Jerry Fahrni

Patient safety is priority one at the hospital where I work as an IT pharmacist. I’ve been involved with several projects designed to improve patient safety, improve efficiency and increase our “cool” factor. Projects have included the implementation of Alaris Smart Pumps, a complete Talyst barcoding solution, upgraded Pyxis ADCs, electronic document management with POMS, a new allergy system, new nursing system for documentation, and now an upgraded pharmacy system. Each implementation has provided challenges and none of them have been perfect. With that said, I can tell you with a straight face that the upgrade to our pharmacy system was the most frustrating thing that I have been through to date.

The maker of our pharmacy system is  Siemens Healthcare. Siemens Pharmacy is a well know pharmacy information system in use by many hospitals across the United States. The pharmacy system is loosely “integrated” with several other products available from Siemens Healthcare including their Soarian nursing system and their medication administration checking system (MAK).

Our most recent upgrade offers a significant step backward in usability while offering virtually no additional benefits. In addition to the serious lack of functionality, the customer service, programmer support, consulting support, and all around implementation leadership offered by Siemens Healthcare (at a significant cost of course) was the worst I’ve experienced in my 12 years as a pharmacist.

Listed below are some of the issues I experienced during our Pharmacy System upgrade.

System

1. The “upgrade” is significantly slower than the previous version. The version we installed is built on the .NET framework, while the previous version was visual basic. The end users are noticing much slower processing speeds, which increases turn around times.

2. The system is poorly integrated with microbiology results, forcing the pharmacists to look in a separate system for culture and sensitivity results. The results are technically available in the pharmacy system, but are presented in such a way that they are difficult to read and interpret.

3. The system is poorly integrated with Siemens own nursing system (Invision and Soarian). These systems routinely balk at various medication orders entered in the pharmacy system generating interface errors which require human intervention.  I find this very interesting as the systems are sold as “integrated” Siemens products. I’d hate to see how they would behave if they weren’t integrated.

4. Poorly integrated allergy interface. The allergy interface is supposed to be bi-directional, but that is not completely accurate. Updates from the nursing system don’t always cross into pharmacy system, creating potentially dangerous situations. Example: a patient is registered as an “outpatient”, typically in the dialysis unit; the pharmacy system lists “no know drug allergies” (NKDA) for the patient; the patient reports a new allergy; the nurse enters the new allergy information, but forgets to inactivate NKDA first; pharmacy does not receive the update because NKDA technically still exists on the patient profile. Any pharmacist will tell you this is a recipe for disaster. The patient could potentially be admitted and receive the very drug they are allergic to because the pharmacy system is unaware of the new allergy. When I asked the Siemens representatives about this obvious flaw, they answered that the system was “working as designed”. Really? You designed a system that purposefully endangers a patient by bypassing vital allergy information?

5. Antiquated report designer. Siemens Pharmacy uses a system of very large SQL tables tied to Microsoft Access for reporting. It’s easy to create reports, but they are S-L-O-W and frequently crash.

6. The patient selection preference is flawed. Siemens offers pharmacists the option to search for patients by a variety of pathways including medical record number, account number, last name, room number, etc. This is a great feature on the surface, but instead of allowing the pharmacists to make the change themselves Siemens opted to make these features accessible only to the pharmacy system administrator. Guess who the pharmacy system administrator is. Yep, it’s me. So, if Joe Pharmacist decides he would like his default search method to be nursing unit instead of patient account number, I have to get into the system and change it for him. This is very inefficient. Pharmacists should be allowed to change their own preferences. That’s the whole point of user preferences, right?

7. Preferences that need to be altered by user type, i.e. pharmacist, must be done on an individual basis. Siemens offers no global edits for user type preferences. Why?

Customer Support

1. The day-to-day support I receive from Siemens Healthcare for minor issues is mediocre. When I need a cart time reset, a patient profile re-indexed, or a file rebuilt their support is sufficient. However, when I require escalation secondary to an issue creating a hardship in the pharmacy the support is seriously lacking. This is unacceptable for such a complex and expensive system.

2. Items that require upper level support frequently go unresolved for months or simply fall off the radar. Siemens has a good system for tracking issues called EIM (Electronic Issue Management). Items are logged, acknowledged by the Siemens technician and each intervention is tracked. Unfortunately, once the item moves beyond the scope of the technician activity slows significantly.

3.  Siemens has assigned our facility a full time consultant. I expect a consultant to tell me what to do and how to do it, not the other way around. Consultants are expected to be domain experts; otherwise it makes no sense to hire them. Several times during our upgrade the consultant failed to supply us with vital information needed to advance the project. Other times the information we received was simply inaccurate. The lack of communication and inaccurate information delayed the project several times. Hiring a “consultant” that is poorly versed in the intricacies of the system is partly the institution’s fault, but partly Siemens fault for presenting this person as the expert.

4. Siemens project management could easily be compared to “self checkout”. Large, expensive implementation projects often have a project manager supplied by the vendor as part of the team. The Talyst and Alaris project managers were superb. The Pyxis project manager was not great, but competent. We hired a third party consultant for our allergy system conversion, and he was always on top of issues and kept us on track. Our automated compounder upgrade went smoothly with the help of a Baxa consultant. The Siemens project management was, shall we say, not up to snuff.

5. Siemens has a large online documentation system that provides access to all manuals, upgrade documentation, etc. Unfortunately, searching the documentation requires diligence and lots and lots of patience. As a pharmacist I am fully capable of performing literature searches and hunting down information. Nothing in my education or career to this point could have prepared me for the difficulties associated with searching the Siemens online documentation.

