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This series focuses on leadership topics within pharmacy practice, including the business of pharmacy, development of leadership skills, career transitions, and more. My name is Kyle Mays, and I'm the Clinical Pharmacy Manager at SSM Health Cardinal London Children's Hospital in St. Louis, Missouri, and I will be your host for today. Today, we are sitting down with several pharmacists to discuss their experience with developing and integrating clinical pharmacy scoring systems within the electronic health record. Before we dive into the discussion, though, we'll have each of them take a moment to introduce themselves. Tim? Hi, I'm Tim Holman. I'm the pharmacy director at SSM Health St. Clair Hospital in Fenton, Missouri. My background is actually in pharmacy informatics, since I've managed IT teams in pharmacy for a number of years before coming over to the operation side again. Hi, everybody. My name is Calvin Ice, and I am a pharmacy manager for training and education for Corewell Health, and I'm based in Grand Rapids, Michigan. I've been able to work with clinical scoring systems throughout the last year as we work to implement that within our system. Hello, everyone. My name is Ariel Therma. I am one of the system clinical managers for pharmacy services with SSM Health. My main sport area is engaging team members to align, optimize, and grow the pharmacy practice model across our system. I've been working with the scoring practice dashboard for about two years now. I'm excited to have this conversation to share what we've learned. Welcome, and thanks for joining us today, everyone. So let's get started. First, let's start with the basics. What is a clinical pharmacy scoring system? Why is it important to us as pharmacists? Yeah, I'll start. I would say a clinical pharmacy scoring system is really trying to take all of the data and information that is in our electronic health records in that patient chart and use that in a cohesive way to present information to our pharmacists who are caring for that patient. You probably talk more about what that really looks like, but I think that's kind of the summation of it. It's taking data using it by the frontline pharmacists. And from my experience, really, how we impact patient care with that is historically a lot of pharmacies operated with a very task-centric model. You're doing kinetics. Somebody else is doing IV to PO. And really, the patient scoring system in my mind has allowed us to become much more patient-focused and careful or patient holistically across a variety of those tasks. Yeah, thanks, Tim, for that description. I think two goals here, too, when SSM Health looked at implementing this in our pharmacy practice, the first goal, ultimately, the patient is where we're focused on. They're the ones that we want to make sure we're giving best quality to. So with that, we wanted to make sure no matter what hospital you walked into, you were getting the same pharmacy services. And so because of that, we really wanted to make sure we had our electronic medical record tools aligned in supporting the pharmacists no matter where they work. So ultimately, providing that quality care to the patient. So for pharmacists, we aim to decrease the cognitive load of their patient monitoring. So a lot of what they were doing was you'd get your patient list or you'd get your team that you're working on, and then you'd have to go and dig. You were detectives, right? You had to go and you had to dig. You had to figure out what information you needed for your management. And we really wanted to move towards pushing that information to our pharmacists with a goal to prioritize the patients that needed the highest medication management needs. And really, the goal was to decrease the overall cognitive load of digging for information to free them up to have more energy to really support the patient. My response on the importance is pretty similar to what Ariel said as well. And in terms of making sure that our patients were receiving the similar care across the organization. And so our clinical scoring system at Corwell Health was somewhat prompted by integration of three different regions of our system moving into one instance of EPIC, which is our electronic health record that we utilize in our system. With this, we, in our destination instance of EPIC, had several different columns within our patient list that our pharmacists had to keep track of each day, trying to make sure they had all the warfarin dosing, all the vancomycin dosing and other things. And so part of our impetus for developing a scoring system was so that we could consolidate some of that information as we continued to integrate with other regions of our system so that as we added in new dosing services, that list of columns did not continue to expand and expand and expand to where it was difficult for pharmacists to manage. And so we developed a scoring system similar to many other organizations that has kind of three different columns that our pharmacists are able to view and sort by and work through information. That was the big impetus behind why we ended up making this change is that we knew we had change coming as we were aligning things as a system and knew that this would probably give our pharmacists the clearest picture and best tools going forward to be able to do work effectively and focus in on the patients that needed attention the