One of the primary goals is patient-centered safety. This is particularly important in the economic environment of the present times. With the limits on Medicare/Medicaid reimbursement for hospital related events such as falls or decubitus ulcers, patient safety is primary. Avoiding confusion caused by medications can help to eliminate some of these safety concerns. Of course, the pharmacy does much more with medications than just evaluate medication side-effects.Efficiency within the pharmacy department today is more challenging than in the past. Patients enter the hospital “sicker” and leave the hospital sooner. The input a pharmacist can make to a disease process through medication knowledge is very helpful for other practitioners. Medication Reconciliation done by pharmacists includes prescription medications, non-prescription medications, herbal products, and dietary supplements.Cost effectiveness is achieved in Wisconsin through a forum and portal used by the pharmacy organizations throughout the state. The Pharmacy Society of Wisconsin (PSW) at www.psi.org contains that portal.(1)The use of an Enterprise EHR enables a patient’s record to be used throughout Aurora’s hospitals, clinics, and pharmacies.Cerner’s ‘Millennium: PharmNet, PowerChart’ , and other software help create a ‘closed loop’ medication administration system that involves the physician, pharmacist, and nursing staff. Orders are communicated between groups and situational awareness is increased in an EHR. Medications are entered into the system by a clinician. Pharmacy verifies and makes the medication available. Nursing administers the medication with the 5 rights of medication which are embedded into the EHR (right patient, right medication, right time, right dose, and right delivery route)Sources:Delivering Patient Safety at the point of care, Stephanie Mills, MD MHCMClaudia Blackburn, MBA, October 14, 2005, http://www.lahimss.org/meetings/Mills_Blackburn_Oct2005.pdf
The pharmacist is the medication expert of the healthcare team. As the medication expert, pharmacists have a great deal of knowledge regarding medications. With the technology of the electronic health record, the pharmacist may play a greater role in bringing medication therapy and management to the forefront of patient-centered care.The pharmacy department is the most logical department for building and maintaining medication order sets.Pharmacists use clinical decision support systems for drug-drug interactions, drug-allergy interactions, drug-alcohol, and drug-formulary checks on medications. Since medications are subject to change in the inpatient setting, the goal of the pharmacy department is to check medications on admission, transfer, and discharge of a patient from an inpatient setting.Management and analysis of medication alerts is part of patient-centered care. Some research has shown that as much as 50% of severe alerts have minimal clinical effect on the patient.(2) Management of these alerts is best done by a pharmacist on a regular basis to eliminate “alert fatigue”.Medication Management Therapy includes; Comprehensive medication review, anticoagulation monitoring, pharmacotherapy consults, immunizations, preventive care measures, and wellness programs to minimize patient risk and maximize patient outcomes.Medication reconciliation is best left to the expert of the healthcare team.
Pharmacists have worked with interfaces on order entry systems for years, and are probably the most knowledgeable member of the healthcare teamregarding these modules.IT professionals working withdifferent areas of an EHR can learn from the pharmacist. EHRs integrated into pharmacy systems need to be able to transfer information to outpatient settings, long-term care facilitates, and ambulatory care settings. EHRs transmit allergy lists and medication lists. Having the pharmacy control these features of an EHR, leads to better patient outcomes.
Drug-Drug interactions are an important part of medication management. Medication lists of an EHR controlled by the pharmacy department automatically check for these interactions to avoid adverse drug reactions. Pharmacy medication lists contain nonprescription medications, dietary supplements, and herbal supplements – all of which may have an interaction with a prescribed medication.Drug allergy lists generated in the pharmacy department separate true drug allergies from drug intolerances, and include over-the-counter allergies, food allergies, and other allergies.Drug-Formulary checks are not a problem in the inpatient setting for most insurance plan programs, but once the patient and their information leave this setting, a patients health plan may have strict benefit rules associated with a retail pharmacy or other healthcare setting.
Management of medication alerts through a clinical decision support system is part of medication management. Avoiding “alert fatigue” is important in a cognitively challenging environment. A complete drug knowledge base is an important element of managing these alerts. Reviewing the medication alerts is also relevant. Drug allergy alerts should never be disabled.
