Skip to content
Publicly Available Published by De Gruyter November 18, 2015

Proof of Concept and Pilot Study on the Development and Implementation of an Electronic Medication Administration Record

Denis Lebel, Geneviève Mercier, Thomas Dulermez, Aurélie Rousseau and Jean-François Bussières

Abstract

Objective: The main objective is to describe the phases of electronic medication administration record development and implementation. The secondary objective is to compare dose information using medication administration record and electronic medication administration record.

Background: Nursing daily work planning is usually done with the use of a medication administration record printed daily based on the information available in the Pharmacy Information System.

Results: We identified six guiding principles. A profile compared to medication administration record and electronic medication administration record, revealed 19 parameters related to drug registration doses. Regarding the development phase, a total of 150 pharmacist hours and 150 nursing hours have been carried out on optimization of electronic medication administration record. During the preparatory pilot phase, voluntary nurses have been invited to identify problems associated with the electronic version. During the pilot phase, a training program was set up. We implemented the electronic medication administration record on 26 November 2014. The pilot study demonstrates that electronic medication administration record has been successfully implemented in a university hospital.

Conclusion: To our knowledge, this is the first pilot study conducted in Quebec that describes electronic medication administration record development and implementation. Our pilot study shows that we were able to face these challenges through the employment of human, financial and material resources.

Introduction

In healthcare facilities, the medication circuit is complex and involves at least 54 steps. All of these steps can be organized into five themes: drug prescription, prescription validation, dose preparation, dose administration and waste disposal (1). Dose administration consists of several steps (2), such as periodically planning nursing staff work, completing the preparation of drug doses, administering drug doses to patients, recording administered drug doses in patient records, eliminating waste and used pharmaceutical supplies as well as monitoring patients.

Planning the nursing staff’s daily work is usually done with the use of a medication administration record (MAR) printed daily based on the information available in the Pharmacy Information System. Recording drug doses administered to patients is done by nursing staff using the printed MAR. The use of MARs poses a certain number of challenges, including not recording doses in real time, the difficulty of locating the MAR when needed and problems related to the legibility of notes, transcriptions, inaccuracies and signatures.

In order to increase the safety and efficacy of the medication circuit, North American healthcare facilities are progressively turning to electronic medical records (EMRs). These EMRs most often include a tool that electronically records drug doses, which is also known as an electronic medication administration record (eMAR). In the USA more than 94% of the facilities that took part in a 2014 hospital pharmacy survey stated they had implemented this tool (3). A literature review carried out by Dulermez et al. noted relatively few publications on the impact of eMARs, but they were for the most part favorable in terms of satisfaction and work ergonomics (4).

In the context of our work to computerize patient records at the CHU Sainte-Justine, we wanted to describe our implementation process and to compare MAR and eMAR.

Methods

This is a descriptive study. The main objective is to describe the phases of eMAR implementation. The secondary objective is to compare observed differences in processes between MARs and eMARs.

This study takes place in a health care facility with 500 acute care beds. Our pilot study was conducted in three pediatric surgical units covering 45 beds where there were 2,692 admissions and 9,717 days-presence in 2014–2015.

The Pharmacy Department offers nominal daily unit distribution based on Pharmacy Information System (PIS) (GesPharx, CGSI TI, Quebec City, Qc, Canada). All the hand-written drug prescriptions are entered into PIS and MARs are printed every day at 11:30 pm. Decentralized pharmaceutical care is offered 40 h a week.

Based on a review of the literature (49) and a review of the regulatory framework (1014), we identified the six main guiding principles that ensure integration into the existing pharmaceutical record: (1) use a common tool for all the professionals in order to limit transcriptions and medication errors, (2) generate MARs from prescriptions entered in EMRs, (3) ensure documentation of administered and non-administered drugs, (4) provide documentation for each steps involved in the administration process, (5) ensure the traceability for each steps involved in the administration process, and (6) respect applicable record-keeping requirements.

eMAR was designed according to these guiding principles. Policies and procedures surrounding the use of the document management tool for recording drug doses were developed. In addition, training has been provided to healthcare workers before using eMARs and periodical audits were held to verify compliance with theses policies and procedures.

We also identified parameters, defined by consensus and compared the existing hand-written process and the new process based on eMAR. We carried out all the work in conjunction with the development phase (a 12-month period), the preparatory pilot phase (two consecutive periods of 24 h and 32 h) and the pilot phase (a 20-day period). Any problems we experienced were noted and whenever possible solved. Final implementation occurred after this work.

