BCMA Overview

1. Resource Patient Management System BCMA Overview

2. Presenters: David Taylor OIT BCMA Federal Lead Mollie Ayala OIT BCMA Co-Project Manager Michael Allen OIT Pharmacy Consultant Phil Taylor OIT BCMA Nurse Lead JoAnne Hawkins OIT Meaningful Use Team Lead Bar Code Medication Administration

3. Objectives • Describe the History of BCMA • Describe the General BCMA Process • Describe Roles and Responsibilities in BCMA Deployment BCMA Overview

4. What is BCMA? • BCMA = Bar Code Medication Administration • BCMA is a separate Graphical User Interface (GUI) application (not a component of EHR) used to Document Administration of Medications BCMA Overview

5. A Short History of BCMA • In 1994, a travelling VA Nurse returning her rental car noticed the car was tracked by scanning a bar code. She realized this might be applied to Medication Administration. BCMA Overview

6. A Short History of BCMA • Such a system would add checks and balances in the Medication Administration Process that could augment the nurse's ability to perform "the 5 Rights" and enhance patient safety, but would not be a replacement for nursing judgment. BCMA Overview

7. A Short History of BCMA(continued) • The Colmery-O'Neill VAMC in Kansas City, where the nurse worked, liked the bar code concept and developed a prototype system utilizing VA's VistA system. This system was terminal based. BCMA Overview

8. A Short History of BCMA (continued) • This Kansas City VAMC system became a model for later national development of the GUI application, Bar Code Medication Administration (BCMA), deployed throughout the VA system starting in 1999 BCMA Overview

9. A Short History of BCMA(continued) • Indian Health Service began implementing the Electronic Health Record (RPMS EHR) in 2004 • Large portions of RPMS and EHR share code with corresponding applications used by the VA VistA system • With the deployment of EHR, and in particular Inpatient Medications, IHS realized that it might be possible to utilize the BCMA application. In 2006, as a proof of concept project, BCMA was deployed at hospitals in Fort Defiance, AZ and Cherokee, NC BCMA Overview

10. A Short History of BCMA(continued) • These test deployments made apparent some differences between the VA's CPRS and IHS's RPMS EHR that needed to be resolved before BCMA could be deployed system-wide. • Needed changes were identified and the VA agreed to incorporate these changes into the BCMA application so that it could function in either a VistA or an RPMS environment. BCMA Overview

11. A Short History of BCMAMeaningful Use Stage 2 BCMA Overview

12. BCMA GUI BCMA Overview

13. How Does BCMA Work? • BCMA allows users to electronically document medications at the bedside or other points-of-care • The Nurse utilizes a mobile wireless computer equipped with a Barcode Scanner • Medication Administration is Verified using Barcodes printed on the Patient’s Wristband, and the Medication Package BCMA Overview

14. What Does BCMA Do? • BCMA identifies the patient, Verifies that the correct medication is administered and Records the administration • BCMA also provides functions such as: • Medications Due List • Variance Log (e.g. Medication Error Reports) • Medication Administration History • PRN Effectiveness Tracking • Missed Medications Reports • Request Missing Med from Pharmacy BCMA Overview

15. Preparation for BCMA • There are a number of tasks that must be completed before BCMA can be implemented at a site BCMA Overview

16. Preparation for BCMAInformation Technology • Functioning Wireless Network in the area where BCMA will be used • Mobile Wireless Workstations with Attached Bar Code Scanners • Pharmacy Bar Code Scanners for inputting Bar Code Data into the Drug File BCMA Overview

17. Preparation for BCMAPharmacy • All “versions” of a medication must be scanned into Inpatient Pharmacy as a synonym for it to be recognized by BCMA (i.e. different NDC numbers, different manufacturer UPC codes, etc.) • This is not a one time project, but requires continuous maintenance • BCMA can use Fileman IENs or any other standard identifiers (e.g. NDC numbers) BCMA Overview

18. Preparation for BCMAPharmacy (continued) There must be a System for Applying Bar Codes to Bulk Medications that do not have Manufacturer Supplied Bar Codes BCMA Overview

19. Preparation for BCMAPharmacy (continued) • BCMA can’t handle Schedule Ambiguity • Schedule rangesmust be removed (i.e. Q4-6H PRN becomes Q4H PRN) • Standard schedules must have defined admin times, e.g. Q4H - 0100-0500-0900-1300-1700-2100 • Re-configuration of the Inpatient Pharmacy Package can be time intensive BCMA Overview

20. Preparation for BCMAPharmacy (continued) • IVs and Piggybacks Must be Configured Correctly so that BCMA can process them: • IV Piggybacks are Unit Dose with a Route of IV and a Schedule (e.g. Q6H) • IVs are Large Volume and Continuous with an Infusion Rate (e.g. 75ml/hr) • Optimization of the Pharmacy Drug File is imperative for successful implementation BCMA Overview

21. Preparation for BCMA(continued) • Pharmacy, Nursing and Providers: • With standard BCMA configuration a medication dose is due the next scheduled administration time • It is important that everyone understand and be trained to this process • For some sites this may be a significant change in process for Ordering Providers, Pharmacists and Nurses BCMA Overview

22. BCMA and Order Verification • To correctly use BCMA, Nurses should administer medications only after the order has been processed by Pharmacy and verified in EHR by Nursing • This may be a significant change in process for Nurses BCMA Overview

23. Giving Non-Verified Meds • BCMA includes a special process to give a Dose of Medication when a Pharmacist is not present to finish the Order • This too may be a significant change in process for Nurses BCMA Overview

