Closed loop medication administration

© 2005 Dr Pankaj Gupta | Slide 1 ICMIT 27 Feb 05- 01 Mar 05
28 Feb 05
CLOSED LOOP
MEDICATION
ADMINISTRATION

Clinical Decision
Support and Patient
Safety – CPOE, BCMA
standards
Dr Pankaj Gupta
Contact:
Dr_pankajgupta@yahoo.com
@pankajguptadr

28 Feb 05
Agenda:
 Healthcare-IT Evolution
 IOM study and CPOE
 Leapfrog group formed
 Examples of CPOE
 FCG Application – CPOE Evaluation
 Question…

28 Feb 05
Healthcare-IT Evolution
EVIDENCE
BASED
MEDICINE
Stand Alone
Application
Knowledge
Management
Integrated
HIS
Computerized Patient Records
• CPOE
• Data Mining
• Knowledge Base
CONSUMER
RELATIONSHIP
MANAGEMENT
ENTERPRISE
INTEGRATION
DEPARTMENT
WORKFLOW
AUTOMATION
DATA
CAPTURE
Hospital IT Infrastructure
•Document Management
•Reliability Improvement
•Save Time
• Knowledge-Driven
• Clinical pathways
• Disease management
• Outcomes measurement
Collector Documentor Mentor
Colleague
Helper
• Personalization
• Web based portals
• Disease Prevention
EFFICIENCY
QUALITY
OF
CARE
BUSINESS
VALUE
•Transaction
•one dimensional

28 Feb 05

28 Feb 05
CPOE for Medication, Laboratory, and Radiology Orders
Objective • CPOE for medication, laboratory, and radiology
orders
• Entered by licensed healthcare professional
• Per state, local, and professional guidelines
Measure • Currently using CPOE
• > 60% of medication orders
• > 30% of laboratory orders
• > 30% of radiology orders
Source: [ ]. Eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during EHR reporting period 6

28 Feb 05
7
Electronic Medication Administration Record — EMAR
Objective • Automatically track medications from order
to administration
Measure • > 10% of medication orders
• CAH inpatient or emergency dept.
• During EHR reporting period
• Where all doses are tracked using eMAR
Exclusion • Average daily inpatient < 10

28 Feb 05
Clinicians can give orders anywhere in the
hospital as they are ubiquitous beings
56% of medication errors occur at time of order*
However medical errors can occur anywhere and need to be prevented
*Source: Bates et al JAMA 1995; 274:29-34.
56%

28 Feb 05
CPOE Orders

28 Feb 05
Dispense at Pharmacy

28 Feb 05
Nursing Station

28 Feb 05
Medication Administration

28 Feb 05
A Story of Errors
A problematic scenario …
• While assessing a patient recovering from a heart
condition, the physician discovers a patient allergy
to the current medication
• Physician orders alternative medication
• Pharmacist dispenses previous medication, unaware
of the new order
• Nurse administers medication without notification of
the change
• Executive lacks solid data to analyze in effort to
prevent future error
Patient becomes a victim of preventable error

28 Feb 05
The Consequences of Error
Likely Scenario:
 Additional days in hospital
 Added costs
Worst Case Scenario:
 Patient dies
 Possible lawsuit
 Institutional black mark
You can do something about it.

28 Feb 05
Integrated System
• While assessing a patient
recovering from a heart condition,
the physician discovers a patient
allergy to the current medication
• Physician orders alternative
medication
• Pharmacist dispenses previous
medication, unaware of the new
order
• Nurse administers medication
without notification of the change
• Executive lacks solid data to
analyze in effort to prevent future
error
• Patient becomes a victim of
preventable error
Disparate System
•While ordering a medication for a
patient admitted with a heart
condition, a physician receives an
alert
•System recognizes a patient allergy
documented by the nurse
•Physician chooses an alternate
drug and modifies the order
•Pharmacist notified of change,
dispenses the correct medication
•Nurse administers correct drug and
documents administration time
•Executive collects better data for
clinical and business analysis
•A positive patient outcome
Integrated Enterprise

28 Feb 05
IOM study “To Err Is Human”
 44,000 to 98,000 people die in US hospitals each year as a result of medical errors that
could have been prevented (according to IOM report based on estimates from two major studies.)
 Preventable medical errors in hospitals exceed attributable deaths to such feared threats as
motor-vehicle wrecks, breast cancer, and AIDS.
Medical errors can be defined as the failure of a
planned action to be completed as intended or the use
of a wrong plan to achieve an aim.
Most common Iatrogenic causes are:
•Adverse drug events
•Improper transfusions,
•Surgical injuries and wrong-site surgery,
•Burns, pressure ulcers,
•Mistaken patient identities.
High error rates with serious consequences are most
likely to occur in ICU, OT, and E Wards.
Total cost of errors is between $17 - $29 billion per
year in US hospitals nationwide. (including expense
of additional care, lost income, lost productivity and
disability)

IOM Study —
Leapfrog Group Formed
“Preventing errors and improving safety for patients
require a systems approach in order to modify the
conditions that contribute to errors.”
To Err is Human: Building a Safer Health System. Washington, DC, National Academy Press, 1999

28 Feb 05
The Leapfrog Group
 A consortium of fortune 500
companies
 Supported by other large
private and public healthcare
purchasers
 Healthcare purchases to be
based on principles that
encourage stringent patient
safety measures
Their goal is to initiate breakthroughs in the safety and quality
of health care in the US
www.leapfroggroup.org