Compliance with prescribed medications is a deep hole. Most patients who do not feel sick, do not take medications. This fact has long been known, and is well documented under studies done on high blood pressure medication compliance. Compliance will be further addressed later in the presentation.Since pharmacists contain the most knowledge about medication on the healthcare team, it seems logical that lead the team on medication reconciliation. Since this process is complex and time-consuming, and if pharmacists are willing to take on this added responsibility, why not let them. With training on HIPPA and patient consent, pharmacists will be able to add more to this process by including non-prescription medications, dietary supplements, and herbal remedies.
Verification involves having the pharmacist, physician, or other qualified staff check the medication orders before it is administered.Using Cerner’s “Millennium” technology, a pharmacist, or qualified staff can view medication orders from any workstation in the facility. Pharmacists may be responsible for multiple patient units and the ability to access the system from any workstation allows them to complete their rounds and still be in communication with EHRs. They review the patient’s profile to detect potential problems with dosage, contraindications, drug-drug interactions, and duplication. Pharmacists check the name of the drug, the patient’s weight, and dose calculations before processing the prescription.Warnings generated by an order entry are flagged by the computer system and reviewed by a pharmacist. Special icons, colors, alerts, and warning boxes are utilized by the computer to communicate problems to the users. “Evidence Links” and “Referential Information” are available on the electronic record to help with decision making.
Remember the IOMs statement: “Patient before technology”.In most cases, the medication is first transcribed and entered into a system prior to being administered. This allows pharmacists and others to verify the medication order.Occasionally a medical emergency may require that medication be administered to a patient as quickly as possible without a delay. In this situation the medication is administered before it has been entered into e-Mar. This is known as “chart before verify”. When this occurs, the built in safety measures are not available in an EHR.Medication given this way is documented as soon as possible after administration, with date and time given, it soon appears on the electronic medication administration record. Sources:Aurora System Nursing Alliance – System Policy, Electronic Medication Administration Record, http://www.aurorahealthcare.org/portals/nurses/student-system/central/art/e-mar-policy.pdf
Centralized pharmacy performs many functions. One of these functions is the repackaging and labeling of bulk and solid medications into Unit dose (unit-of-use). These (unit-of-use) medications are used as frequently as possible. For added security, PIN numbers can be used during loading and storage of medications.Reliable thermal bar-code printers print medication bar-code labels for these unit dose medications. These bar-code labels are produced and affixed to each medication, from tablets to IVs. Significant benefits resulting from adoption of bar-coding are:Quicker and easier processing of unused medications. Items are scanned and returned to inventory shelves - no more manual keyboard entry to retrieve patient information. Inventory and reordering is done via the computersystem. Dispensing and unit-dose placement interfaces with robotic pharmacy equipment. This maintains the inventory of medications.Patient safety is improved with BCMA (Bar-code Medication Administration)The medication(bar-code label) is scanned against the patients (bar-code wrist band) prior to administration . Sources:Bar Code Printers from Zebra Technologies, Rob Raschke, Vince Trier, http://www.pppmag.com/article/104/November_2006/Bar_Code_Printers_from_Zebra_Technologies/?aurora%20health
Bar Code Medication Administration (BCMA) was first implemented by the Veterans Administration around 2001. BCMA involves scanning the patient (via bar-coded wristband) and then scanning their medication (bar-code label) prior to administration, its purpose is to check/confirm the five medication rights. Portable computers with scanners(Stinger Carts, or COWs) and wireless technology has made this “bedside bar-coding” possible. The result is that adverse medication events are greatly reduced and patient safety is improved.The steps as listed from Aurora’s training documentation:Get a Stinger Cart (computer on wheels)Open patient’s electronic chart.Identify meds to be administered using e-MAR, Task List or PAL.Reviews medication orders (Nurse review function) if needed.Gather meds to be given; Must leave in original package with barcode intact.Select medication administration wizard (MAW). Scan the patient wristband to identify correct patient.Scan the medication(s) to be given.If no errors, nurse administers medication(s) to patient.Nurse “signs” medication(s) given via the MAW.Source:Barcode Medication Administration, http://www.aurorahealthcare.org/portals/nurses/student-system/metro/cerner/art/barcode.ppt
CPOE connects the pharmacy and nursing services to review orders, receive reminders and alerts, and provide access to clinical practice guidance. E-prescribing includes these features plus access to the patient’s health plan formulary and transmission of the prescription through a gateway to a retail or mail order pharmacy. An e-prescribing gateway provides secure routing. The largest e-prescribing gateway is Surescripts.CPOE and e-prescribing have many issues. These include the length of time it takes to enter the order, alert fatigue, keeping the drug knowledge base and formularies for e-prescribing up to date, and training new and infrequent users. Problems also include drug names in CPOE which may differ from the drug name in the pharmacy system. The lack of standards in the electronic transmission of prescriptions is a huge source of headaches for most pharmacists. This issue has been addressed by the American Pharmacists Association (APhA) who has brought this issue to the forefront of the HIT Policy Committee and recommends the use of NCPDP SCRIPT (National Council for Prescription Drug Program) standards replace codified SIG and RxNorm because it is widely used by the pharmacy profession and can integrate formulary and benefit information as well as medication history communication among prescribers, pharmacists, and third party payers.(5)E-prescribing tools can include both software as well as hardware, like personal computers, handheld and wireless devices, and touch screens. Eight software vendors achieved Gold Certification: Allscripts, CureMd, Doctations, Dr. First, H2H, NewCrop, Omni MD, RxNT. Rhode Island is the first state to reach 100% pharmacy e prescribing. (This information was taken from NACD’s Surescripts websites)It is imperative that EHRs are consistent across diverse patient care settings. EHRs must have common functionality, and interoperable of elements for the billing and documentation of healthcare services.
