Medication Reconciliation Design Challenges with 2007 Code

1. Medication ReconciliationDesign Challenges with 2007 Code May 2nd, 2007 11:00 – 11:50

2. Who we are • Margie Hunssinger, RN • Manager Clinical Applications Group • Laurie Gift • Manager PharmNet Applications

3. Advocate 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

4. “Most Wired” status by Hospitals and Health Networkspast six years (2000-06) Number 1

5. Medication Reconciliation - Advocate HistoryPreparing 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.

6. Medication Reconciliation - Advocate HistoryElectronic Medication Rec Process - 2005 • Documentation: Electronic Medical Record • Printing the Report • Paper Documentation • Total Process of Medication Reconciliation

7. Medication Reconciliation - Advocate HistoryNurse 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

8. Medication Reconciliation - Advocate HistoryDocumentation on this form is like all forms - 2005 • 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

9. Medication Reconciliation - Advocate History Documentation - 2005 • New Tab • Medication Reconciliation • To View Home Medication Documentation and Current Medications

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

11. Medication Reconciliation - Advocate History Discontinued Scheduled Medications - 2005 Scheduled Medications that have been discontinued in the last 24 hours will be listed as well

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

13. Medication Reconciliation - Advocate History Printed Meds Rec – Final Page

14. Medication Reconciliation - Advocate History Opportunities 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.

15. Medication Reconciliation 2007 Code Challenges Hmmm

16. Medication Reconciliation 2007 Code Challenges • 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.

17. Medication Reconciliation 2007 Code Challenges Is your site 100% CPOE enabled? Every Physician? Who will do reconciliation online? Nursing Pharmacist Physician

18. Medication Reconciliation 2007 Code Challenges • 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

19. Medication reconciliation – 2007Advocate 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.

20. Medication reconciliation – 2007Why 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)

21. Workflow Diagram – Admission / Transfer

22. Workflow Diagram - Discharge

23. Medication Reconciliation – 2007 FunctionalityNavigation

24. Medication Reconciliation – 2007 Functionality Overall med History – all med orders

25. Medication Reconciliation – 2007 Functionality Document Medication by History Active Home Meds Compliance Information

26. Medication Reconciliation – 2007 Functionality Document Medication History

27. Medication Reconciliation – 2007 Functionality Addition of a new Documented Med

28. Medication Reconciliation – 2007 Functionality Reconciliation choices

29. Medication Reconciliation – 2007 Functionality Admission Reconciliation Screen

30. Medication Reconciliation – 2007 Functionality Admission Reconciliation Screen Documented Meds NOT converted to inpatient orders - still active Home meds Actions complete ready to sign

31. Medication Reconciliation – 2007 Functionality Reconciliation History display

32. Medication Reconciliation – 2007 Functionality Discharge Reconciliation

33. Medication Reconciliation – 2007 Functionality Discharge Reconciliation

34. Medication Reconciliation – 2007 Functionality Discharge Reconciliation

35. Medication Reconciliation – 2007 Functionality Discharge Reconciliation

36. Medication Reconciliation Issues – 2007Advocate Listing / Prioritization Killing Bugs ! Issue Spreadsheet

37. Advocate Issue Resolution Process • 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.

38. Medication reconciliation – 2007Advocate 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

39. Questions?