R Richman, L George, A O’Flynn, A Taylor, G Tsaprounis, N Segaert & R Burke
Abstract
Integrated electronic medication management (eMM) has the potential to substantially reduce error rates as well as improve the quality and efficacy of medication prescribing, use and administration. An efficient automated medication management system can improve workflow through the use of pre built, best practice order sets and sentences and comprehensive views of administration activities. In addition, such systems can avoid delays in administering medications eg time is not wasted on searching for medication charts or deciphering illegible handwritten orders.
The design and implementation of eMM and uptake by users is a complex undertaking with a significant impact on a range of people. Despite the known advantages of eMM it has been reported that many implementations have failed or met with high levels of resistance. Reasons for failure include lack of consultation with users and the extensive workflow changes that are required.
A pilot project of an automated medication management process, that utilises a range of Cerner solutions for prescribing (PowerOrders), pharmacy review/verification (PharmNet), administration (eMAR) and limited decision support, commenced on 1st November 2007 in a 24 bed Aged Care ward at Concord Repatriation & General Hospital. It was recognised early in the project that for eMM to succeed it would need to be accepted by clinicians, and in particular nurses. It was important that clinicians were involved in the decision making processes and that their concerns were acknowledged and addressed early on.
Key Factors for Success
Two years prior to implementation clinical champions were identified from all levels of administrative, educational and clinical (hospital and pilot ward) staff. A number of committees were established, including a multidisciplinary project steering committee and specific reference groups (nursing, medical and pharmacy). The nursing reference group was the most active. Policies were devised and many processes mapped out to inform system design. Some issues were explored further using mock medication rounds eg, how double checked drugs or narcotics which require a witness, would impact workflow. A group of nurses, doctors and pharmacists served as super users; testing the system, providing support to staff at implementation and facilitating communication between clinicians and project staff.
A mix of devices (wireless computers on wheels (COWs), tablets and fixed PCs) were evaluated well in advance of implementation. Ward staff were active partners in decision making for the number and type of devices procured. For 12 months leading up to implementation training was available for novice computer users. This ensured that all users were competent in basic computer skills prior to eMM training.
For one week prior and two weeks after implementation a daily meeting was convened with the system architect, eMM analyst, project manager and users to discuss business processes, identified issues and resolutions. Resolution of system issues was given priority. Onsite 24/7 clinical and technical support was provided for two weeks after implementation.
Results
Nursing staff adapted to the new technology in a short timeframe. Immediate resolution or feedback on issues assisted in rapid acceptance of the technology and increased the morale in the ward. Studies indicate that after the initial implementation overall nursing time for medication workflow decreases and indeed the nurses report this to be the case. Preliminary results from a user satisfaction questionnaire (n = 6) indicate that nurses feel confident using eMM and overall prefer it to a paper based system.
Designing and implementing eMM was difficult and presented many challenges. Through extensive consultation, opportunities to change and promote adoption of standards in work practices and policies, and comprehensive training and support, a sense of ownership by nurses has evolved. Accepting the project as an organisation-wide endeavour, early engagement of clinicians, collaborative decision making and early realisation of benefits underpins the success of the implementation.