Post on 21-Mar-2017
www.pharm.monash.edu.au
Meredith Wiseman
Lead Pharmacist, Clinical Informatics
Pharmacy Department, Alfred Health
Professor Michael Dooley
Director of Pharmacy, Alfred Health
Professor of Clinical Pharmacy
Faculty of Pharmacy and Pharmaceutical Science, Monash University
Integrating Advanced Practice Roles into Future Plans
for eMM
Integrating Advanced Practice Roles into Future Plans
for eMM
Advanced practice
eMM
Advanced practice
Current Future
Integrating Advanced Practice Roles into Future Plans
for eMM
Advanced practice
eMM
Advanced practice
Current Future
Cerner Medication
Management solutions
– March 2018
Integrating Advanced Practice Roles into Future Plans
for eMM
Advanced practice
eMM
Advanced practice
Current Future
Cerner Medication
Management solutions
– March 2018
eMM project timeline
eTQC (eMM) Project team
Integrating Advanced Practice Roles into Future Plans
for eMM
Advanced practice
Current Future
2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006
Disease Management Clinic
Unit based clinical
pharmacy services
Changing clinical practice
2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006
Disease Management Clinic
Pre-admission clinic
Unit based clinical
pharmacy services
Changing clinical practice
2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006
Disease Management Clinic
Pre-admission clinic
Unit based clinical
pharmacy services
Weekend clinical
pharmacy services
Changing clinical practice
2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006
Anticoagulation management
Disease Management Clinic
Pre-admission clinic
Unit based clinical
pharmacy services
Weekend clinical
pharmacy services
Changing clinical practice
2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006
Anticoagulation management
Smoking cessation
Disease Management Clinic
Pre-admission clinic
Unit based clinical
pharmacy services
Weekend clinical
pharmacy services
Changing clinical practice
2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006
Anticoagulation management
TDM charting
Smoking cessation
Disease Management Clinic
Pre-admission clinic
Unit based clinical
pharmacy services
Weekend clinical
pharmacy services
Changing clinical practice
Defined scope of practice
Multi-disciplinary support
Formal competency assessment
Formal evaluation
Agreed clinical need
Multi-disciplinary education
Unit based – Team based
Changing clinical practice
Defined scope of practice
Multi-disciplinary support
Formal competency assessment
Formal evaluation
Agreed clinical need
Multi-disciplinary education
Unit based – Team based
Significant problems with the
dosing of aminoglycosides
and vancomycin
Clinical pharmacists would
make recommendations
regarding levels and dosing
Why couldn’t pharmacists
order the levels and dose
directly on the medication
chart?
Therapeutic drug monitoring
Therapeutic drug monitoring
2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006
Partnered charting
Anticoagulation management
TDM charting
Smoking cessation
Disease Management Clinic
Pre-admission clinic
Unit based clinical
pharmacy services
Weekend clinical
pharmacy services
Changing clinical practice
2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006
Partnered charting
Opioid descalation
Anticoagulation management
TDM charting
Smoking cessation
Disease Management Clinic
Pre-admission clinic
Unit based clinical
pharmacy services
Weekend clinical
pharmacy services
Changing clinical practice
Defined scope of practice
Multi-disciplinary support
Formal competency assessment
Formal evaluation
Agreed clinical need
Multi-disciplinary education
Unit based – Team based
Significant problems with pain
management for patients
commenced on opioids
during admission and
continuing when not needed
Opioid De-escalation
Demographic & Baseline Characteristics of the patients
Characteristic Control group (N=98) ODE# group (N=98) P Value
Age (year) – mean (SD) 54.9 (19.3) 53.5 (19.4) 0.61
Male sex – no. (%) 50 (51) 54 (55) 0.67
Hospital LOS - days 8.5 [5,14] 8.0 [5,14] 0.93
Elective admission – no. (%) 54 (55.1) 53 (54.1) 1.00
Pre-existing opioid use – no. (%) 23 (23.5) 30 (30.6) 0.33
Average MOE 24 hours after APS discharge (mg) –
mean (SD)
62.6 (62.6) 68.9 (71.3) 0.11
Resting pain scores* - median [IQR] 4 [3,6] 5 [3,7] 0.12
Adjunct analgesia* – no. (%)
Simple 96 (97.9) 98 (100.0) 0.50
Antineuropathics 52 (53.1) 56 (57.1) 0.67
Other 58 (59.1) 49 (50.0) 0.25
*24 hours after APS discharge; #Pharmacist-led opioid de-
escalation
Opioid De-escalation
% incidence reduction* P value
Nausea or vomiting 14 0.0008
Constipation 43 <0.0001
Sedation 9 0.02
2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006
Partnered charting
Opioid descalation
Anticoagulation management
Smoking cessation clinic
TDM charting
Smoking cessation
Cardiac clinic
Disease Management Clinic
Pre-admission clinic
Lung Transplant
Unit based clinical
pharmacy services
