and Acumen

3

Pharmacy Informatics Residency Program Graduate ( 12-15/year)

4

HIT Certifications (e.g., CPHIMS)

5

AMIA 10x10 course

6

Graduate Studies in Health Informatics

7

Health IT domain examinations (HIT PRO)

8

Computer Science coursework

(31)

6th

How Many Needed?

40,000

more

HIT workers needed

(

Hersh, Wright. AMIA Annual Symp. Proc., 2008

)

40K x 0.2 = 8000 Clinical Informatics

8K x 0.4 = 3200 Med System Focused

3.2K x 0.5 = 1600 Pharmacist Analysts?

(32)

One Drug, Many Databases

Medication information standardization is imperative for success with Health IT.

(33)

7th

Repeated Entry & Upkeep

SMART IV PUMPS ADE SURVEILLANCE RULES ENGINE

CPOE

PHARMACY SYSTEM AUTOMATED DISPENSING CABINETS (ADCs) EHR AUTOMATED DOSE PICKING SYSTEMS BAR CODE SCANNING AT COMPOUND

& DISPENSE

BCMA

EHR AUTOMATED COMPOUNDING ROBOTS EHR EHR EHR

(34)

•

Trade and generic names

•

Dosage forms

•

Strengths available

•

Units of measure*

•

Dose rounding guidelines*

•

Contraindications*

•

Compatibilities*

•

Instructions for use

7th

Lots of Redundant Information

•

NDC Codes*

•

Internal product codes*

•

Manufacturers

•

Routes of administration*

•

Dose conversions*

•

Generic equivalence code

•

Product description*

•

Cost

(35)

7th

Scope & Scale

TOTAL

ITEM TYPE

Example

4,000

drug orderables

aspirin (1)

10,000 drug products (line items)

81mg, 325mg (10)

chewable, buffered, coated suppository, cream

40,000 drug scan codes

manufacturers (4)

(36)

7th

Formulary & Database

Synchronization –

Brookins, 2011

Goals

Single drug formulary information database

Limit manual updating of information that can lead to error

Address special challenges for IDNs and Hospital Groups

(37)

7th

A Limiting Factor

!

We cannot afford to have experienced

healthcare IT staff doing highly

redundant, wasteful, error prone

database upkeep and synchronization.

(38)

The EMR helps keep drug cost increases to an amount that is less than inflation.

(39)

Pharmacy Uses the EMR to Save Money

8th

EMR for Cost Control*

Formulary management

CPOE, e-Rx

Therapeutic interchange

CPOE, e-Rx

Guidelines/protocols

CPOE + CDSS

340B Discount Programs

P

urchasing

/B

illing

Drug Use Evaluation

D

ata

W

arehouse

*Medication cost management strategies, Am J Health-Syst Pharm

2008 65:1368-84.

(40)

Pharmacy Uses the EMR to Save Money

8th

EMR for Cost Control?

“Despite large CPOE costs … hospitals with CPOE did not

have significantly lower cost per case.”

– Teufel RJ, J Med Syst 2011

“BWH spent $11.8 million to develop, implement, and

operate CPOE. Over ten years, … net operating budget

savings of $9.5 million.”

(41)

8th

EMR for Cost Control?

“EMR documentation of antibiotic use … identifies most MRSA and

nearly all VRE transmission risk with surveillance culture sampling of

only 51%

of patients.

… substantial cost savings compared with universal active surveillance.”

– Morgan DJ, Infect Cntrl Hosp Epi 2010

“Implementation of an

Adverse Drug Event alert system …

significant decreases

in pharmacy department costs, variable

drug costs, and severity-adjusted mortality rates.”

(42)

8th

Med Use Improvements Save $$

The EMR provides a means of

standardizing medication use

improvements across enterprises

and patient populations.

However, arriving at real cost savings

can be

S

LOW

G

OING

.

(43)

Chemo, Genes and ↑Complexity

Episodic care was yesterday. Tomorrow is sequenced, always connected, individualized care.

