Purpose/Objectives:
Three years ago, with Health Canada investment, Canada Health Infoway set out with a vision to create a single national e-prescribing service called PrescribeIT? for the benefit of all Canadians. Today this vision has become a reality with 10 jurisdictions engaged, and it has been launched in three provinces. Join us as we share PrescribeIT?s progress to date and the surprising contributions PrescribeIT? has made to the health care community that go beyond the technology.


140 Character Summary:

Purpose/Objectives:
Through the ACCESS 2022 movement and other ACCESS Health initiatives, Infoway is engaging with Canadians, health care practitioners, industry and governments to transform the care experience. With a vision of healthier Canadians through the scale of innovative digital health solutions, Infoway?s strategy puts patients and their providers at the centre of a new pan-Canadian health care ecosystem. Join us as we share the vision, demonstrate our progress and look to the year ahead.


Methodology/Approach:



Finding/Results:

Purpose/Objectives:
University Health Network (UHN) first implemented electronic medication order entry and administration in 2004. Since then, clinical best practices and system technologies have notably evolved. However, the organization had not established formal processes to periodically evaluate 1) existing medication screens from a UHN-wide clinical perspective and 2) opportunities to implement system upgrades that optimize medication order entry. Today, medication screens have accumulated long lists of order options, inconsistent layout standards, and non-customized dosing intervals. These contribute to prescriber confusion and frustration, risking prescribing errors. In June 2017, a project focused on updating medication screens became a UHN priority. The project?s purpose is twofold: 1) to simplify existing order entry screens to support easier, clearer, and consistent prescribing of medications and 2) to implement a formal process that sustains and carries forward the benefits of this work. This abstract highlights the development of electronic medication build standards, its application and associated interim benefits, and describes the emergence of the EPR Medication Order Request for Additions & Revisions (EMORAR) Subcommittee.


Methodology/Approach:
Analysis of the implemented EPR system was conducted by UHN?s Data and Implementation Science senior analysts and Pharmacy Informatics specialists. Multidisciplinary stakeholder consultations informed the project?s guiding principles for improving electronic medication ordering, and new layout and display standards. These were evaluated by UHN Healthcare Human Factors team and approved by Safe Medication Practice (SMP) and Pharmacy & Therapeutics (P&T) committees. Applying the standards, prototypes are developed by project?s clinical pharmacist. UHN references (ex. policies, department specific handbooks, nursing manuals), UHN clinical tools, and UHN-wide data are used to justify modifications. The prototypes are reviewed by a therapeutic-specific Clinical Working Group (CWG) consisting of pharmacists and nurse practitioners. Subsequent iterations are reviewed by physician expert representatives. Additional stakeholders are engaged as needed. Microsoft Excel is used to document 20 metrics describing pre and post screen changes. Regular interim reporting is completed for 3 key clinical metrics from a user-perspective which includes the difference in means and percent change.


Finding/Results:
As of October 2018, 79 medications have been updated. The table below defines the 3 metrics and summarizes the most current results.


Conclusion/Implications/Recommendations:
UHN recognized the need to establish proper committee infrastructure to maintain electronic order entry practice in a well-kept state. A new P&T Subcommittee (EMORAR) led by clinical pharmacy and pharmacy informatics co-chairs was established. This subcommittee maintains integrity of electronic medication screens standards by reviewing change requests and overseeing initiatives involving enhanced system capabilities. New today becomes old tomorrow, hence formal processes are necessary to ensure evolving clinical best practice is supported by existing technology effectively.


140 Character Summary:
Old becomes new: Revitalization of medication ordering practices to meet new build standards at University Health Network?s acute care hospitals.

