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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
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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

April 9, 2010

Preventing DVT Helps Patients and Bottom Lines

PHARMACISTS LYNDA THOMAS, Pharm.D., CACP, and Michael Palladino, Pharm.D., are part of a new wave of clinical specialists who oversee patients’ anticoagulation therapy post surgery.

Michael Palladino, Pharm.D., inpatient anticoagulation coordinator of the Jefferson Center for Vascular Diseases, speaks with a patient about the importance of DVT prevention.

They help ensure that orthopedic surgery patients don’t develop deep vein thrombosis (DVT), a potentially dangerous and often preventable condition common among orthopedic surgery patients. The best defense against DVT, anticoagulant therapy also comes with inherent risks. Leaders at Thomas Jefferson University (TJU) Hospital in Philadelphia see pharmacists as best equipped to keep patients safe post surgery.

“Warfarin is one of the top 10 drugs for medical errors,” noted Thomson, inpatient anticoagulation coordinator of the Jefferson

Center for Vascular Diseases, Thomas Jefferson University (TJU) Hospital in Philadelphia. TJU Hospital performs some 3,000 joint surgeries each year.

A New Wave

The pharmacists at TJU help to ensure that a new wave of clinical specialists who oversee patients’ anticoagulation therapy post surgery and help to ensure patients discharged on warfarin and other blood thinners transition safely home. Preventing adverse events and readmissions are key parts of their jobs.

“It’s an excellent chance for pharmacists to demonstrate the value and the return on investment from implementing these clinical services,” said Cynthia Reilly, B.S. Pharm., director of ASHP’s Practice Development Division.

Pharmacists Key to Prevention

Palladino, who is coordinator of the center’s orthopedic anticoagulation program, and Thomson focus on patient and family education around high-risk medications such  as warfarin and other bloodthinners. Their efforts helped TJU meet recent Joint Commission requirements around patient education for anticoagulant therapy.

In working with patients directly, “we’re first asking questions of the patient to get important information,” Palladino said. He added that pharmacists are best positioned to spot possible risks for each patient and to determine the drug and dose to prescribe to avoid bleeding complications or other risks.

TJU Hospital has instituted a computerized physician-order entry system, with automatic order sets prompting prescribers to assess each surgical patient for bleeding complications before offering appropriate prophylaxis anticoagulant options based on the patient’s risk.

“It’s an educational tool, as well as an order set,” Palladino said.

The pharmacists then work with patients to help them understand their medicines, the importance of follow-up monitoring, adherence, and drug-food interactions, and the potential for adverse drug reactions and drug interactions. Time is also spent calling health plans to advocate for patient needs, such as coverage for certain drugs or equipment.

Pharmacists also oversee proper care transitions for patients, scheduling labs and arranging for home health services. For the latter, pharmacists call each patient twice a week for six weeks post discharge to answer questions and ensure that each patient’s recovery goes smoothly.

“We’re transitioning patients back to the primary care physician,” said Thomson, adding that surgeons appreciate the help.

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