eMARs in LTC

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eMARs in LTC Carla Saxton McSpadden, RPh,
CGP American Society of Consultant Pharmacists
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eMAR Implementation

• According to the Information Technology in Long
  Term Care State of the Industry Multi-Facility
  Research Report released in April 2007,
  conducted by Maestro Strategies on behalf of AHCA
  and NCAL.approximately 25 of those surveyed
  have either installed or own eMAR technology
• According to Health Information Technology Are
  LTC Providers Ready? released by the California
  Healthcare Foundation60 of those surveyed in
  SNFs stated that implementation of medication
  administration applications are a priority
• eMARs can be pharmacy-driven or facility-driven,
  meaning
• Medication info can be entered by facility and
  pharmacy system remains independent OR
• Medication info can be transferred from pharmacy
  dispensing system and system is independent of
  any facility software systems
• OR, there could be a hybrid of the two But,
  fully interoperable eMAR systems are non-existent

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Potential Benefits of eMARs

• Medication orders could be automatically
  populated into the MAR - either from the pharmacy
  or CPOE, which can potentially reduce
  transcription errors and increase efficiency
• Access to drug information, if there is a
  clinical database component
• Screening for drug-drug, drug-allergy, drug-food
  interactions contraindications
• Alerts for sound alike-look alike medications
• Verification of tablet appearance (size, shape,
  color, etc.)
• Medication monographs may be printed for patient
  use and instruction upon discharge
• Alerts when doses are due to be administered
• Documentation for future reference by staff,
  consultants, prescribers, and surveyorseasy
  access to the info, sometimes even if off-site
• Reduction in paper
• Negates the need for monthly recaps between
  facility info and pharmacy info
• Medication inventory management

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SOM and Technology

• New F-Tag 425 in SOM describes guidelines for
  medication administration
• Examples of procedures addressing administration
  of medications include
• Assuring that the correct medication is
  administered in the correct dose, in accordance
  with manufacturers specifications and with
  standards of practice, to the correct person via
  the correct route in the correct dosage form and
  at the correct time
• Residents picture or bar-code are matched to
  ensure correct patient
• Reporting medication administration errors,
  including how and to whom to report
• Reports displaying variations from programmed
  parameters (e.g., meds administered before or
  after time due)
• Authorizing personnel, consistent with state
  requirements, to administer the medications,
  including medications needing intravenous
  administration
• Security to ensure only those who are authorized
  can access medications Also, eMAR system can
  document which staff are administering which doses

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New F-Tag 425 in SOM

• Defining the schedules for administering
  medications to
• Maximize the effectiveness (optimal therapeutic
  effect) of the medication (for example,
  antibiotics, antihypertensives, insulins, pain
  medications)
• Avoid potential significant medication
  interactions such as medication-food or
  medication-medication interactions
• Recognize resident choices and activities, to the
  degree possible, consistent with the medical plan
  of care
• Clinical support component of eMAR system can aid
  in interaction and other contraindication
  screening prior to administration
• Parameters can be set regarding optimal,
  resident-specific administration timeframes -
  which can then be used as administration alerts

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New F-Tag 425 in SOM

• Defining general guidelines for specific
  monitoring related to medications, when ordered
  or indicated, including
• Specific item(s) to monitor (e.g., blood
  pressure, pulse, blood sugar, weight)
• Frequency (e.g., weekly, daily)
• Timing (e.g., before or after administering the
  medication), and
• Parameters for notifying the prescriber
• Clinical support component of eMAR system can aid
  in alerting staff as to which clinical parameters
  to monitor
• eMAR system can accommodate documentation of such
  monitoring