Purpose/Objectives:
Many complex patients experience medication-related adverse events at the time of discharge from hospital. Previous work at Queen Elizabeth Hospital (QEH) identified care gaps that potentially impact adverse events (ref). Specifically, discharge reports containing important medication information were not communicated to community care providers complicating the continuum of patient care. The primary objective of this study is to determine the feasibility of electronically providing patient discharge reports directly to community pharmacy for the purposes of medication reconciliation. The secondary objective is to determine the impact of the improved communication process on emergency department (ED) visits and readmission rates within the first 8 weeks of hospital discharge in a small pilot of patients compared to standard care


Methodology/Approach:
Eligible patients (n=100) identified as complex (taking >5 medications) will be consented just prior to discharge and will provide their community pharmacy contact information from a list of participating pharmacies. Participating community pharmacies will be randomized into two groups receiving either electronically transmitted discharge reports through commercially available software (Access Point Consultant, PASI) or paper copies only (standard care). Initial follow-up with community pharmacists will occur within 4 days of patient discharge to assess numbers of received discharged reports and medication issues (e.g. clarifications, corrections etc.) associated with them. Study participants will be followed to determine if they returned to the hospital at weeks 1, 4, and 8 post-discharge. Pharmacies receiving commercial software will also receive a pharmacy-connected mobile application (Your Health Report, Health QR) to offer their patients to view their complete medication profile and manage their medications. Patients will be asked to provide initial feedback on managing their medications through this platform.


Finding/Results:
Previous work identified only 17% of all discharge reports were received at the community pharmacy. Of the reports that were received, pharmacists reported that some information was missing or unclear prompting follow-up discussions with the hospital. The current follow-up study has gained approval from Health PEI and is currently undergoing research ethics review.


Conclusion/Implications/Recommendations:
This study will evaluate the feasibility of electronically providing discharge reports from a tertiary care centre, with electronic processes already in place, to community pharmacy. The impact of improved electronic communication between community pharmacy, hospital, and patients on subsequent care needs will also be assessed. Final recommendations will include considerations for fully integrated technology requirements for sustained communication between hospital and community pharmacy. References MacDonald K, Cusack M, Qiong S, Lang R, Rinco K. (2017) Care gaps in the electronic discharge medication reconciliation process at an acute care facility. Can J Hosp Pharm. 70(6):430-4.


140 Character Summary:
Can pharmacy-integrated technologies improve the communication of medication reconciliation directives at discharge between hospital and community pharmacy?

Purpose/Objectives:
Adverse drug events (ADEs) are the harmful and unintended consequences of medication use, and are a leading cause of emergency department visits and hospital admissions in Canada. There is a strong need to bridge gaps in informational continuity of care related to ADEs. ActionADE is a user-driven software application that enables the documentation and communication of patient-specific ADE information across a patient?s circle of care, while also meeting national adverse drug reaction reporting requirements under Vanessa?s Law. The objective of this presentation is to report on the development, build, and pilot-testing of ActionADE completed to date.


Methodology/Approach:
ActionADE was developed in conjunction with clinician end-users beginning in 2014. Using a participatory design and action research methodology, the design of ActionADE was informed by a systematic review of existing ADE reporting systems worldwide, extensive qualitative observations, workshops with clinicians, and paper- and web-based pilot testing in one acute care setting in British Columbia. Latest developments in this research program have culminated in the pilot testing of a standalone web-based version of the application among pharmacists. Consistent with previous phases of the research project, the research team has engaged with end-users through workshops, individual on-boarding, and qualitative data collection. This has enabled the iterative refinement of the system, identification of bugs and enhancements, and an understanding of impact on workflow. Utilization statistics were collected to evaluate use and report completion.


Finding/Results:
ActionADE has been designed to integrate ADE documentation into existing clinical workflow processes, enabling multiple provider groups (e.g., pharmacists and physicians) to contribute information to the construction of possible ADE reports that may be completed over time and across care settings. The design process allowed us to mitigate social issues (e.g., uncertainty) and technical issues (e.g., appropriate data fields), resulting in software that is both clinically useful and user friendly, while also producing valuable ADE data as a byproduct of enhanced care. Utilization statistics from the pilot implementation phase show high uptake among users who have significantly increased documentation of ADEs through the use of ActionADE. Field completion and report completion rates are high. Early qualitative research enabled the identification and resolution of 28 software bugs and 74 enhancements. Users are satisfied with the clinical relevance and ease of use of ActionADE. Issues concerning data sources for pre-defined pick lists and user experience have been resolved.


