Strategies to Implement Electronic Medical Administration Record (EMAR) Software Health

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ImplementingEMAR Software

Use this tool to help you distinguish among the different forms of electronic medical administration record (EMAR) software, and access a set of related tools developed by the American Hospital Association, Health Research Trust, and the Institute for Safe Medication Practices.

Instructions for Use

Determine the nature of EMAR you are implementing. What form of EMAR you are implementing greatly drives the capabilities, as well as the policy and procedure changes you may need to make.
If you have not done so already, engage all stakeholders in the process of implementation. While the predominant users of EMARare in nursing, individuals who provide pharmacy, quality improvement, and procurement services are important to have on board. Even if you need to obtain the services of a pharmacy consultant, this can be a valuable investment. A physician champion also can be beneficial in ensuring that the physician community understands the new processes and how nurses will be usingthe system in the administration of medications, monitoring resident reactions, and documenting their activities. Ensuring the proper stakeholders can reduce confusion and increase trust in the new system.
Conduct workflow and process improvement mapping to determine how the application being implemented may change current workflows and processes. Ideally, during your planning for HIT acquisition, you would have mapped, in detail, current workflows and processes and can now identify processes you want to include in the new application and howimprovements can be made.Process standardization will be needed. Some new processes in EMAR may support resident safety but may be new to staff.
Providethe opportunity for all nursing staff and others as applicable to be fully trained. Stress the importance of following policies and procedures and reporting any issues or concerns regarding use. Because processes are often quite different from manual processes, the staff member who may be uncertain about how to handle exceptions often revert back to old manual processes by default rather than seeking advice on how to handle the exception in the system. As a result, workarounds are created, continue, and can produce misleading or erroneous outcomes— potentially detrimental to the resident and/or the organization.
When you are ready to move to a barcode medication administration record (BC-MAR) form of EMAR, usePathways for Medication Safety: Assessing Bedside Bar-Coding Readiness to determine if your organization has the necessary applications, technology, and operational elements in place to move forward. Although these tools are focused on hospital use of EMAR systems, much of the guidance is applicable to the nursing home environment.

Types of EMAR

The term EMARcan describe a general class of applications relating to electronic assistance with medication administration and its documentation. The following areseveral possible application types:

Electronic MAR. In a basic EMAR system, medication orders are entered electronically into the system, initially by the physician or pharmacist, then nursing prints out the forms on paper. The forms use the typical MAR flow sheet for information on medications and their administration. The primary benefit of these forms is reducing nursing transcription errors. They also save nursing time.
Bedside medication verification (BMV) systems. These systems provide MAR formats online to enable nursing staff to not only see what medications must be administered to whom, when, and how, but to allow for documenting the administration as well. In addition to reducing transcription errors, thesystem has reminders to aid in timely administration of medications. Other patient safety features in these products may include the ability to visually compare the medication being given against a picture on the computer; provide nursing staff with alerts to potential contraindications as another check between the provider, pharmacist, and nurse; and enable drug knowledgebase (DKB) reference.
Bar code MAR (BC-MAR) systems. These systems add the dimension of positive patient identification, and thus afford the medication five rights: right patient, right drug, right time, right dose, and right route. This is accomplished through an application similar to the BMV in that it alerts the nursing staff to when medication administration should be performed, provides clinical decision support on potential medication contraindications and reference to a DKB, and verifies through the barcode reading system that the five rights have been assured. Nursing staff administering medications wand the barcode reader over the resident’s bar coded wrist band, the bar coded unit dose of the medication, and the nurse’s bar coded identification badge. The systemchecks for right patient, right drug (including dose and route), and right time (the barcode scanner records a time stamp and documents the administration). Some BC-MAR systems also may be designed to provide a unit dose dispensing drawer that opens to the specific unit dose for the resident identified.

Challenges to Capabilities

All of these systems depend on the right medication having been ordered and the order correctly populating the EMAR system.

