Transitioning to a new Hospital Information System in the Veterinary Teaching Hospital: A Comprehensive Review and Tips for Success Alisha Hill, PharmD, RPh, FSVHP Cornell University

Objectives •  Describe general functionality & expectations of a new

Hospital Information System (HIS) or Electronic Medical Record (EMR)

•  Describe Legal Requirements met by new HIS/EMR

•  Identify challenges to new HIS/EMR implementation

•  Identify tips for successful implementation

Expectations- The Basics •  Improved functionality, capability, ease of use, efficiency

•  Ability to meet legal requirements at state and federal level

•  Less paper reliance

•  Able to support a large number of users/service areas simultaneously

•  User- levels (DVM, LVT, Student, Pharmacist, technician)

•  Accounting and Administrative tools

•  Inventory Management

Evaluation Criteria •  Technology (10%)

•  Overall functionality (10%)

•  Clinical functionality (25%)

•  Administrative functionality (25%)

•  Educational functionality (10%)

•  Research functionality (10%)

•  Vendor Project Management, Implementation/Support (10%)

Expectations - Technology •  Current infrastructure supported •  Cloud based versus Server based •  Mobile friendly, accessible on multiple platforms, PC,

Mac •  Open Application Program Interface (API)/ data transfer •  Offline/Downtime processes •  Data Backup •  Security features

•  Integration with Point of Care software (labs), pharmacy software, dispensing software (ADC), workflow software (ie: Smart Flow)

Expectations- Technology •  Integration and data transfer

•  Historical record •  How much of data from previous system transfers?

(i.e.: Refills, client and patient info, invoices, discharge docs) •  Is it useful? •  Automated Dispensing Cabinets (I.e.: MedSelect, Cubex,

Omnicell, etc.) •  To what extent do systems communicate? •  Data accurately populates to medical record •  Inventory tracking and transfer •  Labs, point of care testing, digital treatment sheets •  Translates to EMR in useful fashion

Expectations – Overall Functionality •  Simplicity

•  Display appropriate amount of info to carry out task No visual clutter

•  Naturalness •  Sense of familiarity, ease of use, intuitive

•  Internal Consistency •  Similar layout & design across workflows

•  Readability & Preservation of Context •  Information stored in a way that is easy to read & interpret

•  Built in Reports •  Useful, searchable

Expectations – Overall Functionality (2) •  Data Storage, Retrieval and Security

•  Is data extraction simple to do? •  Role based permission structure with limitations •  Data Security

Information cannot be deleted or changed once it has happened

•  Change log/audit trail system •  Authentication

•  Auditing Tools •  What is the scope?

•  Accessibility •  Multiple platforms (Mac, PC, tablet) •  Screen/Text can be enlarged, color blindness

•  Support 24/7

Clinical Expectations

Education & Research •  Can organize records based on student, case, disease or

procedure •  Clinicians can view student edits and provide feedback

Student written charts – DVM can edit/approve Students and LVT’s may enter prescriptions, submit for DVM approval

•  Simple & Consistent data entry Standardized treatment and procedure sheets

•  Built in templates Service specific forms

Research •  Clinical trial enrollment and tracking

-Pre-screening forms and client communications •  Charging research accounts •  Ability to extract data for reporting & analysis

Research & Academic reports, Patient & Clinical reports, etc.

Administrative Functions •  Scheduling •  Client/Patient relationships •  Client/RDVM relationships •  Registration •  Alerts

Visible on all patient screens •  Estimates •  Charge entry

Permissions based to modify and approve bills (i.e.: Returned items, alter quantity at pharmacy level)

•  Billing & Payment processing •  Inventory

Product Management Internal orders within departments

Vendor Expectations •  Vendor Reputation •  Client references •  Roadmap

Plan for training, transitioning, follow up (i.e.: Phased transition of Automated Dispensing Cabinets, weekly regroup meetings) Size of development team

•  Support 24/7 Escalation Process Updates

•  Technical Implementation Plan and Project Team Availability On site

•  Training Videos, Demo Site

Pharmacy Module

Pharmacy Module Key Aspects •  Prescription entry and approval with tracking of fulfillment