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New F-Tag 425 in SOM

• Documenting the administration of medications,
  including
• The administration of routine medication(s), and
  if not administered, an explanation of why not
• The administration of as-needed medications
  including the justification and response
• The route, if other than oral (intended route may
  be preprinted on MAR)
• Location of administration sites such as
  transdermal patches and injections
• eMAR system can accommodate documentation of all
  aspects of administration, including time, staff
  administering, response to PRN, route, site, etc
• eMAR system can also prompt for such
  documentation as a reminder for staff
• Providing accessible current information about
  medications (e.g., medication information
  references) and medication-related devices and
  equipment (e.g., users manual)
• Clinical support component can ensure this
  information is more readily available and
  up-to-date than paper versions

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New F-Tag 425 in SOM

• Clarifying any order that is incomplete,
  illegible, or presents any other concerns, prior
  to administering the medication
• If the eMAR system was connected to an
  interoperable electronic prescribing system, such
  clarification could occur electronically Many
  systems currently utilize e-fax communication
  originating from the eMAR
• eMAR system can accommodate documentation of such
  clarification, for future reference by staff,
  consultants, physicians, and surveyors
• Reconciling medication orders including telephone
  orders, monthly or other periodic
  recapitulations, medication orders to the
  pharmacy, and medication administration record
  (MAR), including who may transcribe prescribers
  orders and enter the orders onto the MAR
• This regulatory guideline would be less of an
  issue for facilities with eMAR systems - as much
  of this process would be automatic and any
  action/manipulation by an individual would be
  noted in the system
• Fully interoperable EHR, including e-prescribing
  and eMAR, would be ideal to comply with this
  regulatory guideline

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New F-Tag 425 in SOM

• Example of Severity Level 3 deficiency noted in
  Investigative Protocol at F425
• The facility in collaboration with the
  pharmacist failed to assure that procedures were
  developed and implemented, such as
• An effective procedure/mechanism to assure that
  all medication orders were processed consistently
  and accurately through the stages of ordering,
  receiving, and administering medications
  (including transfer orders, admission orders,
  telephone orders, order renewals, and the MAR).
  For example, a transcription error led to an
  incorrect dose of a medication being administered
  and the resident experiencing spontaneous
  bruising and epistaxis requiring medical
  intervention.

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eMAR withBar-Code Technology

• Bar-code point-of-care (BPOC) medication
  administration systems
• Information encoded in bar codes allows for the
  comparison of the medication being administered
  with what was ordered for the patient
• BPOC systems are believed to be effective in
  preventing medication administration errors but
  are currently implemented in only about 2 of
  U.S. hospitals

- ASHP national survey of pharmacy practice in
hospital settings-2002. Am J Health-Syst Pharm.
2003 6052-68. - CPOE, bedside technology, and
patient safety. Am J Health-Syst Pharm. 2003
601219-28.
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eMAR withBar-Code Technology

• Sample workflow
• Each drug is labeled with a unique bar code
• Bar codes also appear on all patient care
  providers' identification badges and on patient
  wristbands
• Prescriber writes an order, which can be faxed to
  the pharmacy and entered into a computer system
  by a pharmacist/pharmacy techORNursing facility
  staff can enter the orderOR...Order writing and
  entry can be streamlined by CPOE
• Pharmacist dispenses the bar-code-labeled unit
  dose of the medication

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eMAR withBar-Code Technology

• When administering a med, the clinician (i.e.,RN,
  LPN) uses a hand-held device to scan the bar
  codes on his or her identification badge, the
  patient's wristband, and the med
• If the system cannot match the med to be given
  with the order in the system, it alerts the user
  with a visual warning
• At that point, the clinician can change what
  he/she will administer or override the warning
  and continue with drug administration

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eMAR withBar-Code Technology

• The details of the transaction, including the
  name of the clinician administering the
  medication, are automatically captured in an
  electronic medication administration record.
• If a clinician encounters an unreadable or absent
  bar code, he/she can use the computer mouse and
  keyboard to select the dose to be administered
  from a list in the patient's electronic profile.
  This doesnt take advantage of the system's
  error-checking abilities, but it ensures that the
  drug's administration will appear in the
  patient's electronic medication record.

