Building on the success of its closed-loop medication management process, Brigham and Women’s Hospital (BWH) has gone a step further to add safety measures and precise linking capabilities in is chemotherapy medication orders. BWH’s goal was to ensure appropriate scheduling, dispensing, and administration for chemotherapy medications and medications that must be given before, during, and after chemotherapy.

BWH, a 777-bed tertiary academic medical center in Boston, administers 6 million medication doses a year. This complex medication linking project, which involved three main in-house developed clinical systems: computerized provider order entry (CPOE), pharmacy, and the electronic medication administration record (eMAR), earned Brigham and Women’s a finalist award in the Healthcare Informatics Innovator Awards that were presented at this year’s Healthcare Information and Management Systems Society (HIMSS) Conference in Orlando. The Healthcare Informatics Innovator Awards Program recognizes leadership teams from patient care organizations—hospitals, medical groups, and health systems—that have effectively deployed information technology in order to improve clinical, administrative, financial, or organizational performance.

The 18-month medication linking project, completed in June 2009, was the brain-child of a multi-disciplinary group that met weekly and included, physicians, nursing, IT, and pharmacy among other participants. The group worked to ensure complex chemotherapy drug regimens be documented, easily available for physicians to order, and free of drug errors.

“The order linking was part of larger project to look at how chemotherapy is written, dispensed, and administered,” says Jen Rogala, corporate manager, clinical systems development, BWH. “We looked at orders and how they were written and analyzed all orders for investigational protocol and standard regimens for leukemia and bone marrow transplants. And that’s when we came up with the idea that we need to show the relationships and the schedules between certain orders.”

Types of Medication Linkages
BWH identified four types of administration links required for precise chemotherapy scheduling and administration to be implemented in CPOE to ensure they could be properly interpreted by the downstream systems pharmacy and eMAR. Listed below are the four types of links and how many the hospital has in its database:
 

1. “Mix Together Linking,” for medications that are administered to the patient at the same time and are mixed together in bag or syringe; 851 links
2. “Mutually Exclusive Linking,” for two or more medications where all are ordered by the physician, but the nurse will only administer one to the patient; 2,500 links
3. “Time Offset Linking,” for medications that are administered in a predefined sequence with specific lengths of time between start of administrations; 13,570 links
4. “Sequential Linking,” for medications that are administered in a specific sequence, but are ambiguous to time, often defined as ‘give before’ or ‘give after’; 6,947 links

The linking database is the single source of all linking information for the three clinical systems (CPOE, pharmacy, and eMAR). Clinicians retrieve the linking information via web services or managed service provider services that receive and send blocks of information via XML. There are business rules for linking that apply to Partners Healthcare as a whole, but each individual site is able to add to or override these rules.

Lifecycle of a Chemo Order
Chemotherapy treatment plans are pre-defined in CPOE so the physician does not have to individually order each medication in the complex plans. The physician chooses a specific treatment plan and the CPOE system creates the order, does all the weight-based calculations, and clones the pre-defined order links to inform pharmacy and eMAR how these orders are related to each other as far as scheduling. If an order is discontinued or changed in CPOE then the linking services are called to update the links.

Orders are linked on the order level until they are approved in the pharmacy system. Pharmacy calculates administration times for every order based on the links and creates dose-level links. Linked orders are sent to the pharmacy application for approval. Orders are approved one at a time and the schedule of the first order in the treatment plan will drive the schedule for the rest of the orders in the plan. These dose-level links are passed to eMAR to ensure that the meds are administered at the correct times.

When a medication is due to be administered to a patient, the nurse starts the administration process. In this user interface (known as the to-do screen), chemotherapy and non-chemotherapy medications are listed together in the chemotherapy section. All linked medications are identified with the link icon. The nurse can also hover over the icon to view the linking detail.

Further Implementations
Since this system was implemented pharmacists have reported they feel more secure that schedules are appropriately set up, and they enjoy the efficiency of automated scheduling based on the rules of the link. Nurses have expressed the added sense of security in knowing that important medications, such as pre-hydration, won’t be forgotten and that alerts will appear if an attempt is made to administer chemotherapy out of sequence.

Initially, this system was implemented on the BWH clinical services that order chemotherapy: oncology, gynecology, bone marrow transplant, and rheumatology. Since last year when the project was submitted to Healthcare Informatics Innovator Awards Program, few changes have been needed for operation, other than tweaking some business rules—like being able to break a link for individual treatment plans—in the system. Physicians haven’t had to ask for additional link types.

The linking tool was designed to be scalable, so it can be used on other adult clinical services at BWH and at other Partners sites. “It’s really not so much a technical issue to open it up the entire Brigham and Women's inpatient population,” says Rogala. “It’s more of our ability to support it and that’s why we haven’t done it yet.” Massachusetts General Hospital has secured funding for fiscal year 2012 to employ the linking system for chemotherapy related medication orders.

The biggest challenge the BWH team faced was to create an effective tool, without over-engineering it. “We could still be analyzing it now, and we could have come up with 10 different links, so really trying to keep the scope to the must-haves and where the risks were to patients,” says Rogala.

One of the elements that led to the success of the project, Rogala says, was having clinical champions working alongside IT leadership. “Having the clinician and IT working hand and hand was really the key to success, and we didn’t create a system that created a new process, we created a system that mimicked the already existing process,” she adds. “One of the benefits we had was we already automated our closed-loop, so this was something we could build on top of. We tend to do things slowly and add value and safety.”