most. Thanks, everyone. So all exactly does the scoring system function within the electronic health record? Well, I think Tim did a nice job in throwing us to what a scoring system was, but my quick definition of the scoring system is that it's essentially a set of discrete rules that will review the patient charts for information. And then it works to display a set of values set by whoever designs the scoring system into whatever location or locations are designated by that scoring system. So I've mentioned a few times columns on a patient list. So these scoring systems are set up to get in and find information within the patient's record and display that information. However, we tell it to display whether it's a score, like a numerical score or an icon depending upon the column. And so with the scoring system, obviously, numerical value is good because you can pull multiple rules and sets of rules into that and see how many rules are hitting that particular column or trigger or particular scoring system. Yeah, so let's talk through an example, probably a really common example. Most of us manage warfarin still that hasn't completely gone away. So let's say you really wanted to make sure if an INR came back greater than four when a patient was on a warfarin that your pharmacist was notified right away. So you would build out a rule that has the EHR, the EMR, look for warfarin, an active warfarin order, or potentially an active warfarin per pharmacy order, and you would have it look for an INR greater than or equal to four. So any lab result with an INR that's greater than or equal to four, plus a patient on a warfarin on an active order for warfarin, will meet the criteria for that rule to push. So let's say you have Jane, Jane comes in, you verify her warfarin, and now she's sitting there and she's doing okay the first day. Her INR was in range, that warfarin dose was appropriate, and now it's the six AM labs the next day. You're not looking at anything in the verify queue anymore for that warfarin, but that INR level comes back in its five. So what the scoring tool does is it will connect that there's an INR greater than or equal to four, because Jane's INR is five, and she has an active warfarin order of some sort, whether that's warfarin per pharmacy or an active warfarin order. That rule will automatically push real time to the pharmacist list that Calvin was talking about, and depending on where you have that categorized, whether you have it in, let's say, an intervene column or an anti-COA column, it will push to that column and the pharmacist will be able to see that real time as soon as that lab is resulted. So what it allows is the pharmacist didn't have to go into Jane's chart and figure out what the INR was. The system supported the pharmacist to say, "Hey, lab resulted. It's high in the patients on a high risk med." Thanks for the example, Ariel, and again, thanks, Calvin, for laying out a map of how the scoring system kind of functions within our electronic health record. I anticipate a lot of interested parties. So if a health care system were wanting to develop and implement this tool or similar tools, what steps should be taken to ensure a successful build and launch of this tool? So this is the way we're going to proceed. So what that looked like when I was in IT was one, both identifying the tools in the health record to say what options do we have available to us? Are there other examples out there that we could build off of, starting base to build off of, and then work with your operational stakeholders to make sure that the pharmacy operation side is ready for this change as well, because you're going to change how your staff functions and then bring your IT team back in and kind of put it on the development roadmap to make sure that you have both the operational and the IT resources that you're going to need to make this a successful project? And I think Tim gave a great background there of all the build-up that's needed. I think that once you get that organizational support and departmental support to move forward, there are a few things to keep in mind as well. I think one of the things that helped us be successful in our launch of our scoring system was that we kind of started with the familiar for our pharmacist and then used a phased approach, which I understand from Ariel as well. It's similar to what they did. They used a phased approach and continue to build upon their scoring system, so you have to have a perfect product up front. You can continue to build upon things. So our approach that we used was, I mentioned previously, our pharmacist had several columns they were referring to, and so we used the rules behind those columns and just pulled them into scoring systems. In our first phase was basically going live with rules our pharmacists were used to, but just moving them into scoring systems. And then our second phase was adding information to that additional rules, new dosing services that were coming with our system integration and pulling in other items that we were able to borrow from other scoring systems throughout the organization. For example, we had a virtual ICU and we referenced a lot of the rules that they used in some of their scoring systems to pull in, patients that were on multiple vasopressors, rather than recreating our rules from scratch and having our analysts try to figure out exactly what we were getting at. We were able to borrow from other scoring