Conclusion/Implications/Recommendations:
ActionADE is a robust, user-centered software. In the near future, ActionADE will be integrated into existing province-wide clinical information systems with the support of the provincial Ministry of Health and relevant health authorities. This will enable communication of ADEs across a patient?s circle of care, closing critical gaps in information sharing, which will ultimately contribute to the reduction of ADEs by preventing the re-dispensation of medications that have previously caused harm, while also resulting in cost avoidance.


140 Character Summary:
ActionADE is software developed to enable the documentation and communication of ADEs across a patient?s circle of care to close critical gaps in communication.

Purpose/Objectives:
Quality of care is a key initiative across Ontario with significant effort directed at establishing standardized levels of care and metrics for evaluation and ensuring that evidence-based support is available to clinicians and leaders to inform quality initiatives. Health Quality Ontario (HQO) is the provincial advisory body that defines quality, analyzes quality dimensions across Ontario, and creates education and practice materials to support the achievement of quality care. As part of this effort, expert advisory panels were assembled to develop comprehensive handbooks guiding Quality?Based Procedures (QBPs) to foster sharing best practices enabling improved quality, efficiency, and outcomes. The Northwest Local Health Integration Network (NW LHIN), established in June 2005, is headquartered in Thunder Bay and includes Thunder Bay and Rainy River Districts and most of the Kenora District. With the support of hospital Chief Executive Officers (CEOs), clinicians approached the NW LHIN seeking to establish a project to advance the implementation and adoption of digital order sets as the NW LHIN hospitals continue to work towards standardization of clinical pathways. Electronic order sets act as checklists that contain current evidence-based, best practice treatment options in a single document that follows the cognitive flow of a clinician and in Ontario, QBP handbooks were used to inform the development of standardized digital order sets. The purpose of this presentation is to share the journey of adopting digital order sets at Thunder Bay Regional Health Sciences Centre and across the NW LHIN.


Methodology/Approach:
A collaborative process of development, refinement, local adaptation and approvals is essential to success and requires a well conceptualized and executed change management approach. A change management team was established at the TBRHSC, consisting of the champion, project leader, and two part-time trainers/implementation quality resources. It took an average of 5 weeks to hit milestones and approximately 9 months overall to implement a digital order set. Essential steps in the implementation process included targeted training at convenience times, champion support, active follow up on adherence gaps, remedial training and support, and regular walkabouts to foster enthusiasm and awareness among all staff.


Finding/Results:
At present, the NW LHIN, together with its champions and partners, has translated more than 40 QBPs into digital order sets, with the most recent being the opioid order set currently in pilot phase. More than 83 hospitals in the LHIN are participating in the digital order set initiative. What was also discovered is that a standardized change approach is not optimal for a distributed network of hospitals that have significantly differing contexts. While the shared goals of quality are consistent, change approaches in less urban areas must be more customized and supported recognizing local resource and capacity constraints.


Conclusion/Implications/Recommendations:
Order sets have been shown to improve patient safety and outcomes (including a reduction in avoidable 30-day readmissions) in hospitals and outpatient clinics in several studies. Significant progress has been achieved across the NW LHIN to inspire continued effort and customization of change approaches ensuring that all sites in the NW LHIN benefit from this innovation.


140 Character Summary:
Digital order sets are a critical way to improve quality care through standardization, best practice, current research, and customization to the local context.

Purpose/Objectives:
Since 2013, Quebec has been operating a centralized e-prescribing network allowing the electronic transmission of prescriptions between prescribers from primary care and pharmacies across the entire province. The objective of this study was to describe the implementation of the system.