•  Prescription Legal Requirements met during filling and refilling process including generating relevant reports

•  Prescription Management and documentation -Pharmacy profile- Clearly shows current medication list including all fills, refills, history, dates, clinician, qty -All edits and changes are documented

•  Customizable Product Attributes, descriptions, auxiliary labels

•  Inventory capabilities

•  Integration with dispensing cabinets

Pharmacy Module Essentials

•  Sortable Queue Ultimate destination for all prescriptions Priority status, large vs. small animal, inpatient vs. outpatient, pick up vs. mail

•  Dose calculator and comment field mg/kg, m2 for chemotherapy, important double check, prescriber comments •  Pharmacist can easily review medication profile during filling process

Drug interactions, refills/dates on controlled substances, duplicates •  Prescription Entry – User levels and DVM approval

Students and Tech’s may enter, but needs DVM approval prior to filling Non-DVM approval (LVT’s)

•  Screen where pharmacy can monitor approvals Follow up on controlled drug approvals, ADC dispenses Clinicians may approve individually or as a group

•  RX label includes printed RX to check from •  Filling for RDVM’s (External Fill)

Important to maintain relationships, outreach Pharmacist has ability to enter RX

Pharmacy Module - Wants •  Client Portal

Online ordering and payment capabilities •  RDVM portal

Communications, diagnostic results •  External prescription streamline

Compounding pharmacies Transferring abilities and documentation

•  Automated controlled substance reporting •  Drug information monographs •  Credit card storage •  Ability to search by RX# •  Bar coding •  Integration with shipping software

Pharmacy Module (External) Pharmacy Software (i.e.: Guardian, Liberty, ect) Pros Cons

-No development needed -Easily meets reporting needs & Legal Requirements -Storage of credit cards, integrated purchase orders with human vendors -Clinical features (drug intx, allergies) -Customizable reports -Security -Bar Coding -Inventory tracking -Robust product features Control status, expiration date -Compounding documentation

-Must integrate to EMR Internal communications, refill requests, documentation, etc. -Building custom products -Designed for human medications Clinical features may be irrelevant - Information accessibility across EMR – How will orders come across? -Separate system – different downtime, security and back up -Inventory transfers to hospital depts. -Lack of Farm Animal W/D times -Lack of open API

Pharmacy Module (Internal) Internal Pharmacy Module

Pros

(i.e.: EzyVet, VetView, StringSoft, ect)

Cons -Clarity/Fluency of same system -Visibility across EMR -Billing edits may be easier to manage -Teaching opportunities Pharmacy staff may facilitate -Assist in development (ongoing) -Inventory in same system -Building kits and compounds -Inventory transfers within depts.

-End product may be unknown -University product may not be realistic -Users are not experts or developers -External fill challenges -Lack of reporting capabilities – must be developed (legal) -Lack of added clinical features -Lack of custom reports -Legal requirements added complexity -Integration challenges (+/-) -Inventory system may be lacking

Legal Requirements and Critical Needs •  Maintain original RX record, but allow pharmacist to edit

Must be able to edit all aspects (Drug, Qty, Directions, Refills) •  Audit trail

Document any changes made by pharmacists Dispensing pharmacist and date recorded on each refill

•  Prescription Numbers Assigned upon dispensing, Consecutive, readily retrievable

•  Daily dispense log Includes Patient, Prescriber, Drug, RX#, qty, RPh, refills remaining for all new prescriptions and refills

•  Withdrawal times – farm animals Ideally mandatory field

•  Controlled substance reporting for all dispensed medications to go home with clients Report must pull from product variable (i.e.: NDC number)

Legal cont’d •  Label Requirements

•  Pharmacy Name/Address/Phone •  Date Rx filled •  Prescription Number •  Prescriber name •  Name & Address of Owner •  Pet name & species •  Drug name and manufacturer •  Quantity •  Directions for use •  Refills remaining •  Expiration date of prescription and medication (compounds) •  RPh initials who dispensed •  Withdrawal time for farm animals •  “Caution: Federal Law Restricts this drug to use by or on the

order of a licensed veterinarian”