systems within our own system. And so that was helpful using that phased approach because our pharmacist got to start with what they were familiar with and get used to seeing it presented in a different format before we started throwing in a lot of new variables and new rules for them. Obviously, as part of that process, it's very important to educate and educate frequently. So we tried to let our pharmacist know up front when this project was starting, what it was going to look like, and kind of our road map for when we would be implementing it so that we went live in August of 2023. So come August 2023, people weren't surprised that this was coming. They had heard about it a few times. Yes, we didn't tell them all the details up front because we were still developing the details, but it wasn't a complete shocker that it was coming. Once you get through that go live period and hopefully appropriately are able to support the team, it's important to sit back and reflect and adjust as well. And so what we found was when we went live, there were things that didn't work as intended. Fortunately, with phase one, most of it did because we were borrowing from existing rules. When we went live with phase two, that's where things broke down a little bit. And so making sure that you have analyst support at the date and time of go live to be able to quickly get in and play with things and fix them is highly important to make sure that you're going to be successful because you don't want to end up with pharmacists getting flags that mean nothing because they're flagging on every patient because the rules completely broken in the background. You need to be able to adjust and fix that quickly. But yeah, after that initial go live, the focus was continuing to build and continuing to go forward. And so for us, I think one of the things that we had to keep in mind is how do we discreetly bright rules that can appropriately pull information. I think one of the things that we worked on between our phase one and phase two go live was we wanted to be able to identify patients that were on therapeutic and oxygen. And that's where it got a little bit tricky. And I'll use a specific example here is got a little bit tricky to figure out how exactly you write this rule. Because if we just use doses of an oxyparin greater than 40 milligrams, that might not be completely reflective. If we have some patients that are on higher prophylactic dosing in our trauma population, for example, sometimes we'll go higher based on patient's weight. And so what we ended up devising in order to try to catch patients that were truly on therapeutic. An oxyparin is that we looked at patients from a weight based dosing perspective. So anybody that was on more than half a milligram per kilo of an oxyparin in a single dose was then flagged as being more of a therapeutic an oxyparin recognizing that's still probably not 100% accurate. But at least it got us closer than if we just set our limit at an oxyparin 40 milligrams. It also allowed us a bit to be able to apply that scoring system into our pediatric population who would never very many times would not be dosed higher than 40 milligrams in a single dose. And so we were able to use that logic and just had to play around with the rule and the logic to make it work appropriately. So consider that as you have suggestions coming in from team members is how do you actually write this rule to be appropriate and have it fire appropriately and then making sure that you tested appropriately. And I think I might call Ariel in here. She's got a great example of how they test things at SSM in terms of having kind of a validation column. So Ariel, you want to talk a bit about that one? Yeah, that's a great point. So we also learned that you can test things as much as you want in a test environment as soon as you push it into production or that live environment, it still could not work exactly the way you think it should. Some of the things that cause that are you know, you may have different coding for labs at different ministries. And so a lot of rules connect to labs or results that come from different departments and that can have slightly different numerical codes depending on the hospital. It's kind of unpredictable when you're in testing environment to see that. And so what we decided to do and we're supported with is we made a validation column. So we've talked about patient lists in the columns being really where these rules push. So we do have a preset standard system columns that have our main ones that we expect all pharmacists to be using and managing. But we added a rule validation column that's not in that standard template. And so we have a designated group of people which we call frontline councils. Those are our friendly members who are engaged with this process who have pulled in that column. And then any rule that is new gets pushed to that column first so that they can validate if it's pushing correctly. If the criteria is accurate, if it's really noisy, sometimes we've had rules that end up being really noisy but not value added. And so now we're able to pre-screen that with a small group of frontline pharmacists, clean it up, optimize it, and then decide where to push it to the rest of the pharmacy team. That has been a really big win as we've really been trying to clamp those rules like Calvin was talking. Thanks for sharing guys. Our wants to take in, especially when we consider like how