Customizing an Electronic Medical Record to Automate the Workflow and Tracking of an Antimicrobial Stewardship Program

Abstract

Background Documenting the actions and effects of an antimicrobial stewardship program (ASP) is essential for quality improvement and support by hospital leadership. Thus, our ASP tallies the number of charts reviewed, types of recommendations, how and to whom they were communicated, whether they were followed, and any effects on antimicrobial days of therapy. Here we describe how we customized the electronic medical record at our institution to facilitate our workflow and data analysis, while highlighting principles that should be adaptable to other ASPs. Methods The documentation system involves the creation of a novel and intuitive ASP form in each chart reviewed and 2 mutually exclusive tracking systems: 1 for active forms to facilitate the daily ASP workflow and 1 for finalized forms to generate cumulative reports. The ASP form is created by the ASP pharmacist, edited by the ASP physician, reopened by the pharmacist to assess whether the recommendation was followed and to quantify any antimicrobial days avoided or added, then reviewed and finalized by the ASP physician. Active forms are visible on a real-time “MPage,” whereas all finalized forms are compiled nightly into 65 informative tables and associated graphs. Results and Conclusions This system and its underlying principles have automated much of the documentation, facilitated follow-up of interventions, improved the completeness and validity of recorded data and analysis, enabled our ASP to expand its activities, and been associated with decreased antimicrobial usage, drug resistance, and Clostridioides difficile infections.

Impact of removing ESBL designation from culture reports on the selection of antibiotics for the treatment of infections associated with ESBL-producing organisms

“…Our antimicrobial stewardship program (ASP) is described in a separate publication. 3 The Microscan LabPro Command Center database (Microscan WalkAway 96 Plus, Beckman Coulter) was used to identify adult and pediatric patients with positive cultures for ESBL-producing Enterobacteriaceae during the 6-month periods before revised breakpoints were implemented (January 1, 2017, to April 30, 2017) and after the revised breakpoints were implemented (May 1, 2017, to October 31, 2017). Patients and isolates were excluded from the current analysis if any of the following conditions applied: treatment initiated in the outpatient setting, no antibiotics prescribed, antibiotics were prescribed for an indication unrelated to the clinical culture, central nervous system (CNS) infection, organism not reported in the EMR (eg, final report of "mixed flora"), polymicrobial cultures with varying susceptibilities impacting antibiotic selection, or isolates demonstrating resistance to all β-lactamβ-lactamase inhibitor combinations (BL/BLIs) and/or carbapenems.…”

Identifying Opportunities for Workflow Automation in Health Care: Lessons Learned from Other Industries

“…44,47 The degree of automation was generally linked to the complexity of tasks within a workflow, types of decision rules involved for the workflow, sophistication of technology needed, technology availability, and human intervention needed. 64,[83][84][85] Determining the degree of automation requires reviewing workflows and their context. For example, in a semi-conductor manufacturing plant, workflows across the production line were reviewed to determine which could be fully automated, semi-automated, or should remain manual.…”

“…The literature showed that a poorly automated workflow can affect quality and trust 45 50 55 60 61 and, in contrast to other industries, such as manufacturing, health care providers, staff, and patients contribute to a co-produced service involving coordination, communication, and commitment to an intended health goal or status. 3 19 84 The foundational role of the provider–patient relationship in the human experience of care delivery underscores the importance of selecting workflows to automate that create and maintain trust in the humans and technology involved. Moreover, patient privacy and data security are important considerations in health care delivery, 1 which calls for a critical need for careful planning and protection in highly automated workflows.…”

Using Technology to Enhance Antimicrobial Stewardship Impact in the Acute Care Setting

“…Harvin and colleagues also demonstrated the significant reduction in time to intervention from 24 to 8 h with the use of their scoring tool [13]. Cerner offers a similar stewardship module which has been shown to decrease antimicrobial days of therapy, increase susceptibility of E. coli and P. aeruginosa to ciprofloxacin or decrease C. difficile infections in several recent studies [14,15]. Initial implementation was also associated with an approximate $600,000 decrease in antimicrobial drug acquisition costs [14].…”

“…Documentation is essential to demonstrate the stewardship team's impact on patient care. Katzman and colleagues utilized an antimicrobial stewardship form hosted by Medmined which can interface with EMRs such as Cerner [14]. Kullar and colleagues describe the use EPIC "i-Vents" for documenting stewardship interventions but are only visible to pharmacists [18].…”