By Matt Enell, Pharm.D., clinical informatics pharmacist, Michigan Medicine, Ann Arbor
Michigan Medicine went live with Epic, our current electronic health record (EHR), in June of 2014. At that time, barcode scanning of human breast milk was deemed out of scope for several reasons. It was perceived as a labor-intensive workflow for nursing, and Epic was lacking in functionality at that time.
After our EHR went-live, there were a few near-misses and actual administrations of breast milk to the wrong patient. During this time, there were also a handful of incidents where patients received formula that conflicted with documented allergies.
Due to these events, a team was assembled to review both the workflow and Epic functionality as well as develop a barcoding solution to help prevent these incidents. Another impetus to implementing barcode scanning of breast milk was the Healthcare Information and Management Systems Society (HIMSS) Stage 7 certification as barcode scanning of breast milk is one of the required criteria.
We initially had to decide if we wanted to use Epic or partner with a third-party software to implement the scanning. Software features we compared were inventory management, allergy checking, cost, required interfaces, etc. Ultimately we decided to utilize Epic. While Epic’s functionality was fairly new and did not have all of the “bells and whistles” of the third-party software, it would not require any additional interfaces, costs would be minimal, and we would also be able to have allergy checking.
To prepare for this process, we converted all of our breast milk orders into medication records. We also converted all our enteral nutrition orders (both pediatric and adult) to medication records to take advantage of allergy checking. Though enteral nutrition orders were converted to medications, barcode scanning of all nutrition elements was out of scope for this project.
We estimated the project would take six months. This timeline included workflow discussions, Epic build, user acceptance and quality assurance testing, training and implementation. We considered the time needed to build the new orders, create new labels/label printing workflows and update order sets and reports so they displayed correctly.
We mimicked current workflow as much as possible throughout this project. Even though we switched to medication records, they did not behave the same way as a typical medication order in our system. We restricted the orders from the electronic medication administration record (eMAR), relocating the scanning function to flowsheet documentation. Nurses would use existing active orders reports to know when to give the breast milk or formula. The orders were also blocked from the pharmacist verification queue. We deviated from Epic’s recommended workflow when it came to label printing as we have a milk room at our hospital responsible for the operations functions surrounding breast milk. It behaves in many ways just a pharmacy, but was not accounted for in Epic’s workflows.
Throughout the course of the project, we encountered many issues that we had to work to resolve. Most of the issues stemmed from trying to make Epic’s recommended workflows align with ours. The largest issue, however, was how these new breast milk/formula orders were displayed. Since they are nutrition orders, but built as medication orders, they were showing up in the medication section of the patient’s chart. Even though we provided education, this was confusing for staff. Therefore we continued to update reports, provide additional education and worked with Epic to correct this issue.
Since we have implemented breast milk barcode scanning we have not had any new incidents of a patient receiving the wrong breast milk or of an enteral nutrition formula given to a patient with a conflicting allergy. We did see a small uptick of risk reports after going live concerning patients missing a feeding because of how the orders were displayed. After actions were taken to address this, the incidence of these types of reports decreased. There was also a worry about increased workload for nurses prior to implementation, but after going live that was never realized, and the process was well received.
Overall, lessons learned with this project were the importance of workflow validation, the flexibility needed to customize this project to meet our needs, and how beneficial Epic’s involvement was in initial discussions.