Closed Loop Medication Management (CLMM) system is a fully electronic medication management process that integrates automated and intelligent systems to completely close the inpatient medication management and administration loop, and seamlessly document all the relevant information.

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Closed Loop Medication Management –
A Preferred Way To Go Forward For Providers
16 August, 2017 | Author: Prachi Naik, Manager- Consulting
CitiusTech Thought
Leadership

2. 2
Overview of Closed Loop Medication Management
What is Closed Loop Medication Management (CLMM)?
Closed Loop Medication Management (CLMM) system is a fully electronic medication management
process that integrates automated and intelligent systems to completely close the inpatient
medication management and administration loop, and seamlessly document all the relevant
information.
Why is CLMM needed?
CLMM improves paper centric medication management workflow by standardizing the process,
reducing variation, identifying and eliminating unnecessary steps and reducing opportunity for errors
among the care team members. The closed-loop process provides access to a consistent and real-time
patient clinical information at the point of care.
If an EHR system has to certify to EMR Adoption Model (EMRAM) Stage 6 or Meaningful Use (MU2)
Stage 2, CLMM implementation becomes mandatory.
This document provides an overview of CLMM system, which is an end-to-end automation from
medication prescription to medication administration. This document provides insights to
physicians, nurses and pharmacists who intend to reduce medication errors by automating
medication management workflow.

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Agenda
 CLMM Highlights
 Eight Rights of Medication Administration
 IT Systems involved in CLMM
 CLMM Workflow
 CLMM Benefits
 Recommendations to implement CLMM
 References

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CLMM: Highlights
Stages in Medication Process
 Ordering/ Prescribing
 Transcribing and Verifying
 Dispensing and Delivering
 Administering
 Monitoring and Reporting
Components of CLMM
 An active medication order
 An electronically identified provider (nurse)
 A bar-coded drug
 An electronically identified patient
Impact on Medication Process
 Enhance patient safety
 Improve efficiency
 Reduce medication errors
 Increase patient identity confirmation
before medication administration
Addressing Medication Errors
 Automating emergency department care
processes
 Automating bedside care processes
 Automating perioperative care processes
 Preventing medication errors at patient
discharge
Impact on Medication Process
 Computerized Provider Order Entry
 Bedside Verification
 e-Prescribing
 Medication Reconciliation
Technologies Used
 Computerized Provider Order Entry (CPOE)
 Clinical Data Repository (CDR)
 Drug information systems / databases
 E-Pharmacy, pharmacy ordering and
information systems
 Barcode technologies
 Radio Frequency Identification (RFID)

5. 5
Eight Rights of Medication Administration
The “8 Rights of Medication Administration” are a set of 8 standards that ensure safe nursing
practice and reduce medication errors:
Right Patient
The medication is administered to the intended patient for whom it is
meant.
Right Medication
The medication to be administered matches the medication order for
the patient.
Right Dose
The dose of the medication to be administered matches the dose of the
medication ordered for the patient.
Right Route
The route of medication delivery matches the route specified in the
medication order.
Right Time
The medication is administered as per the time schedule in the
medication order.
Right Documentation
The documentation should clearly reflect all of the above attributes
along with electronically recorded time and date as per the
synchronized system clock
Right Reason Confirming the rationale for the ordered medication, what is it treating?
Right Response
Document monitoring of the patient whether drug has desired effect

