Overview and Workflow Considerations with RPMS Pharmacy 5/7 and the Electronic Health Record

1. Overview and Workflow Considerations with RPMS Pharmacy 5/7 and the Electronic Health Record Brian Wren Pharm.D., BCPS Chief, Pharmacy Services W.W. Hastings Indian Hospital

2. Medication Reconciliation • Pharmacists are best suited to provide this service • Provider consistency? • How far are providers willing to go?

3. W.W. Hastings Outpatient Medication Reconciliation • The (ORX) convention is used with “dummy providers” • All active, pending and hold medications are imported into the provider template • The provider then reconciles medications on that list. If a patient is taking a medication that is not in the file an email is sent to one of two pharmacists

4. Continued… • The dispensing pharmacist then completes the medication reconciliation note (see example) • An email will also be sent if the pharmacist notices that a med the patient is taking is not in the file (most common occurrence)

5. Continued • The medication reconciliation sheet is then printed and given to the patient • Patients are encouraged to bring it back at the next visit • ORX labels do print at W.W. Hastings

6. Talking Points • What do pharmacists do when the patient is not taking a medication on the list? • What is done when the patient does not know the dose? • Does medication reconciliation occur on refills?

7. Other Examples? • Carnegie • Phoenix Indian Medical Center

8. Why Pharmacy v5/7? • New patches will require V5/7 • Required for AudioCare, robotic, & ADC interfaces • Medication order checks • Laser Labels • Paperless Refills

9. Pharmacy 5/7 Workflow Considerations • To hold or not to hold • Filling from appointment to appointment • Utilization of technicians • Paperless refills-When and How

10. Paperless Refills • Site Parameter • Streamlines coding issues and pharmacy refill documentation • Provider ordered refills-(More of an issue when E.H.R. is installed)

11. Paperless Refills • There is no need for registration to create a visit with this system • PCC/Data Entry will notice an increase in errors • Tip: If a medication is taken off hold there will be a missing POV

12. Paperless Refills • Question: What do you do when there is no appropriate diagnosis for the medication that is being refilled?

13. Why EHR • Mandate by IHS Director • More efficient access to clinical data • More effective billing and coding practices • Consults/referrals

14. IHS-EHR Benefits • Patient safety focus • Organized management of data • Clinical reminders (In progress) • Provider order entry

15. Terminology • CPOE-Computerized Provider Order Entry • CAC-Clinical Application Coordinator • GUI-Graphical User Interface • Vista-Veterans Health Information System & Technology Architecture

16. EHR Essentials • Commitment • Provider Acceptance • Robust Network

17. Network costs FTE costs Decrease in efficiency (may be temporary) Training Scheduled rollout is best Use of the E.H.R. initially for CPOE may be considered Facility Considerations

18. EHR Workflow • Education of staff (particularly providers) is extremely important • New orders will be entered by providers and verified by pharmacists • Accuracy of provider entry is paramount

19. E.H.R. Challenges for Pharmacy • Difficult (time-consuming) to link individual med orders to a specific visit • Continuity of pharmacy refill visits-original orders, intervals, documentation of drug monitoring • Pharmacists are “tied” to computer terminals verifying orders

20. More Decisions and Issues • Who maintains the quick orders, drug file etc. • Are completed provider notes a prerequisite before meds can be filled? (Please say yes!) • How will schedule II medication be processed?

21. Continued… • How/when will pending meds be processed • How/when will pharmacy be notified when orders are pending • Option 1: Checking the queue periodically • Option 2: Patients present to the pharmacy with a “routing slip” given to them when their provider visit is completed

22. Training Providers (Pharmacy Opportunity) • Pharmacy should participate and assume an active role in this endeavor • Time spent training providers will drastically improve the efficiency of order verification by pharmacists • Maximize quick orders

23. W.W. Hastings Approach • All chronic medications are 30 days with 11 refills • Providers are required to reorder all medications that patients are taking at each visit-This streamlines the medication refill screening process • A RX refill note is completed for all medication refills

24. Pharmacist Decentralization • Maximizes efficiency and pharmacist interaction with physicians • Increases patient satisfaction/decreases wait times • Challenges • Patient counseling using “show and tell” • Space • Difficult for small sites

25. No Paper? • Discontinuation of usage of summary labels • Try to extrapolate the best paper processes to the electronic format (i.e. How did we do this on paper?) • Tracking medication errors

26. Pitfalls • Minimize the transition time between “paper” and electronic processes • Pharmacy may need to negotiate a cessation date for the usage of orders written on paper • Providers should not be allowed to switch from the E.H.R. back to paper (i.e. when they are busy)

27. Workload Distribution January 2004

28. Workload Distribution January 2007

29. Demonstration • Tour of E.H.R. • Processing a paperless refill • Processing a pending order