Just as with many other areas of hospital operations, healthcare leaders are increasingly adopting and implementing IT solutions within pharmacy departments to streamline medication-management systems, improve workflow and increase patient safety.
Yet even as many healthcare IT leaders see the benefits of adopting IT solutions such as computerized provider order entry (CPOE) systems, there are numerous barriers and challenges connected to CPOE technology when it comes to pharmacy operations. Indeed, without including the key hospital stakeholders, especially clinical pharmacy and nursing staff, hospitals can find it difficult to realize all the advantages of CPOE systems.
Many hospital pharmacy leaders at small, rural hospitals, in particular, are finding that, as with many other IT implementations, the initial deployment of these technologies can actually create unintended challenges for physicians, clinicians and pharmacists. For smaller hospitals faced with budget constraints and limited resources, transitioning from the traditional paper-based prescription pad to digital processes for prescribing and medication review requires careful consideration of the financial and staffing complexities.
To this end, many hospitals are deploying telepharmacy services to support their CPOE technology and are finding that the combination of telepharmacy and CPOE tools has enhanced provider workflows, medication safety, patient safety and even the financial bottom line.
Kelly Meeks, the director of pharmacy (DOP) at Crawford Memorial Hospital, a critical-access hospital in Robinson, Illinois, says the 25-bed hospital implemented a CPOE system in 2008, yet there were challenges to clinician adoption and use of the technology. “The challenges were prescriber-specific, so doctors who are very tech-savvy took to it. It’s a big change and requires certain thinking and thought processes. Electronic orders don’t always mirror the clinicians’ thought process. So, some doctors easily made that transition and some had trouble. It was not a mandatory thing, until the Meaningful Use criteria hit,” Meeks says.
Many smaller hospitals do not provide 24/7 on-site pharmacy coverage as hospital executives are challenged with rationalizing expanding pharmacy departments and hiring expensive resources when the volume isn’t there. “As a critical-access hospital, we’re a small, rural hospital, we don’t have 24/7 pharmacy services, so from 8 am to 4:30 pm the orders come to pharmacists for verification,” Meeks explains. “After 4:30 pm, the medication orders go to nurses for acknowledgment, but prior to deploying telepharmacy services, those orders waited until 8 am the next morning, at which point the pharmacists, who are trained for looking at drug therapy management and renal dosing, reviewed them. So there was a gap in the pharmacists’ review of the medication orders.”
In 2011, Crawford Memorial deployed a telepharmacy platform working with PipelineRx, a San Francisco-based company that provides medication management services with a focus on clinical telepharmacy. Two years later, in 2013, Crawford Memorial expanded its CPOE systems to the emergency room and physicians, clinicians and pharmacists found that implementing telepharmacy not only filled critical gaps in pharmacy services but also improved the efficiency of the CPOE process.
“Not having a pharmacist here two-thirds of the day, that’s a huge gap in pharmacy services and the telepharmacy service provides 24-hour medication order review and verification by a clinical pharmacist. We were looking to use this telepharmacy platform to close that loop and optimize our operations,” Meeks says. Prior to the use of telepharmacy services, Meeks and her pharmacy staff were spending 30 minutes to three hours in the morning catching up from the orders that came in overnight. “It’s difficult to efficiently care for patients in the morning when you’re spending so much time catching up. This process enhances efficiency and safety,” she says.
At Claxton-Hepburn Medical Center, a 102-bed hospital in Ogdensburg, N.Y., hospital leadership implemented telepharmacy technology while also rolling out an electronic medical record (EMR) system and those implementations occurred six months prior to deploying the CPOE system.
“One reason we brought in telepharmacy services is that, as a rural hospital, we’re not 24/7,” Greg Guimond, director of pharmacy at Claxton-Hepburn Medical Center, says. “Knowing that we were going to an EMR, the chief nurse operator wanted all the information available electronically so orders show up in the EMR to be verified by a pharmacist. So that meant either bringing on a second or third shift as we’re 7 [am] to 5 [pm] seven days a week, or going with a telepharmacy service,” he says.
Claxton-Hepburn Medical Center also uses a telepharmacy platform provided by PipelineRx. The company provide hospitals with a fully managed and staffed remote medication order verification (RMOV) service. The hospitals have access to trained clinical pharmacists, and also specialty pharmacists such as oncology, for continuous medication order review baesd upon each hospitals’ established systems, policies, procedures, protocols and formulary.
Clinician and Pharmacist Workflow
Some hospital leaders have found that the use of CPOE systems can double the workload for the hospital pharmacist and can actually slow down turnaround times.
“With CPOE and the complex pre-built order sets, pharmacists are now not only verifying an increased number of medication orders but are also responsible for entirely new medication order requests from other clinical departments that may have not had real-time 24/7 pharmacy oversight or had negligible medication order volume,” Brian Roberts, CEO and founder of PipelineRx, says.
Guimond has found that remote staffing through telepharmacy is a cost-effective way to supplement pharmacy staff and enables 24/7 medication review. Additionally, medication orders are processed faster and clinician workflow has improved, he says.
“With the old paper format, the doctor writes the order on the form, the nurse will acknowledge the order and later picks up the order and it was a labor-intensive, time-consuming order entry process. Now the physician enters it, the pharmacy and the nursing staff can see the order is in the system and the nurse is available to administer it. The turnaround time from physician order to the patient getting the medication is much quicker,” Guimond says. “And, I think those who have fully embraced it have found it to be a more efficient workflow.”
