Electronic Medical Record (EMR) Safety Results of CAH Testing. Tom Johns, PharmD Shands at the University of Florida

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1 Electronic Medical Record (EMR) Safety Results of CAH Testing Tom Johns, PharmD Shands at the University of Florida

2 Vendors Evaluated CPSI Healthland Cerner

3 Test Patients Test Patient A Age: 76 y/o Sex: Male Weight: 75 kg Height: 72 inches Allergies: blank SCr: 2.0 mg/dl (estimated CrCl 34 ml/min) Test Patient B Age: 13 y/o Sex: Female Weight: 0 kg Height: 60 inches Allergies: penicillin SCr: 0.8 mg/dl

4 Add the following home medications under Nurse login (test required medication fields; test ability to enter supplements; test ability to select drug name from pre-defined list) (Healthland) Medication reconciliation pathways are intuitive and complete. Discrete fields are available for medication name, dose, route, and frequency. Medication name is selected from a drop down menu. Fish oil as a dietary supplement was also present in the drop down menu of medication names. All fields are required for order entry. Frequency can be customized to specific days of the week (e.g. daily on Monday, Wednesday, and Friday). (CPSI) The system does not require all medication fields to be completed. Medication name can be selected from a drop down menu. PRN indication is not required. Herbal supplements are included in the medication drop down list for selection and entry into the system. (Cerner) Distinct fields were available to capture the medication name, dose, route, and frequency. Medication names are selected from a drop down menu. Medication name defaulting is not present. The system allowed fields to remain blank, as complete medication information may not be available during the admission process.

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8 Place inpatient verbal order for bisacodyl 10mg rectally qhs PRN constipation under Nurse login (test ability to place orders with allergy field blank; test conditions for Nurse acceptance of verbal orders) (Healthland) Nursing is able to enter verbal medication orders into the system under any condition. Medication orders cannot be entered until the allergy field is complete. (CPSI) Medication orders cannot be entered if the allergy field is left blank. Nurses can enter verbal orders under all conditions. (Cerner) Medications were allowed to be placed without completion of the allergy field. However, the user is presented with a warning letting them know that allergies have not been documented. Unfortunately, the user may override the alert and enter the order without documenting the patient allergies. We encourage the hospital to investigate this programming point to determine if it is possible to restrict ordering on inpatient floors, but allow for a more liberal practice in the ED area. PRN indication field is not required.

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10 Add new allergy for morphine under Nurse login (test allergy requirements to capture type and symptoms). Add allergy for asprin (test if system allows misspelled allergies) (Healthland) Misspelled allergies are not accepted by the EMR. Allergy names are selected from a pre-defined list. Allergy type and symptom is not required. (CPSI) Misspelled allergies were not allowed. The system does not contain a field to distinguish between adverse drug reactions and true allergies. A symptom field is present, but not required to be completed. There was a drop down menu that listed common symptoms for selection. It appears the severity field is required to be completed. Alert trigger for previously entered medications, after a new allergen was entered into the EMR. (Cerner) The system contains allergy fields for allergen, type, and symptoms. The allergen is selected from a codified list, but the user can input a misspelled allergy without a barrier, which could be viewed as a safety concern if the allergy is not detected by the clinical decision support software. The allergy symptoms may also be documented from codified entries, but this field is not required to be completed by the user.

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13 Order Zosyn 4.5g IV q6hr (test renal function dose adjustment alerts should be reduced to at least g IV q6hr for CrCl ml/min) (Cerner) Under a provider login, we attempted to input the above Zosyn order. Unfortunately, the system did not provide an alert for the dose deviation based on poor renal function. The hospital staff describe that they receive these types of alerts, but were unsure why the system did not fire for this example. We also added an order for vancomycin 1g IV q12h, with similar results.

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15 Order Morphine 2mg IV q4hr PRN pain (test PRN indication requirement; test morphine allergy) (Healthland) Morphine allergy alert was generated with the test. Individually entered medication allergy names appear over the allergy icon. Up to 5 allergens are listed. Recommend the organization conduct a test by listing 6 medication names to determine the length of the display. If multiple alert types (e.g. allergy, drug-drug duplications) fire, it appears allergy alerts are prioritized to display first. There is no functionality to force a user to enter a justification to override an alert. No alert trigger for allergies entered after medications have already been ordered. PRN indications are not required to be entered into the system. The specific PRN indication must be typed into the special instruction field. As this appears as text information, no alerting will occur for any duplicate PRN medications. (CPSI) PRN indications are not required. CPSI flagged this entry due to presence of morphine allergy. Provider is required to select justification for override.

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18 Order HYDROmorphone 4mg IV q4hr PRN pain (test high dose; test default doses; test allergy cross-reactivity; test therapeutic duplication with morphine; test use of TALLman lettering) (Heathland) TALLman lettering functionality is present in the system, but not consistently used. The 4mg dose was allowed during order entry, with no warning to the user of the excessive dose. The dose field appears to be a default field that may be defined by a system administrator. Recommend changing the hydromorphone default dose to 0.5mg for the intravenous route. An allergy alert fired against the patient morphine allergy for the hydromorphone entry. (CPSI) TALLman lettering is not used within CPSI at this CAH. However, from another CAH, it appears this functionality does exist. Medication names are listed as all capital letters, except in the context of order sets. A default dose of 1mg was present. In addition, an entry was available to select a 4mg dose. This entry should be removed. Therapeutic duplication alerts do not fire.