If yournursing home does not yet have a computerized provider order entry (CPOE) system, transcription of the medications ordered still must take place manually.
The BC-MAR system also depends on having bar-coded unit doses available. For some nursing homes, this can be a significant challenge. Drugs may not be packaged in unit dose form, which may be more expensive. You can purchase a unit dose drug packaging system, but this is another application that adds cost and time to the process. Finally, not all drugs are easily bar coded. For example, drugs administered through IV bagscan be challenging, though not impossible.
Naming conventions of the drugs used in the EMAR/BC-MAR may not be the same as the drug names in the ordering system. Pharmacy systems generally record drug names using the National Drug Code (NDC), which is a naming convention used in naming packages of drugs. The name of the manufacturer, brand name, serial number, and other such information are all elements embedded in this code. However, when physicians enter medications into CPOE systems and when nurses record these medications in a MAR, they may use terminology that is more clinically relevant. In addition, physicians may leave it up to the pharmacy to supply the specific brand stocked, or to substitute a generic equivalent as applicable. A closed-loop medication management system with CPOE, pharmacy interface, and EMAR/BC-MAR enables mapping to occur automatically to provide equivalency between the two naming conventions. If the systems are stand alone or not well-integrated without the mapping on the naming conventions, the result can be confusing.

Policy and Procedure Changes

When any form of EMAR is adopted, yournursing home may have a higher reporting of medication errors. The following are common causesof medication errors:

Incomplete patient information (e.g., not knowing about patients’ allergies, other medicines they are taking, previous diagnoses, and current lab results)
Unavailable drug information (e.g.,lack of up-to-date warnings)
Miscommunication of drug orders, caused by poor handwriting, confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units, and inappropriate abbreviations
Inappropriate labeling of a drug whenprepared and repackaged into smaller units
Environmental factors (e.g., lighting, heat, noise, interruptions) that can distract health professionals from their medical tasks

Review policies in advance of the implementation of EMAR (and other components of medication management), define terms carefully, and recognize that your organization likely is not having more actual errors, but having better reporting. Errors also should be classified by their type, including those that are not errors, but adverse reactions that may have been anticipated, and near misses. Different organizations use different definitions for these concepts, often driven by required reporting systems. The following definitions are supplied by the Agency for Healthcare Research and Quality (AHRQ).

Adverse drug event.In some reporting systems, this is an encompassing term referring to actual errors, near misses, and adverse drug reactions. In other reporting systems, adverse drug event refers solely to harm caused by an actual error in medication management. The source of the error may be from one or more sources, as described above. In implementing an EMAR system, one of the most frequent increases in error is due to timing. Many EMAR systems identify a timing error as one with a narrow window. Everyone needs agreeon what an acceptable window of time is. If the window is smaller than before due to other reporting requirements, workflow and processes should be studied to determine the impact of this change in definition.
Near miss. An event or situation that did not produce injury, but only because of chance. This good fortune might reflect robustness of the individual (e.g., a person with a specific medication allergy receives a similarly compounded medication, but has no reaction) or a fortuitous, timely intervention (e.g., a nurse happens to realize that a physician wrote an order in the wrong chart). EMAR systems often are able to identify these near misses when an alert or reminder is invoked in the clinical decision support component of the application.
Adverse drug reaction. This reaction is an adverse effect produced by the use of a medication in the recommended manner. These effects range from nuisance effects (e.g., dry mouth with anticholinergic medications) to severe reactions (e.g., anaphylaxis due to severe allergy).

In addition to defining errors, another area of policy to consider is adherence to procedures. Because EMAR systems significantly change workflow, be sure to:

Engage nursing staff in all aspects of workflow and process changes during implementation.
Ensure that these changes are monitored for adherence and potential need to make adjustments.

Unfortunately, many systems are installed with workflow changes that staff has not been engaged in understanding or had any input into. As a result, staff may find workarounds to solve either real or perceived problems in workflow. The result can be significantly less safety improvement than anticipated and even increases in productivity issues. Be flexible in studying these issues and work through necessary changes, while still freezing changes into place that are critical.

Assessing Readiness

The American Hospital Association, Health Research & Educational Trust, and the Institute for Safe Medication Practicesoffer an excellent tool, Assessing Bedside Bar-coding Readiness,

This toolkit was prepared by Stratis Health, the Minnesota Medicare Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 10SOW-MN-SIP-HIT-13-06 031313

For support using the toolkit

Stratis Health Health Information Technology Services

952-854-3306 

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