24. Administration Process • The basic process of passing Medication remains the same as before implementing BCMA • Remember that Medication Administration is a Nursing Process and BCMA is not a substitute for Nursing Judgment! BCMA Overview

25. Administration Process(continued) • The Provider orders Medications in EHR • The Pharmacist finishes the Order in the RPMS Pharmacy Package • The Nurse verifies Medication Orders in EHR • The Nurse gathers Medications from Automated Dispensing System or other location Note: A Due List can be generated by BCMA • The Nurse takes the BCMA mobile workstation to the Patient along with the Medications or uses a workstation at the bedside BCMA Overview

26. Administration Process(continued) 6. The Nurse Identifies him/herself to the system 7. The Nurse identifies the Patient: 1. Scan Bar Code on Wrist band 2. Verify Patient Identity 8. The Nurse scans the medications and BCMA checks: 1. Right Drug 2. Right Dose 3. Right Route 4. Right Time BCMA Overview

27. Administration Process(continued) 9. The Nurse administers Medications to the Patient • Documentation of Administration is "automatic" in BCMA when the bar code is scanned • Since documentation (via scanning) occurs before the Medication is actually administered, BCMA has mechanisms to “ungive” doses that are refused or dropped. BCMA Overview

28. Adminstration Record Access Once Medication Administration is documented using BCMA, this information is immediately available for viewing by Providers and others on the Reports Tab in RPMS EHR BCMA Overview

29. Who should participate in BCMA deployment? • Director of Nursing • Nursing Manager • Nurse Informaticist • BCMA CAC or BCMA Superuser(s) • Director of Pharmacy • Inpatient Pharmacist • Inpatient Pharmacy Informaticist • Clinical Application Coordinator • IT Department/Site Manager • Quality/Risk Manager and/or Safety Officer BCMA Overview

30. Understanding Roles • Medicine, Pharmacy, Nursing and IT have each tended to only consider their own roles • All the different disciplines involved must understand the roles and functions of each other BCMA Overview

31. Making BCMA Work • Pharmacy: • BCMA requires that all the Drugs are Correctly Configured in the Pharmacy package which includes correct dispense doses, and entry of the bar code numbers into what is called the synonym field • All Drugs Must be Properly Packaged with Readable Bar Codes BCMA Overview

32. Making BCMA WorkPharmacy • Drugs Dispensed via Pyxis or Omnicell must match the way the order is finished in RPMS • Order cannot be finished for 20mg tablet, if 10mg tablets are supplied BCMA Overview

33. Making BCMA WorkInformation Technology • BCMA Hardware Must Function Correctly, including wireless network connectivity of the laptops and the bar code scanners themselves • “Hot-swappable” Workstations and Bar Code Scanners need to be Readily Available when hardware stops functioning. BCMA Cannot Be Used if the Hardware is Not Functioning • Bar code Armband Printers must be available where needed BCMA Overview

34. Making BCMA WorkAdmissions/Registration/Nursing • Patients Must Have ID Armbands With Readable Bar Codes when Admitted • New Armbands must be Re-printed if Bar Codes Become Unreadable or are Removed • Workstations must be Plugged In to Maintain Charge when not in use • Non-functioning Hardware needs to be Reported to IT in a Timely Manner BCMA Overview

35. Making BCMA Work • For BCMA to Function, there Must be open lines of Communication and Provision For Feedback Between Everyone Participating in the process • Prompt Correction of Problems Must Be Stressed as some problems may prevent administration of medications! BCMA Overview

36. Making BCMA Work Successful Implementation Involves, Providers, Pharmacists, Nurses, IT Support Staff, and Others… BCMA Overview

37. Continuous Process • Ensuring the Functioning of BCMA is Not An End Goal, but a Continuous Process • There will Always be New Drugs, Equipment Repair and Replacement, Printing of Removed Armbands and Many Other Things that Require Ongoing Attention BCMA Overview

38. Commitment to Excellence BCMA requires a commitment to Excellence in Patient Care. BCMA Overview

39. Important Question This seems like an awful lot of work! Why would we want to go to all this trouble? BCMA Overview

40. Why BCMA? • BCMA will Improve Patient Safety by Reducing the Incidence of Medication Errors • “Safety First, because Second is too late” • BCMA will Help meet Meaningful Use Measures (whose Ultimate Goal is Improvement of Patient Care) BCMA Overview

41. Improved Patient Safety • Thousands of Patients are Injured or Die in the United States Due to Medication Errors Every Year • A 2004 study found a Medication Error Rate was 111.4 Errors per Every 1000 Orders!1 • A typical Unit of 10 beds can easily administer 400 doses or more per week • 1 Seeley C, et al. “A baseline study of medication error rates at Baylor University Medical Center in preparation for implementation of a computerized physician order entry system”. Proc (Bayl Univ Med Cent). 2004 July; 17(3): 357–361 BCMA Overview

42. Medication Errors • You may be having Over 40 Unreported Medication Errors Per Week on a single 10 bed Nursing Unit! • Errors go unreported, not because Nurses or Pharmacists are hiding them, but because they don’t even know they have occurred! BCMA Overview

43. Why BCMA? • The Goal is to Continuously Improve The Process of Medication Administration and thus ensure the Five Rights: • Right Patient • Right Medication • Right Dosage • Right Time • Right Route BCMA Overview

44. The Goals? Meeting Meaningful Use Increased Patient Safety BCMA MU BCMA Overview

45. Questions & Discussion BCMA Overview