The Billings Clinic, a pioneering integrated health system based in Billings, Montana, encompasses a multispecialty physician group with 275 physicians and 80 mid-level health professionals, and a 272-bed hospital, and encompasses a total of 3,500 employees. The organization, the largest patient care organization in Montana, has long been a pioneer in care management and other innovations.
Leaders at Billings Clinic continue to innovate along numerous dimensions. Among them is an ongoing initiative to improve medication administration. Jacob Thiesse, PharmD, a clinical pharmacist who also carries the title of informatics pharmacist, has been helping to lead that initiative in the organization. Indeed, Thiesse delivered a presentation in Orlando, Fla., in February during HIMSS14, the annual conference of the Chicago-based Healthcare Information and Management Systems Society. In that presentation, he spoke about ongoing integration and interoperability work encompassing the Cerner Millennium electronic health record (EHR), with PharmNet (an integrated EHR with pharmacy suite), as and the Omnicell ACD system, from the Mountainview, Calif.-based Omnicell. Thiesse met with HCI Editor-in-Chief Mark Hagland at HIMSS14 and spoke with him again shortly afterwards in greater detail regarding his organization’s initiative in this area. Below are excerpts from that interview.
Could you explain a bit of the background regarding the current initiative to improve patient safety through IT interoperability?
Certainly. We had already moved some way along our journey before the recent enhancements. We had already been live for some time with Omnicell medication-dispensing cabinets. But even though the Omnicell cabinets were indicating to users when medications were removed, there were still some problems, so we approached Omnicell about it. We traced the source of the problem back to the context of the eMAR [electronic medication administration record]. The problem was that everything that’s on the eMAR was missing at the time when the meds were taken. There was an interface, and it sends patient ADT and ordering information; but it didn’t know when a patient had gotten a particular med, when a nurse dispensed it. There’s a readout on the cabinet that says, this is the particular order, and the last time it was pulled was at this time. But there’s no more context than that; it could have been pulled from different cabinets or from the pharmacy. And so even though it’s helpful to have that on the cabinet, it’s not as good as having that information in the eMAR.
When a nurse dispenses, the nurse keys in the information?
Let me walk you through it. Before, typically what would happen is that the nurse would somehow know it was time for a patient to get a medication. Usually, the nurse is at the bedside and the patient is complaining of pain, or perhaps the nurse is just at the nurses’ station and knows it’s time to check vital signs, etc. So the nurse would head to the Omnicell cabinet, and it would have a list of active orders there. So everything was available that the patient could receive at any particular time; but it doesn’t have a list of things that are appropriate to receive at that particular moment. So the nurse would select from the cabinet the items they remembered they were supposed to give, or had written down to give at that time. And anything not in the Omnicell cabinet, they’d grab from a different bin. And at the bedside, they’d scan the patient’s wristband and the med, and then would type that dispensing into the eMAR; we’ve had an eMAR for six or seven years.
So essentially, the nurse would have to scan the medication and click the scan button, and then it would enter it into the eMAR. So there’s that. That was our only fail-safe for making sure a patient was getting the right meds and it wasn’t a duplicate and that someone hadn’t come by before and done so. So we were pretty much reliant on the bedside barcoding and scanning system.
So to contrast that with what we’ve got now, we’ve recently implemented mPage, Cerner’s latest way to display data that’s interactive. It runs on HTML and Java, so it’s a familiar interface. This was put together to support interoperability between Omnicell and Cerner. So what it does is that it displays each of the items scheduled for the patient to receive at one particular time; and it also displays “PRN meds,” or as-needed meds.
So information is being populated directly into the eMAR from the EHR?
Within the EHR, the eMAR populates the page with things appropriate to go and give, and that’s coordinated with live information coming from Omnicell as to where those medications are stored. So the difference here is that, in contrast to the past situation, in which the nurse would have to write down what the patient was supposed to get, and then later enter that information into the eMAR, and hopefully not be interrupted on the way to doing so—now, the nurse heads over to the Omnicell machine, and all the meds that she/he queued up in the Omnicell machine are accounted for, and the machine says to the nurse, ‘You have queued meds—would you like them now?’ And the nurse will be prevented from possibly making an error if the nurse is interrupted; and if another nurse had just dispensed, say, clozapine, that drug would not then even appear on the list of queued meds, because the Omnicell machine is getting the information from the MAR, so the MAR won’t even allow the clozapine 100mg to be dispensed. So now we’ve introduced further upstream an opportunity to prevent giving the wrong medication. And further, because this is now in the EHR, if there are any lab values or vital signs that the nurse should know, it’s right there, and if their hematocrit is less than 10, I shouldn’t give clozapine.
So this will trigger from Cerner?
Not automatically, no. But the other tasks—they could toggle over to the labs and check. The hematocrit information isn’t available at the machine.
