This presentation discusses integrated hospital medicines management and Taranaki District Health Board's experience implementing related systems and processes. It outlines the problems with medication management in hospitals, including high rates of adverse drug events. It then describes New Zealand's national response through an integrated hospital medicines management program involving electronic medication reconciliation, prescribing and administration. Taranaki DHB is a lead site implementing these initiatives. The presentation concludes by discussing Taranaki DHB's vision, project phases, benefits of an integrated system, lessons learned, and ongoing challenges.

1. Integrated Hospital Medicines
Management
Elizabeth Plant
Director of Medication Management
Dr Kanaka Ramyasiri
Clinical Architect
Taranaki District Health Board, Health Intelligence Ltd

2. This presentation
• The problem with medication and allergy
management within the hospital setting.
• The national response – Integrated Hospital
Medicines Management
• Taranaki DHB’s experience as a local
champion

3. The Problem
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have no what you used to
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idea what’s have, as well as
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these new things.
GP
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hand written
hand written medication? I’d
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script. Who do Pharmacy
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are you being
are you being
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prescribed right
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now?
med that’s not
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listed in your last
listed in your last patient
patient Patient Hospital
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discharge
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summary?
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the discharge
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medication?

4. Adverse Drug Events
• Adverse drug events occur in 0.7% of all patients
admitted. (Harvard Medical Practice Study, N Engl J Med.1991)
Extrapolated to New Zealand
• 50,000 patients per year admitted to acute care
hospitals will experience an adverse drug event each
year.
• 120 people will die from an adverse drug event.
• Preventable annual hospital drug cost = $411 million.

5. The response
• HQSC | Medication Safety Programme
• NHITB | Medicine information is a key
component in every feature of the National
Health IT Plan
• Hospital eMM programme is jointly sponsored
by HQSC and NHITB
• 4 Lead DHB sites being supported to implement
two key initiatives:
– eMedicines Reconciliation (eMR)
– ePrescribing and Administration (ePA)

6. Orion solution
eMR
•Reconciles medicines on admission with what charted with what they are discharged on.
Communicates reasons for changes:
•Allows results of inpatient medication reconciliation to be seen as a table in the
eDischarge Summary (eDS) sent to GPs
•This information remains available within the hospital for re-use

7. ePrescribing and eAdministration
CSC solution - MedChart
•Replaces paper charting processes
•Enables electronic prescribing and administration management within the
hospital
•Information can feed through to the hospital dispensing system
(ePharmacy)
•Information can feed through to the discharge eMR and eDS being sent to
GPs

8. Taranaki District Health Board (TDHB)
• Small provincial hospital, 245 beds
• Serves a population of 104,000 people – or 2.8% of New Zealand’s
population (4,430,689)
• General medical / surgical and full range of services
• Pharmacy Department operating Monday to Friday
8am – 5pm; Saturday and Sunday 10am – 12noon
• One small remote hospital (Hawera) - one hour away, 20 beds, as
well as an ED
• New hospital project underway
• e-Medication Management Project seen as key to drive change

9. TDHB e-Medication Management
Vision
“…Clinicians and other stakeholders will be able to prescribe,
dispense, and review medications reliably via online electronic
tools accessed through the TDHB Clinical Portal or their local
system of choice (such as their GP practice management system).”
“Patients will have appropriate online access to their medication
history.”
“Bedside verification will be used within the hospital setting.”

10. Hospital eMM
ADMISSION TO HOSPITAL DISCHARGE FROM HOSPITAL
Allergy Warning + ADR
Medication Medication Key
and allergy and allergy Documents:
information e-Medicine Reconciliation (eMR) information
from: to:
e-Prescribing & e-Administration (ePA)
• Patient (+ family,
caregivers) • Patient • Dx summary
(inc MCS)
e-Dispensing (ePM)
• GP/specialist • Dx scripts
• GP/specialist
• Community • MCS
Automated Drug
pharmacy Distribution System • Yellow Card
• eMR • Community
• Rest homes pharmacy • Patient
• Input by qualified
professionals Information
• Other hospitals Leaflet
• 3+ sources used • Rest homes
• Ambulance • Discrepancies
listed as
• Other hospitals
unintentional /
intentional
Discrepancies must be resolved by a doctor within 24 hours of
arriving in Hospital
Patients own medicines into “green bag”
MCS = medication changes summary

