Collaboration Story: Bellin and Gundersen Health System and DrFirst

CHIME Member:

Praveen Chopra

Chief Digital and Information Officer

Bellin and Gundersen Health System

CHIME Foundation Firm:

DrFirst

Executive Summary

At Bellin and Gundersen Health System, we are dedicated to bringing together the right people with the right technologies to solve problems for our patients and our health system. With a patient-first mindset, we adopt innovative solutions not just for technology’s sake but to deliver real and measurable results. We also believe in elevating the human component in every healthcare process, using tools such as AI to give our clinicians the time and information they need to do what they do best—care for patients.

Based on this philosophy, we launched a project to integrate intelligent automation within our Epic EHR to reduce manual processes, decrease administrative burden, improve workflows, and enable our clinicians to work at the top of their license. The project required creative partnership among vendor partners that sometimes have competing interests. We worked collaboratively with DrFirst, Epic Systems, Surescripts (a pharmacy software vendor), and internal developers to test, implement, and measure the flow of medication data across the various platforms and interfaces. We were the first organization using Epic to deploy this intelligent automation solution, so we needed to work with multiple companies and digital interfaces to ensure success and mitigate risks.

Introduction

The digital transformation of healthcare brings enormous opportunities for improvement, but also presents new challenges. One major pain point for many health systems involves medication management, especially the manual and repetitive clicks and keystrokes required for medication reconciliation and prescription renewals—essential tasks for quality care and patient safety. Without smooth electronic processes, the burden of translating and transcribing clinical data into discrete fields in the electronic health record (EHR) falls on the clinicians and care team, which can cause preventable errors and add to the epidemic of burnout.

In January 2022, to improve the safety and efficiency of medication reconciliation and prescription renewals, we launched a project to integrate intelligent automation within our Epic EHR. By reducing the manual entry of data, we hoped to decrease administrative burden, improve workflows, and enable clinicians to work at the top of their license.

The project required creative partnership among vendor partners to deploy DrFirst’s AI-enabled solution in our Epic EHR. We were the first organization using Epic to deploy this intelligent automation solution for prescription renewals, so we needed to work with multiple companies and digital interfaces to ensure success and mitigate risks. In addition to DrFirst, we worked collaboratively with Epic Systems, Surescripts (a pharmacy software vendor), and internal developers to test, implement, and measure the flow of medication data across the various platforms and interfaces.

Challenge 1: Gathering Medication History

External medication history sources often don’t provide the detailed information our clinicians need for medication reconciliation, and patient interviews don’t always yield the best results. At Gundersen Health, our clinical team had access to a medication history feed within Epic, but information was often missing. As a result, our staff needed to make phone calls to pharmacies to gather and confirm a patent’s medication list, then enter the information manually into our Epic EHR, which is not only time-consuming but also increases the likelihood of human error and the potential for adverse drug events (ADEs).

Challenge 2: Renewing Prescriptions

While it may seem simple, completing medication renewals is one of the most redundant tasks in the EHR for our clinicians and staff. When a patient is out of refills, the pharmacy system sends an electronic renewal request to the provider. Unfortunately, the pharmacy system doesn’t speak the same language as our EHR. A lack of standardization, natural variations in prescription instructions, and national drug codes (NDCs) that don’t align between healthcare practices and pharmacy drug databases all contribute to free text data, which requires staff and clinicians to manually re-enter data and causes frustration with clinical workflows.

Renewal requests contain specific prescription instructions (known as “sigs”), such as medication dosage, route, and frequency, that don’t match our EHR’s nomenclature (for example, “by mouth” versus “oral”). A single sig, such as “Take 1 tablet by mouth daily,” could be represented hundreds of different ways. In addition, mismatched data needs to be fixed on the back end of the EHR by pharmacy informaticists to try to prevent future mismatches. This requires a sig-mapping table, which allows sigs that have a perfect match in the table to be imported into the patient record automatically. Unfortunately, keeping that table up to date is a time-intensive, manual process that poses a significant administrative burden on pharmacy informaticists.

Challenge 3: Batling Burnout

It’s no secret that clinicians are suffering from burnout due to work-related stress. A 2021 Medscape report found “too many bureaucratic tasks” was the top cause of physician burnout, with 58% of 12,000 respondents citing these non-clinical chores as a contributing factor. A 2022 report by independent research firm KLAS found that clinicians who are very dissatisfied with their organization’s EHR are nearly three times as likely to leave their jobs compared to clinicians who are very satisfied. Unfortunately, when clinicians are suffering, patient experiences can suffer as well.

