ASHP InterSections ASHP InterSections

July 16, 2015

IT Wizardry Streamlines Hospital Discharges, TOC

Wing Liu, Pharm.D.

Wing Liu, Pharm.D.

THE TRANSITION OF CARE (TOC) after hospital discharge remains perhaps the most vexing stage in the healthcare continuum. Lapses during patient hand-offs between the hospital and a patient’s home or a post-acute care facility often include incomplete information about key aspects of care. For pharmacy care, such breakdowns typically show up as multiple, conflicting, and erroneous medication lists.

At Vanderbilt University Medical Center (VUMC) in Nashville, Tenn., patient care during TOC has improved with the use of a new software program designed by Wing Liu, Pharm.D., product manager for the inpatient computerized physician order entry (CPOE) system, and his IT team.

“We asked ourselves, ‘How can we do a better job of coordinating all aspects of the transition to ensure patient care remains uninterrupted at a high level, regardless of where patients go?’” Dr. Liu said.

The Discharge Wizard app pulls together all elements of TOC into a single application.

The Discharge Wizard app pulls together all elements of TOC into a single application.

Rolled out in 2012, the Discharge Wizard application pulls together all elements of TOC into a single application, including the often daunting process of medication reconciliation.

The solution links directly to VUMC’s electronic health record (EHR), allowing clinicians to merge and exchange key information between the two IT platforms, such as patient demographics, follow-up appointments, patient core measures (e.g., congestive heart failure), healthcare team members, current medical status, bed location, and diet and exercise regimens.

The application even compels users to conduct medication reconciliation to complete the discharge process.

“It’s designed well and is easy to use,” said Amy Myers, Pharm.D., BCPS, a clinical pharmacist at VUMC.

“During the medication reconciliation process, the system allows you to choose, medication by medication, which to stop and which to continue. The result is a single, accurate medication list, which is also accessible through the EHR. That’s a huge benefit.”

Easy-to-Read Discharge Plan Streamlines Patient Handoffs

Ultimately, the system produces a discharge plan. All patients receive an easily readable discharge letter that includes medication schedules, follow-up appointments, additional care instructions, and educational material. For patients headed to a post-acute care facility, the plan is transmitted to the new healthcare providers via fax, email attachment, or with an accompanying paper record.

Nicole Callendar, R.N.

Nicole Callendar, R.N.

“One of the best features of this solution is the option to customize the discharge report based on the patient’s destination,” said Nicole Callender, R.N., staff nurse and support liaison for the application. “The orders tell the patient exactly what is needed for his or her care.”

To encourage rapid adoption of the Discharge Wizard application into the current discharge workflow, Dr. Liu wanted the app to be a model of simplicity. By all accounts, he succeeded.

Although the application is optional, biweekly utilization reports show that clinicians use it in about 95 percent of discharges. The most useful feedback about the system’s impact on workflow and patient care, he added, comes from anecdotal reports by users vs. quantitative measures.

Any member of the care team can easily launch the application through the CPOE, but only healthcare providers and select clinical pharmacists can save information. The software guides them through a sequence of fields to gather all of the relevant information needed for a discharge report. At any point, the process can be paused and restarted by another clinician, for example, in the case that a pharmacist needs to get involved in the medication reconciliation component.

Applicability to Post-Acute Care Facility Transfers

Originally, the Discharge Wizard applied only to patients discharged home. But a Centers for Medicare & Medicaid Services grant called “IMPACT: Improved Post-Acute Care Transitions” highlighted the need for an expanded role for the system to include patients transferred to post-acute care facilities. This is a patient group that is typically burdened by complex, mutable drug regimens.

Amy Myers, Pharm.D., BCPS

Amy Myers, Pharm.D., BCPS

“This is a very vulnerable population, especially for medication errors, yet it’s often excluded from TOC studies, which typically focus on patients going home,” Dr. Myers said. “It became apparent that we needed to improve our system for sending transfer orders to the new facility.” The more robust application went live in fall 2014.

Once VUMC nurses realized that using the software application meant they didn’t have to handwrite discharge orders anymore, and that patients could actually read the reports, they were sold, said Nicole Callender.

“Now, it’s part of the culture and widely embraced,” noted Callender. “It’s at the point where, if you’re a bedside nurse who doesn’t have a printed discharge letter from the Discharge Wizard to give to the patient, that nurse is going to call the provider to ask for it.”

