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.

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.”

According to Martin, who says he believes his hospital is now a HIMSS Analytics Stage 6 (based on HIMSS Analytics' EMR Adoption Model which evaluates the progress and impact of EMRs in acute care), the biggest lesson learned is that the entire pharmacy process is that it's evolutionary. “What happens is the pharmacy winds up impacting people both upstream and downstream, so the whole planning process has to be done in conjunction with medical staff, nurses, pharmacists, with IT, because at the end of the day it's all about the workflow.” He believes if hospitals implement some kind of technology in the pharmacy that creates additional workflow angst upstream or downstream, work-arounds will develop. “So we need to see how we can leverage the efficiencies as well as the patient safety goals and objectives in conjunction with the workflow,” he says. “It has to happen as the by-product of an efficient workflow and not by adding work.”

Akerson concurs that ownership of pharmacy systems belongs to the entire hospital, not the pharmacy. “If I had to give one piece of advice, wherever you start — CPOE, robots, or anything else — plan it as a group,” she says. “Nurses, physicians and pharmacists view the world quite differently, and it's never mattered. With these systems, it now matters. There's a natural conflict in the way they think which has to be worked through.”

At Gartner, Handler has advice for CIOs shopping for a pharmacy system. “The reality is that the ability to buy a good standalone pharmacy system is going away, and CIOs are going to buy it from a McKesson or a Cerner,” he says. “I would counsel them to make those decisions with an eye to the future, so if you're not yet ready to buy (for example) Cerner CPOE, that you have some sense that the pharmacy system might lead you down that path in the future. You do it in the context of an enterprise strategy that says, ‘When or if we get to the point where we want to do closed loop med-admin, will that decision help or hurt us?’”

Laureto believes closed loop requires thought and continuity. “You have to put a team together and work on it year after year because there are so many steps involved,” she says. “It's not like it's a project, it's a process.”