We are committed to helping our clinicians avoid burnout by automating repetitive tasks and reducing the amount of time they spend working in the EHR. This is especially important post-pandemic because telehealth and the use of patient portals requires clinicians to spend more time in the EHR managing patient care. Prescription renewals are one of the most common types of in-basket messages for care teams and are a low-cognitive, repetitive task that requires significant time from care team members. A JAMIA study found that in-basket messages were the biggest driver of increased EHR time, with patient messages up 157% and prescription messages up 130% from pre-pandemic levels. The study calculated that each patient message translates to 2.3 additional minutes clinicians spend in the EHR.

A Collaborative Effort

To address these challenges, we established a cross-functional team spearheaded by our Medical Director of Informatics, Dr. Rajiv Naik. Working in partnership with DrFirst, Epic Systems, and Surescripts, we deployed DrFirst’s intelligent automation solution to fill gaps in medication data as it’s transmitted across incompatible systems.

The medication history solution brings in more patient information from pharmacy benefit managers (PBMs), EHRs and health information exchanges, fill data from national and local pharmacies, and payer records. The integration of DrFirst’s solution into our Epic EHR would support familiar workflows and require minimal effort from our IT department.

Besides adding more patient data than we received previously, the medication history solution uses AI to improve the quality of that information and make it available directly in our established clinical workflows. Using clinical and statistical context, the AI cleans and structures medication history data to prevent missing information while reducing the need for our clinicians to enter the data manually. It normalizes sig information into consistent terms, translates NDCs between different databases, safely infers missing information, and processes free text so it pre-populates into discrete fields. Ready access to the data within our Epic EHR alleviates the clinical burden of numerous system logins and multiple mouse clicks.

But it’s not enough to throw technology at a problem and hope that it works. Instead, we needed a partner to help us connect innovative technologies with our people and existing processes for ideal results. Weekly project meetings were key to our success, focusing on specific tasks and ensuring we had open communication to keep the project running efficiently.

Ryan Miller, PharmD, BCPS, Application Analyst and Pharmacist, collaborated closely with the DrFirst team to ensure the proper data sets were being processed to add clean medication history data to our standard feed as part of our initiative to improve medication reconciliation. Monthly executive meetings were held to evaluate our performance and progress along the way. Once the solution was up and running, our clinical applications team worked with DrFirst and multiple stakeholders throughout Gundersen Health to test, validate, and ensure physicians and other clinicians could access the consolidated medication data in real time.

Since we launched DrFirst’s medication history solution, we have converted more than 378,633 medicaton sigs without clinician intervention. A subset of these conversions had no sig provided in thirdparty data, and the sig was inferred by the AI technology. Another subset had a sig available, but only in free-text form, and the AI converted these to a discretely defined sig in the database.

In July 2023, we also identified more than 1,847 additional high-risk medications from more than 462 unique patient medication profiles, which annualized would add up to 22,164 medications and 5,544 patients that would not have been identified by our legacy data feed.

Streamlining Prescription Renewals

Gundersen Health was the first health system to implement DrFirst’s prescription renewal solution, which uses AI to streamline incoming requests within our existing Epic workflows.

Dr. Naik worked closely with DrFirst’s clinical and technical teams to implement the solution, which pulls sigs into discrete data fields as the medication renewal crosses interfaces from the pharmacy to our medical record. Given the importance of a seamless integration in our Epic EHR, the Gundersen and DrFirst teams worked closely with our Epic counterparts with regular communication and diligent project management to keep all three teams in sync.

DrFirst’s AI transcribes sigs directly into our EHR, eliminating the need to create and maintain a sigmapping table and removing the requirement for a perfect sig match. The AI infers clinical meaning and improves its performance over time by learning to translate, structure, and codify medication data with greater speed and efficiency.

Working with the DrFirst team, we conducted pre-implementation testing, with a team of clinicians reviewing the results generated by the AI engine and making adjustments as needed. For quality control and patient safety, sig mapping was tested rigorously prior to go-live and post-implementation, and mapping tables were updated by pharmacy informaticists to prevent medication errors. When the AI cannot infer data with certainty, it leaves that field blank, prompting an alert for someone to manually fill in the correct information. With testing, we felt confident by the time we went live that there was a very high degree of accuracy.

Before we could integrate the new solution into our Epic EHR, however, it needed to be certified by Surescripts, the health information network that provides our medication history data feed. DrFirst augments the standard feed with 10% to 20% more e-prescribing data, standalone EHR data, and connections to local and independent pharmacies. To ensure accuracy of the imported data, Surescripts required testing and verification of the new solution.