to build this tool and prepare for launch and deal with our never endings issues that can arise. So I think it's a fair question, especially as pharmacy leaders is how is this being used by your pharmacy team members? It's one thing to have the tool in place but another of how it's being used on a day-to-day basis. So what are your guys' thoughts on this tool being used and the pharmacist workflows? Yeah, so similar to SSM, we at Corewell Health kind of adapted this as our primary list for all pharmacists to be able to reference on the inpatient side. And with it, we have ours broken down into three columns or three scoring systems. There's an intervene scoring system, which is something we expect all pharmacists to be able to review and interact with, kind of regardless of time of day. It's primarily lab results that are coming back. So Ariel's example of an elevated INR would flag this column so that the pharmacist would be alerted regardless of time of day that, oh, we might need to follow up on this sooner rather than later. We also have a dosing service and consult column that pulls in. That kind of drives our pharmacy dosing services and ensures that anything that our pharmacist are managing does pull into that column. And so our pharmacists are able to utilize that to make sure that patients who have a true pharmacy dosing service following do get reviewed on a daily basis. And then beyond that, we call it the assess column, which is more of a there are potential items on this patient's profile or labs that this patient has or certain medications that we might want to alert pharmacists to, but it's less discrete on terms of what the function of the pharmacist might be and certain populations might care about certain items more than others. And so we kind of use that as more of an acuity piece where if a patient scores pretty highly in this column, you're probably going to want to try to prioritize their review as well, even amongst the patients that are getting the true pharmacy dosing services as part of their care. And so that's kind of how we utilize ours in practice and try to help it be a tool for pharmacists to be able to prioritize their care and make sure that they're getting to patients that have items that we consider maybe higher alert than other items so that we're able to hopefully impact their care positively. Yeah, I'm going to echo a handful of a Kelvin just shared too, which is great. As we were talking through this together, I was like, this is fantastic. We're using a system very similarly to support pharmacy in kind of a universal way. So lots of fun to hear how people are using it. So I'll share from more of a system standpoint of how we see it. And then I'll hand it over to Tim to discuss how he sees it at the ministry level. So as a system group, we built standard work around this tool. So just like Kelvin was sharing that they have their three set columns. We as well have set columns. We have four. So we have the intervening column and we use it very much the same way as Kelvin was saying. It's a med safety, time sensitive type rules are pushing there. So we consider those step now high priority. And then we have our consult column, which per our standard work is high priority. And we expect pharmacists to get to all of their consults since that is delegated care to the pharmacist, you need to get to that every day. Then we use the assess column and we define that as you must look at those rules within your shift. So those are daily monitoring rules that we push there. And then there's a monitoring column, which is review within this day. So a lot of the ones that go there are dox go there, high risk meds that maybe don't need a lot of follow up. But we as pharmacists want to be aware post that order verification phase that a patient's on any of those meds. So with that, we have standard work saying how or supporting the pharmacist of how they would prioritize through those columns. So as you heard me saying, intervene as a high priority column consults is a high priority column. And then assess and monitor our considered moderate priority. So that kind of helps them move through their day. Or if they move into a skeleton shift, because maybe they got sick calls, it really helps drive where the priority should be. And the rules have built the trust with the pharmacist to know those truly are the patients that they need to put eyes on. We've also done standard work down to the level of each individual rule. And the goal with that is you can get metrics from all of these rules. So every time a pharmacist signs off, I don't think we've talked enough about metrics, Kelp, and that they can get from us. But you can get metrics from every single rule that the pharmacist is signing off. We call them silent events, because they just happen in the background once the pharmacist hits except on their rule. So because of that, we wrote standard work with every single rule so that we can make some assumptions when when evaluating that data. We've learned a lot with the different metrics that push from that. And we're still optimizing the different buttons that we can report out. But it's really been fun to capture what the pharmacist are doing, the different touch points that they have in a patient. There's a lot of touch points that we just consider part of our everyday process. And we now can visibly share that with them. So we definitely were using the metrics as well. And we use the