Informatics and Medication Safety Systemness and Standardized Healthcare Delivery

1. Informatics and Medication SafetySystemness and Standardized Healthcare Delivery Justin Sebakijje, PharmD, BCPS Clinical Pharmacy– Informatics, Medstar Washington Hospital Center September 2018

2. Disclosures • I, Dr. Justin Sebakijje, have nothing to disclose and have no Conflicts of Interest.

3. Objectives At the completion of this activity, the participant should be able to: • 1. Define Pharmacy Informatics • 2. Identify the role of pharmacy informatics • 3. Describe the challenges of Computerized Prescriber Order Entry (CPOE) • 4. Describe the concept of "Systemness" as applied to Healthcare Systems • 5. Define the limitation of Information Technology (IT) • 6. Describe the future of Pharmacy Informatics and healthcare delivery

4. Terms Defined Systemness Standardization Describes: the process of implementing and developing clinical standards Includes: Evidence-based practice, policy, and consensus Goal: best practice principles applied to a high standard of care • Describes:alignment among core characteristics of a health care organization • Includes: structure, culture, technology, processes, people and rewards • Goal: to produce measurable value in the patient experience, per capita cost of care, and population health

5. Roles Defined Clinical Informatics Pharmacist Informatics Pharmacist Develops the processes to improve outcomes in patient safety Informatics pharmacists implement, train, and maintain complex technologies to facilitate and automate the medication use process • Definition: an expert in human factors, patient safety, and the use of technology to optimize care delivery processes • Role: incorporates both an understanding of process (Informatics Pharmacist) and the knowledge to convert process into practice (IT Pharmacist) • Prerequisite: Need to understand and develop solutions to improve outcomes, patient safety and efficiency and can build those solutions into their EHRs and other technologies • IT Pharmacist • Builds complex technical medication solutions • Expert in the technical and/or functional aspects of core build • Converts processes into technical solutions

6. Case • 92 yo African American female presented to the ER from a nursing home with fever, cough, and chills • Lab values: Scr 2.0 (CrCl 15) • Physical Exam: Pt lethargic • Empirically (HCAP): vancomycin 2g IV q12 and Zosyn 2.25 mg q6hr • Day 3: cultures grew klebsiella, so prescriber ordered addition of gentamicin to regimen • Day 5: Pt went into Acute Renal Failure and expired • Question: how can we prevent this from occurring?

7. Case continued Process Questions Technical Solutions Medications are ordered via the “CPOE” system. Medication order is validated by pharmacist through Med Manager Medication is administered by the nursing when tasks fire on the eMAR • How are medications ordered by prescribers? • Which medication orders are validated by pharmacists? • When are medications administered by nurses?

8. Process Breakdown: Workflow Inpatient Workflow Technical Workflow • Med is ordered by prescriber through CPOE • Med order is validated by pharmacist through Medication Manager • Med is administered by the nursing when tasks fire on the eMAR

9. Solutions Breakdown: Technical Tools • Medication Build (Formulary Manager) • Order Sentences (Bedrock) • Powerplans (DCP Tools) • Clinical Decision Support (PhadB Tools) • Reports (Discern Analytics) • Unit Based Cabinets (Pyxis Medstation) • Medication Administration (Alaris Pump) • Other (Tsubs, autoverification)

10. Medication Build • Key Questions for Medication Orderable Builds • How can we build medication orderables to ensure that they are administered appropriately? • How can we build medication orderables to ensure that they are routed quickly and precisely? • How can we build medication orderables to ensure compliance with hospital policy and practice? • How do we ensure that the medication reaches only the intended patient?

11. Medication Build Cont Vancomycin Vancomycin Build • How can we build medication orderables to ensure that they are administered appropriately? • How can we build medication orderables to ensure that they are routed quickly and precisely? • How can we build medication orderables to ensure compliance with hospital policy and practice? • How do we ensure that the medication reaches only the intended patient?

12. Order Sentence Build • Key Questions for Order Sentence Build • Are medications ordered differently depending on differing patient populations? • What is the most common route for the medication? • Is their a common duration for the medication? • What is the most common dosages for the medication?

13. Order Sentence Build Cont Vancomycin Vancomycin Build • Are medications ordered differently depending on differing patient populations? • What is the most common route for the medication? • Is their a common duration for the medication? • What is the most common dosages for the medication?

14. PowerPlans • Key Questions for Powerplan Build • Are their labs that are commonly ordered with a particular medication? • Are loading doses and maintenance doses apart of the medication coarse? • Are their differing policies in place that cover medication prescribing? • Can this medication grouping be embedded within another medication grouping?

15. PowerPlan Build Vancomycin Vancomycin Build • Are their labs that are commonly ordered with a particular medication? • Are loading doses and maintenance doses apart of the medication coarse? • Are their differing policies in place that cover medication prescribing? • Can this medication grouping be embedded within another medication grouping?

16. Clinical Decision Support • Key Questions for CDS Build • What types of CDS exist? • Is the CDS alert actionable? • Which clinician should see CDS alerts? • How complex should the CDS alert be?