Once Surescripts certified DrFirst’s AI-powered prescription renewal solution, Epic agreed to make it available in the App Orchard marketplace, now known as the Epic Connection Hub. DrFirst worked with Epic’s App Orchard Technical Services (now known as Vendor Services) to thoroughly test the solution along with the Gundersen Health team. This effort ultimately contributed to the product documentation DrFirst created for all customers after Gundersen Health’s project went live.

Prior to implementing the new solution, we had up to 1,000 unmapped sigs per day being assigned to our pharmacy informaticists, making sig-mapping an unmanageable task. With DrFirst, we’ve reduced that number to about 100 unmapped sigs, 90% of which are complex medications that can’t be completely mapped. This has saved our pharmacy informatics team significant time, decreasing administrative as well as clinical burdens.

After the implementation, we saw a 202% improvement in the number of clean sigs imported, resulting in 84% of incoming prescription renewal data either partially or fully populated in the EHR.

“Before partnering with DrFirst, only one-quarter of our prescription renewals had complete medication details, which meant most electronic renewal requests required staff to enter data with keystrokes and clicks,” says Dr. Naik. “Now we’re importing complete sig details for over 80% of our patients’ medication renewals. That’s a big time-saver for our staff and clinicians for this redundant task in the electronic medical record.”

Before implementing DrFirst’s solution, we were matching 27% of sigs in Epic. In the 14 months since golive, the DrFirst solution has processed 450,937 prescription renewals with 86% of sigs imported into discrete fields in our Epic EHR, which is a 59% improvement. That saved our clinicians 766,715 clicks and keystrokes on prescription renewals, for an estimated time savings of 639 hours.

Data Analytics for Continuing Improvement

Unlike other projects that end when the software is installed, our partnership with DrFirst is continuing beyond implementation. To fully leverage the benefits of AI-powered medication management, we are continuing to work with DrFirst to monitor how our team is using the new technology. We receive data from DrFirst’s analytics tool that helps us measure how our staff is performing with the technology and where we have opportunities for improvement.

One data point indicates the percentage of sigs being imported from medication history records rather than being keyed in manually. While our nursing care team in the acute care setting is importing new home medications 89% of the time, some people are manually entering information without looking at the list of patient medications. Others view the medication history list, but still enter the information manually. DrFirst gathers information about how our end users interact with their AI solutions, and they use that data to continue to refine and improve the user experience.

Compared to other similar projects, this was one of the smoothest go-lives we have experienced, and was a great example of teamwork, open communication channels, and a shared goal and vision. Our collaboration with DrFirst and Epic Systems not only simplified workflows to gather medication history and renew prescriptions, but also highlighted opportunities to improve synergies between our people and processes.

Praveen Chopra | Chief Digital & Information Officer | Bellin and Gundersen Health System

Praveen Chopra is chief digital and information officer of Bellin and Gundersen Health System. Praveen joined Gundersen in 2021 to focus intensely on the system’s digital transformation efforts to benefit patients and staff. Praveen has executive experience championing innovative, consumer-centric outcomes across healthcare, retail, and consulting industries through creative use of information and emerging technologies. He brings extensive expertise in improving governance and inter-departmental collaboration, including electronic health record excellence, telehealth expansion, digital user experience, insights management, and strategic growth planning and execution.

Praveen previously served as CIO for George Washington University Medical Faculty Associates, one of the largest academic medical centers in the Washington, D.C. metro area. Prior to that, Praveen was CIO and Transformative Innovative Environment Officer at Thomas Jefferson University - Jefferson Health System. He has also served as CIO and Chief Supply Chain Officer at Children’s Healthcare of Atlanta.

Before a transition to healthcare, Praveen also held leadership roles at the Home Depot headquarters and at Accenture.

Sources:

1. Relationship between medication errors and adverse drug events, 1995.

htps://pubmed.ncbi.nlm.nih.gov/7790981/

1. Death by 1,000 Cuts: Medscape National Physician Burnout and Suicide Report 2021.

htps://www.medscape.com/2021-lifestyle-burnout

1. March 2022 KLAS Report. htps://www.beckershospitalreview.com/ehrs/5-key-stats-onclinicians-ehr-burnout.html

1. Journal of the American Medical Informatics Association, Volume 29, Issue 3, March 2022, Pages 453–460. htps://doi.org/10.1093/jamia/ocab268