Typically, when a medication order is entered into the EMR by the physician, it is then routed to a pharmacist for review and verification. However, pharmacy workflow within these systems can be limited and can become further disjointed when non-electronic orders need to be managed. A telepharmacy software platform can be layered over the EMR to manage all pharmacy order types—electronic, fax, hand-written. Additionally, the platform can be integrated with hospitals' CPOE systems, and the remote pharmacists have secure access to the hospitals’ electronic health record (EHR) and other information systems.
“With the medication turnaround time, the order goes right to the e-queue and you know right away that the orders are there and the turnaround times are quite fast,” Meeks says. PipelinexRx reports that with its telepharmacy platform the average turnaround time for medication order review is eight minutes.
Guimond also has found that the use of telepharmacy services with the CPOE system has significantly improved workflow in the pharmacy as well.
“Before we deployed the CPOE system, first thing in the morning, the orders from overnight would be piled up, and the first hour and a half to two hours of the day would be brutal with processing orders and getting the morning round out,” he says. “With the telepharmacy service on at night, there is no longer that backlog of morning orders. It’s dramatically changed the workflow in the pharmacy.”
Guimond says the telepharmacy platform is just one example of how health IT implementations have enhanced operations and address specific challenges faced by small, rural hospitals. “I find that health information technology really helps facilities like mine that are rural and it enables us to work on the same platform and with the same level of expectations as a larger facility would. It helps level the playing field and gives us the same edge. It doesn’t take a lot of bodies anymore to throw at things to make things work,” he says.
Of Crawford Memorial, Meeks says, “For the size and scope of this hospital, we’re very wired. The hospital administration acknowledge the importance of and support the use of technology to improve things and to optimize our operations,” she says, pointing out that the hospital uses a clinical surveillance tool, Sentri7, to provide clinicians with real-time, specific, criteria-based information. “That technology is another step we’ve taken to decrease the time spent in manual look-up and gives the pharmacists more time to focus on other work,” she says.
Prioritizing Patient Care and Patient Safety
Guimond contends that having each medication order reviewed by a trained pharmacist significantly enhances patient safety. “The telepharmacy has helped us tremendously as now I have the entire evening and night covered with a pharmacist and it’s likely that that wouldn’t have happened before. We’re too small to spend that kind of money to pay for a pharmacist to be here 24/7. We would still be reviewing orders in the morning if it were not for remote pharmacy technology that’s available,” he says.
Further, using remote staffing to supplement clinical pharmacy staff enables hospital pharmacists to expand their role and dedicate more time to face-to-face patient interactions and other clinical programs. Essentially, telepharmacy services enable the pharmacist to “get out of the pharmacy,” Meeks says. Onsite pharmacists are able to walk the patient floors and be at the prescriber’s elbow, showing them how to enter the complex orders and help eliminate their initial frustration with CPOE, she adds.
“That’s been huge for us,” she says. “Depending on how many admissions we get overnight, with our census of 25, we might get one or two admissions overnight, or it can be eight, nine or 10 admissions, and we would spend the bulk of the next morning catching up and also the prescribers are writing more orders. Going to 24/7 coverage with telepharmacy, the pharmacists come in in the morning and are able to have a shift huddle and review what happened overnight and then go into the clinical rooms and sit with the hospitalists group to assist with order entry.”
She adds, “From a patient safety issue, it’s safer to have pharmacy reviewing the medications; pharmacists catch more medication errors as it’s what we are trained to do.”
Guimond acknowledges he had initial concerns about using remote pharmacists to supplement his pharmacy department. “With the model that this company works on, there is a pharmacist covering multiple hospitals on a shift, so how are they going to learn our system and quirks? And how well-trained are these people?”
Prior to deploying the technology, the vendor conducted a WebEx to train the remote pharmacists on the hospital’s specific policies and procedures. “They train the pharmacists on just our system and the quirks of our facility. We had to go on faith a little bit, but once we got the training, I began to notice the intelligent questions being asked during the hand-off process and the concern for patients,” he says.
For the pharmacy staff, the process is seamless, Guimond says, as at the end of the day shift, the on-site pharmacy staff give a hand-off to the remote pharmacist and there is another hand-off in the morning. “In addition to learning our policies and procedures, they are trained on any quirky billing issues and physician preferences, so they really are an extension of my pharmacy,” he says.
Roberts says the use case for telepharmacy extends beyond small, rural hospitals. Large integrated delivery networks have deployed telepharmacy software platforms to optimize their in-house pharmacy staff across facilities, basically to run their own telepharmacy service. Larger hospitals can flex up or down their use of telepharmacy services according to their patient volume. Additionally, large health systems have implemented telepharmacy to support smaller hospitals in the region with virtual labor and to support telemedicine programs.
“We work with healthcare delivery organizations from 25-bed critical-access hospitals up to 700-bed academic medical centers,” Roberts says, noting that healthcare delivery organizations are seeing cost savings from 30 to 70 percent by using telepharmacy technology. “We’re just in the early innings of the game. I think with value-based care coming and with an increased focus on the continuum of care, telepharmacy technology can benefit a lot of areas of healthcare, from hospitals to nursing homes and retail and other pharmacy environments, where clinicians need prescription verifications,” he says.