17. Clinical Decision Support Cont Vancomycin Vancomycin Build What types of Clinical Decision Support exist? Is the Clinical Decision Support alert actionable? Which clinician should see Clinical Decision Support alerts? How complex should the Clinical Decision Support alert be?

18. Reports • Questions we need to think about • What type of Data can be pulled? • How can Data be used to show prescribing trends? • How can this Data be used to justify policy and practice?

19. Reports Cont How Medications Ordered Usage Report

20. Medstations Key Questions • What types of Standard Stock should be kept in unit based cabinets? • Are their situations where medications need to be pulled without an order? • When should medstations be restocked?

21. Medstations Cont Vancomycin Vancomycin Build • What types of Standard Stock should be kept in unit based cabinets? • Are their situations where medications need to be pulled without an order? • When should medstations be restocked?

22. Alaris Pumps Key Questions • Are there ways to ensure medications are administered appropriately? • Are their safeguards in place to ensure medications are not infused too quickly? • What determines the pump parameters?

23. Alaris Pump Cont Vancomycin Build Vancomycin • Are there ways to ensure medications are administered appropriately? • Are their safeguards in place to ensure medications are not infused too quickly? • What determines the pump parameters?

24. Systemness • Describes:alignment among core characteristics of a health care organization • Includes: structure, culture, technology, processes, people and rewards • Goal: to produce measurable value in the patient experience, per capita cost of care, and population health

25. Standardization Across Healthcare-Systems • Barriers to Systemness and Standardization • Size of hospital • Volume of medication usage may be an issue • Ex. Argatroban (rare vs. constant) • Patient population • Type of patient population may be an issue • Ex. Norepinephrine concentration (Peds vs. Adult) • Marginal Budget • Budgetary considerations may be an issue • Ex. Disproportionate share hospitals

26. Final Thoughts Limitations to Consider • Maintenance • Over-engineering • Rules and Alerts • Medication Shortages • Flexibility • Therapeutic Interchange • Communication • Building and Testing • When systems break

27. Case Revisited • 92 yo African American female presented to the ER from a nursing home with fever, cough, and chills • Lab values: Scr 2.0 (CrCl 15) • Physical Exam: Pt lethargic • Empirically (HCAP): vancomycin 2g IV q12 and Zosyn 2.25 mg q6hr • Day 3: cultures grew klebsiella, so prescriber ordered addition of gentamicin to regimen • Day 5: Pt went into Acute Renal Failure and expired

28. Question 1 • What is in place to prevent prescribers from ordering Vancomycin 2 g q12 hrs infused over 15 min and not ordering appropriate labs, in terms of: • Prescriber Knowledge Base • Pharmacist Knowledge Base • Medication orderables, sentences, powerplans, clinical decision support, pyxis medstations, and alaris smart pump • All of the Above

29. Question 2 • Once a standardized Powerplan is “System-wide”, how can we ensure build is safe and effective? • Wait to see if another medication safety event is reported in a larger pool of patients • Limit Vancomycin prescribing to only the best clinicians to ensure no adverse medication events occur • Run monthly reports looking for inappropriate prescribing habits and trends • All of the above

30. Summary • Systemness describes an alignment among core characteristics of a health care organization • Clinical Pharmacy Informaticists are experts in human factors, patient safety, and the use of technology to optimize care delivery processes • Clinical Pharmacy Informatics Describe utilize various Process and Technical solutions to add safety to the system • Barriers to Systemness and Standardization exist and should actively be addressed • Limitations to Systemness as applied to complex Healthcare Systems must be weighed appropriately

31. References • Lauer, George. "P4P Summit Ushers in New IT Word -- 'Systemness'". California Healthcare Foundation. Archived from the original on 2013-04-15. • Tollen, Laura. "IHP Roundtable Explores "Systemness"". Kaiser Permanente Institute for Health Policy. Archived from the original on 2013-04-15. • Barry S. Bader; Edward A. Kazemek; Roger W. Witalis; Carlin Lockee (2005). "Pursuing Systemness: The Evolution of Large Health Systems" (PDF). The Governance Institute: 9. • https://www.ashp.org/pharmacy-student/careers-in-health-system-pharmacy/informatics • Gardner RM, Overhage JM, Steen EB, Munger BS, Holmes JH, Williamson JJ, Detmer DE (2009). "Core content for the subspecialty of clinical informatics". Journal of the American Medical Informatics Association. 16 (2): 153–7. • ASHP website: https://www.ashp.org/pharmacy-student/careers-in-health-system-pharmacy/informatics • Xie, Zongjie; Hall, Jeremy; McCarthy, Ian P.; Skitmore, Martin; Shen, Liyin (2016-02-01). "Standardization efforts: The relationship between knowledge dimensions, search processes and innovation outcomes". Technovation. Innovation and Standardization. 48–49: 69–78.

32. CE Access CodeInformaticsSystemness Participants have until November 6, 2018 to earn 1.0 contact hour of Continuing Pharmacy Education (CPE) credit for this activity by full session attendance/participation AND successful completion of the online activity evaluation and post-assessment test. Access to the evaluation and test is through use of the CE access code as displayed on this slide. After November 6th, 2018 NO CE credit will be available for this program. Credits will be transferred electronically to the CPE Monitor System.