www.pharm.monash.edu.au

Meredith Wiseman

Lead Pharmacist, Clinical Informatics

Pharmacy Department, Alfred Health

Professor Michael Dooley

Director of Pharmacy, Alfred Health

Professor of Clinical Pharmacy

Faculty of Pharmacy and Pharmaceutical Science, Monash University

Integrating Advanced Practice Roles into Future Plans

for eMM

Integrating Advanced Practice Roles into Future Plans

for eMM

Advanced practice

eMM

Advanced practice

Current Future

Integrating Advanced Practice Roles into Future Plans

for eMM

Advanced practice

eMM

Advanced practice

Current Future

Cerner Medication

Management solutions

– March 2018

Integrating Advanced Practice Roles into Future Plans

for eMM

Advanced practice

eMM

Advanced practice

Current Future

Cerner Medication

Management solutions

– March 2018

eMM project timeline

eTQC (eMM) Project team

Integrating Advanced Practice Roles into Future Plans

for eMM

Advanced practice

Current Future

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Disease Management Clinic

Unit based clinical

pharmacy services

Changing clinical practice

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Disease Management Clinic

Pre-admission clinic

Unit based clinical

pharmacy services

Changing clinical practice

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Disease Management Clinic

Pre-admission clinic

Unit based clinical

pharmacy services

Weekend clinical

pharmacy services

Changing clinical practice

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Anticoagulation management

Disease Management Clinic

Pre-admission clinic

Unit based clinical

pharmacy services

Weekend clinical

pharmacy services

Changing clinical practice

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Anticoagulation management

Smoking cessation

Disease Management Clinic

Pre-admission clinic

Unit based clinical

pharmacy services

Weekend clinical

pharmacy services

Changing clinical practice

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Anticoagulation management

TDM charting

Smoking cessation

Disease Management Clinic

Pre-admission clinic

Unit based clinical

pharmacy services

Weekend clinical

pharmacy services

Changing clinical practice

Defined scope of practice

Multi-disciplinary support

Formal competency assessment

Formal evaluation

Agreed clinical need

Multi-disciplinary education

Unit based – Team based

Changing clinical practice

Defined scope of practice

Multi-disciplinary support

Formal competency assessment

Formal evaluation

Agreed clinical need

Multi-disciplinary education

Unit based – Team based

Significant problems with the

dosing of aminoglycosides

and vancomycin

Clinical pharmacists would

make recommendations

regarding levels and dosing

Why couldn’t pharmacists

order the levels and dose

directly on the medication

chart?

Therapeutic drug monitoring

Therapeutic drug monitoring

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Partnered charting

Anticoagulation management

TDM charting

Smoking cessation

Disease Management Clinic

Pre-admission clinic

Unit based clinical

pharmacy services

Weekend clinical

pharmacy services

Changing clinical practice

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Partnered charting

Opioid descalation

Anticoagulation management

TDM charting

Smoking cessation

Disease Management Clinic

Pre-admission clinic

Unit based clinical

pharmacy services

Weekend clinical

pharmacy services

Changing clinical practice

Defined scope of practice

Multi-disciplinary support

Formal competency assessment

Formal evaluation

Agreed clinical need

Multi-disciplinary education

Unit based – Team based

Significant problems with pain

management for patients

commenced on opioids

during admission and

continuing when not needed

Opioid De-escalation

Demographic & Baseline Characteristics of the patients

Characteristic Control group (N=98) ODE# group (N=98) P Value

Age (year) – mean (SD) 54.9 (19.3) 53.5 (19.4) 0.61

Male sex – no. (%) 50 (51) 54 (55) 0.67

Hospital LOS - days 8.5 [5,14] 8.0 [5,14] 0.93

Elective admission – no. (%) 54 (55.1) 53 (54.1) 1.00

Pre-existing opioid use – no. (%) 23 (23.5) 30 (30.6) 0.33

Average MOE 24 hours after APS discharge (mg) –

mean (SD)

62.6 (62.6) 68.9 (71.3) 0.11

Resting pain scores* - median [IQR] 4 [3,6] 5 [3,7] 0.12

Adjunct analgesia* – no. (%)

