Physician-Pharmacist-Patient Communication: The Value and Benefit of Extending an EMR into Community-Based Pharmacies

Transcription

1 Physician-Pharmacist-Patient Communication: The Value and Benefit of Extending an EMR into Community-Based Pharmacies The EMR XTRA Experience at the Group Health Centre in Sault Ste. Marie, Ontario

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3 Agenda Who is Group Health Centre? Why was the EMR XTRA project launched? What is the EMR XTRA project? What were the results of the EMR XTRA project? Lessons Learned What s next? 3

4 The EMR XTRA Experience at the Group Health Centre in Sault Ste. Marie, Ontario WHO IS GROUP HEALTH CENTRE? 4

5 Sault Ste. Marie is located in Ontario, about 400 miles north of Grand Rapids Sault Ste. Marie is progressive, modern sophisticated city of 75,000 Situated at heart of Great Lakes on border with Michigan Naturally gifted -one of the most picturesque in North America Winner of the first Canadian Excellence award for a Quality Community 5

6 Group Health Centre provides primary care to 75% of Sault Ste. Marie residents 6

7 Group Health Centre is a partnership of two organizations Sault Ste. Marie and District Group Health Association (GHA)! Not-for-profit, charitable corporation! Governed by volunteer, community-based Board! Owns physical facility, equipment, furnishings! Employs all non-physician staff including allied health professionals and support services Algoma District Medical Group (ADMG)! Independent corporation of 67 physicians (38 GPs, 16 Specialists, 13 Associates/Visiting Specialists! Wide range of specialties, including anaesthesia, cardiology, dermatology, emergency medicine, internal medicine, neurosurgery, obstetrics & gynaecology, ophthalmology, paediatrics, psychiatry, sports medicine and surgery 7

8 Group Health Centre employs a multidisciplinary, patient-focused team! Unique health organization! Established 1963 by Steelworker s Union! Not-for-profit! Multi-disciplinary! Multi-specialty! Multi-site! 67 Physician providers! 180 other professional health care providers! Over 62,000 patients on the system Electronic Medical Record since

9 Group Health Centre is recognized for its Health Promotion Initiatives (HPI) HPI aims to develop and evaluate evidence-based outcomes management programs in order to improve the quality of health care for GHC patients GUIDELINES BY THEMSELVES DON T WORK Aid the provision of Appropriate Evidence Based Care Primary Care and Patient-centric Population Health Approach Continuous Assessment and Evaluation Outcomes Based 9

10 HPI Example #1: Diabetes GHC providers focus on achieving evidence-based process and clinical outcomes, measured for diabetes patients using the Good Health Outcomes in Diabetes ( GHOD ) score Process Outcomes! BP within 6 mo! HbA1c within 6mo! Lipids annually! Albuminuria annually! Foot exam completed in past year! Eye exam completed in past year! On ACE-I/ARB! On ASA/antiplatelet! On Statins Clinical Outcomes BP within 6 mo and <=130/80 mmhg HbA1c within 6 mo and <=.07 Lipids annually and LDL <

11 HPI Example #1: Diabetes

12 HPI Example #2: Anticoagulation Clinic Total number of patients in program 583 Largest community AC clinic in Canada INR results in therapeutic range (+/- 0.2) are 84% (target compliance >70%), excellent quality control usual care benchmarks are in the 40-60% range Major bleeding events are rare (<1%) 12

13 HPI Example #3: Congestive Heart Failure Number one admission diagnosis in most hospitals in Canada High re-admission rate (>25%) High mortality rate Incidence and Prevalence Increasing Since 2000, there has been a coordinated approach to the care a patient receives after leaving the hospital. All information is tracked and viewed by all involved in the care of that patient. 13

14 HPI Example #3: Congestive Heart Failure Through the program, re-admission rates have dropped by 43% and have been sustained 14

15 Health Promotion Initiatives supported by an enterprise EMR All GHC staff share a single Electronic Medical Record (EMR) system resulting in better communication, coordination of care and patient management Before EMR XTRA, pharmacists not part of the Circle of Care 15

16 The EMR XTRA Experience at the Group Health Centre in Sault Ste. Marie, Ontario WHY WAS THE EMR XTRA PROJECT LAUNCHED? 16