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CLMM IT Systems: Computerized Provider Order Entry
 Computerized Provider Order Entry (CPOE) is a system that enables healthcare providers to
electronically enter, modify and cancel orders in inpatient and ambulatory settings
 CPOE orders include medication, laboratory, admission, radiology, referral, procedure and
dietary orders
Advantages of CPOE
 Prevents errors by ensuring standardized, legible, and complete
orders
 Improves compliance with guidelines and efficiency of hospital
workflow
 Provides faster transmission to ancillaries (laboratory, radiology,
pharmacy and others)
Combining CPOE with Clinical Decision Support System (CDSS)
 Assists providers in timely and efficient decision making
 Provides recommendations and warnings such as contraindications,
IV incompatibilities, duplicate therapies etc.
 Prevents clinical errors such as drug-drug interactions, drug-
allergies, etc. through interaction checks
 Prevents potential conflicts involving lab results, diet or disease
 Saves cost, improves quality of care and enhances patient safety
Examples
1) Patient allergic to
Erythromycin
Warning: The use of
ERYTHROMYCIN BASE may result
in an allergic reaction based on a
reported history of allergy to
ERYTHROMYCIN BASE
2) Patient with lab test result
indicating presence of
Clostridium difficile
Recommendation: Vancomycin
is used to treat an infection of
the intestines caused by
Clostridium difficile, which can
cause watery or bloody diarrhea

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CLMM IT Systems: Bar Code Medication Administration
 Bar code medication administration (BCMA) is a barcode system designed to:
• Prevent medication errors
• Improve the quality and safety of medication administration
• Generate online patient medication records
 It consists of a barcode printer, a barcode reader, a mobile computer (with
Wi-Fi) server and software
BCMA Workflow
Each medication is
labeled with a
unique barcode
Administration
Nurse scans barcode
on the patient’s
wristband and then
the medication
barcode
Ensure electronic
verification that the
right patient gets the
right dose of the
right medication at
the right time and by
the right route
Barcoded
Medication
Order Entry and
Verification
Dispensing
Documentation
Physician
electronically enters
medication order
Order is sent to
pharmacy for
verification
Pharmacist
dispenses barcoded
unit dose of the
medication to the
patient's floor
Automatically
document
administration if
scanned dose
matches to a
pharmacist-approved
medication order &
patient is due for
current dose
If the dose does not
match with valid
order, the application
issues a warning

8. 8
CLMM IT Systems: Other Automation Technologies
Biometrics
Fingerprint Scanning  Scan and compare digitized fingerprint image with image data stored in database
Iris Scanning  Scan and compare iris of the eye, patterns of blood vessels and flecks on the iris
Advantages  Use of unique measurable characteristics of human beings
 Provide automatic authentication of patient using biometric devices with
embedded software
 Enhance patient safety by using identity verification systems
RFID
RFID  Radio Frequency Identification uses radio waves for collecting and transferring
patient data
 RFID technology is used by nursing services to improve the efficiency of
operations such as patient identification, nurse identification, medication
identification, and closed loop medication administration processes that improve
patient safety
Advantages  Enhances patient safety
 Eliminates medication errors and adverse events related to patient
misidentification

9. 9
CLMM IT Systems: Automated Dispensing Cabinets
 An Automated Dispensing Cabinet (ADC) is a computerized drug storage cabinet designed for
hospital pharmacy that dispenses medications near the point-of-care
 ADCs are also called unit-based cabinets (UBCs), automated dispensing devices (ADDs),
automated distribution cabinets or automated dispensing machines (ADMs)
 ADCs incorporate sophisticated software and electronic interfaces to synthesize high-risk
steps in the medication use process
Advantages
• Provide computer controlled storage, dispensation, tracking, and documentation of
medication distribution on the resident care unit
• Saves significant time in the daily workflow of nurses
• Control and track drug distribution
• Provide secure lockbox storage for controlled substances until needed
• Prevent waste and drug diversion through multi-factor authentication (Using the 8 rights
as authentication parameters) to the secure vault and audit trails
• Improve patient safety by providing drug-allergy, drug-drug interactions, advising on high
risk medication (heparin, insulin) and avoiding confusion with "sound alike" medications