Allie D. Woods, Pharm.D., director of ASHP’s Section of Pharmacy Informatics and Technology, said that hospitals and health systems across the country need apps and systems like the Discharge Wizard to help reduce errors and improve medication reconciliation.

“It’s critical that TOC information is shared with all healthcare providers in a single location. This system is definitely a step in the right direction for healthcare technologies,” she added.

From the perspective of pharmacy informatics, the project has been eye opening, added Dr. Liu.

“As a pharmacist, I’ve been involved in creating an application for which my role was envisioning what it should do and how to get there,” he said. “It’s taken a team of four full-time software engineers working on it to get this far, and it’s been very gratifying to see the difference that it’s made for patients and healthcare providers alike.”

–By Steve Frandzel

Editor’s Note: The project described in this article was supported by Grant Number #1C1CMS331006 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

February 2, 2015

SNOMED CT Codes: Making the Case for Pharmacy Services with Hard Data

SNOMED_IG_V7MOST PHARMACISTS ARE NOT FAMILIAR with SNOMED CT – yet. But it’s a good bet they’ll start hearing the acronym a lot more and learn that it represents a major step toward normalizing reimbursement for pharmacy services.

SNOMED CT is a clinical coding nomenclature that contains more than 300,000 codes to document patient care in the electronic health record (EHR) – simply put, it’s a language that all EHRs will use to “talk” to each other.

Unlike other commonly used coding systems, such as ICD-9 and ICD-10, SNOMED CT is not used for billing. It’s also far more specific and complex. SNOMED CT is controlled by the International Health Terminology Standards Development Organization (IHTSDO).

In the U.S., the National Library of Medicine manages SNOMED CT. As of 2012, SNOMED CT was being used to some extent in more than 50 countries.

A Common Language

“Think of SNOMED CT as the Rosetta Stone for health information. It allows different electronic health record systems to understand one another,” explained Samm Anderegg, Pharm.D., M.S., BCPS, pharmacy manager with the Oncology Service Line at Georgia Regents Medical Center in Augusta, GA. Anderegg serves as one of the ASHP member representatives on the Pharmacy Health Information Technology Collaborative (Pharmacy HIT Collaborative) workgroup that is responsible for submitting and vetting the codes.

Samm Anderegg, Pharm.D., M.S., BCPS

Samm Anderegg, Pharm.D., M.S., BCPS

“Clinicians are moving away from free text and towards discrete data documentation. This structures the data in a way that it can be packaged and sent to other healthcare providers at different institutions,” he added.

The Collaborative is an alliance that includes ASHP and a dozen other professional and industry groups whose goals include ensuring that health information technology supports pharmacists in healthcare service delivery; achieving pharmacists’ integration within health information exchange; and supporting national quality initiatives enabled by health information technology. The Collaborative found very few codes among healthcare coding systems for documenting direct patient care provided by pharmacists.

“We know that we take care of patients, and we know we have an impact on care, but pharmacy has been behind the curve when it comes to documenting that impact,” said Anderegg.

That’s all changing. In 2012, the Collaborative submitted and won approval for more than 250 codes specific to medication therapy management in the SNOMED CT system. The Collaborative’s Value Set Committee, chaired by Anderegg, will maintain and update the codes to stay current as pharmacy practice evolves.

Demonstrating Pharmacists’ Contributions to Patient Care

For pharmacy, the availability of universal, pharmacy-specific coding will provide an unparalleled opportunity for pharmacists to document their actions, track resulting outcomes, and prove, with hard data, the value of medication therapy management in patient care.

A guide to SNOMED CT issued recently by the Pharmacy HIT Collaborative offers a compelling case for why the new codes are so important.

Ultimately, we want to justify the value of our services by tying what we do to patient outcomes.

“As we move toward more team-based care delivery modes, it is vital for pharmacists to be able to demonstrate their ongoing contributions to patient care,” said Anderegg.

“Adopting and using MTM SNOMED CT codes will enable pharmacists to capture those contributions in discrete data documentation, instead of free text and narrative, which can’t be analyzed in any meaningful way.”

For years, SNOMED CT has lingered in the background of U.S. healthcare. Then, recently, the Centers for Medicare and Medicaid Services declared that a significant portion of medical coding must be reported in SNOMED CT in order for EHR technology to be certified. Such certification is required for health systems to qualify for Medicare and Medicaid “meaningful use” financial incentives.