17 Preventable adverse drug events are the fourth-leading cause of death in Ontario 1 Over 10 Ontarians die every day unnecessarily because of adverse drug events Source: Ontario s ehealth Strategy

18 Medications are often not being taken safely or appropriately by Ontarians It is estimated that there will be 394,000 preventable adverse drug events resulting in: 240,000 physician office visits 36,000 hospitalizations 4,000 deaths Source: Ontario s ehealth Strategy

19 There is evidence supporting the value of pharmacists in primary health care Clinical evidence demonstrates pharmacist-provided services result in: Greater patient safety Improved disease and drug therapy management Effective health care spending including savings in a variety of arenas Improved compliance Improved quality of life Source: 2004 Pharmacist and Primary Health Care: Canadian Pharmacists Association 19

20 The EMR XTRA Experience at the Group Health Centre in Sault Ste. Marie, Ontario WHAT IS THE EMR XTRA PROJECT? 20

21 EMR XTRA provides pharmacists access to GHC s enterprise EMR system Launched in May 2007 Partnership with Canada Health Infoway, Group Health Centre, Ontario Pharmacists Association to expand the circle of care to include pharmacists With patient consent, pharmacists can access pertinent patient information in EMR (labs, care plan, program notes, progress notes, DI test results, allergies, etc.) No psych, counselling or social history Development of web portal for patients to access their health information 21

22 Patients enthusiastically signed up for EMR XTRA Patient information sessions were held with 98% of patients attending and providing consent to allow their pharmacy access to their EMR record 22

23 All 23 community pharmacies in Sault Ste. Marie participated 23/23 community pharmacies enrolled in EMR XTRA project 64/70 pharmacists attended a clinical refresher, and IT and privacy training 23

24 Pharmacists in Sault Ste. Marie access patients electronic medical records Pharmacists in Sault Ste. Marie area were the first in Canada to access lab test results, allergies and other vital data from consenting patients electronic medical records Collaboration with Primary Care Physicians (PCP) at Group Health Centre (GHC) and access to the EMR means that pharmacists have accurate and comprehensive medical data about the patients for whom they provide care Enhanced circle of care increases the opportunity to provide better, safer care to these patients and to help reduce adverse medical events 24

25 The project studied implications of extending EMR access to pharmacists What are the benefits and IT adoption implications of including pharmacists in the circle of care? 1. Improve clinical interactions between clinicians and with patients 2. Improve ability to manage patients medications 3. Identify workflow processes and issues of managing EMR XTRA patients 4. Improve adoption of technology over time 5. Improve patient access to appropriate care providers 6. Identify ongoing costs for continued provision of EMR XTRA

26 The EMR XTRA Experience at the Group Health Centre in Sault Ste. Marie, Ontario WHAT WERE THE RESULTS OF THE EMR XTRA PROJECT? 26

27 Patients, primary care providers (PCP) and pharmacists participated in EMR XTRA Patients 318 patients with a diagnosis of Diabetes Mellitus and/or Congestive Heart Failure Over 60% of the patients enrolled over the age of 60 Primary Care Providers 8 Family Physicians and 1 Nurse Practitioner Participating PCPs have average or above average computer proficiency Pharmacists 64 pharmacists from 23 pharmacies enrolled Participating pharmacists mostly recent graduates or experienced clinicians with over 20 years of experience 27

28 Before EMR XTRA, pharmacists did not always have ready access to key information Before EMR XTRA, pharmacists did not have ready access to: Full patient records Critical information to optimizing medication management Key pieces of information that could prevent negative outcomes such as hospitalizations and adverse drug reactions 28

29 Incorporating EMR XTRA into pharmacy practice Access of Lab Values & Monitoring Parameters Narrow Therapeutic Index Drugs Recommend lab tests be ordered based on patient information relayed to pharmacists Eg. Visual disturbances, fatigue and confusion in a patient on digoxin Eg. SCr for elderly patients on flouroquinolones for dosage adjustments Before EMR XTRA Guessing game " Detective work Discussions with patient only Information relayed to physician not always accurate 29

30 Incorporating EMR XTRA into pharmacy practice Progress Notes Clinical Intent Reason for action taken 90% of the time confirmed and/or clarified pharmacist question Patient wants to know why on medication ramipril Blood pressure? Cardiovascular protection? Renal protection? Albuminuria? Before EMR XTRA Guessing game " Detective work Discussions with patient only Information relayed to patient not always accurate Consistency of message 30