Results

Development phase

Regarding the development phase, a total of 150 pharmacist hours (3 persons) and 150 nursing hours (2 persons) have been carried out on discussions, documentation and testing over a period of 12 months. Based on the manufacturer’s initial outline, we identified the features, displays and ergonomics of the eMAR. We worked on numerous iterations of the eMAR to obtain a version that could be piloted.

Preparatory pilot phase

For the preparatory pilot phase, we used the eMAR for two consecutive periods of 24 h and 32 h in pediatric surgery units.

During this phase, nursing staff volunteers were asked to double document all the drug doses they administered on MARs and eMARS in order to identify any eMAR-related issues. Various types of issues were identified (eg technical problems, display problems, problem features, interactivity problems). Each problem was analyzed and corrective action was taken.

Pilot phase

As regards the pilot phase, a training program of 60 min was set up and 50 training sessions were offered to 100 people in November 2014. We have implemented in the pilot phase the eMAR from 26 November 2014. All the nursing staff was invited to double document all the drug doses they administered using MARs and eMARs for a period of twenty days. A support team made up of a nurse, pharmacist, pharmacy research assistant and super-users was available 24 h a day. Informatique technical support staff members were also called upon.

Permanent implantation

On 16 December 2014 the printing of MARs was interrupted and only the eMARs was used. The steps that needed to document the administration of medications on eMARs varied according to the type of medication (Table 1 and Figure 1).

Figure 1: Comparison diagram for MAR and eMAR processes.

Figure 1:

Comparison diagram for MAR and eMAR processes.

Table 1:

Administration steps documented in eMAR by drug type.

Intermittent IV drug, PO, IR, SC, IM, topical, intradermal, otic, ophthalmic, intranasal, sublingual, stoma, levine, intra vaginal, inhalation, endotracheal and intraosseous
Prepared, Administered, Scrapped (DC), Stopped
PCA/ICA/epidural
Prepared (DC), Began (DC), In progress, Programming validation (DC), Programming modification (DC), Bag changed (DC), Derogatory manual bolus (DC), Scrapped (DC), Stopped
High risk of continuous intravenous infusions
Prepared (DC), Began, In progress, Programming validation, Programming modification, Bag changed, Stopped
Parenteral nutrition and continuous infusions with additives
Prepared (DC), Began, In progress, Programming validation, Programming modification, Bag changed, Stopped
Intravenous antineoplastic
Checked (DC), Began (DC), In progress, Rinse started, Finished, Programming modification (DC)
Medication IV intermittent high risk
Prepared (DC), Began, In progress, Rinse started, Finished

Compared profile

We described the difference between MAR and eMAR in Table 2. We identified 19 parameters related to drug registration doses. This table demonstrates the potential advantages of eMAR for many of the parameters. The eMAR is more accessible, updated without delay, archived automatically and available to multiple users at the same time. The information can be sorted in many ways. New drug prescriptions entered by the pharmacy team are immediately available on patient wards. Managing the drug administration schedule is easy and it can be done in real time. Each drug administration is recorded at the current schedule at which the dose has been given and each person involved in the drug administration process can be easily identified. The eMAR review goes through a more detailed process than the paper one. More drug information sources are available to the nurse and relevant information is displayed in context of the drug administration itself. Other variables showed more similarities between MAR and eMAR. Figure 1 displays a comparison diagram for both MAR and eMAR processes.

Table 2:

Profile compared to MAR and eMAR related to drug registration doses.

