A lot has changed in the clinical informatics world in the past five years, and the landscape around clinical IT implementations looks quite different now. With the meaningful use requirements under the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act pushing patient care organizations to work with clinical data in ever-more-integrated ways and to comprehensively implement successful computerized physician order entry (CPOE) systems; and with mandatory programs under federal healthcare reform forcing hospitals to more efficiently gather and act on data in order to reduce avoidable readmissions and document and improve clinical outcomes, the old interfacing is out, and integration and interoperability are in.
Indeed, the landscape has been altered to such a degree that a strategic IT choice that might have made sense five years ago—to implement a new pharmacy information system from a completely different vendor from one’s new core electronic health record (EHR)/CPOE system—just doesn’t make sense anymore, except in exceptional cases.
At the same time, healthcare IT leaders and industry experts report, the quality of the pharmacy components being offered by the largest EHR vendors has steadily improved. On the one hand, the reality remains that some of these components are still separate products, even as they’re marketed as being elements in integrated wholes. On the other hand, the functionality of these pharmacy IS products is improving to the point where these products are eliciting greater satisfaction on the part of CIOs, CMIOs, and other healthcare IT leaders—not to mention end-users. For example, according to the “Top 20 Best in KLAS Awards” report released late last year by the Orem, Utah-based KLAS Research, 100 percent of those surveyed regarding the Epic Willow product from the Verona, Wis.-based Epic Systems Corp. said they’d buy that product again; 86 percent of the users of Allscripts Sunrise Pharmacy, from the Chicago-based Allscripts, would use that system again; 82 percent of those using Cerner Millennium PharmNet from the Kansas City-based Cerner Corp. said they’d buy that product again; and 78 percent of those using GE Healthcare Centricity Pharmacy from the Chalfont St. Giles, U.K.-based GE Healthcare said they’d use that product again.
So where does that leave CIOs, CMIOs, and other healthcare IT leaders working everything out in the trenches? It’s definitely a mixed picture, depending on where individual hospital organizations are with their overall clinical IS implementations. First, some hospital organizations are still struggling along with old legacy standalone pharmacy systems, even as they’ve moved forward on EHR/CPOE. The healthcare IT leaders at those organizations face significant issues, should they choose to try to maintain their legacy pharmacy systems for any length of time going forward. More commonly, as hospital organizations replace their core EHR/CPOE systems, they’re facing issues around the degree to which the pharmacy components coming from the same vendor are truly integrated/interoperable, or are in fact “interfaced under the covers,” as some refer to the situation in which the pharmacy and EHR products bear the same corporate name, but are not interoperable at the level of software coding.
Moving Forward in Minnesota
Brian Patty, M.D., and Brad Rognrud are certainly familiar with the latter situation. As the CMIO and director of pharmacy informatics at the four-hospital, 650-bed HealthEast Health System in St. Paul, Minn., they are living with the day-to-day reality of interfacing the pharmacy IS and EHR from the same vendor, in this case, the Atlanta-based McKesson Corp. “We chose right from the get-go to go with our pharmacy component from our core vendor,” Patty reports, “though the decision predated me; but Brad was here.”
Brad Rognrud
Several years ago, “We were using McKesson’s ClinicPac system, and there were a lot of advantages in terms of speed,” Rognrud says; “but it didn’t offer everything we needed. So we included McKesson’s Horizon Pharmacy system in our EHR implementation.”
Was it a compromise for the pharmacists accepting McKesson’s pharmacy component over a standalone solution? “We had also considered Mediware Worx Suite” (from the Lenexa, Kan.-based Mediware), says Rognrud. “Ten years ago, they were a fairly popular system. When we put that system up against McKesson’s Pharmacy Horizon system, they came up about the same. So the advantage went to McKesson. Of course, the reality is that the McKesson system was—and to this day, still is—interfaced, not integrated. So there are a lot of challenges, even though it’s McKesson on both sides.
“At least there’s only one vendor involved, so they can’t point fingers at anyone else if something’s not working,” Patty notes. Also, Rognrud adds, “When you’re talking about integration or interfacing with the EHR, the core really is between CPOE and eMAR” (the electronic medication administration record).
Drilling down one more level, Patty offers his thoughts about some of the complex issues that CMIOs, CIOs, and pharmacy IT specialists will be struggling through over the next few years in hospital organizations nationwide. “When you’re talking about closed-loop meds administration management,” he says, “from the time the med is ordered until the time it’s administered, you have multiple potentials for problems, because you have the order going to the pharmacy and then to the eMAR. The route that that initial order travels between the time it’s ordered by the physician and is then delivered to the patient, can cross multiple, multiple systems, so it is a challenge; kudos to Brad and his team for making it seem seamless” to the organization’s end-users.
Brian Patty, M.D.
What’s more, Patty says, “Anything you do that’s not on your core vendor’s platform can create challenges and force workarounds that create the potential for error. I’ve always been a strong proponent of sticking with your core vendor if at all possible, for such things.” He and Rognrud both strongly urge healthcare IT leaders to stick with one core vendor for EHR, pharmacy, and eMAR; and then, Rognrud says, “There are other decisions that need to be made, in terms of, how do I integrate with my pharmacy automation? One area is your unit-dose automation, and that’s where you get to the Pyxis and other systems; but there’s an IV component as well, and that’s an area that’s really starting to grow right now. So the workflow of your IV preparation within your pharmacy—making sure that that process is going well in preparation for barcoded meds administration.”