6. The documentation on the upgraded pharmacy system and the “test plan” read like a list of bug fixes and provides little to no continuity for the actual testing. Component testing was scattered throughout the test plan in the order the bug was found and fixed. Testing an intravenous piggyback could appear on page 13 and again on page 462. The test plan would have been much more efficient had items been placed in some logical order. Testing workflow was seriously hampered.  I have no knowledge of who creates either the documentation or the website portal for Siemens, but they should be fired. The existing system should be scrapped and rebuilt from scratch with help from someone with a better track record.

Upgrade

I’m not sure I should be calling our new system an upgrade. As previously mentioned, the new user interface is a step backward in functionality and usability. Some of the most obvious problems are mentioned below.

1. Loss of icons in the navigator. The previous version of Siemens Pharmacy offered colorful icons in the navigator associated with key functions (see image – previous version on left, new version on right). This may sound insignificant, but inclusion of these icons saves a tremendous amount of time by offering visual queues to key on. I have become comfortable with the blue “e” that represents a link to an important website for drug information or the familiar green “folder” icon that represents the patient’s active medication profile where a pharmacist spends a majority of their time. The absence of visual queues in the navigator is a tremendous oversight by the developers of the Siemens Pharmacy System. It is horribly generic and seriously plain.

2. The new system is much slower. I know I mentioned this above, but it deserves mentioning again. Our department enters between 1700 and 2000 orders each day and a couple of seconds per order adds up quickly. The system was not designed by me, but I’m taking a lot of heat over the speed. I expect improved performance from an upgrade, on any system.

3. New thermal labels. Our pharmacy upgraded from dot-matrix to thermal label printers at the same time as our pharmacy system upgrade. The labels look great and provide a readable barcode for bedside scanning. Unfortunately the programmer for Siemens didn’t upgrade all label types, which means certain label types don’t print.  The most significant losses were our repackaging labels and discontinuation labels for intravenous products. The later resulted in the loss of several thousand dollars in wasted intravenous medications. Siemens deflected blame by saying that we did not ask for all label types to be converted to the new thermal system. I suppose that’s true, but my expectation is that their project manager would have mentioned the conversion of all labels at some point in the testing process. I wonder how many upgrades Siemens Healthcare has done over the years. Wouldn’t you think this information would be on a project plan somewhere? It is not, nor should be, the customers responsibility to know the ins and outs of the upgrade. Where was our “consultant” on this issue?

4. The disappearing navigator. The navigator is the area in the pharmacy system where links to commonly used functions reside. Pharmacists utilize these links several hundred times daily to access advanced lab views, historical data, drug information, etc. In their infinite wisdom, Siemens decided to have the navigator automatically close when viewing a patient’s medication profile. Just to be clear, a pharmacist spends 95% of their time going between the navigator and the patient’s medication profile. To open the navigator the pharmacist must click on the header and select the “expand navigator” command from the dropdown menu. Siemens called the change an “enhancement” designed to provide a larger view of the patient’s medication profile. I can live with that explanation, but at least give us the option to turn it off. Unfortunately it is hard coded and cannot be changed. Any Siemen’s user group that thought this was an improvement obviously does not work in a busy pharmacy.

5. “Rx Send Message” is a function used by our decentralized pharmacists to communicate important messages to our technicians. The message entered by the pharmacists appears on the same printer as all our medications, making it ideal because those printers are constantly being checked. The upgraded pharmacy system does not support the “Rx Send Message” on a thermal label printer. It would have been nice if someone would have mentioned that during one of the several meeting we had during testing. The incompatibility of the “Rx Send Message” function is nowhere in the upgrade documentation and when I mentioned the problem during testing I was told that the function was problematic in the test environment, but would work once we moved it to production.

6. The PCO search function is MIA (for an explanation of PCOs look here). The previous version of Siemens Pharmacy offered the ability to search for PCOs by code while building an order set. This was a great function as our system contains thousands of PCOs, and scrolling through them looking for the right one is time consuming. Unfortunately, the upgrade removed the “Search by PCO code” function. Now I am forced to scroll through page after page of PCOs until I find the correct one and move it into the order set. Thankfully I use a PCO naming convention that keep all items used in a given order set together.

Lessons Learned

Ultimately everything we do is a learning experience and this process was no different, but finding the positives has been a challenge.

I have created a system for classifying current issues into three tiers. Tier one represents all the problems that can be resolved quickly and provide some positives for the pharmacists and technicians using the system. Tier two contains the problems that require significantly more work to resolve. The issues in tier two have been escalated up the Siemens hierarchy which has unfortunately been one of the biggest problem areas for Siemens in the past. Tier three contains the problems that Siemens support says cannot be resolved or items that are “working as designed”. I will continue to search for solutions for tier three issues outside the Siemens network. Users of software products are a creative bunch and typically find “work arounds” or ways to improve the system without the help of the vendor. I have already reached out to the Siemens Pharmacy user community via listserves and personal contacts. The feedback I have received has been less than comforting as many users are experiencing the same issues.  At this point in time, the only choice I have is to continue to move forward and make improvements whenever and where ever possible.

Some day I hope to be in a position to make decisions pertaining to product selection and implementation. When that day comes, unless significant advancements are made, I will exclude Siemens as a contender. And from what I have heard from other “in the trenches” IT Pharmacists, I have arrived at a popular conclusion.