ParametersMAReMAR
AccessibilityUnique access point from a paper copy in the binder in circulation in the service with the applicable MARs to a nurse; most often a mobile nurse has the binderFrom any computer station located on each unit-dose cart; presence of computer stations at the nursing post as well as in the care unit pharmacies
Update frequency by the pharmacyEvery 24 h with printouts and as new products are sentThroughout the day from 8:00 am to 12:00 pm
Sorting and fillingAutomated paper printing of MARs in each care unit at 11:30 pm; at the beginning of the night shift, a clerk or nurse distributes the new MARs in the binders and removes the expired MARs from them in order to file them in the patient’s paper recordAutomatic digital printing of MARs in order to file the completed versions in the patient’s EMR; a PDF file of each day is generated and archived under the appropriate digital taba
Consultation and postingA single MAR for one patient at a time by consulting the binderOne or more MARs for one or more patients at a time according to the selected view
Consultation of prescribed dosesIn alphabetical order by generic name, whatever the frequency; except for manual additions that are not sorted in the current versionSorting of medications by group: medications with schedules, medications without schedules and medications as required. In each group, the medications are sorted according to alphabetical order
Record of new prescriptions validated by the pharmacyHandwritten mode with obligation to confirm the fax of the pharmacy prescription in the patient’s paper recordThe new prescriptions are entered by the pharmacy on line and validated by the nursing staff
Managing schedule changesBy completing a paper form that must be faxed to the pharmacy; a pharmacy technical assistant proceeds with online modification. The schedule change is sometimes validated by a pharmacistDirectly on line by the nursing staff
Recording dosesInformed approximate time. Handwritten mode with an interval of 59 minutes more or less with respect to proposed timeTime may be easily corrected if not documented in real time. Online mode with precise time
Comments regarding the doses administeredUse of a reference character (*) in the paper record with relevant comment in progress notes (ex.: missed dose, as patient left for a test)Comments allowed in a block of text attached to each dose
Management of drug infusionsRecording on the nurses’ notesRecording directly on eMAR
Doubled checkedHandwritten entry of initials next to time and dose that was double checkedElectronic signature with a message requiring the presence of an authorized third party confirming the act
Manuel addition following new prescritpionPaper mode and need to consult tools, Intranet or speak to a pharmacistElectronic mode with coding of generic and access to all the relevant tools on line
Description of administration stepsGenerally, one steps is recordedWorkflow is traced making it possible to identify the administrative steps performed and caregivers who performed the act
Signature entryHandwritten entry of initials next to the time and each dose administered. Signature entry along the bottom of the sheet, at first initialsSecure access to the software at the beginning of the operations and automatic signature entry for all subsequent actions
Medication reviewNursing staff must compare expired MAR with new MAR for each entry that is not necessarily in the same order given the manual modifications, i.e., additions and discontinuationsThe module displays the expired version and the new version of the prescription; pairing of all the prescriptions is offered
Laboratory results consultationAccess through the paper or electronic recordContextual access linked to the eMAR
Availability of administration documentation to the pharmacistThe pharmacist must contact the floor nurse or pharmacist to verify information in the paper MARPossible anytime and anywhere without interrupting other people
Review of the doses administeredOne page at a time; one single documented status (i.e., dose given or not)Several days at a time with overview of medication; several documented statuses (i.e., dose given or not)
Consultation of the original handwritten prescriptionBy consulting the paper record by searching by dateVisualization in the digital prescription review module at the pharmacy linked to eMAR entry

Issues management

During these various phases, some issues that were encountered could be solved and the eMAR was optimized based on the healthcare staff’s expectations. Some problems were solved with software change (e.g. improvement of the nurse workload overview, addition of an icon to highlight the new prescriptions, streamlining communication with the pharmacy). Other problems needed updated policies and procedures to better describe what is expected of the nurse. Some other problems could not be solved, such as the nurse’s need to reconnect to the eMAR to obtain medications at various locations because of the drug circuit. Moreover, as long as the electronic prescription is not developed, the nurses must manage manual addition following new prescription. Those manual addition are very time consuming and required some vigilance.

Various unsuccessful tests were done in a tablet environment, which turned out to be less than optimal in terms of both display and maintaining wireless connectivity.

Discussion

To our knowledge, this is the first proof of concept study conducted in Quebec that describes eMAR development and implementation. Since December 16, 2014, eMARs have been used continuously in three pediatric surgery units and their deployment has begun in the facility’s other services.

Benefits

The eMAR developed offers a number of tangible advantages such as documenting the acts performed in a legible way, ensuring the traceability of the administration process and recording drug doses by all the caregivers involved, limiting interruptions, facilitating access to eMARs, accelerating the prescription review process, limiting transcriptions and displaying pertinent contextual information in real time.

Issues

Developing and implementing an eMAR is not a simple change to make. Besides managing the change and taking into consideration any potential obstacles (1517) our team faced the following challenges: (a) training of basic computer knowledge to healthcare staff (the computer had until then mainly been used to consult laboratory or imaging results), (b) eliminating doubts about relying solely on computer archives and avoiding spurious paper documentation, (c) optimizing different task ergonomics (i.e., displaying all the doses according to hour of administration rather than patient), (d) documenting dose administration in real time, (e) dealing with complaints linked to the slowness of the terminals and other technological limitations. Our pilot study shows that we were able to face these challenges despite human, financial and material constraints.

eMAR use in North America

Most American facilities use EMR-management integrated systems (ex.: EPIC) that include eMARs. Very few facilities in Canada and Quebec have the financial resources for such tools (i.e., ~ $80–$700 million/facility) (18). EMR deployment in Canada continues to lag. Healthcare Information and Management Systems Society (HIMSS) is a global information technology company with more than 52,000 people involved in the development, use and evaluation of technologies. This company periodically collects data on the rate of implementing information technologies, including EMRs, based on an 8-stage scale. A stage 0 organization has no computerization of the drug-use circuit whereas a stage 7 organization provides a complete electronic medical records and allows to share and warehouse data (e.g. 95% of patients and 95% of medications have closed loop process for medications) (19).