Access to a patient’s prescription benefit allows prescribers to choose medications that are on the formulary and covered by a patient’s drug benefit. Immediate access to a patient’s current and past prescriptions helps the provider understand the cycle of dispensing related to a prescription. Prescribers can use this information to improve safety and quality. Prescribers can gain insight into a patient’s medication adherence. Electronically routing the prescription to the patient’s pharmacy improves accuracy in the prescribing process. It saves time by reducing phone calls and faxes related to prescriptionrenewal. It authorizes as well as reduces the need for pharmacy staff to key in prescription data. (This information came from: The Nations e-Prescription Network Website). GI Associates Triage Department at St Luke’s Physician Office Building, an independent owned physician group, utilizes e-prescription, and has noticed a significant improvement in safety and time spent doing prescription refills.
Wisconsin ranks 31, in the 2009 Statistics, in safe prescription state rankings. TheNEPSI (National E-Prescribing Patient Safety Initiative) estimates approximately 990 physicians were actively e-prescribing in 2009, with 897 pharmaciesparticipating in e-prescribing . Approximately 53.25% of patients had prescription benefits. The incentive payment for 2000 was 2%.
E-prescribing grew from 68 million in 2008 to 191 million in 2009. The number of prescribers routing prescriptions grew from 74,000 at the end of 2008 to 156,000 by the end of 2009. Source: Surescripts
Accuracy/Safety: A study from the Center for Information Technology Leadership estimates e-scribing with clinical decision support has the potential to reduce adverse drug events by greater than 60% over traditional paper base writing. E-scribing has automated checks for dangerous drug to drug and drug-allergy interactions. Fraud and/or tampering of printed prescriptions, by patients, is eliminated with e-prescribing. Errors in interpreting name and dose of drug are eliminated with e-scribing. Accuracy and safety lowers health care costs for everyone.Efficiency: A 2004 study by MGMA’s (Medical Group Management Association) Group Practice Research Network estimated that the time spent managing unnecessary administrative complexity related to prescriptions can be valued at approximately $15,700 per year for each full time physician. A study by Brown University in 2006 showed the average time spent managing prescription refills was cut in half through implementing e-scribing. Instant access to the patient’s insurance formulary coverage increases efficiency in choosing medications, and decreases the cost for the patient and insurance. E-scribing improves the medication reconciliation process via consistent and reliable data from a trusted source.Compliance: Patients appear to have more follow through with prescribed medication using the e-prescribing system. It avoids the chance for a patient to misplace or lose the script before getting it filled. Providers can do a better assessment of patient compliance with chronic medications. Through Medication Therapy Management (MTM) the pharmacist is able to review all medications, dietary supplements, vitamins, and herbal remedies. All products are checked for interactions with prescribed medications. The pharmacist then produces a Medication-related Action Plan (MAP). This collaborative plan between the pharmacist and the patient contains a list of action items for the patient to use in the self-management of medications, dietary supplements, vitamins, and herbal remedies. Patients reluctant to mention side-effects of medications sometimes get the courage to do so with this pharmacy measure.(6) McKesson’s Pharmacy Intervention Program includes a series of behavioral coaching sessions for pharmacists which has shown the interventions helped patients achieve their medication goals.