Step by Step in New Jersey
One of the core challenges in all this is of course a very complex set of issues around timing and process, as Gene Grochala, CIO of the two-hospital Capital Health system based in Trenton, N.J., knows well from experience. In his case, managing multiple transitions over time has brought into high focus the challenges of working out pharmacy IS/EHR interoperability.
Essentially, Grochala says, what happened at Capital Health is that, “In our city hospital in Trenton, Capital Health Regional Center, we went with Keane and iMed, which is from Keane, and kept the old legacy pharmacy system, called MediWare. In the newer hospital, we went live with the EMR in 2009, and just went live with the pharmacy IS in May, switching from MediWare to the new Keane pharmacy component on May 20.” Meanwhile, the new suburban facility, Capital Health at Hopewell, opened on Nov. 5, 2011, and opened with both Keane’s EHR, and soon afterward, its pharmacy IS. In other words, the organization’s flagship hospital spent three years interfacing the Keane EHR to the iMed pharmacy IS, with Capital Health’s leaders knowing that they would transition everything once the new suburban hospital had opened and gone live with the new EHR and pharmacy system from the same vendor.
All this necessarily involved making some IT and workflow compromises, but it’s been working, Gorchala says. And, the reality, he adds, is that “MediWare’s Worx Suite product was a great product, and a lot of our pharmacists didn’t want to give it up, but they saw the future.”
Most importantly, Grochala says, “under the Stage 2 requirements of meaningful use, you’re going to have to have CPOE at 60 percent, and you’re going to have to have your pharmacy system integrated,” so there really was no choice about what course of action to take in this instance. In any case, he said, “True CPOE is really about the medications; and it’s through medication ordering, when you get the clinical decision support on adverse drug events, etc., where CPOE proves its value,” which is the whole point of the meaningful use process to begin with.
One industry expert who has a firm grasp on the broader context of all this is Jane Metzger, research principal in the Waltham, Mass.-based Global Institute for Emerging Healthcare Practices of the Falls Church, Va.-based CSC. “If we look back in history, people tended to entertain the concept of a separate pharmacy system when there was limited CPOE happening, and also when there was more limited eMAR than today,” Metzger notes. Years ago, of course, “niche vendors had much deeper functionality for the pharmacy, as in so many other areas.” But as the entire overall architecture of clinical information systems advanced in sophistication, particularly with regard to CPOE, Metzger says, “ultimately, the definition of a core clinical information system came to include a pharmacy component.”
The challenge now, Metzger says, is that “There are big data and software issues involved” in creating integration between pharmacy information systems on the one hand and CPOE and eMAR systems on the other. “Remember,” she says, “these were not only systems that were foreign to each other; they were also designed by different people, so you’ve got some mapping problems to begin with. For example, the drug formulary and the medication order master files really have to exist on both sides of the interface. And medication is one area where both are constantly changing, especially today. We’ve got drug shortages, and people are very tightly mastering their formularies, and literally, a drug shortage will pop up within the same day. So you’ve got a physician using medication order master files that literally might be gone in the afternoon, and then you’ve got a pharmacist who’s got to fill the order. And I remember people talking about batch updates to the files.”
It’s all these sorts of issues that CIOs, CMIOs, vice presidents and directors of clinical informatics, pharmacist informaticists, and all those involved in clinical IT implementations across the clinical disciplines in hospital organizations, will have to address going forward. And, Metzger says, “Yes, if you really just stuck with the Stage 1 requirements, you could possibly limp along” with an interfaced pharmacy-CPOE-eMAR architecture. But once hospitals begin the MU-mandated process of documenting patients’ medication orders, “The process challenges just cascade; because what patient has just one medication order?”
So meaningful use, she says, is virtually mandating the end of entirely standalone pharmacy information systems going forward. What’s more, she notes, “It said a lot to me when [core clinical] vendors like Epic and Cerner said a few years ago, no dice, we’re not going to do it”—provide support for interfacing their EHRs with standalone pharmacy information systems. Instead, she has two pieces of advice for healthcare IT leaders in hospitals and health systems. First, immediately dump any remaining legacy standalone pharmacy information systems and move forward very quickly with core clinical vendors’ pharmacy components; and then, “Pay very close attention to all these clinical handoffs” that involve the transitioning and sharing of information across the clinical disciplines, “because if you don’t pay extraordinary attention, they can kill a CPOE implementation, and also have critical safety consequences.”
Fortunately for leaders of more advanced hospital organizations, things have already moved forward considerably because of their overall clinical IT development. As HealthEast’s Patty puts it, “When I look at the requirements of meaningful use, it was all stuff that we had intended to do anyway. It all made sense in terms of harnessing the EHR for clinical care. There was some stuff that we had to change the timing around on, but it was all stuff we would have done anyway. But they really hit the nail on the head in terms of what they required. In terms of pharmacy, it touched on the level of CPOE usage specifically around medication orders and the eMAR, and rightfully so.” These are things that all hospital-based organizations should be working forward on in any case, he insists.
For More Pharmacy Coverage:
The Pharmacist Informaticist View
The difficulty of addressing interoperability and getting specific for payers
By Mark Hagland
The Next Horizon: Integrating Pharmacy across the Inpatient-Outpatient Divide
VCU Health CMIO makes the best of a situation facing healthcare IT leaders in integrated health systems nationwide
By Mark Hagland