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.
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 (4–9) and a review of the regulatory framework (10–14), 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.
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.
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.
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.
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.
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.
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.
Developing and implementing an eMAR is not a simple change to make. Besides managing the change and taking into consideration any potential obstacles (15–17) 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.
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.
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.
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.
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About the article
Denis Lebel is an assistant director at CHU Sainte-Justine’s Pharmacy Department since 1999. He practices as pharmacist since 1992 and assumed teaching duties at the University of Montreal in 1992. Denis Lebel obtained his B.Pharm in 1992 and his Master of Science in 1993. He received the Fellow of the Canadian Society of Hospital Pharmacists title in 2005. He has received numerous awards for excellence. He regularly gives conferences and has contributed to many research projects and publications.
Geneviève Mercier works as a clinical nurse specialist in nursing informatics at CHU Sainte-Justine in Montreal, a pediatric university care centre. After obtaining a Bachelor’s degree in nursing at University of Montreal in 2002, she started her practice at CHU Sainte-Justine as a clinical nurse in pediatric oncology. In 2007, she obtained her Master’s degree in nursing science and became a clinical nurse specialist in pediatric oncology. In 2013, Genevieve Mercier joined the EHR team at CHU Sainte-Justine as the informatics nursing specialist for the development of their home-grown EHR.
Thomas Dulermez is a pharmacist. Following the start of his pharmacy study, he expanded his clinical pharmacy activities by completing his pharmacy residence in Parisian hospitals in 2010. In 2014 he obtained his D.Pharm and he performed an internship at the Pharmacy Practice Research Unit, CHU Sainte-Justine, Montreal.
Aurélie Rousseau is a D. Pharm candidate. She obtained her master of science (clinical research) in 2014 at Université Claude Bernard, Lyon. Currently, she performs an internship at the Pharmacy Practice Research Unit, CHU Sainte-Justine, Montreal since April 2015.
Jean-François Bussières, pharmacist, obtained his B.Pharm in 1988 and his Master of Science in 1992 from Université Laval and his Masters of Business Administration from McGill Université de Montreal, in1992. In 1996, he became Head of the pharmacy department of CHU Sainte-Justine. In addition, he combines the functions of Head of the Pharmacy Practice Research Unit, Clinical professor at the Université de Montreal and guest speaker at Université Laval. He received numerous awards for excellence, including the Louis-Hébert price in 2000, the innovation of Pharmacists Award in 2013, and Roger Leblanc Award of Excellence in 2001, and other awards from the Canadian Society of Hospital Pharmacists. He was also recognized with Outstanding Contribution Award for teaching at the Université de Montréal.
Published Online: 2015-11-18
Published in Print: 2016-03-01
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.