standard work to support that for our teams. I'm fully echo what Calvin and Ariel have said about how the tool is set up and how we're using it in basics there. But without repeating what they said, I will say we at Sinclair Hospital really made a point of trying to integrate this with all of our pharmacists. So I think some of our hospitals decided to do it kind of for their decentralized day shift primarily. And we we decided this was an important tool for us to standardize and elevate the practice of all of our pharmacists across all of our shifts. And so we found the prioritization piece of it to be very helpful on nights and weekends when folks weren't trying to get to a whole house of of patients and maybe not getting there. They at least got to those most important elements for those patients who needed our intervention the most. So that was a great thing. And I think it elevated the practice of all of our pharmacists. The other thing I think it really helped us as we try to drive the integration between those who are in our central pharmacy and those who are practicing decentralized and really a massive people who cross over between those two things. This we assigned two of our patient care units to our centralized pharmacy team each day. And so they're in there practicing with the scoring tool, they're developing those skills, knowledge of how that works. So it's much easier than to cover gaps to send someone out to a different unit because it's the same tool. They can work with a different population, maybe a couple different interventions based on care of those patients. But in large part, we can deploy any of our pharmacists to any of our areas on any given day or shift. And they're comfortable that they know what to do. So I think using that as a tool really to help integrate and elevate the practice of your pharmacists as a huge benefit and how to use it. Yeah, thanks for sharing, Tim. I agree with anything that we can use to help elevate pharmacy practice and help kind of prioritize patient care is going to be welcome, especially as it seems all the hospitals seem to be increasing and the number of patients we're seeing on a daily basis. Kind of changing gears slightly. And some of these items have already been touched upon. What are some lessons learned from your guys's perspective when implementing my clinical scoring tool? It can be technical, something that you encountered in the clinical standpoint. So we're just even impact to workflow. Yeah, I can get started with this one. And I mentioned this a little bit earlier as well. But absolutely, one of the biggest lessons that I learned is that despite extensive testing, there will certainly be hiccups moving this into a live environment. And so ensuring that you should do a ton of planning upfront and a ton of testing on any rules that you're going to roll out within a scoring system. But despite that, there will probably be some hiccups when it moves to a live environment in a greater population who's exposed to these rules as you have it pull in from various patient charts. And so that'll reveal some of the issues. And when it comes up, it's just important to have a plan in place on how to deal with that. And so that was one of my biggest lessons that I've learned through both phases of our go live of our process. But we'll hopefully, as an organization soon, we'll be moving into more of an optimization phase where we'll be looking at adding rules based on what individuals want. And it's been great to be part of this group and panel, because I've gotten to learn some things from the group as well. So we'll definitely be employing or at least seeking to employ that validation column that Ariel mentioned, because that helps to get to a lot of those issues of if you're able to push this out into a live environment and have a dedicated set of users tested, that's great. You know, even with that, I'm sure it's still not 100% of the time captures all specific scenarios for all patients, because all patients are different. But at least it helps you try to make those tweaks up front and limit the amount of inaccurate rules that are firing for your pharmacist. Now, one lesson learned we had kind of clinical privilege is we incorporated our staff into the tool very well. People felt comfortable using it. And then we got our residents starting on rotation and they were like, well, how do we take a patient centric view where you're supposed to be taking care of everything about that patient and then split off part of those responsibilities for the resident as they're first getting started. And so that was a bit of a challenge. And so our team had to work through that and really talk about how do we share the note that we're creating off of this, how do we who's going to complete this rule or that rule, or maybe just dividing your care responsibilities and saying that resident really does need to take care of kind of that smaller group of patients, but do it more holistically. And so I think depending on how you build your rule and your tools, that can look a little bit different. But I do think it's an important thing when you have learners, trainees, even new employees who are kind of just getting their feet wet in these tools and you're kind of working with alongside someone who's established, make sure you've thought through what role they're going to play and how that's going to interact with everyone else who's caring for that patient. Yeah, those