10. 10
1. Monitor patient
and document
correctly
2. Make informed
care decisions
3. Computerized
provider order
entry
4. Review and
verify
order
5. Dispense
bar coded
unit dose
medication
6. Store medication
securely
7. Assess patient
prior to administering
medication
8. Scan patient
& med barcode
prior to
administration
9. Administer
medication to
patient
CLMM Workflow: Using Pharmacy Automated System
CLMM Clinical
decision
support tools
Legible, complete
order goes to
pharmacy
Secure storage in
ADCs and
medication carts or
workstation on
wheels
Check the 8
rights of
medication
administration
Medication administration
recorded electronically

11. 11
CLMM Workflow: Using Pharmacy Automated System
1. Physician monitors the patient, appropriately documents clinical details and makes informed
care decisions
2. Physician enters medication orders through Computerized Physician Order Entry System
(CPOE)
3. Clinical Decision Support System (CDSS) prompts physician with information to avoid drug
interactions, allergies and adverse drug events
4. Pharmacists verify medication orders, which are then sent automatically to Inpatient
Pharmacy Automation System
5. ​The unit dose barcoded drug sachets from pharmacy are stored at the ward’s Automated
Dispensing Cabinets (ADCs) or medication carts or workstation on wheels
6. Nurse scans patient’s RFID/ bar coded wrist tag which unlocks the assigned automated
medication cabinet
7. ​Nurse then scans unit dose bar coded drug sachet(s), before administering the medicines to
ensure 8 rights
8. Details are recorded electronically once medication is administered

12. 12
CLMM Benefits
Integration
 Integrate physician, nurse and pharmacist workflows
 Achieve connectivity and reporting from the point of prescription to
bedside medication administration
 Eliminate all manual order transmission & transcription activities
Real-Time Information
 Provide consistent real-time patient and clinical information to all
caregivers
 Flag real-time medication variations on Electronic Medication
Administration Record (EMAR)
Compliance
 Improve adherence and compliance to medication procedures and
policies
Safety
 Prevent Medication Errors (ME) and Adverse Drug Events (ADEs)
 Maintain medication history
 Improve patient safety and quality of care
Scheduling
 Schedule tasks and reminders for medical staff
 Eliminate shift and 24-hour chart checks
Others
 Simplified processes
 Time savings and reduction in cost

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Recommendations to Implement CLMM
Application Development
 For implementing CLMM, a provider will require existing applications or new apps to
be developed to support end-to-end user based workflow
 For storing clinical data effectively, clinical data model is required
 Additionally, Medication Administration Record module would be required for
effective medication management workflow
Integration Services
 In order to achieve CLMM, if a provider has existing Pharmacy, EHRs/ Nursing
Information systems and Medication Administration records in place, the above
systems should be integrated at the point of care
 This will pull medication schedules into task manager and uniquely identify
medications with the help of drug databases like First Databank, Medi-Span
RFID Implementation
 For effective CLMM working, a provider would require to implement RFID
technology by setting up an interface between barcode scanner and clinical systems
used
UI/UX Development
 Medication administration record app would require intuitive and user-friendly,
workflow/ role-based usability UX focused designs
Implementing CLMM effectively will increase the Medication Management Workflow efficiency

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References
 https://www.ihis.com.sg/Project_Showcase/Healthcare_Systems/Pages/CLMM.aspx
 http://www.rncentral.com/blog/2012/the-rights-of-medication-administration/
 http://www.nursingcenter.com/ncblog/may-2011/8-rights-of-medication-administration
 https://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/downloads/Stage2_HospitalCore_16_Electronic
MedicationAdminRec_eMAR.pdf
 http://www.himssanalytics.org/emram
 http://cstproject.ca/news/closed-loop-medication-management-safety-win
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4765644/
 https://www.ijirset.com/upload/2015/september/154_IJIRSET-15-394-%20proof.pdf
 https://www.eiseverywhere.com/file_uploads/30dbeb4d0631fded7390e49858f04575_HIMSS
16NordicLasVegasPresentationJonH.Fridriksson.pdf

15. 15
Thank You
Author:
Prachi Naik
Manager - Consulting
thoughtleaders@citiustech.com
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