When did you go live with this innovation?
We went live with this in two units in the winter of 2013, and the two units are our transitional care unit (TCU), a long-term unit, like nursing home care; and also in our short-stay unit. And our adoption in our TCU has been nearly 100 percent. The anecdotal information—it used to be something like an hour and a half for a med pass. You’ve got two nurses and about 20 residents, and every morning at 9 AM, all the residents get their medications. So the med pass is the process of nurses delivering the meds to the resident. And with regard to the process of preparing and passing the meds—looking at the eMAR, deciding what they need to receive, selecting the meds from the machine, and repeating that for residents 2 through 10, now they’re able, from the room or from where the resident or patient is, they can click the buttons over the machine, and the machine dispenses the appropriate meds in a few minutes. So there’s been a reduction in time there. The staff is pretty satisfied as a result.
Do you have any patient safety metrics on this yet?
Patient safety metrics are always self-reported, so to try to compare something that was self-reported before and is still self-reported is hard. But anecdotally, it is reducing the amount of time the nurse spends in meds administration; the nurses are saying they’re spending less time in front of the machine.
And are they feeling more confident?
Well, the timeframe is shorter, and it’s easier to do overall.
Can you talk about the increased confidence that you and your colleagues have now in your medication administration safety processes?
I certainly feel more confident, yes. I feel more confident that the nurses are using the most up-to-date information to choose meds for the patients. If I make a meds order change as a pharmacist, the nurses will see it immediately now, because it’s within the electronic medical record and not over an interface. I feel like with implementing SinglePoint from Omnicell, which takes all the meds and puts them into the machine.
Previously, medications that were compounded, that were created custom for patients, we would keep in a bin on the wall, so that when nurses went to do their med pass, they’d pull items from the machine, and from the bin on the wall; and Omnicell will keep track of the medications coming from the main pharmacy and will allow us to put those into a bin for a specific patient. Really, everything should be separated specific to that patient; we shouldn’t have a pile of meds on a counter for all patients. It’s more like a best practice.
And so instead of having cubbyholes and stashes of medications, we’re trying to consolidate all the meds for each patient within one particular place within the Omnicell; and because the nurse knows where those meds are, they’re able to queue those meds appropriately.
That seems obvious, at least conceptually.
Actually, it’s really hard to get these things done. And in moving forward in this area, we came across quite a few workflows, some of them unique to my organization and some not unique. But one of the advantages of having a strong beta relationship like this is that I can talk to my partners—I talk to Omnicell people every week, and have conversations around how likely it is we can get something fixed and in what timeframe. It’s really been the best kind of beta partnership I’ve had with vendors, because there really is a commitment on Omnicell’s part and Cerner’s part to make this successful, in contrast to partnerships with some other vendors, where, what does marketing want us to get to, and once we’re at that point, we’re done.
How do the vendors refer to the different aspects of this?
The fact that all medications are in the machine, that element is called SinglePoint. Meanwhile, eMAR-ACD is the queuing process, with “ACD” standing for “automated dispensing cabinet. Meanwhile, Cerner refers to this as a CareAware interface.
What should CIOs, CMIOs, CNIOs, and other informaticists and clinical informaticists, know about this?
First, they need to go and understand what their current medication administration process is, and then to learn where the gaps are in their current process. So often, I see an executive purchasing a technology or product or solution, and they haven’t identified the problem they’re trying to fix. In this case, as a workaround of not having an eMAR integrated with meds cabinets, we literally put laptops next to the dispensing cabinets. So the initial conversation with Omnicell was, this is what we’re thinking of doing, do you have anything better? And initially, the answer was no, but a couple of years later, they said, hey, we’re thinking of creating something, would you like to beta with us?
So determining the workflow, and what the benefit to the nursing workflow and pharmacy workflow would be, to any new implementation, that’s important. It all starts with knowing what the opportunities are. And in this case, the opportunities around closely averted medication administration errors—it was, we are missing the context of the eMAR at the point of dispensing. And having a multidisciplinary team of nurses, pharmacists, quality people, and a few physicians working on this, was also essential. Throughout the process, we have gone and looked at the errors coming out of the current process, and have discussed them from a quality perspective, and solved them from that perspective.
How broadly have you implemented this process now in your organization?
We’re now on four units. At the beginning of this month [April], we went live with our inpatient cardiology unit; and in inpatient cancer care, we’ve been live on eMAR-ADC for about a month and a half now. And the original pilot units have been live since December of 2013. So we’re rolling it out unit by unit, and with each unit we roll it out to, we find more things we can shore up and things that don’t work well. Overall, we’re finding the most benefit in those units where the patients have longer stays. And our short-stay units are mostly staffed by floater nurses, and they know the benefit of this, yes. And they want it everywhere. We continue to work out issues, but it’s heartening that the nurses are asking for all of this.
