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12/19/2003

AHRQ Announces New Technology Grant Opportunities

Donna Young

The Agency for Healthcare Research and Quality (AHRQ) on November 21 announced that it is making $41 million available for health systems to develop, implement, or study information technology systems, such as computerized prescriber order-entry (CPOE) systems, to improve patient safety and quality of care.

Applications for the grants are due by April 22, 2004 (see box).

The awards will support over 100 new research and demonstration projects, including $14 million going to small and rural hospitals and communities for implementation grants, the agency indicated.

Pharmacists need to be “at the table to provide a leadership role” for health systems that are seeking the grants, said Steven S. Rough, pharmacy director for the University of Wisconsin Hospital and Clinics in Madison.

The Agency for Healthcare Research and Quality (AHRQ) expects to award up to $24 million to fund as many as 48 new implementation grants, with up to $14 million going to small and rural hospitals and communities. The request for applications (RFA) emphasizes the importance of community partnerships. AHRQ will provide up to 50% of the total costs in matching funds, not to exceed $500,000 per year, for each project.

Letters of intent are due February 6, 2004, and applications are due April 22, 2004. For further information, go to the NIH Guide at http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-04-011.html.

As much as $7 million is expected to be awarded under the second RFA to fund up to 35 new planning grants to provide communities and organizations with the resources needed to develop their health information technology infrastructure and compete for future implementation grants. At least $5 million is expected to be used to support applicants from rural and small communities. Projects can last up to one year, and applicants may request budgets of up to $200,000 in total costs.

Letters of intent are due February 6, 2004, and applications are due April 22, 2004. For further information, go to the NIH Guide at http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-04-010.html.

Demonstrating the value derived from the adoption, diffusion, and use of health information technology will be the focus of the third RFA, awarding approximately $10 million to up to 20 new grantees. The objective of these projects is to provide health care facilities and providers with the information they need to make informed clinical and purchasing decisions about using health information technology. Applicants may request budgets of up to $500,000 per year in total costs.

Letters of intent are due February 6, 2004, and applications are due April 22, 2004. For further information, go to the NIH Guide at http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-04-012.html.

Rough’s health system was among 13 AHRQ challenge grant recipients announced on November 3.

The University of Wisconsin Hospital and Clinics—a 471-bed academic medical center—was awarded $270,175 to evaluate the reduction of medication errors by using a “smart” i.v. infusion pump system that is integrated with a medication administration bar-code scanning system, Rough said.

The health system’s pharmacy team “spearheaded” development and implementation of the project, he added.

Pharmacists should be engaged with research and implementation projects funded by federal grants, Rough said, to help provide to a health system’s administrative leaders objective data that shows “patient safety and reduced errors,” as a return on investment of a capital purchase of technology.

“If you can help an organization understand you’re going to increase patient safety, avoid harmful errors, which costs a lot of money on the back end, and at the same time improve staff-level satisfaction with their jobs and retention, those are huge benefits that are quantifiable,” he maintained.

The University of Wisconsin will be one of the first health systems in the United States to integrate McKesson Corp.’s Admin-Rx point-of-care medication bar-code scanning system with Alaris Medical System’s Medley with Guard Rails i.v. infusion pump system, Rough said.

“We are going to be a beta site for the integration of those two technologies,” he said.

The health system will conduct a failure mode and effects analysis (FMEA) of the i.v. infusion pumps alone and a follow-up analysis after integration of the two technologies to determine if error rates have decreased by using the systems and if new problems have been introduced into the quality of working life and satisfaction of nurses, pharmacists, and physicians, Rough said.

“When you lay technology over an existing system you can have intended effects but also unintended effects,” Rough said. “So we hope to prospectively analyze not just error rates but new sources of error and the impact it has on health care provider job satisfaction.”

The University of Wisconsin Hospital and Clinics implemented its bar-code scanning system in December 2001.

Rough’s health system was awarded a 2003 ASHP Best Practices Award in Health System Pharmacy in December for its study of the impact of point-of-care bar-code scanning on medication- administration error rates and nursing satisfaction.

The health system plans to fully integrate the bar-code system with the i.v. infusion pump system before the end of 2004.

“We want to know whether or not it’s the smart pumps by themselves or the smart pumps integrated with the bar-code scanning technology that really make a difference, or what’s the add-on improvement with the integration,” Rough said. “The second aim of this study is to determine the impact of these technologies on . . . the end users of the products, and what impact does it have on the quality of working life, like job satisfaction, stress level, organizational commitment and involvement, and workload. So we expect that this will improve perceptions of quality of care and job satisfaction, but we don’t know it.”

