According to a recent report from Orem, Utah-based KLAS, pharmacy information systems earn the lowest satisfaction ratings of any area ranked. Though some pharmacy systems deliver a solid product, for many, the integration with a separate core clinical system for this high-volume area is becoming too risky.

In the last three or four years, sales of best-of-breed pharmacy systems have dropped dramatically, and overall, provider pharmacy system selections have trended towards enterprise solutions. “Anytime you enter an order somewhere, it introduces opportunity for an error,” says Jason Hess, research director at KLAS and a principal author of the study. “If you can eliminate opportunity for deviation on the order itself, you're better off. It's just safer.”

So, must CIOs turn to their core vendor's offering? For many, it depends on whether their vendor has one. But for hospitals whose core clinical vendor doesn't have a pharmacy option, all is not lost - there are ways to make integration work.

Trinitas Regional

The greatest majority of hospital orders are for medications, according to Judy Comitto, CIO and vice president of information technology at 521-bed Trinitas Regional Medical Center, a community hospital in Elizabeth, N.J. “There's a lot of volume in pharmacy, and a lot of variation,” she says, citing tablets, liquids, injectables, dosages and pediatric dosages. “The components of every medication are huge.”

The number of those components has grown, and are one of the reasons that though even four years ago having a single platform was not considered that critical, it is now.

The other major factor? Today's push to CPOE demands it. “It's just the challenge of the closed loop process,” says Hess. “If you go to the expense of getting your physicians engaged and doing CPOE - and that's a huge undertaking - when that order gets to the pharmacy, you've got somebody re-keying it from one screen to another screen. Think about how inefficient and unsafe that is.”

And the Federal stimulus package is only accelerating the trend towards an integrated pharmacy, as the discussion around CPOE heats up. “The medication order is such a key piece in that patient care process, I think that speaks to the reason why we're not seeing best-of-breed purchases in big hospitals anymore,” says Hess. “If you're going to do CPOE, get the pharmacy integrated.”

KLAS maintains that when it comes to pharmacy, few hospitals over 200 beds are buying best of breed, ringing up their core clinical vendor instead.

For Comitto, it was the only pharmacy solution she would consider. Comitto was one of the earliest adopters, selecting Atlanta-based Eclipsys' Sunrise Pharmacy in 2007 to go along with her Sunrise core clinical (Clinical Manager) system.

According to Hess, Clinical Manager is still a relatively recent product offering, which can make for a painful implementation. “But I've talked with some customers that are extremely happy,” he says.

Comitto is one of those happy customers. “We decided, in 2002, to go to Sunrise clinical in a phased approach, and we had to wait because Eclipsys didn't have a pharmacy solution for Sunrise at the time. We needed that piece to move forward with CPOE,” she says. Trinitas went live on CPOE and Pharmacy in October of 2007.

Denver Health

Gregory Veltri, CIO at Denver Health, is about to go live on Siemens (Malvern, Pa.) Soarian after using the company's Invision clinical product since 1996. Invision is interfaced with Siemens Pharmacy. Because the Soarian suite does not currently offer a specific pharmacy component, Siemens is interfacing Siemens Pharmacy to achieve a full offering. “It's an older system, yes, but it is also mature,” he says. “Pharmacy systems are critical to hospitals, and I wouldn't get on a newer pharmacy system today.”

According to Hess, “The big hole is that Siemens is not building Soarian pharmacy. They are basically saying stay with Siemens Pharmacy and we'll integrate it.”

For Veltri, that wasn't a problem.

“I don't know why everybody thinks they're not integrated,” says Veltri. “Our interface is from CPOE in Siemens Invision to Pharmacy and it works like a champ.” Denver Health got Pharmacy and Invision back in 1996, and according to Veltri, they function as an integrated system using HL7 messaging.

Veltri has integration history with both Invision and Soarian (though he's not yet live on Soarian), and is satisfied with both. Though a separate system, Siemens Pharmacy had a long history of interfaces to Invision. “It works because it's an established interface and people have been on it for years,” says Hess.

At Denver Health, 96 percent of physician orders are online with Invision, and Veltri plans to achieve the same results when he goes live with Soarian. “Pharmacy is the center of the universe here,” he says.

For outpatient pharmacy, Denver Health uses GuardianRx (Carepoint, Charleston, S.C.) - ADT and allergy information flows among Siemens Invision, Siemens Pharmacy and GuardianRx, ensuring these applications are synchronized. The process is as follows: electronic inpatient orders are placed in CPOE and flow to the Pharmacy system (Siemens); get checked by the pharmacist; move to the Pyxis units (Dublin, Ohio-based Cardinal Health) and then, using MAK (medication administration checking bar-coding technology), are administered by the nurse. MAK is also a Siemens product that is integrated with Pharmacy. “It takes, on average, 7.5 minutes to get an order into the Pyxis unit available for administration,” says Veltri.

But is there a downside to the Siemens interface? According to Hess, CIOs need to look at how long it has taken the Invision sites to get Siemens Pharmacy interfaced - although he says the newest release of Soarian will help. “But it's still not the same architecture, and for some CIOs, the fact that Soarian pharmacy isn't being developed means they decide to look elsewhere,” he says. “There are others who say, ‘We'll interface the same way we did to Invision.’”

Veltri says he believes that once Siemens fully delivers all the latest Soarian features and functionalities, the game will change. “You're going to start seeing a shift to people considering Soarian as a contender and player, and you'll see that in two, maybe three years.”

Before deciding to go Soarian, Veltri says he talked to other CIOs and went on site visits. “We wanted to know how painful was the switch from the Invision-Pharmacy interface to the Soarian-Pharmacy interface,” he says. “And in the early days, the Soarian interface didn't work either.”

Those early kinks, he's convinced, have been solved. “I think if you talk to the early adopters, some of them are switching from Soarian (and from Siemens altogether) because they gave up. But for the ones who stuck with it and have upgraded to Soarian C6 consider it an outstanding product,” Veltri adds.

Never easy

Whether interfacing or integrating with a core clinical suite, implementing pharmacy systems is always difficult. “There's a lot of volume in pharmacy. The components of every medication order are huge, and the build is long,” says Comitto. “It took us at least a year.”

Comitto says she brought in outside help to assist. “The pharmacists still had their day jobs,” she says, adding that CIOs need to consider additional staff - and that IT should not pick up the entire burden. And, having gone live with both CPOE and pharmacy at the same time, she says going that route means the build of both systems must be done as a unit, with ownership shared between the clinicians and pharmacists. “There are orders and builds on one side that make sense to clinicians and then the order that comes across to pharmacy has to make sense to the pharmacists. They have to work together,” she says.

At Denver Health, Veltri says he used a rapid improvement project management style for pharmacy implementation. “We put nurses and doctors in a room for a week designing screens and workflows, and we haddesigners from Siemens in as well,” he says. “The nurses put in 7,200 hours to design the screens and everything that changes their process of care.”

That process of care for pharmacy, whether from the clinical core vendor or not, means taking a look at the workflow. Most agree it is the change in workflow that will make or break the implementation.

“Technology enables bad processes to be really bad processes if you don't change the workflow,” says Veltri. “Anytime you try and put electronics on top of anything, you've got to change the workflow. And people still ignore that.”

Is there any future in standalones? According to Hess, they are continuing to sell in small community hospitals, though the main reason is usually financial.

But the question remains as to whether CIOs will ditch their clinical offering if it doesn't have pharmacy. Comitto believes the answer is probably not. “When you make a huge investment in an EMR, what else can you do but make it work? I know my fellow CIOs, and no one is going out there and admitting defeat,” she says.