Weekend clinical
pharmacy services
Haematology clinic
Changing clinical practice
2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006
Partnered charting
Opioid descalation
Anticoagulation management
Smoking cessation clinic
TDM charting
Smoking cessation
Discharge summary
Cardiac clinic
Disease Management Clinic
Pre-admission clinic
Lung Transplant
Unit based clinical
pharmacy services
Weekend clinical
pharmacy services
Haematology clinic
Changing clinical practice
2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006
Partnered charting
Opioid descalation
Anticoagulation management
Smoking cessation clinic
Stroke call-out
TDM charting
Partnered Pharmacist Medication
Charting Expansion project
Smoking cessation
Discharge summary
IBD clinic
Cardiac clinic
Disease Management Clinic
Pre-admission clinic
Lung Transplant
Unit based clinical
pharmacy services
Weekend clinical
pharmacy services
Haematology clinic
Changing clinical practice Sepsis call-out
Cellulitis management
Integrating Advanced Practice Roles into Future Plans
for eMM
Advanced practice
eMM
Advanced practice
Current Future
Integrating Advanced Practice Roles into Future Plans
for eMM
Advanced practice
eMM
Advanced practice
Current Future
Chief Pharmacy Information Officer (CPIO)
PDF of CHIO PD
CPIO
Structure of eTQC
reporting lines
Integrating Advanced Practice Roles into Future Plans
for eMM
Advanced practice
eMM
Advanced practice
Current Future
Chief Pharmacy Information Officer (CPIO)
Clinical Informatics Services
Integrating Advanced Practice Roles into Future Plans
for eMM
Advanced practice
eMM
Advanced practice
Current Future
Chief Pharmacy Information Officer (CPIO)
Clinical Informatics Services
Medication Charting
Director Pharmacy
Dep Director Pharmacy
Medic
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eT
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Informatics
Defined scope of practice
Multi-disciplinary support
Formal competency assessment
Formal evaluation
Agreed clinical need
Multi-disciplinary education
Unit based – Team based
Significant problems with
medications at admission ie
wrong, delayed, unknown
Pharmacist involvement
traditionally retrospective
Why couldn’t medications get
‘sorted” as soon as the
patient presents
Partnered charting
• Pharmacist charting credentialing
program was developed with input
from medical and nursing
• Formal guideline developed for
charting model
• Implemented in two weeks
Partnered charting
36
Partnered charting
37
Partnered charting
© 2015 Confidential Draft
Discussion Document
38
Partnered charting
© 2015 Confidential Draft
Discussion Document
39
Partnered charting
Partnered charting
Clinical significance of errors
Pharmacist charting Medical Charting
No. of errors No. of errors P-value
Total 19 1573 <0.0001
Insignificant 11 (0.3%) 904 (20%) <0.0001
Low risk 1 (0.02%) 58 (1%) <0.0001
Moderate risk 6 (0.15%) 292 (7%) <0.0001
High risk 1 (0.02%) 285 (6%) <0.0001
Extreme risk - 34 (0.8%) <0.0001
Partnered charting
Integrating Advanced Practice Roles into Future Plans
for eMM
Advanced practice
eMM
Advanced practice
Current Future
Chief Pharmacy Information Officer (CPIO)
Clinical Informatics Services
24hour Pharmacy Services
Medication Charting
2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006
Partnered charting
Opioid descalation
Anticoagulation management
Smoking cessation clinic
Stroke call-out
TDM charting
Smoking cessation
Discharge summary
IBD clinic
Cardiac clinic
Disease Management Clinic
Pre-admission clinic
Lung Transplant
Unit based clinical
pharmacy services
Weekend clinical
pharmacy services
Haematology clinic
Emergency Department Sepsis call-out
Cellulitis management
Trauma call-out
Current: 7am – 9pm service and on call
Integrating Advanced Practice Roles into Future Plans
for eMM
Advance Pharmacy practice roles requirements in eMM
• Authorisation for charting by pharmacists
• Ability to customise clinical review and documentation to
align with prescribers
• Pharmacy champions to engage, promote and explain our
advance practice roles at all levels.
2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006
Partnered charting
Opioid descalation
Anticoagulation management
Smoking cessation clinic
Stroke call-out
TDM charting
Smoking cessation
Discharge summary
IBD clinic
Cardiac clinic
Disease Management Clinic
Pre-admission clinic
Lung Transplant
Unit based clinical
pharmacy services
Weekend clinical
pharmacy services
Haematology clinic
Emergency Department Sepsis call-out
Cellulitis management
Trauma call-out
Current: 7am – 9pm service and on call
Future: 24hours service
Medication management systems: Thinking about what to do
Electronic Medication management systems:
Acknowledgements – Site visits
Princess Alexandra Hospital, Qld
Fiona Stanley Hospital, WA
St. Stephens, Hervey Bay, Qld
Austin Hospital, Vic
Peninsula Health, Vic
Cerner site visits, USA
Canada, Toronto
Thank you!