Simple 96 (97.9) 98 (100.0) 0.50

Antineuropathics 52 (53.1) 56 (57.1) 0.67

Other 58 (59.1) 49 (50.0) 0.25

*24 hours after APS discharge; #Pharmacist-led opioid de-

escalation

Opioid De-escalation

% incidence reduction* P value

Nausea or vomiting 14 0.0008

Constipation 43 <0.0001

Sedation 9 0.02

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Partnered charting

Opioid descalation

Anticoagulation management

Smoking cessation clinic

TDM charting

Smoking cessation

Cardiac clinic

Disease Management Clinic

Pre-admission clinic

Lung Transplant

Unit based clinical

pharmacy services

Weekend clinical

pharmacy services

Haematology clinic

Changing clinical practice

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Partnered charting

Opioid descalation

Anticoagulation management

Smoking cessation clinic

TDM charting

Smoking cessation

Discharge summary

Cardiac clinic

Disease Management Clinic

Pre-admission clinic

Lung Transplant

Unit based clinical

pharmacy services

Weekend clinical

pharmacy services

Haematology clinic

Changing clinical practice

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Partnered charting

Opioid descalation

Anticoagulation management

Smoking cessation clinic

Stroke call-out

TDM charting

Partnered Pharmacist Medication

Charting Expansion project

Smoking cessation

Discharge summary

IBD clinic

Cardiac clinic

Disease Management Clinic

Pre-admission clinic

Lung Transplant

Unit based clinical

pharmacy services

Weekend clinical

pharmacy services

Haematology clinic

Changing clinical practice Sepsis call-out

Cellulitis management

Integrating Advanced Practice Roles into Future Plans

for eMM

Advanced practice

eMM

Advanced practice

Current Future

Integrating Advanced Practice Roles into Future Plans

for eMM

Advanced practice

eMM

Advanced practice

Current Future

Chief Pharmacy Information Officer (CPIO)

PDF of CHIO PD

CPIO

Structure of eTQC

reporting lines

Integrating Advanced Practice Roles into Future Plans

for eMM

Advanced practice

eMM

Advanced practice

Current Future

Chief Pharmacy Information Officer (CPIO)

Clinical Informatics Services

Integrating Advanced Practice Roles into Future Plans

for eMM

Advanced practice

eMM

Advanced practice

Current Future

Chief Pharmacy Information Officer (CPIO)

Clinical Informatics Services

Medication Charting

Director Pharmacy

Dep Director Pharmacy

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Informatics

Defined scope of practice

Multi-disciplinary support

Formal competency assessment

Formal evaluation

Agreed clinical need

Multi-disciplinary education

Unit based – Team based

Significant problems with

medications at admission ie

wrong, delayed, unknown

Pharmacist involvement

traditionally retrospective

Why couldn’t medications get

‘sorted” as soon as the

patient presents

Partnered charting

• Pharmacist charting credentialing

program was developed with input

from medical and nursing

• Formal guideline developed for

charting model

• Implemented in two weeks

Partnered charting

36

Partnered charting

37

Partnered charting

© 2015 Confidential Draft

Discussion Document

38

Partnered charting

© 2015 Confidential Draft

Discussion Document

39

Partnered charting

Partnered charting

Clinical significance of errors

Pharmacist charting Medical Charting

No. of errors No. of errors P-value

Total 19 1573 <0.0001

Insignificant 11 (0.3%) 904 (20%) <0.0001

Low risk 1 (0.02%) 58 (1%) <0.0001

Moderate risk 6 (0.15%) 292 (7%) <0.0001

High risk 1 (0.02%) 285 (6%) <0.0001

Extreme risk - 34 (0.8%) <0.0001

Partnered charting

Integrating Advanced Practice Roles into Future Plans

for eMM

Advanced practice

eMM

Advanced practice

Current Future

Chief Pharmacy Information Officer (CPIO)

Clinical Informatics Services

24hour Pharmacy Services

Medication Charting

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Partnered charting

Opioid descalation

Anticoagulation management

Smoking cessation clinic

Stroke call-out

TDM charting

Smoking cessation

Discharge summary

IBD clinic

Cardiac clinic

Disease Management Clinic

Pre-admission clinic

Lung Transplant

Unit based clinical

pharmacy services

Weekend clinical

pharmacy services

Haematology clinic

Emergency Department Sepsis call-out

Cellulitis management

Trauma call-out

Current: 7am – 9pm service and on call

Integrating Advanced Practice Roles into Future Plans

for eMM

Advance Pharmacy practice roles requirements in eMM

• Authorisation for charting by pharmacists

• Ability to customise clinical review and documentation to

align with prescribers

• Pharmacy champions to engage, promote and explain our

advance practice roles at all levels.

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Partnered charting

Opioid descalation

Anticoagulation management

Smoking cessation clinic

Stroke call-out

TDM charting

Smoking cessation

Discharge summary

IBD clinic

Cardiac clinic

Disease Management Clinic

Pre-admission clinic

Lung Transplant

Unit based clinical

pharmacy services

Weekend clinical

pharmacy services

Haematology clinic

Emergency Department Sepsis call-out

Cellulitis management

Trauma call-out

Current: 7am – 9pm service and on call

Future: 24hours service

Medication management systems: Thinking about what to do

Electronic Medication management systems:

Acknowledgements – Site visits

Princess Alexandra Hospital, Qld

Fiona Stanley Hospital, WA

St. Stephens, Hervey Bay, Qld

Austin Hospital, Vic

Peninsula Health, Vic

Cerner site visits, USA

Canada, Toronto

Thank you!