(7)Lower healthcare costs: The cost savings for patients with chronic diseases and MTM is significant. The APhA (American Pharmacists Association) includes medication management in its clinical quality measures. Chronic diseases with medication management expected to lower healthcare costs include;Diabetes, congestive heart failure, coronary artery disease, high cholesterol, anticoagulation therapies, COPD, and asthma. Preventative quality measures with expected cost savings include; influenza and pneumonia vaccinations, and medications to avoid in the elderly. The last class of patients expected to have cost savings include; management of antiviral utilization and use of Hepatitis A vaccine in Hepatitis C patients, antidepressant utilization in patients with major depressive disorder, management of ADHD, and medication management for individuals with alcohol or drug dependency.(8) Controlled substance prescriptions are currently ineligible for e-prescribing. The DEA has a proposed rule for e-prescribing controlled substances. The APhA has issues with this proposed rule which include; the workflow of long-term care settings where the prescriber is not onsite, management of Collaborative Drug Therapy Management (CDTM) where pharmacists participate in the initiation or modifying of prescription orders per a protocol, the oversight of glitches or transmission failure which does not allow for the faxing of prescriptions, and the flexibility to reprint controlled substance prescriptions labeled as “not valid” for reports.(9)It is difficult to get an e-prescribing system with the ability to document tapering doses, such as prednisone and corticosteroid medications.Entering all the pharmacies demographics into the computer system initially, and updating pharmacy address changes and phone numbers takes a lot of manpower time. The system also has to be checked for pharmacy duplication.
Small and large hospitals are utilizing the services of remote Intensive Care(ICU) pharmacy units. Remote monitoring provides another opportunity to improve patient care and reduce costs. Remote ICU pharmacists are available to make recommendations or alert the hospital staff to concerns.Aurora has 246 ICU beds that utilize remote ICU and telemedicine technology . There are at least 5pharmacists and 2 pharmacy technicians on staff at the e-ICU facility.Another trend is the ability of applications to share data from different platforms. Standards are being developed so that systems are able to communicate and transfer data. While smart-phones will never have the computing power of desktops, and wireless networks do not have unlimited capacity to transfer very large files, overall the capabilities of both are slowly improving. Bar-coding will be used as much as possible to promote efficiency, continuity and safety.Five notable pharmacy associations have written a letter to the ONCHIT department asking that pharmacy information systems be certified. The reasons for this certification process include the integration of the pharmacy systems into an EHR. Additionally, these associations are asking for bidirectional communications among various healthcare providers and settings, with access to critical patient healthcare information including diagnosis and laboratory values. Mentioned also is the certification of personal health records, remote dispensing machines, clinical decision support tools, smart infusion pumps, patient monitoring equipment and laboratory data systems. (10)Sources:Implementation of pharmacy services in a telemedicine intensive care unit, American Journal of Health-System Pharmacy, Vol. 65, Issue 15, 1464-1469, 2008, http://www.ajhp.org/cgi/content/abstract/65/15/1464Cool Technology of the Week ,http://geekdoctor.blogspot.com/2010/11/cool-technology-of-week.html
Ehr And Pharmacy
Cheryl, Regina,Carolny and Gary
• Explain the goals of the pharmacy department in an EHR• Discuss the role of the pharmacist in diverse healthcare settings• Justify verification, drug packaging, and bar-coding• Discuss the differences between CPOE and e-Prescribing
Building and Maintaining of Medication Order Sets Implementation of Drug-Drug, Drug- Allergy, and Drug-Formulary Checks Management and Analysis of Medication Alerts Medication Management Therapy Medication Reconciliation
Pharmacists’ are familiar order entry systems Interfacing can include order driven dispensing cabinets and robotics Bar-coding and smart pumps can be integrated into pharmacy information systems
Drug Allergy Lists Drug-Drug DrugInteractions Formulary checks
• World Health Organization estimates that up to 50% of patients do not take their prescribed medications(3)• Greatest potential for morbidity reduction is the resumption of home medications during acute stays and at discharge(4)• Medication reconciliation is a complex process
