"When you look at medication management across the continuum of care and all the processes involved, they're complex and have multiple points of failure," says Mark Siska, assistant director of informatics and technology for pharmacy services at the Mayo Clinic, Rochester, Minn. "There are a number of opportunities for distraction and miscommunication, so automating medication management and connecting everything is very challenging."
The medication loop includes entering the order, having it checked for interactions, allergies and other contraindications; transmitting it to the pharmacy where the pharmacist translates the order to a specific form and number of doses; and having it sent to the unit, where floor staff do a final check of the "five rights": right patient, right drug, right dose, right route, and right time. Finally, the medication is administered and details are recorded in the medication administration record.
Though the first stage of federal electronic health record meaningful use requirements stop short of a completely computerized medication loop, a third of the core requirements involve an aspect of medication safety (see chart, p. 42).
Historically, hospital pharmacies often purchased "best of breed" stand-alone computer systems so that they could get some advantages to automation even if the rest of the hospital hadn't yet embraced clinical computing. But as hospitals move toward adopting electronic health records, those stand-alone systems are largely disappearing in favor of the pharmacy systems provided by EHR vendors.
"No one is shopping around for separate pharmacy systems anymore," says Coray Tate, clinical research director for KLAS Research, Orem, Utah, which tracks hospital buying patterns and satisfaction with health information technology. "They'll look for an overall electronic health record system and whatever pharmacy system the vendor has, they'll just put that in. All the pharmacy systems are pretty decent, and the need for integration [with the EHR] outweighs everything else."
That integration means that the pharmacy system uses the same database as the EHR, eliminating the need to pass information back and forth and risk miscommunication. An integrated system can also use expert rules to make decisions that would be too complex to automate in an interfaced environment, says Anne Bobb, a registered pharmacist and manager of clinical informatics and documentation, Northwestern Memorial Hospital, Chicago, which uses an EHR from Cerner Corp., Kansas City. Mo.
For example, while a physician may enter an order for a certain drug, dosage and frequency, it falls to the pharmacist to tailor that order to what's available in the hospital's formulary and the needs of the patient. The physician may order 100 milligrams of a certain drug, and the pharmacist will fill it with two 50-milligram tablets, or a liquid version for a patient who can't swallow pills. Where the pharmacist used to enter those details by hand, about 85 percent are now determined by the system at the point the order is entered, based on rules devised by the pharmacy.
"The pharmacist just has to OK the order and it goes back to the medication administration record and the EHR," Bobb says. "We have a closed loop with limited human interaction except at the point where you need human judgment."
Integration issues
But integration produces its own set of challenges, says Karl Gumpper, director of pharmacy informatics and technology for the American Society of Health-System Pharmacists.
Gumpper is concerned that even when both systems come from the same vendor, they're not always as well coordinated as they need to be. For example, pharmacists sometimes need to do clinical documentation, if they've recommended a change in dosage or found a problem when reconciling medication lists. The pharmacy system and the EHR have different user screens to accommodate the separate needs of physicians and pharmacists, and information entered in the pharmacy might not make it into the physician's view of the EHR.
"There's a chance your recommendation or intervention might not even be seen," Gumpper says. If the pharmacist switches over to the physician's view, they may no longer have access to all the information they see as a pharmacist, opening the door to confusion and error.
Mayo's Siska regrets forfeiting the flexibility that stand-alone systems offer. "One huge disadvantage of integrated systems is that if you make a change in the pharmacy, it can affect the users on the ordering and charting side," making it difficult to improve systems or adapt them to changing circumstances, he says. He dreams of "integrated best-of-breed" EHRs, similar to home theater systems where components from different manufacturers work smoothly together because they all use the same set of hardware and communication standards. "I want plug and play," he says. "That's the ultimate solution.
Most hospitals still don't have bedside bar coding, which provides an automated check of the five rights, says Erin Sparnon, senior project engineer at ECRI Institute, a research group based in Plymouth Meeting, Pa. And even those that do often find they need to engineer the last part of the loop themselves. "Many hospitals have been sold a vision of closed loop medication administration, but when they sit down with their vendors to see what they can buy, most of them end up falling short," she says. One common barrier: an interface between the pharmacy information system and "smart" infusion pump servers, so that instructions for IV administration don't have to be rekeyed into the pump. While some hospitals have accomplished this link, it's been done with a customized interface.
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