Before any of that happens, though, healthcare providers must adopt SNOMED CT, integrate the coding into their EHRs, and make it available to frontline medical staff. It’s a formidable task that has hospital IT departments and healthcare IT vendors across the country teaming up to sort out the myriad challenges. Already there are a number of products that translate – or “map” – codes from the well-known ICD-9, and its ICD-10 successor, into reportable, standardized SNOMED CT codes.

What the Codes Mean for Pharmacy’s Future

In the meantime, ASHP and the Pharmacy HIT Collaborative are pushing hard to raise awareness of SNOMED CT, according to Allie D. Woods, Pharm.D., director of ASHP’s Section of Pharmacy Informatics and Technology.

Allie D. Woods, Pharm.D.

Allie D. Woods, Pharm.D.

“Pharmacists need to know not only that these codes exist, but also what they mean for the future of our profession,” she said. “Frontline pharmacists can help by learning more about SNOMED CT from ASHP and other organizations and speaking with informaticists at their institutions, then discussing its benefits with colleagues and pharmacy managers.”

Woods noted that although the codes have been in existence for two years, few pharmacists are ready to use them yet. “Our greatest hope is that these codes will be used in the effort to obtain pharmacist’s provider status and, eventually, to bill for services. We’re just not quite there yet,” she said.

SNOMED CT eventually will become the coding norm, allowing pharmacists to produce data-rich reports pooled from multiple EHR systems.

“It all starts with incorporating the codes into pharmacy documentation within the EHR and making sure that pharmacy clinicians, IT staff, and administrators are all involved in that process,” said Anderegg. In addition, according to Anderegg, pharmacists need to begin building these codes into the EHR in an intelligent way so that the data can be reported and analyzed.

“Ultimately, we want to justify the value of our services by tying what we do to patient outcomes. If we can do that, the sky is the limit,” he said.

–By Steve Frandzel

January 16, 2015

New EHR Improves Outcomes at The University of Kansas Hospital

Filed under: Ambulatory Care,Clinical,Current Issue,Feature Stories,Managers,Quality — Tags: , , — jmilford @ 5:34 pm
clinical_pharmacy_2 Google

The new Clinical Efficiency System that is part of the EHR used by pharmacists at The University of Kansas Hospital ensures that clinicians see the most critical patients first.

CLINICAL PHARMACISTS BEGIN THEIR SHIFTS much the same way as most clinicians: They examine patients under their care and proceed from there.

But when faced with dozens of patients, each one with different needs and clinical complexities, which ones need immediate attention? Which can wait? Sorting out the choices subjectively is time-consuming and inefficient, and reduces the amount of time a pharmacist can spend with patients.

“We want our pharmacists to come in and, based on patients’ clinical acuity, examine their most critical patients first. Choosing patients alphabetically or by room number won’t achieve that,” said Samaneh T. Wilkinson, M.S., Pharm.D., Assistant Director of Pharmacy at The University of Kansas Hospital in Kansas City.

“Instead, we wanted to have the electronic health record (EHR) guide pharmacists based on a patient’s clinical needs, with the primary goals of improved efficiency, clinical consistency, and better patient outcomes.”

To that end, Dr. Wilkinson spearheaded implementation of the Clinical Efficiency System (CES), a complex software package developed by the hospital’s IT department and integrated with the hospital’s existing EHR.

Flow Sheets Provide a Snapshot of Patients

The system instantly provides pharmacists with a “snapshot” of each patient in real time, immediately registers updates as a patient’s condition changes or when he or she receives treatment, and alerts pharmacists when interventions may be needed. The CES comprises three principal components: flow sheets for daily documentation and clinician hand offs, a pharmacy scoring list, and a rounding navigator.

Samaneh T. Wilkinson, M.S., Pharm.D.

Samaneh T. Wilkinson, M.S., Pharm.D.

Flow sheets track pharmacist-managed therapies that require detailed documentation, including antimicrobial stewardship, anticoagulation monitoring, and venous thromboembolism (VTE) prophylaxis assessment.

Similar to a Microsoft Excel spreadsheet, flow sheets display rows labeled with key parameters and patient-specific data, and allow users to add notes. The display ensures that daily documentation is up to date during hand-offs between clinicians.

For example, a drop-down menu allows pharmacists to quickly assess a patient’s VTE risk. If necessary, the pharmacist can quickly relay the information to the patient-care team to initiate VTE prophylaxis. Flow sheets also include hyperlinks to other pertinent information, such as lab values and current anticoagulant therapy.