31 Incorporating EMR XTRA into pharmacy practice Diagnosis & Allergies & Past History More complete and accurate information Allergies not always consistent between pharmacist record and physician record Prevention of drug allergy interactions Safer treatment for patients Before EMR XTRA Lack of information means greater risk of adverse drug reaction Lack of information means sub-optimal treatment options for patient 31

32 Incorporating EMR XTRA into pharmacy practice GHC Program Notes ADEC (Diabetes notes) CHF (Nurses notes from CHF Program) Nurses Notes These other allied HCP also see patient more often than provider More information about the patient s care Before EMR XTRA Problem with access to medications Other GHC programs note in chart Pharmacist did not see notes or receive Rx to reflect changes Patient presents to pharmacy and not able to receive Rx until provider is contacted 32

33 Incorporating EMR XTRA into pharmacy practice Medication Record Most beneficial piece Pharmacists are medication managers, experts Full access to medication record means better and more efficient provision of care Safer for patient for pharmacy to have full access to updated record Eg. Emergency calls for patient list that does not reflect the verbal changes to the patients regimen Before EMR XTRA Problem with access to medications Pharmacy cannot fill without order Dose adjustments conveyed to patient, but not to pharmacy 33

34 Incorporating EMR XTRA into pharmacy practice Medication Record Most beneficial piece Pharmacists are medication managers, experts Other Improved Patient Outcomes Select and/or recommend cost-effective drug therapy options Screen for diseases Managing chronic therapies for diabetes, asthma, osteoporosis, cholesterol and anticoagulation Providing more effective information, education and counselling An informed patient is a safer patient Identifying barriers to compliance Monitoring outcomes and unintended consequences of drug therapy 34

35 Incorporating EMR XTRA into pharmacy practice Education Consistency of message from all providers to the patient Educated patient is a safer patient Providing patient information that is consistent with the provider is essential to optimizing outcomes Patient knowledge relates to: Proper use of medications Inquiries as to safety of combining OTC or herbal medications that may interact Taking a more active role in chronic disease Better outcomes Less adverse events 35

36 Final Evaluation Results Improve clinical interactions between clinicians and with patients What are the benefits and IT adoption implications of including pharmacists in the circle of care? Improve ability to manage patients medications Identify workflow processes and issues of managing EMR XTRA patients Improve adoption of technology over time Improve patient access to appropriate care providers Identify ongoing costs for continued provision of EMR XTRA

37 Pharmacist activities with PCPs and patients increased in quantity Pharmacist-PCP activities, by type Counts per patient Pharmacist-patient activities, by type Counts per patient! 97%! 57% Baseline Baseline Postimplementation Postimplementation 37

38 and quality PCPs perceptions of quality of interactions with pharmacists Percent of Always or Often responses; Initiated by pharmacist Professionally satisfying Initiated by PCP Good use of my time Conducted through assistant/tech Helpful Mutually respectfu Timely Focused on patient mgmt Baseline Post-implementation Related to administrative issues Clinically related Related to info PCP provide pharmacist Related to info pharmacist provides PCP 38

39 Pharmacists and patients perceived improvement in quality of interactions Pharmacists felt their ability to manage and empower patient self-management of chronic conditions improved Pharmacists perceptions of quality of interactions with patients Percent of Always or Often responses My interactions with patients are: Professionally satisfying Coordinated & complementary with other clinicians Mutually respectful Based on informed decisions Clinically related Patients perceived an improvement in the coordination and consistency of their care Patients perceptions of quality of interactions with pharmacists Percent of Always or Often responses My interactions with pharmacists are: Mutually respectful Related to issues that can be better handled by others Related to managing chronic conditions Baseline Focused on empowering self-mgmt Post-implementation Related to administrative issues Coordinated and consistent with other care Focused on helping me with all my medical conditions Timely Focused on most urgent problem Source: Post-implementation survey results

40 In the first year, pharmacists provided 844 services in 353 patient encounters Top 5 pharmacist services provided Counts Provide initial or F/U review 353 Provide health education 230 Provide drug information 177 Identify DRP 59 Other 5 Resolve DRP with patient 25 40

