In this three-part series on medication administration, HCI looks at the information exchange points in the process where errors are most likely to be made. Last month, our first installment examined the initial patient encounter and physician order. In this issue, we analyze the pharmacy, and how drug orders are received and filled. Next month, our focus will turn to the final step in medication delivery — the bedside transmission of drugs from nurse to patient.
The pharmacy is a key piece in closed loop medication administration. But with the increasing shortage of pharmacists in this country, using the pharmacist's time more efficiently is becoming essential. Pharmacy information systems are in place in most hospitals, but not all are integrated or interfaced for maximum efficiency and accuracy. Robotics can help with pills, but they're expensive. And as many hospitals move to EMRs, most agree the pharmacy needs to be a key part of the enterprise integration plan. Does the pharmacy system have to be the same as the hospital's EMR? And is CPOE the necessary first step to closed loop?
Most will agree that CPOE is not only the best way to get an order to the pharmacy and into the pharmacist's work queue, but the best place for decision support when it comes to medications. And many say that decision support will become even more important as personalized medicine and genomics make medication ordering that much more complex.
“A lot of this comes down to philosophy,” says Thomas Handler, M.D., research director at Stamford, Conn.-based Gartner Inc. “You can put the onus on the pharmacist, but most of the decision support should come at the time of the order for the physician. My belief is that there is virtually no good excuse for a hospital not to be doing CPOE.”
But what are the options if a hospital isn't using CPOE? One option is MOMs — medication order management systems that are increasingly utilized by hospitals. Using scanners and e-files, the physician order is sent to the pharmacy information system. These standalone systems only transmit the order in an image format, but the scanners are very high resolution and allow a pharmacist to zoom in for detail. “It's not CPOE, but it's a grand improvement over fax,” says Mark Neuenschwander, principal at Bellevue, Wash.-based Neuenschwander Consulting. “You can blow it up and get more detail.”
Whether the order gets to the pharmacy through fax or CPOE, first- and second- level decision support in a pharmacy information system picks up allergies, drug-drug interactions, dosing information and more. Ultimately, pharmacists still use their expertise and knowledge as a final check, no matter which system they are using.
But can the pharmacy information system be best of breed or must it be from the same vendor as the EMR?
“For three years, Gartner has been saying that pharmacy needs to be integrated and not interfaced,” says Handler. “We're finding more and more of our clients looking for a vendor whose CPR (computerized patient record) has integrated pharmacy. The physician, the nurse and the pharmacist should be using the same system that's integrated, not interfaced.”
Gregg Martin, CIO at Arnot Ogden Medical Center in Elmira, N.Y., agrees. “The communication from a workflow standpoint between physician, pharmacist and nursing is so important that they should all be running off the same database.” Arnot Ogden is using QuadraMed (Reston, Va.) for both its EMR and pharmacy information system. With that setup, alerts, messages or updates to the patient's medication profile are instantaneous. “We are not relying on any interfaces that might break down,” Martin says.
But when legacy systems abound, interfaces are often necessary. The EMR and pharmacy information system can be interfaced, says Handler, but with caveats. “The difficulty is if you've got decision support in your CPOE system and a different decision support in your pharmacy information system you have to make sure the rules are synchronized, so when something changes it has to change in both.”
Handler adds that a single vendor for both systems will also reduce the frustration of alerts and avoid the dreaded alert fatigue. When both are in real synch, the pharmacist can see overrides from the physicians and not have to call back constantly with questions. He points out that this is an area fraught with danger. “There are work-arounds all over the place,” Handler says. “Most of them don't work. That's why we see these big errors.”
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.