“The connectivity is very useful,” said Lucy Stun, Pharm.D., a critical care pharmacist at KUMC. “From the VTE flow sheet, I can easily see when the last TPA or aspirin was given, and what time the next dose of heparin can be given safely.”

The scoring list provides an overview of patients monitored by a particular pharmacist, guiding each clinician through his or her caseload based on clinical acuity as calculated by intricate algorithms.

This process, according to Dr. Wilkinson, reduces subjective determinations and the attendant time they require and ensures that pharmacists focus on patients most in need of their expertise. The scoring list, said Dr. Stun, “also creates a more efficient workflow because the pharmacist knows what major changes happened overnight and what they need to take care of first.”

Augmenting the scoring list is a rounding navigator that provides an in-depth review of each patient with a large amount of specific, pertinent clinical information, with more hyperlinks to reports, summaries, and documentation.

A Boon to Efficiency

According to Dr. Stun, the CES dramatically improves efficiency and streamlines workflow.

“I can now glance at my color-coded screen and see what’s completed or what needs to be done based on the color coding—green, yellow or red,” she said.

“At the end of rounds, I always look at the screen to see what’s left to do. That may be checking if a patient has had DVT prophylaxis or if we’ve completed a medication reconciliation. It’s right in front of us.”

Dr. Stun said the system is particularly helpful in keeping the pharmacy team focused during rounds, when there are typically multiple, concurrent distractions.

Allie D. Woods, Pharm.D.

Allie D. Woods, Pharm.D.

“If someone on the care team asks me about a patient’s status, all I have to do is look at the screen to get a complete picture,” she said.

Allie D. Woods, Pharm.D., director of ASHP’s Section of Pharmacy Informatics and Technology, said the scope and results of the project are impressive.

“Hospital pharmacists are often responsible for dozens of patients every day. Setting priorities and deciding which patients to see and when can be very difficult, especially with all of the distractions that come up throughout the day,” she said.

“The scoring list alone helps pharmacists work more efficiently. They are able to triage patients more rapidly, and then adjust the amount of time they spend with patients based on their specific clinical needs. This system results in better patient care.”

Ensuring that Patients Know Pharmacists are on Their Care Team

The CES has also led to increased interaction between pharmacists and patients.

“It carves out more time during the day for face-to-face contact that previously might have been spent looking for information and evaluating a patient’s status,” said Dr. Wilkinson. “Our pharmacists can meet more patients and say ‘Hello, I’m your pharmacist. Do you have any questions about your medications? Can I clear up anything for you before you leave the hospital?’

“We want every patient who leaves our hospital to know that a pharmacist took care of them during their stay.”

Dr. Stun acknowledges that since CES implementation, she spends more time at bedside, particularly when conducting medication reconciliation or preparing patients for discharge.

“We used to just counsel patients who were taking high-risk medications,” she said. “Now we also counsel patients who have heart failure, COPD, pneumonia, or myocardial infarction, or if they have had an organ or bone marrow transplant.”

We want every patient who leaves our hospital to know that a pharmacist took care of them during their stay.

Success has also been quantified: Pharmacy admission history capture and pharmacist-supported discharges have increased by 96.4 percent and 85.6 percent, respectively. Dr. Wilkinson has determined that patients who were discharged after pharmacists educated them about their medications and conducted medication reconciliation are 30 percent less likely to be readmitted to the hospital within 30 days.

Readmission rates for patients with conditions that predispose them to repeat hospital stays (e.g., acute myocardial infarction, chronic heart failure, and COPD) also have fallen. During the last Joint Commission accreditation review, the reviewers noted the exceptional quality of the hospital’s medication reconciliation process. “The CES made that possible,” she said.

One unexpected, but welcome outcome, was a 30 percent jump (from 62 percent to 92 percent) in the number of positive responses to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) question about patient perceptions of how well they were prepared to go home.

“Now, more than 90 percent of our patients feel adequately prepared for discharge. That was eye opening,” said Dr. Stun.

As with any major organizational change, the system planners encountered some resistance. Abundant training and a grace period were critical for overcoming anxiety associated with the change. After the initial roll-out, pharmacists had more than three months to become familiar with the system before its use became mandatory.

Now, the CES is an integral part of the culture for the hospital’s 54+ FTE staff pharmacists, and Dr. Wilkinson’s team is continually soliciting user feedback and looking for ways to improve it.

— By Steve Frandzel

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