Pharmacy Profile •  Accessible whether or not patient has current open

clinical record •  Searchable by client or patient

Able to have multiple patients under one client •  Past and present medication list, including automated

dispenses •  Ability to differentiate automated dispenses from

prescriptions filled by pharmacy •  Able to manage RX

(Refill, edit amount being dispensed, canceling RX) Partial fill while retaining original RX quantity Returns, credits , tied to inventory, invoice, EMR Transfers to other pharmacies with documentation

Expectations – Inventory & Products

•  Product Attributes •  Control status •  Control schedule (CII or CIII-V) •  Unit of use (mL, vial, tablet, capsule, etc.) •  Comments on product home page •  Codes/line numbers to distinguish (oral, inj, opthal, etc.) •  Multi item kits •  Actual cost, pricing cost, discount fields, service fees •  Synonym field/alternate name/generic links •  Historical updates •  Product designation (medication, supply, vaccine) •  Links to auxiliary labels •  Manufacturer, or NDC number •  Lot Number and/or Batch tracking (+/-)

Inventory & Products

•  Ability to dispense inventory that is zero or negative •  Ability to refill fractional amounts •  Ability to limit refill number and expiration date on

controlled substances Cannot put refills on C-II’s, controls expire 180 days, etc.

•  Auxiliary labels tied to product, customizable •  Ability to look up price of product without adding to

invoice •  Ability to fulfill floor requests/Inventory transfer to hospital

departments Create pick sheet, transfer when fulfilled

•  Product min/max/critical reorder amounts

Automated Dispensing Cabinets - Expectations •  ALL transactions captured

Includes returns, waste, etc. Audit trail which cannot be changed or altered

Temporary or Emergency patient options •  Reliable, Accessible, Timely

Especially in critical care areas Drawers open and record transactions as expected

•  Streamlined User Interface Obvious pathway transactions

•  Secure Storage and User Access Permissions (zoned)

Prevent unauthorized access Biometric scanner with alternate entry method

•  Support 24/7

Automated Dispensing Cabinets •  Generates useful reports

Can be automated Expired products Restock/Pick sheets Transaction history by user, product

•  Assists in tracking inventory Discrepancy flags, resolution protocol Count backs- blinded/unblinded

•  Integration - Transactions populate to medication profile Can clearly see what, who, when “Med Orders” versus backwards approvals

•  Customizable drawer/product set up Can be customized/easily managed Individual item access Control of potential medication errors

Challenges •  Developers lack of understanding pharmacy

regulations and processes Software developers may not understand legal requirements

•  Time Line Time to importing data, training, and “going live”

•  Training Provide time to staff during working hours

•  Simplicity of approval and refill processes Must be clear and straightforward

•  User based permissions Some users have abilities they should not – modifications must be made for teaching hospital environment

Challenges continued •  Workarounds

If a process is unclear staff will find another way (i.e.: Refills) which may cause further confusion

•  Invoice Closures (Daily or Rolling) Pros and Cons to each for different areas of hospital Must show dates individual items added, not just closure date

•  Buy In Changes must appeal to entire customer base Having other veterinary schools on board

•  Speed/Efficiency Cloud based Added inventory control features (i.e.: count back and batch tracking)

•  Integration Not always in real time Still a work in progress

•  Inventory Model is very different for multi department institution Transferring capabilities, batch tracking

Food for Thought

•  Recent article in Fortune Magazine “Death by a Thousand Clicks: Where Electronic Health Records Went Wrong”

•  Must be critically evaluating functions of the system and aware of how much trust we are placing in it for the care of our patients Does it work like it says it does?

•  Pharmacists have a professional responsibility to ensure that appropriate policies, procedures, and quality-assurance programs are in place to address the safety, accuracy, security, and patient confidentiality of automated pharmacy systems, including automated dispensing devices. - ASHP Guidelines on the Safe Use of Automated Dispensing Devices

Tips for Success •  Allow plenty of time for training, make mandatory

Trial/Demo sites, Create videos or hold live sessions Test many scenarios

•  Identify experts within your team Implementation team

•  Create detailed workflows, identifying problem areas •  Encourage clients to get maintenance refills before

transitioning May cut down on added stress

•  Ask lots of questions!

Questions?