11. End-to-End Medicines Management (simple)

12. Pyxis
Medstation
in ICU

13. Benefits of an Integrated System
• No transcribing between systems
• Reduction in error
• Improved efficiency
• Reduced time for clinicians on data entry
• New Model of Care - will change the way clinicians
deliver care to patient
• Medication information and decision support available at
patient bedside

14. Project Phases to Date
• November 2010 – Pharmacy Dispensing System
implemented with improved integration to Pyxis.
• June 2011 – Electronic Medication Reconciliation System
implemented with associated clinical change management.
• April 2012 – Allergy Project to go-live in MedChart
(e-Prescribing system) hospital wide for all patients; allergy
status and process of verification to be built around this.

15. Project Phases to Date
• 9 July 2012 – Electronic prescribing / administration to
go-live – beginning of staged rollout – Ward 1 AT&R.
• December 2012 – eMR to ePA Integrated solution to be
tested as soon as new integration development available
from software vendors.
• From August 2013 – Full hospital rollout for
e-Prescribing / administration scoped and underway.

16. Clinical Change Process
Key Principles for Success
• “Clinical Change Champion” on the floor
• Branding for the project
• Training needs to be targeted and preferably one-on-one
• Initial training, followed by audit of six interventions
(eMR), then specific one-on-one training to fix deviations
• Identify the barriers to using the system and fix as soon
as possible

17. Use Measurement Tools and Make
Relevant Goals
• Use a dashboard to report results regularly
– must be visible in the ward
• Make the targets relevant to the clinician group
– ie use targets that they can influence
• Have positive incentives:
– “Go for Gold” Coffee Cups! (something they like!)
– regular newsletter with names of excellent achievers
– presentations and morning teas to thank the team
– praise and encouragement goes a long way

18. Photos of Dashboard

19. “Going for Gold” Coffee Cup

25. Clinical Change Management Lessons
• International literature indicates the following factors are
important for the success of e-Prescribing systems:
– This is a complex redesign of clinical processes, which will change
virtually all processes around medication management and thus will
be challenging for clinicians.1, 2, 3
– Workflow analysis is essential.
– Barriers to the use of new technology need to be identified and
addressed before and after implementation, to ensure appropriate
use of electronic medication management systems.1, 18

26. Clinical Change Management Lessons
– Socio technological change depends more on
organisational context than technology change. 17
– e-Prescribing systems can lead to increased mortality
if implemented poorly ie too rapidly, low efficiency
and with a lack of consideration to changes in
workflow processes. (Han Y, 2006)
• Two paediatric hospitals implemented same system - one
well, one poorly (in six days), with different mortality
outcomes.

27. Clinical Change Management Lessons
– End to end systems are more successful than ad hoc systems. 1
– The two hospitals most successful in implementing e-Prescribing systems
have both designed the systems to fit their own workflows.
1, 5, 6, 7
– Many adverse drug events result from poor design rather than human
error. 1, 16
– Administrative type errors (ie; documentation and “completeness”) will
decrease with electronic solutions due to forced compliance. 8, 9
– To decrease clinical errors and “patient harm”, some degree of decision
support is essential but this should be introduced slowly as clinicians adjust
to the changes and to avoid “alert fatigue”. 10, 11, 1, 12
– Customisation of decision support is important for ownership and
adherence. 13, 14

28. Lessons from the Westbrook Studies
Comparison of two e-Prescribing Systems on Prescribing Error Rates
• Both systems were associated with a statistically significant reduction in total
prescribing error rates (>55%)
– mainly attributed to a reduction in administrative prescribing errors {incomplete, illegal and
unclear prescriptions} NOT clinical prescribing errors
• The rate of system related errors can be significant (35% error rate introduced)
• The same system can produce different outcomes in different wards
– don’t assume that you can just go from one ward type to another without considering the
different variables
• The different prescribing systems (Cerner and MedChart) introduced different types
of system related error (e-iatrogenesis)
Reference : www.plosmedicine.org January 2012 Vol 9 Issue 1 e1001164

29. Clinical Change management lessons
Westbrook et al:
•Clinicians’ greatest concern was the associated work practice
changes
•Qualitative and observational studies may identify the nature of
these changes
•The results highlight the need to continually monitor and refine
the design of these systems to increase their effectiveness,
appropriateness and safety
•The complexity of undertaking real world studies should not be
underestimated
Reference : www.plosmedicine.org January 2012 Vol 9 Issue 1 e1001164