28 Feb 05
Initial Safety ‘Leap’ Summary
 An Rx for Rx
 Computer Physician Order Entry (CPOE)
 Up to 8 in 10 serious drug errors prevented
 Attempt to capture other erroneous orders as well
 Sick People Need Special Care
 ICU Daytime Staffing with CCM Trained M.D.
 risk-adjusted outcomes comparison
 > 10% mortality reduction
 Practice Makes Perfect
 Evidence-based Hospital Referral (EHR)
 risk-adjusted outcomes comparison
 > 20% mortality reduction for 7 complex treatments

28 Feb 05
Why CPOE?

28 Feb 05
The LeapFrog Group Says:
 Assure that physicians enter at least 75% of medication orders via a computer system
that includes prescribing-error prevention software
 Demonstrate that their in-patient CPOE system can alert physicians of at least 50% of
common, serious prescribing errors, using a testing protocol now under development by
First Consulting Group and the Institute for Safe Medication Practices
 Require that physicians electronically document a reason for overriding an interception
prior to doing so
 Post the interception rate to leapfrog website

28 Feb 05
Drug Duplication

28 Feb 05
Allergy

28 Feb 05
Drug-Drug Interaction

28 Feb 05
Drug-Food Interaction

28 Feb 05
Order Category Examples of Erroneous Orders
Therapeutic
duplication
Order of Tinidazole when Metronidazole
is already being given
Allergies and cross-
allergies
Penicillin prescribed for patient with
documented Penicillin allergy
Contraindicated route
of administration
Gentamycin prescribed orally
Drug-drug and drug-
food interactions
Anti-hypertensives with diuretics; Digoxin
AND Quinidine; Doxycycline with milk
Contraindication/dos
e limits based on
patient diagnosis
Brufen in patient with asthma
Dose limits Any drug given in doses exceeding upper
limit
Contraindication
dose limits based on
patient age and
weight
Adult dose of Ciprofloxacin in a newborn
e limits based on
laboratory studies
Normal adult dose Ciprofloxacin in
patient with elevated creatinine
e limits based on
radiology studies
Medication prescribed known to interact
with iodine to be used as contrast
medium in ordered head CT exam
Corollary Ordering anti-coagulant without checking
for Bleeding Time
Cost of care Ordering hospital admission for a OPD
proceedure
Basic
Advanced
Expert
Alerts: basic, advanced, and expert levels

28 Feb 05

‘Even if there are alerts physicians can just
ignore them and go on with bad practices if
they want to.’

28 Feb 05
If you only know the clinical
information system has “alerts”
You DON’T know enough
about the system. . .
. . .You need to ask more
questions! :
 WHAT makes the rule fire [order, note, lab result, etc.]?
 When does the alert fire [fire before or after the order is committed to the database]?
 How does the rule get to the user [real time, slightly delayed or not until device is docked]?
 Any escalation intelligence or forward chaining of rules?
 Does the product track alerts and capture data for alert outcomes and statistics?

28 Feb 05
Give Me That Message NOW!
Not to my pager in 30 seconds!

28 Feb 05
University of Virginia
 Hospital attempted to introduce mandatory CPOE in 1988
 Introduction went badly
 Although some technical issues, many were social
 Challenged basic institutional assumptions
 Forced people to modify established routines
 Time issues substantial
 Most physicians spent <1 hour/day
 Some on busy services spent >4 hours/day
Massaro T, Academic Medicine, 1993
CPOE Failures

28 Feb 05
 Implementation failed
 Application had to be turned off, even though it was working
 Physicians complained bitterly
 Said that too much unnecessary decision support was being
displayed
 Was slow
 Didn’t fit workflow
Cedars-Sinai CPOE Implementation
CPOE Failures

28 Feb 05
CPOE Adoption and Benefits
 David Bates MD, at Boston’s Brigham and Women’s Hospital,
demonstrated that CPOE reduced error rates by 55% — from 10.7 to
4.86 events per 1000 patient days.
 Length of stay at Wishard Memorial Hospital in Indianapolis fell by 0.9
days, and hospital charges fell by 13% after implementation of CPOE
 A recent study at Ohio State University also identified substantial
reductions in pharmacy, radiology, and laboratory turn-around times, and
there was a reduction in length of stay in one of the two hospitals studied

28 Feb 05
 Incentives
 Incentives paid for the implementation not the product
 Different Systems
 OP Orders and IP Orders in different systems
 Group of Hospitals may have different EMR
 Direct Orders
 Lab orders given directly to the Lab bypassing EMR
 Radiology orders given directly to Rad Lab
 Additional Orders
 Test/Imaging during the tests/procedure
 Imaging done with Dye or without Dye
 Denominator is elusive across systems!
 Confidence level vs. ROI

28 Feb 05
 Integration Issues - Data silos, Data Loss
 Hardware Issues - Wi-Fi, Scanner failures
 New Nurse not yet trained
 Retrospective catchup after Emergency
 Patient ID Bands cut off
 Miscoded medications
 Empty unit dose packages
 Delivered without scanning
 Damaged Bar Codes
 Override of Alerts
 Cost reduction ? ROI ?

28 Feb 05
Questions?

THANKS!
Dr Pankaj Gupta
Head – ACCESS Health Digital
digital.health@accessh.org
Twitter: @pankajguptadr, @accesshdigital
LinkedIn: drpankajgupta, accesshdigital

Closed loop medication administration

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