Environmental Scan of Implementation Strategies for Formulary Restrictions of Antimicrobials Across Epic Hospitals in Ontario

Abstract

Background: The use of the electronic health record software Epic continues to expand across hospitals in Ontario with an impact on pharmacy workflows. Formulary restrictions of antimicrobials is a common antimicrobial stewardship (ASP) strategy; however, a standardized or optimal method to leverage Epic functionalities has not been identified in the literature. Aims: The primary aim of this project was to identify and compare how hospitals utilizing Epic in Ontario currently implement their formulary restrictions of antimicrobials. The secondary aims were to identify potential facilitators and barriers that should be considered when implementing formulary restrictions in the Epic system, and identify successes and setbacks from hospitals with identified formulary restriction workflows. Methods: A mixed-methods environmental scan was conducted between February and April 2024, which targeted ASP pharmacists. Phase I was a voluntary online survey that was distributed to 14 Epic hospitals in Ontario. Phase II was a semi-structured, virtual follow-up meeting with survey respondents who agreed to participate. Descriptive statistics were used to summarize background information on the hospitals and stewardship programs, as well as stewardship strategies and workflows. A subgroup analysis was performed based on the responses related to successes and setbacks, and thematic analysis was conducted for the responses from the follow-up meetings. Results: The survey had a 100% response rate (n = 14) and 50% of survey respondents participated in the follow-up meetings (n = 7). Of the 14 hospitals, 12 (85.7%) reported using formulary restrictions of antimicrobials as an ASP strategy. 11/12 (91.7%) have built them in Epic. The most frequently used Epic build for formulary restrictions of antimicrobials was an automated prompt or pop-up when the antimicrobial was selected for order. For pre-authorization, requesting providers to enter the name of the authorizing infectious diseases (ID)/ASP physician or pharmacist in the order form was the most frequently used. The subgroup analysis suggested that additional ASP funding, time since Epic go-live and size of the organization were not driving factors for success in implementing formulary restrictions in Epic. Furthermore, it appeared the more effective Epic builds prompted communication or discussion with the ID team. Enforcing formulary restrictions emerged as a separate theme from the ones pertaining to the Epic build itself. The key link in the concept map that closed the loop among the themes was communication between ASP and the Willow team. Conclusions: Most hospitals utilizing Epic in Ontario use formulary restrictions of antimicrobials as an ASP strategy and have implemented them in Epic through various builds in the system. Multiple facilitators and barriers were identified when implementing these restrictions. Future efforts should focus on optimizing resources allocated to ASPs and Willow teams to facilitate implementation of Epic builds that are tailored to each ASP’s workflow and address each hospital’s needs.