Medications are reviewed by physicians, pharmacists, and nursesStandardized icons indicate a status or problemEvidence LinksReference Information
Chart Before Verification is used in emergency situations when a delay is harmful to the patientChart Before Verification has NO safety checks
Centralized pharmacy operations Streamlined drug distribution and dispensing Repackaging of bulk medications into unit-dosed portions Creating specialized complex mixtures Integration of PharmNet with bar-code printing ( makes BCMA possible)
Real-Time Check that identifies the correct patient, medication, dose, time, and delivery method Real-Time documentation of medication Prevents against: - Wrong patient, wrong medication, duplicate dosing, incorrect route of delivery Calculates sliding scale dosing
o CPOE occurs in the inpatient setting, while e-Prescribing occurs in the outpatient setting Both involve the transmission of physician orderso CPOE and e-Prescribing featureso HIMMS defines e-prescribing as the electron generation of prescriptions through an automated data entry processing system utilizing software, and a transmission
By using a computer or hand held devicea prescriber can electronically: Access a patient’s prescription benefit information Access a patient’s consent Access a patient’s current and past prescriptions Electronically route prescriptions to the patient’s pharmacy
Advantages Accuracy/Safety Efficiency Compliance Lower healthcare costsDisadvantages Prohibition of e-prescribing controlled substances Difficulty recording tapering doses Entering pharmacy names into the system
Remote ICU pharmacy services utilized More portable devices Increasing use of bar-coding technology for specialty, complex, and high-risk medication administration Certified Pharmacy Information Systems and possibly other healthcare equipment
The goals of pharmacy include patient- centered safety, efficiency within the pharmacy department, and cost effectiveness. Pharmacists have diverse roles. These include inpatient pharmacists, retail pharmacists, and pharmacy consultants. Verification, drug packaging and bar-coding have made the pharmacy efficient and safer for patients. Hospitals use CPOE, while clinics use e- prescribing for medication management.
1. www.pswi.org, PSW Facilitates Dialogue among Wisconsin’s Hospital Pharmacy Directors and Managers, http://pswi.org/communications/jurnal/2010/hospforum030110.p df, Retrieved 11/19/2010.2. http://rxinformatics.com, The Pharmacist’s Guide to Meaningful Use, http://rxinformatics.com/content/pharmacists-guide- meaningful-use, Retrieved 11/19/2010.3. http://www.mckesson.com, McKesson and Pfizer Partner to Support Pharmacists’ Role in Patient Care, http://www.meKesson.com/en- us/McKesson.com/About%2BUs/Newsroom/Press%2BRelease%, Retrieved 11/19/2010.4. http://www.ncbi.nlm.nih.gov, Evaluation of Patient Interventions and Recommendations by a Transitional Care Pharmacist, K Bruce Bayley et al, Therapeutics and Clinical Risk Management 2007:3(4) 695-703.5. www.pharmacist.com, APHA Comments to ONCHIT Policy Committee, APhACommentstoONCHITPolicyCommitteeonERxandMeaningfulUse0 12710FinalwithAttachments.pdf.AdobeReader, Retrieved 11/18/2010.
6. www.pharmacist.com, Letters to the HIT Policy Committee Information Exchange Workgroup, http://APHA CommentstoONCHITPolicyCommitteeonERxandMeaningfulUse01271 0FinalwithAttachment.pdf.Adobe Reader, Retrieved 11/18/2010.7. http://www.mckesson.com, McKesson and Pfizer Partner to Support Pharmacist’s Role in Patient Care, http://www.mckesson.com/en_us/McKesson.com/About%2Bus/Ne wsroom/Press%Retrie2Brleases%, Retrieved 11/18/2010.8. www.pharmacist.com, Letters to the Centers for Medicare Medicaid Services, https://www.pharmacist.com/AM/Templates.cfm?Section=Home2& CONTENTID=22813&TEMPLATE=/CM/ContentDisplay.cfm, Retrieved 11/18/2010.9. www.pharmacist.com, Letter to Drug Enforcement Administration Attn: DEA Federal Register Representative/ODL, www.pharmacist.com,APhACommnetstoONCHITPolicyCommitteeon ERxandMeaningfulUse01271FinalwithAttachments.pdf.AdobeRea der, Retrieved 11/18/2010.
10. www.amcp.org, Letter to ONCHIT Attn: Certification Programs Proposed Rule,www.amcp.org/data/legislative/anaysis/Pharm acy%20Organizations%20Joint%20letter%20t o200NC%20on..., Retrieved 11/18/2010.