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Preventing Med Errors

• Using a Bar-Coded Medication Administration
  System to Prevent Medication Errors. Sakowski J,
  et al. Am J Health-Syst Pharm. 2006, January 6.
• A retrospective audit of warning and error
  reports generated by a BPOC system to
  characterize warnings, explore how users respond
  to warnings, and identify prevented and observed
  medication administration errors.
• Sample of 17,025 attempted administrations

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Preventing Med Errors

• Results
• 7120 (42) of the attempted administrations
  received 1 or more warnings or alerts
• 187 instances (1.1 of all attempted
  administrations) where the clinician's reaction
  to a BPOC system-generated warning prevented a
  patient from receiving a dose that would have
  violated one of the five rights of drug
  administration
• The length of time a unit had been using the BPOC
  system did not significantly affect the rate of
  prevented errors
• Of the prevented errors, 23 (12) involved drugs
  recognized as having a high potential for causing
  serious adverse drug events
• morphine or other opioids
• insulin
• anticoagulants (i.e., heparin or warfarin)
• potassium
• sodium chloride

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Preventing Med Errors

• 477 instances (2.8 of attempted administrations)
  where the user overrode a warning and continued
  with an administration that differed from the
  written order
• Most common types of errors that occurred despite
  a system-generated warning were
• Doses being given earlier than scheduled (35)
• Administered dose differing from what was ordered
  (26)
• Doses with no corresponding order in the system
  (20)

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Preventing Med Errors

• Perception that alerts are frequently
  irrelevant"warning fatigue" from receiving
  numerous inappropriate warnings may result in
  some medication errors
• What caused the noise?
• System setup issues..dissimilar nomenclature
  (e.g., unit discrepancies such as mg vs. tablet)
• Lack of pharmacist availability to enter orders
  in cases where CPOE was not utilizedcausing no
  matching order errors
• Incompatibility between programmed standard
  pharmacy administration schedules and clinician
  availability to meet the pharmacy schedules (e.g,
  respiratory therapists)

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To improve eMAR implementation

• Use of similar or standardized terminology among
  systems that are communicating with one another
• NDC
• RxNorm
• May need to develop new workflow and staffing
  procedures based on system
• Periodic assessments to confirm that users are
  adopting the technology as expectedincluding
  observing for "work-arounds

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eMAR and Interoperability

• To be fully interoperable, the following systems
  must be electronic and must be able to
  communicate with one another
• Pharmacy - dispensing
• Nursing - administration
• Prescribers - ordering
• LTC facilities often have eMARs as stand-alone
  products, which can offer benefits in and of
  themselves

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eMAR and Interoperability

• A fully-interoperable EHR is ideal, otherwise
  errors may be introduced and the eMAR may not
  meet its potential for improving safety and
  efficiency Without interoperability
• List of residents and medication orders will
  either be manually entered into the eMAR system
  or will be populated by the pharmacy system
• Wrong resident could be selected for
  administration of a med
• Resident information may not be up-to-date
• Medication orders may not be up-to-date or
  accurate
• Assumptions might be made about medication orders
  because communication/clarification with pharmacy
  and prescriber are burdensome - i.e., only via
  phone or fax
• Duplicative and/or contradictory notes about
  medication-related issues in the various systems
  and charts

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eMAR and Interoperability

• A fully-interoperable eMAR with EHR could allow
  for
• Automatic population of med-related sections of
  MDS
• More efficient medication regimen review (MRR) by
  consultant pharmacists, especially for interim
  MRRs conducted off-site - as outlined in new SOM
  guidelines
• More efficient application process for third
  party prior authorizations that require
  historical medication utilization information or
  clinical outcomes/monitoring information
• More accurate and efficient controlled substance
  reconciliation and record management
• Accurate and efficient documentation of
  disposition (e.g., removal from med cart,
  destruction/return, etc.)
• More accurate and efficient inventory management
  - including documentation as to why meds were not
  available for administration when those
  situations arise

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