A $200,000 AHRQ grant helped St. Jude Children’s Research Hospital in Memphis, Tennessee, “accelerate” and “structure” a planned expansion of its CPOE system, said Bruce A. Warren, director of pharmacy information systems.

Prescribers at St. Jude use CPOE for diagnostic imaging, echocardiograms, and rehabilitation services orders, said pharmacist Donald Baker, clinical liaison in the hospital’s clinical informatics department.

The system has also been implemented in the health system’s pediatric HIV and hematology clinics, he added.

The children’s research hospital plans to expand the use of the CPOE system for chemotherapy orders, which currently is a paper-based system, Warren said.

The health system’s vendor, Cerner Corporation, is currently developing a CPOE system for chemotherapy medications, he added.

St. Jude administers chemotherapy to about 30 children per day in its outpatient infusion center and approximately 15 to 20 children per day in the inpatient units, Baker said.

The health system is “definitely committed to CPOE,” he said. But, he added, “the open question is whether or not we would have gone to such a formal analysis from the patient safety perspective had we not gotten the grant. Getting the grant kind of forces us to do that formal analysis.”

As part of St. Jude’s AHRQ challenge grant award, it had to identify a high-risk process that could be evaluated from a patient safety perspective, Baker said.

“What we are trying to accomplish with this project is to formally analyze our current chemotherapy process from the point the physician orders something all the way through to where a nurse administers it,” he said. “We will analyze each step in our current process for its possibility of having a failure and then analyzing what are the chances of that failure occurring, and what are the chances of that failure being caught or not being caught, and what are the consequences if it’s not caught.”

The FMEA process will allow St. Jude to determine risks associated with using a commercially available CPOE system for chemotherapy orders, Warren said.

“Its aim is to eliminate the risk before we put [CPOE] in,” he said.

For instance, he said, with CPOE, “we won’t have legibility problems but we’ll have other problems that we have to sort through and make sure that we are aware of those problems and try to correct them before they happen.

We will be able to test it and see some of the things that could happen.”

Kaiser Permanente Health Plan of Colorado is using a $950,000 AHRQ challenge grant to refine and evaluate a pharmacy alert system that intercepts medication errors after a drug has been ordered but before a pharmacist dispenses the drug, said emergency physician David Magid, assistant director of Kaiser’s clinical research unit.

The system was first developed to identify critical drug–drug interactions, but the health system is expanding the alert system to warn if an inappropriate drug is prescribed to patients who are pregnant or have renal insufficiencies and for high-risk drugs that require the monitoring of laboratory test values, Magid said.

Pharmacist Robert E. Rocho, pharmacy technology and innovation manager for Kaiser, said that even though his health system has “99%” implemented CPOE, the system used by prescribers “really doesn’t have drug-interaction screening in it. At the time we built it, that was something that we left to the pharmacy. We don’t really catch these errors or potential errors at the prescribers’ order-entry point. We’re actually catching them on the back end as the pharmacy fills the prescription.”

Rocho’s team developed a two-way interface between the pharmacy’s system and the laboratory’s system so that test results and other patient information could be automatically sent to the pharmacy system.

When the pharmacy alert system detects a problem with an order, such as a potential drug–drug interaction, instead of the automated dispensing system printing a vial label for the order, the system prints a “stop label,” which warns the pharmacist to check the medication order and consult with the prescriber.

“So we interrupt the dispensing process using this stop label and then what [the pharmacist has] to do is go in and assess the interaction, and in order to get the label out they have to complete some sort of a documentation process so that we know who did what and why they did it,” Rocho said.

The health system developed a set of intervention guidelines, available in paper and electronic formats, that provides pharmacists with background information about drug interactions and adverse events and lists choices for alternative medications.

“When they do call the doctor and talk about the interaction, they’re well informed, they have some alternatives in mind, and they can just speed right through the intervention with the provider to get to an alternative,” Rocho said.

Any adjustments in dosing or changes in orders are automatically sent to the patient’s electronic medical record and the CPOE system, Rocho said.

As part of the alert system project, Magid said he plans to conduct three randomized trials using data from 4,000 patients who are pregnant, 19,000 patients with chronic kidney disease, and 21,000 patients who receive high-risk drugs requiring laboratory monitoring.

“We have a nice collaborative relationship between the research unit and the pharmacy department on some designing, implementing, and evaluating innovative programs to improve medication safety,” said Magid.