Problems

Problem #1 – With the initiation of CPOE, it was determined that the time it took pharmacists to enter orders into the Pharmacy Management system was reduced about 40%, but with the corresponding increase in order entry accuracy. But our pharmacists were still busy and we did not have good way to document what they were really doing. Was management going to cut our staff? Could we justify our staffing levels? (Our current Pharmacy system was just lacking in capturing Pharmacist activities.)

Problem # 2 – Implementation of CPOE and electronic Pharmacy systems put Pharmacists into a “list” focused mentality. “If it’s not on the work-queue list I’m not going to worry about it – If it’s not on the IV to PO list ………” This results in: • A reduction in proactive patient profile review. • A reliance on alerts - if I don’t get an alert - everything is OK. • Less motivation to do the other “things”.

We wanted a “Total Patient Focus” - not an alert, work-queue or list focus.

Question – Ever have a patient who was followed very closely by the ATB pharmacokinetic team, but ended up having a stroke because someone didn’t see the inappropriate change in anticoagulation therapy? Or something similar?

Problem # 3 – In our particular circumstance – the information the Pharmacists needed to perform intelligent, proactive Patient Profile Reviews was in several distinct applications – we needed all the data in one place. (Our EHR and Pharmacy System try to do this but the interface is cumbersome – and we can’t keep track of our activities in it.)

Related to this problem: • The gauntlet our staff had to go thru to generate even the simplest reports.

• The impossibility to generate complex reports/queries.

• We used way too much paper!

Solution

None of our current applications were very useful (if they were we wouldn’t still have these problems) and some of the commercial ones we looked at were too expensive or didn’t meet our needs.
So we built our own. (See sidebar) Motivations/Adoptions (Big Brother meets Field of Dreams)

With the initial app complete, a requirement was made that every patient should have their profile reviewed (at a minimum) and that a Pharmacist must document this review every 48 hours. This turned out to be effective in getting Pharmacists to go to this new app (cracking the whip), but not so useful in having it embraced as a useful tool. Ever work somewhere when one day management dictates you need to start tracking your time? – “You now need to keep track of every minute you spend here and what project you’re working on.” There are not too many things I can think of that ticks off well-intentioned, hardworking people then to cause them to do more menial administrative stuff. (See Ruffling Feathers below). We had to get Pharmacists to want to use it. To encourage true adoption, we started adding features that would entice the Pharmacists to use the app for more than just entering work activity.

*Remember those lists we didn’t want Pharmacists to use? * We added a visual icon if a patient met certain criteria. Instead of a patient being on the list – we put the list on the patient. A subtle change perhaps, but a significant mindset shift. So with a quick glance we can see those patients who have no DVT prophylaxis, are IV to PO candidates, have pharmacy consults, are being discharged, are on a high alert med….. This creates a visual “priority” to help with workflow.

We have also looked into creating a patient score based on these things and others such as:

 Age

 Number of meds

 Number of Beers meds

 How long have they been here?

 Etc.

We’re still looking into this - evaluating the criteria, seeing how it might improve workflows….

Other enhancements included quicker access to:

• calculation tools,

• renal dosing information,

• lab data with better graphing,

• cultures with sensitivities,

• Medication reconciliation support,

• Vitals and other Nursing documentation

With staff now using this app, we now had access to data on what activities which Pharmacists were documenting on which patients. We could also see which patients had no documented Pharmacist activity. A pretty handy management tool.

But perhaps the biggest push to adoption was peer pressure. Once some of the pharmacists started using it and leaving cogent progress notes, usage exploded. From 1/1/2015 to 10/1/2015, pharmacists have entered 23,793 “notes” about our patients. About 2,650 “notes” a month or about 85-90 “notes” per day. *A note is documented workload activity (I educated a patient, I did a chart review, I caught a duplicate therapy) or a progress note/communication about patient therapy.

Another key point (Ruffling the feathers)

Implementation of this application created a bit of a stir with the Pharmacy staff. Questions arose about work priorities, responsibilities, and follow-up. Guided by some very talented managers, the pharmacy staff worked together to identify and draft a new “understanding” of Pharmacists workload priorities. Getting the staff involved in this was crucial to its success. And because we built the application ourselves, we can add features and change things ( and fix things) very quickly. The staff feel a part of it’s development.

Current State

So we now have:

• A Pharmacy Intervention and Documentation system that is integrated into the daily Pharmacist workflow and allows our Pharmacists to work on a “Patient” basis and not a list or alert basis.

• Electronic progress notes for Pharmacy Consults.

• A way to track workload with exponentially enhanced productivity tracking.

Side Effects

o PSN

• We configured the system to automatically enter a patient safety event whenever a Pharmacist entered a “medication error” or “duplicate therapy” intervention. Our med safety tech wasn’t happy but it’s helped us reduce our duplicate med orders.

o Education

• The interventions the Pharmacists have been leaving have been a terrific learning tool for our students and residents. Knowing that students will be reading them makes the Pharmacist enter better comments.

o Reports

• Having the entire system a data access web based has made reporting and information lookup exceeding fast.

o RPh to RPh communication

• Whether it’s just leaving notes or the transition of Kinetic Consult care, the online and immediate access to information and comments has significantly improved all patient specific communication.

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