41 and were better able to manage patients medications Drug-related problems (DRP) identified Counts per patient Medication management recommendations made by pharmacists to PCPs Counts per patient! 94% 1.20! 246% Baseline Baseline Postimplementation Postimplementation

42 However, project activities were driven by small group of early-adopter pharmacists Cumulative total of assessments completed Counts Number of assessments completed, by pharmacy Percent Remaining 18 pharmacies Top 5 pharmacies 42

43 Increasing adoption of electronic tools requires changes Pharmacists compensation drives ongoing cost of EMR XTRA under current reimbursement model Program success will require significant investment in change management Outdated compensation schemes 43

44 Key takeaways from EMR XTRA evaluation Benefits of extending EMR access to the complete circle of care team on improving clinical interactions, medication management and patient safety are clear Patients understand the value pharmacists bring to their care Systematic, concerted change management efforts are required to drive adoption, even for the most technologically advanced clinicians money by itself is not enough! 44

45 Key takeaways from EMR XTRA evaluation Engaging and leveraging early adopters as project champions is an effective strategy to achieve results Despite adoption challenges, primary care providers, pharmacists and patients all recognize the benefits of EMR XTRA Continuing and expanding EMR XTRA will require a sustainable pharmacist reimbursement model, a structured change management strategy, and an investment in technology infrastructure 45

46 Personal Information Access My Health Matters anywhere, anytime

47 My Health Matters anywhere, anytime EMR XTRA Patients have access to their own health information to encourage self management of their chronic illnesses.

48 94% of patients strongly or moderately agreed that using the portal made them feel like valued members of the care team 98% of patients strongly or moderately agree that they are happy with the portal Using the portal makes feel like a valued member of the care team 94 Overall, I am happy with the Portal 98 My contribution to managing my own care has increased 88 Portal is simple and easy to use 89 I feel my healthcare providers refer to information on the portal 96 I am comfortable modifying my information regularly 85 I feel more organized and in control of managing my conditions with the portal 88 I feel more organized and in control of managing my conditions with the portal 88

49 What have we learned?

50 What have we learned? You can t use a 2 legged stool 50

51 The process provides the needed support. 51

52 Stakeholder Engagement & Commitment: The Commitment Curve Internalization Degree of Support for the Change Commitment Phase Acceptance Phase Preparation Phase Contact Adapted from Daryl R Conner (1992) Awareness of Change Unaware Confusion Negative Perception Positive Perception Understand the Change Time Decision to NOT support Institutionalization Adopt /Use Install / Implement Support Withdrawn after Implementation Support Withdrawn after Extensive Implementation Effort Commitment Threshold Disposition Threshold Compliance and Commitment 52

53 Clinician Engagement

54 Outline a common purpose between the project and clinicians

55 Identify and engage champions and early adopters

56 Get to know the culture

57 Involve clinicians from the beginning 57

58 Choose messages and messengers carefully

59 Communicate often and keep the messages clear

60 Be candid

61 Value the Clinician s time

62 Make things simple and easy for clinicians Integrate with clinicians workflows Consider how pharmacists use computers in their pharmacies Understand desired future state processes and then decide on technology required to enable 62

63 Remove obstacles to participation Work with pharmacy head offices to deal with business, technology barriers Provide incentives to pharmacists to participate Provide clinical and technical training and support upfront and throughout the project 63

64 Provide back up and front line support

65 Key Messages Silos that exist with in health care sector act as barriers to better health outcomes and work to increase costs while decreasing services 1 Integration of technology and interaction between health care providers improve patient safety Expected results of Implementation of medication management systems will help prevent each year 217,000 adverse drug events, 132,000 physician office visits, 20,000 hospitalizations and 2,200 deaths due to adverse events 2 Source 1: 2004 Pharmacist and Primary Health Care Canadian Pharmacists Association Source 2: Ontario s ehealth Strategy

66 The EMR XTRA Experience at the Group Health Centre in Sault Ste. Marie, Ontario WHAT S NEXT? 66

67 Start by doing what s necessary, then do what s possible, and suddenly you are doing the impossible. Saint Francis of Assisi

68 Questions?

69 Please contact us if you have more questions Lucy Fronzi Group Health Centre Senior Manager Marisa DeRubeis BSc Phm, PhmD, RPh, CRE Group Health Centre Pharmacy