(44)

Med Use Regimen Complexity

9th

A chemotherapy regimen: FOLFOX4

DRUG DOSE OVER ON DAYS

Oxalaplatin 85 mg / m2 _{2 hours} ₁

Leucovorin 200 mg / m2 _{2 hours} _{1 and 2}

then

5-Fluorouracil 400 mg / m2 _{5 minutes} _{1 and 2}

then

5-Fluorouracil 600 mg / m2 _{22 hours} _{1 and 2}

PRE MEDICATIONS

HYDRATION, PAIN, ANXIETY, ANTI-NAUSEA, OTHER

Every 2 Weeks for 10 cycles

gauging response and toxicity

(45)

Med Use Regimen Complexity Increasing

9th

„Multi-modal analgesic pain

management‟ – ASA, 2004

BEFORE SURGERY

3

NSAIDs (e.g., Ibuprofen) Tylenol (Acetaminophen) pregabalin or gabapentin

DURING / AFTER SURGERY

> 8

NSAIDs and Acetaminophen Epidural or intrathecal opioids Local anesthetics and epinephrine

Clonidine

Patient controlled analgesia with systemic opioids Regional peripheral and infiltration nerve blocks Opioids by oral, transdermal, subcutaneous routes

(46)

Med Use Regimen Complexity Increasing

9th

Genetic Individualization

CODEINE

ENZYME

MORPHINE

CYP2D6

Ultra-rapid

Extensive

Metabolizer

Intermediate

Metabolizer

Poor

Metabolizer

(47)

Med Use Regimen Complexity Increasing

9th

A Moving Target

As medication-use

systems are being

deployed, the complexity

of medication-use is

increasing.

The systems

therefore remain

behind

the needs curve.

(48)

Business D

IS

continuity

Clinical care continuity during EHR downtime is a serious area of concern.

(49)

Business D

IS

continuity

10th

No Power. Sustain Life with Backup.

D

IS

(50)

Business D

IS

continuity

10th

Fallacy: Revert to Paper = Continuity

•

Unsafe -

risk

/benefit

•

disabled safety net

• ↑↑↑

missing information

•

Unknown -

slow

down

•

how to process orders

•

how to document care

•

Unsustainable -

D

IS

continuity

• ↑

footprint of systems

•

minutes

vs.

hours

vs.

days

t

d

is

ru

p

t

48h 24h 72h

(51)

No Power = No Information

10th

IBM Fellow – Grady Booch

Software engineer’s perspective:

> The promise, the limits, the

beauty of software. - 2007

http://www.youtube.com/watch?v=adiVOdztQ34

2020s – “total dependence”

“It will be very difficult to live

and work and play without

(52)

Pharmacy‟s „Top 10‟ for CIOs

1 Scope

Oversized Footprint

2 Architecture

Like Building a Cathedral

3 Practice change

4 Drug Supply Chain

Difficult Problems

5 Safety & Efficiency

To Do but Not To Benefit?

6 Pharmacy Staffing

Not Exactly a Pipeline

7 Redundant Work

Disparate Databases

8 Saving Money

9 Complexity

Increasing Steadily

10

Downtime

Total Dependence

(53)

T

HE

E

ND

:

Medication-Use Mega System

Automated Product Selection CDS DOSE, TIMING SMART IV PUMPS ADE SURVEILLANCE RULES ENGINE

CPOE

PHARMACY SYSTEM LABELS AUTOMATED DISPENSING CABINETS (ADCs) eMAR _{HX, DX}LABS EHR AUTOMATED DOSE PICKING SYSTEMS AUTOMATED ADC PICK-N-REPLENISH ORDER SETS CDS BUG-DRUG, CORE MEASURES, P-KINETICS CDS INDICATION, DOSE, DDI, DFI,

UTILIZATION

BAR CODE SCANNING AT COMPOUND

& DISPENSE

BCMA

EHR INHERENT ORDERING SAFETY AUTOMATED TREATMENT FAILURE IDENTIFICATION PHARMACIST PATIENT TRIAGE SYSTEM AUTOMATED COMPOUNDING ROBOTS CDS COMPATIBILITY, ADMINISTRATION DISPENSED PRODUCT LOCATION TRACKING EHR AUTOMATED

PRESCRIBING _TO_RACKINGUTCOME

AUTOMATED ORDER VERIFICATION PROACTIVE IV DRIP REFILLS PATIENT-SIDE DELIVERY SYSTEMS CDS DDI/ALLERGY COMPUTER ASSISTED IV FLUID ANALYSIS EHR EHR

Coordinated,

Synchronized,

Standardized

@

“Common

points of

tangency”

along

the

Med-Use

continuum.

(54)

10 Things Every CIO Should Know

About M

EDICATION

M

ANAGEMENT

T

ECHNOLOGIES