It's a Pill

University of Illinois Medical Center at Chicago won the HIMSS Davies Award for closed loop medication administration on a Cerner Millennium EMR, and was one of the first to use Cerner's PharmNet pharmacy information system. Though both the EMR and pharmacy information system are from Cerner, CIO Rose Ann Laureto says her approach is a bit of a hybrid. She interfaces Cerner's PharmNet with Mountain View, Calif.-based Omnicell, a stacking system that manages inventory and restocking for patient-specific medication. “We have our challenges with interfacing and keeping everything in synch as we upgrade one product. But we're able to make sure the workflow continues,” she says.

Donna Akerson, director of clinical transformation at McLean, Va.-based BearingPoint Consulting, says as hospitals move to CPOE, integration of pharmacy and EMR will become more critical. “Until they move to CPOE, it has not been that important. Once you want those orders to be bi-directional — and the orders are complex for things like chemotherapy — then it becomes difficult to interface,” she says.

Interfaced or integrated, when it comes time for the pharmacist to consult with the physician on an order change, it seems that new technology is not always a solution. Though many pharmacy information systems can send an alert back to the physician via pager or directly in the EMR, most hospitals still rely on the telephone. “Contacting the physician?” Laureto asks and laughs. “We use the good old fashioned way that's tried and true: We call. We don't even use wireless.” She has company — everyone contacted for this article said they did the same.

Once the order has been reconciled in the pharmacy, and a physician has made any changes necessary, the order needs to be filled. According to Neuenschwander, the accuracy of filling the carts is critical. “On-demand packaging machines pick more accurately than humans,” he says. “They're packaged on demand according to the patient profile fed from the pharmacy information system. All these machines are bar code assisted.”

Pharmacy robots are another good choice, albeit an expensive one. And, of course, they need to be interfaced. According to Akerson, one popular pharmacy robot is the San Francisco-based McKesson's Robot Rx dispensing system, which has an advantage: It can be used with almost any pharmacy information system. “They've made that transferable so you can use their robot,” he says.

Martin's closed loop at Arnot Ogden automatically sends the pharmacist-authorized order to the patient's eMAR where the nurse can see it. “This is where the process gets interesting and automation can really start driving some efficiencies,” Martin says. Arnot Ogden is also in the process of employing Pyxis (from Cardinal Health, Dublin, Ohio) medication dispensing machines. “The workflow is the pharmacist putting the med on the electronic MAR telling the nurse she can give it, but the med may not be on the floor for the nurse to give it yet. Now the pharmacy has to prepare the distribution cabinets that go up to the units on a regular basis. And then those meds get taken out of that cabinet and put at the patient's bedside in a locked drawer.”

According to most in the space, including Laureto, bar coding is the single best way to avoid medication errors. “Our plans are to take bar coding to the bedside. We know it is the way to go, it's just an issue of cost and priority.”

Will bar coding in the pharmacy become the standard? Not necessarily, according to Akerson. She says, “It's a direction, but it's expensive. The problem is that in order for bar coding to work, it has to have unit dosing, which many hospitals can't pull off.”

Neuenschwander believes bar coding is so important that as soon as a hospital can, it should go that route. “Hospital CIOs can implement bar coding at any point when the time is right. There is no technology that has greater significance for accuracy than bar coding.” But, he says bar coding is not a catch all for medication safety. “Bar coding is to patient safety what seatbelts are to automobile safety. And for seatbelts, rule number one is you have to wear them,” he says. “You still have to drive safely and obey the law. Just because we scan at the point of care doesn't mean we can get sloppy leading up to it.”

One trend on the horizon for smaller hospitals where CPOE or bar coding may not be a reality is sharing a pharmacy information system. That solution also addresses the shortage of pharmacists nationwide. “What we're seeing in smaller hospitals is connecting with other hospitals so you can share that same pharmacist,” says Akerson. “The drugs can be on site at the small hospital but the orders go to a central pharmacy where the pharmacist can do the checks, the alerts and the reporting.”