2005 C.I.P.A. Winners

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University Health Network

Medication Order Entry and Administration Record System

The University Health Network (UHN) encompasses three Toronto hospitals - Toronto General, Toronto Western and Princess Margaret - as well as Toronto Medical Laboratories. In addition to being a major teaching hospital for the University of Toronto, UHN has five research institutes renowned internationally for the advancement of care through excellence in research and innovation, especially in cancer research.

With an operating budget of nearly $900 million, UHN's 1,200 physicians and 11,000 affiliated staff serve the needs of 30,000 inpatient cases and 950,000 outpatient visits annually.

Challenges

At UHN, the process associated with ordering, filling and administering drug prescriptions to patients - commonly referred to as Medication Order Entry/Medication Administration Record (MOE/MAR) - typically begins with a doctor visiting a patient on a ward and reviewing paper-based charts describing the patient's medical and medication history.

If drugs need to be prescribed, the doctor fills out a medication order form, or issues a verbal order to a nurse, who fills out the form on the doctor's behalf. A nurse can also receive instructions via telephone. Other than in an urgent situation, those drug order forms are placed in a box on the ward, where they are picked up by the ward's pharmacist every couple of hours for processing.

After entering the information from the medication order forms into UHN's online pharmacy system, the pharmacist reviews each one and then signs off in the pharmacy system to authorize that the drugs be dispensed to the nurse for administering to the patient.

Once the order is approved, the nurse manually transcribes information from the order form on to yet another form - the Medication Administration Record (MAR) - on which the patient's complete medication schedule is mapped out. Each time the medication is administered to the patient, the nurse signs the MAR.

"This is largely a time-consuming, manual and inefficient process," exclaims Stephanie Saull-McCaig, director, information management, acute care at UHN. "It is also fraught with opportunities for errors that could affect patient safety."

Objectives

Seeing a growing need to improve medication process efficiency and ensure patient safety and the quality of patient care, UHN launched its MOE/MAR project. It sought to improve the medication ordering and administration process and minimize the risk of drug mishap by reducing medication-order transcription errors and providing online clinical decision support for doctors and pharmacists, including electronic order validation and alerts for potential drug incompatibilities and drug-allergy interactions.

In addition to patient care and safety, UHN was also hoping to make better use of caregiver time by improving medication-delivery processes. After several years of development, a phased implementation of the MOE/MAR project began in the summer of 2004.

Solution

The electronic MOE/MAR process integrates UHN's health information system (HIS) with its pharmacy system to provide computerized order entry by physicians, electronic nursing documentation at the bedside, and electronic validation of orders by the pharmacist.

"This was only possible through a highly successful collaboration of UHN clinicians, IT and Information Management staff, vendors and consulting partners," Saull-McCaig notes.

With more than 6,000 networked computers throughout UHN, plus remote access available via a secure Internet-based connection, UHN physicians can log on to the HIS from virtually anywhere. They can see, along with lab results, radiology results and other EHR elements, a patient's complete medication history as well - all without having to go to the ward to review paper charts. The physician can submit a medication order electronically, eliminating the need for paper orders. Completed orders automatically go to the pharmacy system, where the pharmacist is flagged that orders are ready for processing.

The pharmacist reviews and validates the orders online, eliminating the use of the pharmacy drop box as well as the need to enter information from paper orders. Once the pharmacist approves the order and electronically "signs" the pharmacy system, a workstation on each ward flags the nurse that medication orders are pending. When the nurse logs on to the system to accept the outstanding orders, they are automatically posted to an electronic version of the MAR, eliminating the previous task of transcribing medication order information onto a paper MAR. This can all be done by the nurse at bedside, using wireless technology and a special cart with a built-in PC, enabling the nurse to spend more time with patients.

The system improves patient safety beyond just eliminating the transcription errors that could accompany traditional paper orders, Saull-McCaig says, adding that, "The new system adds more checks to the medication process to ensure correct drug administration, including greater involvement by the physician right at the time of the initial order entry."

Implementation of the new system is proceeding from department to department throughout UHN. It has already been implemented for most of Toronto General and the in-patient services at Toronto Western, and work is under way at the out-patient department of Princess Margaret.

Innovative Use of Technology

A feature of the system that helps to ensure that only proper drugs are administered is the Clinical Decision-Support Alerting capability. Based on specialty databases residing within the HIS that contain drug and drug compatibility information, this feature provides an alert to any physician attempting to place a drug order that could create potential problems due to: incompatibility with other drugs already prescribed for that patient, drugs being prescribed contrary to an allergy recorded in the patient's profile, or duplicate prescriptions. The alert feature provides a significant step forward in protecting patients, where previously there was no automatic checking or alert notification.

"What started as just another IT project actually turned out to be a huge change-management initiative that is not only yielding huge benefits for patients but also changing the organization as a whole," Saull-McCaig says.

"The process has brought together the three disciplines - physicians, nurses and pharmacists - to discuss policies and look at how to make tangible improvements. This will translate into valuable learning for other Canadian hospitals endeavouring to make similar changes."

A 2005 CIPA Winner!

For its exceptional application of information technology to solve real-world business problems and bring greater benefit to all its stakeholders, University Health Network has been awarded a Gold Best of Category Award from the 2005 Canadian Information Productivity Awards in the Customer Care, Not For Profit category.

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