30. Sittig et al
Significant Body of Experts in the USA
Principles:
• If the system is not available then you won’t get the benefit
• If users choose not to use it then you won’t get the benefit
• If the system is not efficient then you won’t get the benefit
• So you need to get workflow, structure and process right first
before measuring the outcome measures.
• The measures need to be ones that can reasonably be
measured in hospital organisations
Reference : AIMA 2007 Symposium Proceedings

31. A Closer Look at Allergies
•Patient Allergy & ADR information is typically held in disparate sources within the hospital setting and
communicated via various channels.
–Patient administration system
–NHI sourced information
–Clinical Portal
–Pharmacy Dispensing System
–Paper drug charts
–Paper clinical notes
–Paper or electronic Medicines Reconciliation documentation
–Discharge summaries
–Etc etc.
•Disparate locations of allergy information which often “drop off” on subsequent patient episodes, or
during the admission on recharting).
•We attempted to consolidate the source of truth of coded allergy information within the hospital as
much as possible as part of the solution architecture.
Demonstration: Allergy Management within the system.

32. Allergies – Electronic Information Flow
ePharmacy
Dispensing
MedChart SMT
Decision
Prescribing Support Discharge
Decision Summary
Support & eMR
NHI MedChart Concerto
Medical Portal
PAS Allergies
Warning Patient
System Service Summary

33. A look at the system – Allergies

34. A look at the system – Allergies

35. A look at the system – Allergies

36. A look at the system – Allergies

37. A look at the system – Allergies

38. Recommendations (Early Lessons)
• Identify the barriers and the workarounds as they occur to either fix
them or remove them. Make sure you have the resources to be able
to be responsive.
• Ensure vendor provides training environment early.
• Super User Training needs to happen well in advance of Go-Live.
• It is essential that the people who are to be trained at all levels are
identified well in advance and that all their details are correct.
• Dedicated clinical Super User resource is a must, especially from
nursing perspective since the nursing workflow changes are
significant.
• Involvement of a Junior Doctor at the detail process level pays
dividends.

39. Recommendations (Early Lessons)
• Implementation of ward infrastructure (wireless networking,
laptops, trolleys) at least two months before Go Live greatly eased
workflow changes and encouraged staff to “go electronic” well
before the prescribing started. It also allowed a good timeframe to
remove any issues and impediments with laptops, wireless
infrastructure and other network issues.
• Involve the unions early to ensure they are comfortable with the
project and have confidence in the team.
• Procuring equipment takes longer than anticipated so ensure
plenty of time is allowed for this.
• Ergonomic workplace assessment needs to be carried out in
relation to the COWS (computers on wheels) to prevent
occupational overuse syndrome. We already have one nurse with
indications of uncomfortable arm movements.

40. Challenges
• There are existing e-Prescribing systems but none are integrated
with electronic medication reconciliation, dispensing and
automated drug distribution.
• Led to requirement for three different software vendors to partner
in project.
• Integration complexity slows the project timelines.
– required TDHB to change the order of implementation
• Stand alone components
• Subsequent joining up
• Evaluation framework not defined in time for baseline data to be
collected pre-Go Live.

41. Challenges
• The different professional domains involved adds to the complexity
of needing to find a solution that meets the requirements of all
groups:
– eg requirements for generic prescribing for doctors, compared to
dispensing of specific brands for pharmacists or administering specific
doses for nurses.
• Bringing all the professional domains together:
– Technically
– Professionally
• Integration into the Clinical Portal environment.
• Challenge of future need for linking into GP/ community pharmacy
e-Prescribing and centralised data repositories, to enable true end
to end medication management for Taranaki.

42. References
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2008; 15:585-600.
2 Gay T. Report - A Case Study on Computerized Physician Order Entry - A Blueprint for a Beginning. E-Health A division of the Massachusetts
Technology Collaborative 2006; December.
3 Ormond C. Discussion paper: CPOE. Institute for Health Policy 2005;1-22.
4 Sittig D F et al. Recommendations for Monitoring and Evaluation of In-Patient Computer-based Provider Order Entry Systems:
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