BAPTIST HEALTH Medical Center in North Little Rock, Arkansas, is a 220-bed hospital with services in general, orthopedic and cardiac surgery, interventional cardiology lab, oncology, general medicine, OB/GYN, pediatrics and outpatient wound care.

Prior to implementing Clinical Xpert CareFocus from Thomson Reuters, we used a manual process for identifying clinical intervention opportunities that started with pharmacy requesting reams of paper containing all active medication orders for each patient from the nursing unit. We would then manually comb through these documents, online labs, and demographic data, to identify clinical or formulary issues that needed to be addressed.

Automating Clinical Surveillance
In automating this process with CareFocus, our initial focus was on increasing workflow efficiency while having a positive impact on Joint Commission and CMS core measures. The preliminary clinical queries we developed included

• Targeting of renally impaired patients on renally eliminated medications (e.g. imipenem/cilastatin, eptifibatide, lebofloxacin, etc.)

•  Patients with positive preliminary or finalized microbiological cultures                                   
  
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      •  Ensuring cost effective utilization of expensive medications                                            
        
•  Possible serious side effects caused by medications                                                           
  
•  Appropriate medication therapy

With CareFocus, data queries are built into the program with staff input. An example of a query could be as simple as, “I would like to see all active patients with a serum potassium greater than 5 mEq/L,” or as complex as, “I would like to see all active patients on the 3B nursing unit with a diagnosis of congestive heart failure (CHF) without an active order for an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB).”
Each clinical query is set to run at specified times throughout the day, thereby ensuring an updated, real-time list for the largest clinical impact. Using customizable profiles, our IT department can deploy data to different departments within the hospital system, including dietician, case coordination, infection control, nursing, and others.

Using the Data
We can aggregate data from virtually all hospital information systems including demographics, pharmacy, laboratory, radiology, dictated reports and online charting software in order to create our surveillance profiles. Every quarter we create reports describing the type of interventions, trending, and cost savings/avoidance achieved by the pharmacy team. Reports are built using Pendragon software and Excel. These reports are emailed to all pharmacists and posted within the department. This allows us to track staff productivity and cost savings/avoidance, and the data is considered during our pharmacists’ annual performance evaluations. We also share the intervention results data with administration, medical staff, and nursing via our Quality Review Committee. This helps senior administration better understand how clinical pharmacists make a daily positive impact, both clinically and financially.

The Implementation Process
In June 2006, our clinical pharmacists were trained on the functionality, flexibility, and manipulation of CareFocus and input from staff was obtained to develop clinically relevant queries. Pharmacy workflow and accountability were then re-organized. At present, each clinical shift is assigned CareFocus queries for daily review. Since its initial implementation, several changes have occurred. Pharmacy no longer reviews CHF or acute myocardial infarction core measures; we now have a separate care coordination team that uses CareFocus to monitor core measures and other key clinical initiatives. This is a good example of how we can adjust workflow and resources within the hospital, and take advantage of automation to expand our clinical impact.

Changes in Clinical Interventions
Since implementing CareFocus, our approach to the daily workload is more standardized and we can assign priorities to the clinical staff as needed. Not only have we seen the quantity of interventions increase, but the quality of our interventions has increased as well.

We have found that it is important to avoid queries that are too broad. For example, we started with a query that showed every patient with an active order for meperidine.  In order to improve the effectiveness of this query, we modified it to return only those patients that fall outside the American Pain Society recommendations for meperidine use. CareFocus queries are customizable so we can adjust them to ensure we are reaching the right patients. Creating a daily priority list, rather than setting out to conquer every problem, will allow you to make significant clinical improvements (and realize cost savings) without increasing staffing levels. CareFocus has certainly helped us to manage our workload more efficiently and effectively, and with future enhancements it will continue to grow with our department.

In Conclusion
CareFocus mines data for us and presents it in a timely and easy to use format. By doing this, we can enhance efficiency and productivity. It is important to note that this system does not replace a pharmacist’s critical thinking skills required to interpret the query results or the professional relationships needed to produce a change in therapies through real-time interventions.

 
Kevin Robertson, PharmD, BCPS has been the clinical coordinator for pharmacy at the Baptist Health Medical Center in North Little Rock, Arkansas since 2003. He received his PharmD in 1996 from the University of Arkansas for Medical Sciences, and completed an ASHP accredited Pharmacy Practice Residency at Methodist Hospital of Memphis in 1997. He acquired his BCPS in 2005.