are some green lessons learned. We definitely felt those for SSM. I would say to add to what was shared is engaging that frontline staff as early in the process as you can. So we initially put together, we did onsite visits and we evaluated our 20 plus hospitals processes, did some cross-walking as a leadership team, and then worked with our ministry clinical managers who do take care of patients, but they have split duties of patient care and then doing nonpatient care responsibilities as managers. And so that was our initial team that developed the foundational build, did the test environment things and then rolled it out in phases to our hospitals. As we were halfway through phase rollout, we had some of our frontline pharmacists share like, you know, do we get to be part of this conversation going forward? It was a fantastic question because absolutely we wanted them part of their work. What I think we were trying to pull it to get, there's a lot of things to review and send that out. And so we never thought to ask. And so we did put together a QR feedback code so they could submit feedback that way, but what ultimately came out of them asking, you know, we want to be engaged, we want to be part of this build is we made those frontline councils that I talked to earlier. So what are our frontline councils? So we have a GenMed Council and a Quick Care Council. They are application-based positions, so our frontline teams applied for those roles. We have representation from every region and they have a vote to support every hospital within the system. So they bring those rural ideas to us like Kelvin was saying, the optimization phase, the growing phase, the clean phase, they support all of the feedback that comes from the rest of the frontline pharmacists. They evaluate it, determine if it's something that we should discuss, we should work with. And so we really took to heart what they said as we were going through the first phase of implementation. And we've had some great engagement from those frontline council members. And I would say the product of the rules being rolled out are much better with those who are regularly using them. So that was a really big lesson learned. The earlier you can engage a team of your frontline staff who are going to be using that tool on a day-to-day basis, the much better quality of your actual product. Yeah, I agree. Getting end user inputs early and often is certainly going to be beneficial in the long run as you guys are working through any project development. So as we get close to wrapping up today's podcast, I would like to just see what opportunities exist for collaborating and idea sharing, especially when it comes to something that's electronic-based like this tool. How do you guys find yourselves like sharing or working with others? Yeah, I'll call first on that one. So I think first and foremost using similar terminology, so a patient scoring tool for pharmacy. What we did discover is we went from different calls as we were all calling it something slightly different. And so we didn't think to connect and talk more about it so that we could share the ideas we learned. But really sharing at any national committee or conferences that you're able to go to, whether it's a poster or a recorded presentation, those are all very helpful. I've had a few that I've done through our visit partner. I've been able to really connect with other people who were like, oh yeah, we're using that too and just be able to have that one-on-one conversation. So really sharing with those different committees and then never underestimate your state conferences either. So using your state teams to talk with and sharing it even within just your state can really help get the word out and continue to share with others this great tool for your pharmacist. Yeah, I mean looking natural in state but also local. I know within SSM we have system-wide group of presentations every year to talk about cool new initiatives and this was presented there as a tool that was done even with frontline councils that Ariel was talking about. I think it's important so my role as pharmacy director one of the ways I stay connected is really through my frontline staff. And so I have several folks on that team just as a champion for this project and I wanted my team to be involved and have a lot of say and how this was done. And so you can free up those resources to really make the product better. I make the workflows better, the rules better and then you get better patient care out of it. The other thing again with my background in informatics I'll say this originally germinated with me just as an informatics professional going to some of the informatics meetings or working with other users of your particular electronic health record or even use of other records and talking to your vendor about how they can incorporate some of these tools, how you might be able to accomplish and the things you're seeing from other people. So for all those informatics professionals out there you have an important role to play. Make sure that you're looking for cool new ideas as well and taking them to your operational folks. Yeah, great. Great ideas. Well, that's all the time we have today. I want to thank Tim Calvin and Ariel for joining us today to discuss their experience with creating and implementing a clinical pharmacy scoring tool within the electronic health record. 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