EHR Optimization in a Behavioral Health Hospital: Patient Safety Win

Impact Advisors’ Clinical Performance Solutions Service team was hired by a large behavioral health hospital to assist in the optimization and adoption of their EHR solution. They significantly lacked adoption of clinical documentation forms as well as stalled implementation of significant EHR functionality.

After meeting with executive sponsors, Impact Advisors’ leadership staffed a team of clinical EHR specialists to assess the organization’s current state, with a requested focus on Clinical Documentation and Medication Management. This effort began with Impact Advisors’ proven methodology: the analysis of people, process and technology. Interviews were conducted with operational leads and clinicians in various disciplines who utilized the EHR as well as the Technology Support staff that were leading the efforts. Key personnel were “shadowed” to observe their operational workflow and allow full understanding of how the EHR accommodated delivery of patient care for various clinical roles. As a result, Impact Advisors delivered a report that included a detailed description of the organization, and provided observations and recommendations for all areas managed by the interviewees and/or departments observed.

This initial phase of work also yielded a roadmap of itemized initiatives that could be undertaken as sub- projects to increase EHR functionality and adoption. The recurring theme throughout the identified initiatives was to align the Behavioral Health Hospital EHR with industry best practice to ensure that quality would be maintained or enhanced with any modifications.

The sub project identified as the major focus for the IA team was the implementation of Medication Management. It was discovered early on that that the hospital EHR implementation plan failed to include the industry best practice of Closed Loop Medication Management, proving to be a significant challenge. To be considered a “closed loop,” four failure points needed to be addressed in the solution: Prescription, Transcription, Dispensing and Barcoding.

One failure point resolution with the planned EHR solution came in the Dispensing process. An Automatic Dispensing Cabinet (ADC) was being deployed. The application would be interfaced to the Pharmacy System at the point of orders verification. Stocking the ADCs with the use of barcode scanning would reduce errors in this process. With interfaces between ordering and verification applications and the ADC, errors would be reduced at the point of administration, too, as nurses are guided to the correct medication drawer when selecting a specific patient order.

The Prescription failure point resolution was partially within scope. At this time, the Behavioral Health hospital leadership did not support Computerized Provider Order Entry (CPOE). Rather, the Prescriber would continue to write paper orders that would be scanned to the pharmacy. A licensed pharmacist would then enter the order into the EHR and be able to utilize the Clinical Decision Support functionality. To clarify any medication warning or alert, the pharmacist would need to interact with the ordering provider. Therefore, prescribing errors would be avoided at the point a licensed pharmacist would act on Clinical Decision Support data and never be fully entered into EHR unless discussed with the ordering provider.

The other two failure points were out of scope: Transcription and Barcoding. Error rates with paper orders would continue. CPOE would not be implemented for ordering providers until the Pharmacy Informatics team felt the medication ordering process and formulary was safe and efficient for provider use. Barcoding was not included as a scanning solution had not been configured or tested with their EHR and no hardware had been determined. Failure to scan both the patient’s armband and medication at administration prevents ensuring the Five Rights of Medication Administrations (5 Rights) and results in the greatest risk in medication administration errors.

Reversing three key decisions was unlikely, but Impact Advisors concluded that excluding barcode scanning would be too great a deviation from clinical best practice. To get the executive leadership on board, our team suggested a phased approach by implementing the scanning solution at a smaller 180-bed facility, allowing the team to address any issues on a lesser patient population.

• The Impact Advisors team facilitated the effort to identify a bar code scanning application that could be developed, tested and piloted during the first phase. Once the solution was in place, our analyst worked with the Pharmacy Informatics team to determine the scan rate for the formulary inventory. It started at approximately 70% and by go live, with the failed scan rate hovering around 5%.
• Impact Advisors recommended operational reports on scanning. The first was for failed scans of medication labels. This report is run and managed by Pharmacy Management. Pharmacy staff investigate to correct any labeling issue so that future dose scans do not fail. Another report to track scanning of medications and of patients bar codes was created to assist nursing management with compliance to the new policy thereby increasing adherence to the standard 5 Rights which is regarded as the standard for safe medication practice.
• The operational leads expected a longer duration for each unit’s medication pass that required scanning. They needed to plan for additional staffing to avoid running beyond the two hour policy window. The Impact Advisors team worked with the nurse medication administration team to conduct a time trial mimicking a realistic medication pass. The findings were analyzed and process changes were made. A second time trial followed. The result was that all units administered all medications within the policy window within the first 48 hours of the implementation.By working with the client project resources, vendors and operational leads to complete cutover tasks ahead of schedule and to provide 7/24 hours support post implementation, a successful Phase 1 implementation of the Medication Management solution was experienced on November 1, 2016.

The following EHR functionality was implemented:

• Implementation of EHR medication order entry
• eMAR, medication verification within the EHR
• Barcode scanning of medications
• Barcode scanning of the patient
• Automated Dispensing Cabinets
• Interfaces between Ordering, Verification and Dispensing systems
• New operational reports to assist in various medication management processes

The Providers and staff at the first location have enthusiastically adopted the functionality. Phase 2 Go Live is planned for the secondary facility in Spring 2017 with the client project team utilizing the proven project/change management and operational readiness strategies. When the EHR Optimization project is complete, the organization is expecting a big win for all patients as Patient Safety will be improved throughout the organization.