Methodology/Approach:
A longitudinal descriptive analysis of aggregated usage data, obtained from the Ministry of Health, from July 2017 to March 2018 was performed. An observational exploratory study was also conducted in a typical pharmacy, selected from the region with the highest utilization in the province, to estimate the proportion of different types of prescriptions. All prescriptions dispensed from Monday June 11 until Friday June 15 2018 were collected from the pharmacy registry and analyzed according to their type (manuscript, verbal, fax, printed, electronic).


Finding/Results:
In March 2018, 3 946 prescribers sent an electronic prescription (eRx) through the system using a certified EMR. Figure 1 presents the proportion of prescriptions that were dispensed, sent electronically and retrieved electronically from July 2017 to March 2018. On average, only 11% of prescriptions were sent electronically by the prescribers. From those electronic prescriptions, 14% of them were retrieved in pharmacies, Hence, only 1.9% of all dispensed prescriptions in the province were electronically transmitted and retrieved. In a typical pharmacy of LanaudiŠre, 34% of all dispensed prescriptions were eRx (Table 1). Interestingly, another 20% of prescriptions were printed using a certified EMR, but were not transmitted to the eRx system, and pharmacists had to enter the prescriptions manually. This observation suggests that despite an increased adoption of the electronic prescribing system, its transmission feature might be an issue. Table 1. Proportion of each type of dispensed prescriptions in a typical pharmacy in the region with the highest adoption by prescribers Prescription type Proportion (%) Manuscript 23 Typewritten form 6 Fax 15 Verbal 2 EMR generated - printed only 20 EMR generated - printed and electronically transmitted 34


Conclusion/Implications/Recommendations:
The adoption of the e-prescribing system is low, both by prescribers and pharmacies. This observation might be in part attributable to the incomplete implementation of the system, where pharmacists are asked to wait for the paper copy of the prescription to electronically retrieve it. Further work is needed to facilitate adoption and increase the potential of a now promising technology that has managed to overcome many of the pitfalls of such systemic networks.


140 Character Summary:
This study demonstrates that the adoption rate of e-prescribing by prescribers and dispensers in Quebec is still low. The transmission feature seems to be an issue.

Purpose/Objectives:
This presentation details Canada Health Infoway?s approach in the implementation of a national e-prescribing service. As this innovation has the potential to change how healthcare is delivered in numerous settings, stakeholder engagement is an important part of its long-term development.


Methodology/Approach:
As part of its feasibility study, stakeholder engagement and feedback informed the service?s creation and development, and ongoing feedback from users and other stakeholders continues to inform its evolution. A governance structure was established to help develop and inform the services future advancement.


Finding/Results:
A feasibility study was the first step in developing the service to ensure the Canadian healthcare system was digitally enabled to support national e-prescribing. Stakeholders helped to identify and refine the service to address the challenges faced by community prescribers and pharmacists in the prescribing process and core functions and detailed specifications were further validated through a REOI and RFP process. This led to the business requirements of the service and the limited production release (lean approach) for rollout. Ensuring seamless integration into the clinical systems (EMR and PMS) was accomplished by workflow analysis onsite in the practices of prescribers and pharmacists, ahead of implementation. Once the service was initiated, support was provided via multiple avenues. Onsite support was provided, feedback was collected in end-of-day reports, follow-up calls and feedback sessions were held where prescribers and pharmacists were brought together to discuss the end-to-end experience. A formal engagement structure including working groups and task forces was then launched to ensure meaningful consultation and structure the feedback from key stakeholder groups. The service is currently live in two provinces and plans for additional jurisdictions are underway.


Conclusion/Implications/Recommendations:
Stakeholder engagement helped achieve successful initial implementation of a national e-prescribing service and will continue to inform its evolution. Prescribers and pharmacists are now starting to adopt the service that they helped design and that meets their community prescribing challenges.


140 Character Summary:
Stakeholders are helping to inform the development and evolution of Canada?s national e-prescribing service.