19 (Cerner) TALLman lettering is available within the system and used appropriately. We had a lengthy discussion with the hospital staff about the dose regimen displays for hydromorphone. The present configurations allow the provider to select predefined dosages of up to 2mg IV q4h PRN. We re concerned that this display may inadvertently guide the provider to higher doses than appropriate. We encourage removal of the predefined dosage of 2mg IV q4h PRN, and only display the 0.5 mg and 1 mg entries. We also noted a display entry for 4mg and 8mg hydromorphone when attempting to enter a custom dose The provider was presented with a dosing alert when we attempted to order 4mg IV q4h. This was encouraging as the system does contain this functionality. We encourage the customization of default PRN indication to be more appropriate for the given medication. For example, with hydromorphone the default PRN indication should be severe pain. PRN indications were listed in the system alphabetically, which presents a problem for the pain indications displayed as mild pain, moderate pain and severe pain. Ideally, these should be displayed as Pain Mild, Pain Moderate, and Pain Severe, so they appear together on the system list.

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23 Order Fentanyl transdermal patch 50mcg/hr topically q72hr (test ability for EMR to provide ordering instructions to providers) (Healthland) Contains a special instruction field that can be pre-populated from the master drug file. This will enable standardized information to be displayed for order entry and also appearance on the emar. (CPSI) Contains an instruction field that can be prepopulated from the master drug file. This will enable standardized information to be displayed for order entry and also appearance on the emar.

24 Order Metformin 500mg po BID (test renal function dose adjustment alerts new orders should not be initiated at this CrCl (34mL/min), may be continued if home medication but dose adjusted by 50%; test default MET medication names) (Healthland) The MET test passed, as the system does not default medication name into the required field after typing the first letters of the name. User is directed to a drop down list to select the correct medication. (CPSI) When MET is typed into medication name field, a drop down list of names is presented to the user. The system does not default a drug name into the name field. (Cerner) The system allowed for this entry without presenting a dose range alert. The system does not default drug names into the field based on abbreviations or entering the first few letters of the drug name.

25 Ciprodex Otic 4 drops each EYE BID (test route restrictions, should only be allowed in ears) (Healthland) Unable to order ear drops to be placed in the eye. Routes are customized to each medication as a safety feature. This significantly reduces the risk of selecting an inappropriate route for a given medication. (CPSI) Auralgan was selected to test this function of the system. Unfortunately, CPSI does not restrict the route for any medication. Any route may be selected from a drop down for any medication. (Cerner) The system does not customize routes by the medication type. We were easily successful in ordering the ear medication, Auralgan, with an eye route.

26 Attempt to open another patient while first patient profile remains open (test number of patients allowed open at one time; test for presence of ID-verify alert or an ID-reentry function ) (Healthland) Only one patient record is able to be displayed at any one time. If the user opens the first patient, then opens a second patient, the first patient profile is automatically closed. (CPSI) The system is configured to only display one patient at a time. (Cerner) Medical staff are presently allowed to open 3 patients at the same time. This has recently been reduced by the health system. Having 3 patients open at one time could pose a serious risk of inadvertently placing orders or other documentation on the wrong patient. Consider reducing the number to 2 if possible. There is currently no secondary functionality to prevent this error from occurring.

27 Peds: Place inpatient order for ceftriaxone 1000mg IV q12hr under MD login (50mg/kg/day) (test ability to place medication orders without patient weight; test weight based dosing in pediatrics (mg/kg or mg/kg/day); test allergy cross-reactivity) (CPSI) The system appears to not contain weight-based dosing functionality. (Cerner) Pediatric weight based dosing is available in the system. However, weight based dosing is intermixed with adult dosing, which could result in a selection error. Investigate the ability to restrict the display of adult entries while entering orders for pediatric patients. Noted the acceptance of the order for ceftriaxone 2,000.25mg, which was automatically calculated by the system. The system should be able to round doses appropriately for both pediatric and adult patient types.

28 Peds: Add patient weight of kg (test ability to limit weight input to metric system; test decimal point limitation) (Healthland) Both metric and conventional units are accepted by the EMR. The display fields could be confusing to the end-user as lbs appears within the numerical field and kg is outside the field. Weight values to the right of the decimal point are accepted (i.e. 75.5). Recommend working with vendor to list only metric weight in all applicable fields (e.g. order entry, emar, etc). (CPSI) Pounds and kilograms are both displayed by the application. In addition, the system allows weights to be recorded in hundredths, which is clinical insignificant and could lead to error. (Cerner) The system allowed for capturing and display of weights in metric units. The system also allowed inputting weights with units to the right of the decimal point. The hospital should investigate this programming point to determine if a setting could allow for truncating this value.

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31 CPSI (Additional Comments) 1. Nursing medication order entry screen is not contemporary, intuitive, and has potential to lead to error. We re concerned about complexity of using the cursor to navigate the alphabetical lookup screen in an effort to locate the correct medication. In addition, the black lettering on red background is difficult to visualize and should be considered for modification by the vendor. 2. We re concerned about major differences in the ordering screen layout between all user types (e.g. Nursing, Pharmacy, and Physicians). Most contemporary EMR systems create uniformity in screen design to aid problem solving between disciplines. This should be focus for enhancement by CPSI. Once a medication is selected, the fields for entering dose, route and frequency are very cumbersome for the Nurse user type and could easily lead to error. 3. We had the opportunity to listen to an ARNP describe a serious situation encountered while ordering STAT medications. If a medication is ordered STAT by the provider, a duplicate entry is created and must be discontinued if the original intent was a one time order. This workflow bug must be corrected immediately by CPSI to prevent inadvertent administration of unnecessary medications. 4. For injectable medications, the drop down arrow selections in dose field contained both mg strength and ml volume as options for selection. Ordering medications by volume is a known safety hazard and this option should be removed. Medications should only be allowed to be ordered by the intended dose in the appropriate units (e.g. microgram, milligram, gram).

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