On December 31, 2014, HIMSS noted that 89.2% of American healthcare facilities (out of 5,467 sites evaluated) had attained at least stage 3, which includes the use of an eMAR, compared with 37% of Canadian facilities (out of 641 sites monitored) (20). In the Canadian report on hospital pharmacies, only 14% (23/161) of the respondents stated they had implemented e-prescription (e-Rx) as of March 31, 2014 (21). Generally speaking, the facilities with e-Rx also had a module that allowed the electronic recording of drug doses. Lastly, data from the Ontario Hospital Association reveal an eMAR adoption rate of only 27% (20). All of these data confirm the extent to which Canadian facilities lag behind their American counterparts.

Until now, the North American facilities that have been able to reach stages 6, 7 and 8, as proposed by the HIMSS, have implemented integrated systems rather than a myriad of interfaced systems. Most facilities in Quebec now use an “à la carte” product strategy with bidirectional interfaces. As it is the scenario adopted by our facility, it is essential that the eMAR interface with the e-Rx program and EMR. Other EMR management software programs have been acquired in the facility and discussions are under way in order to confirm secure bidirectional interfaces with the EMR and the eMAR. The full potential of the eMAR can however be realized if it also interfaces with the e-Rx program.

After deployment in all of our facility’s care units and outpatient clinics, the next phase will be to develop the use of barcode readers in order to reinforce the security of the administration of doses by confirming the identity of the patient, caregiver and medication to be administered.

Limits

Our study was conducted in three pediatric surgery units in a teaching hospital. This may in theory jeopardize the external validity of our results. We are sure each implementation will have their specific challenges. However, we think our results can be used to facilitate implementation in other care settings. Within the context of this pilot study, we did not evaluate the impact on health outcomes (ex.: mortality, morbidity, compliance), costs, medication errors or even workloads targeted by the technology. In the second phase of our work, we will focus on assessing some of these outcomes.

Conclusion

To our knowledge, this is the first pilot study conducted in Quebec that describes eMAR development and implementation. Our pilot study shows that we were able to face these challenges through the employment of human, financial and material resources.

Acknowledgements

The nursing staff of surgical units, the team of IT, pharmacists and senior-pharmacy technicians of the pharmacy department, supporting departments involved.

Funding: None declared.

  1. Conflicts of interest statement: Denis Lebel and Jean-François are also consulting for CGSI TI Inc. Other than this, authors state no conflict of interest. All authors have read the journal’s publication ethics and publication malpractice statement available at the journal’s website and hereby confirm that they comply with all its parts applicable to the present scientific work.

References

1. Groupe de travail sur l’introduction de systèmes automatisés et robotisés utilisés pour la distribution des médicaments dans les établissements de santé au Québec. Les systèmes automatisés et robotisés utilisés pour la distribution des médicaments dans les établissements de santé au Québec. Rapport et recommandations du groupe de travail. [Internet]. 2005 [cited 2015 Mar 18]. Available from: http://publications.msss.gouv.qc.ca/acrobat/f/documentation/2005/05-719-01.pdf.Search in Google Scholar

2. Seidling HM, Lampert A, Lohmann K, Schiele JT, Send AJ, Witticke D, et al. Safeguarding the process of drug administration with an emphasis on electronic support tools. Br J Clin Pharmacol. 2013 Sep;76(Suppl 1):25–36.10.1111/bcp.12191Search in Google Scholar PubMed PubMed Central

3. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Prescribing and transcribing-2013. Am J Health Syst Pharm. 2014 Jun;71(11):924–42.10.2146/ajhp140032Search in Google Scholar PubMed

4. Dulermez T, Lebel D, Mercier G, Bussières JF. Enregistrement des doses de médicaments administrées aux patients par le personnel soignant en établissement de santé : revue de la littérature. Annales de l’URPP. 2015 Jun; 1–10.Search in Google Scholar

5. Brown TR. Handbook on institutional pharmacy practice. 4th ed. Maryland: American Society of Health-System Pharmacists; 2006. 572 p.Search in Google Scholar

6. Manasse HR, Thompson KK. Medication safety: a guide for healthcare facilities. Maryland: American Society of Health-System Pharmacists; 2005. 392 p.Search in Google Scholar

7. Holdford DA, Brown TR. Introduction to hospital & health-system pharmacy practice. Maryland: American Society of Health-System Pharmacists; 2010. 416 p.Search in Google Scholar

8. Chisholm-Burns MA, Vaillancourt AM, Shepherd M. Pharmacy Management, leadership, marketing and finance. 2nd ed. Burlington: Jones & Bartlett Learning; 2014. 590 p.10.1093/ajhp/70.4.373Search in Google Scholar

9. Bussières JF. Législation et systèmes de soins. 10th ed; 2014. 963 p.Search in Google Scholar

10. Agrément Canada. Gestion des médicaments. [Internet]. [cited 2015 Jul 13]. Available from: https://www.accreditation.ca/fr/gestion-des-m%C3%A9dicaments.Search in Google Scholar

11. Loi sur les aliments et drogues. [Internet]. 2015 Jun [cited 2015 Jul 8]. Available from: http://laws-lois.justice.gc.ca/PDF/F-27.pdf.Search in Google Scholar

12. Loi réglementant certaines drogues et autres substances. [Internet]. 2015 Jun [cited 2015 Jul 8]. Available from: http://laws-lois.justice.gc.ca/PDF/C-38.8.pdf.Search in Google Scholar

13. Loi sur la réglementation des médicaments et des pharmacies, L.R.O. [Internet]. 1990 [cited 2015 Jul 8]. Available from: https://www.ontario.ca/fr/lois/loi/90h04.Search in Google Scholar

14. Loi sur les infirmières et infirmiers. [Internet]. 2014 Apr [cited 2015 Jul 8]. Available from: http://www2.publicationsduquebec.gouv.qc.ca/dynamicSearch/telecharge.php?type=2&file=/I_8/I8.html.Search in Google Scholar

15. Guérin A, Lebel D, Bussières JF. Importance de la gestion du changement en gestion des risques et de la qualité. Pharmactuel [under press].Search in Google Scholar

16. Guérin A, Lebel D, Bussières JF. Barrières relatives aux changements en pharmacie : perspective des étudiants en pharmacie canadiens. Can J Hosp Pharm. 2013 May-Jun;66(3):198–201.10.4212/cjhp.v66i3.1260Search in Google Scholar PubMed PubMed Central

17. Guérin A, Lebel D, Hall K, Bussières JF. Change management in pharmacy: a simulation exercise and identification of change barriers by pharmacy leaders. Int J Pharm Pract. 2015 [under press].10.1111/ijpp.12199Search in Google Scholar PubMed

18. Moukheiber Z. The staggering cost of an EPIC Electronic Health Record might not be worth it. Forbes [Internet]. 2012 Jun [cited 2015 Jun 29]. Available from: http://www.forbes.com/sites/zinamoukheiber/2012/06/18/the-staggering-cost-of-an-epic-electronic-health-record-might-not-be-worth-it/.Search in Google Scholar

19. Integration of information – sharing of thought. Canadian Hospital Pharmacy Leadership Conference; 2015 Jun 06; Toronto, Ontario.Search in Google Scholar

20. Healthcare Information and Management Systems Society. About HIMSS. [Internet]. [cited 2015 Jun 23]. Available from: http://www.himss.org/aboutHIMSS/.Search in Google Scholar

21. Doucette D. Drug distribution systems. In: Hall K, Wilgosh C, Bussières JF, Doucette D, Musing E, Mcnair K et al., editors. Hospital Pharmacy in Canada Report 2013–2014. [Internet]. 2015 [cited 2015 Jun 23]. Available from: http://www.lillyhospitalsurvey.ca/hpc2/content/2015_report/chapter_c%20.pdf.Search in Google Scholar

22. Truchon S. L’administration de médicaments : rappel des obligations déontologiques. [Internet]. 2004 [cited 2015 Jun 29]. Available from: https://www.oiiq.org/pratique-infirmiere/deontologie/chroniques/ladministration-de-medicaments-rappel-des-obligations-deo.Search in Google Scholar

Received: 2015-8-17
Accepted: 2015-9-21
Published Online: 2015-11-18
Published in Print: 2016-3-1

©2016 by De Gruyter Mouton