My current position is the first in which I’ve been involved in an FMEA, and I’ve personally found them to be powerful tools. We did an FMEA prior to implementation of our BCMA system and came up with what I thought was a pretty good list of things to look out for. Of course what the administration chooses to do with that information is a different story, but at least it’s available if needed.

I’m now involved in an FMEA for our CPOE project. It’s interesting that the issues associated with CPOE are much different than those associated with BCMA and much scarier. The scale of the CPOE project is several orders of magnitude bigger than the BCMA project. One of the biggest issues brought up during discussions on CPOE has centered on what to do when the physician selects the wrong patient or the wrong medication; notice I used “when” and not “if” because it’s going to happen. In the paper world an incorrect order is often found because the patient’s information on the physician order sheet doesn’t match the name on the chart. In the electronic world there’s no such safety. I also believe it’s significantly more difficult for the physician to grab the wrong chart than it is to select the wrong patient. I could be wrong, but I don’t think so.

How do you prevent a physician from choosing the wrong patient? Good question. Feel free to chime in at any point with a solution. One thing that crossed our minds was the use of some type of proximity system where the physician could only enter orders on a patient after scanning their wrist band or by using some type of RFID tag that automatically brings up the patient medical record when entering the room. I think it’s a valid idea, but implementation would be a bear. Throw in the fact that physicians don’t believe they can make a mistake and the battle is on.

Now assume the physician gets the patient right, but chooses the wrong drug. After all, when you search for captopril you’ll get more than one option if your hospital formulary contains more than one dosage form, tablet strength, etc. For example, depending on your system setup searching for “pro” could result in “Protonix” or “propranolol”. Both come in 40mg strengths, but they aren’t even close in what they’re used for; I’ve actually seen this error. Unless the medication ordered by the physician is wildly out of line you might never know what the intent was. The likelihood of something like this causing harm is low, but it could cause delays in therapy or possibly expose the patient to unnecessary medications. So how do you prevent this from happening? I personally think floor based pharmacists doing real-time medication evaluation and disease state management is the best approach here. Being involved with the patient’s care plan is the only real safeguard against something like this.

These are complex issues and I don’t have great solutions. If you have any ideas or have seen something in practice that might work I’d love to hear from you.

This years Innovations conference was heavy with sessions on ARRA, meaningful use and CPOE. I’m not surprised as this is where all the money will be for vendors involved in HIT over the next several years.

Anyway, I feel there are a couple of presentations I attended yesterday that are worth mentioning.

CPOE Lessions Learned: A Pharmacy Perspective
Franklin Crownover, RPh - Pharmacy Computer Coordinator, Tufts Medical Center, Boston, MA

Tufts Medical Center is a well known teaching hospital affiliated with Tufts University. The hospital is 451 licensed beds and offers all the normal patient services that y0u would expect to find in a facility that size, i.e. critical care, ED, pediatrics, a NICU, etc. In addition I’ve known Franklin for a couple of years now and have had some great conversations with the man during that time. He is quite brilliant and I frequently use him as my personal consultant for all things Siemens.

Apparently CPOE implementation is quite difficult and Tufts ended up running approximately one year behind their original implementation schedule. Franklin had some very interesting things to say about why their CPOE implementation fell behind, but the best reason he gave was that “it was hard“. That about sums it up.

Other reasons for the difficulties included the complex nature of the CPOE build, lack of resources dedicated to the project, unfamiliarity with the product and it’s functionality and lack of physician involvement. Franklin said it was a miracle that the project ever got off the ground. Not encouraging words.

The project team consisted of nursing, pharmacy, information technology, a Siemens consultant and a Dell-Perot consultant. This is consistent with other facilities I’ve spoken with. However, the lack of a physician on the team is disturbing.

Some of the things I took away from the presentation include:

• Identify available pharmcy resources and get them involved early.
• Pharmacy needs to understand the system by attending appropriate education provided by Siemens or other third party.
• Don’t underestimate the resources needed, and when you think you have enough, push for more.
• Don’t try to copy the paper process. Figure out new ways to do it in the electronic system.
• Develop a painstakingly thourough test plan.
• Clean up your order set process before starting CPOE project.
• Invest in an evidence based order set system like Provation or Zynx (Tufts uses Provation)
• Don’t try to build, track and maintain the order sets yourself; they tried and failed. (One of the slides from the presentation was a great flowchart for their process of authoring and approving order sets)
• Standardize whenever possible, i.e. G, GM, or GRAM; CAP, CAPS, or CAPSULE; etc.
• Serval Siemens specific items that I won’t bore you with here.
• “Make it idiot proof”. I love this line. Who do you think he was talking about?
• Finetune the alerts for physicians whenever possible, i.e. don’t burden them with useless garbage.

Overall Franklin had a lot of negative things to say about the CPOE project in general, and even took a couple of shots directly at Siemens. But he did it in a humorous way while offering some sound advice.

Are You Ready for CPOE? Do You Have What it Takes with Pharmacy to Prepare and Implement CPOE Successfully?
Brian George, PharmD, Assistant Director of Pharmacy and Judy Miller, Clinical Analyst for phamrayc systems, MedCentral, Mansfield, OH

The MedCentral system consists of a couple of hospitals totalling 351 licensed beds, and is one of the 2010 ‘Most Wired Hospitals’ so I was very interested in what they had to say. This presentation took a slightly different approach than Franklins, but provided a lot of the same details, i.e. resources are important, evidence based order set development (Zynx), standardization, etc.

The one thing the MedCentral presentation did that the Tufts presentation didn’t was break down the number of pharmacy hours necessary to complete various phases of the project. Needless to say it’s a lot of hours.

My impression

Both presentation were helpful in my quest to secure informatin for our upcoming CPOE build and implementaiton. Unfortunately much of what I suspected regarding the difficulties involved have been confirmed. I believe we have fallen into the same trap as Tufts with a lack of resources and physician involvement, but only time will tell. I’m really not looking forward to banging my head against the wall for the next 8 months.

“Working the spreadsheet” was mentioned several times throughout both presentations, and each time I cringed in my seat. It’s strange to hear pharmacists talk about sitting in front of a computer hour after hour doing nothing but changing the word ‘CAP’ to ‘CAPSULE’. It just seems to be an odd use of resources. I don’t know, maybe I’m just overly sensitive. With that said I have a sneaking suspicion that I’m in for a long year. I’m just sayin’.

The goal of one of the meetings I attended last week was to discuss the resources necessary to implement a CPOE system. Needless to say the project is going to be resource heavy. When it came time to tease out the IT pharmacist part of the project I was a little surprised at what I heard. The time requirements weren’t surprising – several hundred hours – but where the pharmacist fits into the entire scheme was.

Are you ready? Wait for it…wait for it… The pharmacist’s job is to manually build the CPOE drug formulary using a spreadsheet. After all the preaching I’ve done in regards to what an informatics pharmacist should and should not be doing, it was all I could do not to laugh out loud when the Siemens consultant laid out the work plan for the CPOE project.

You see, the pharmacy drug master, a.k.a. formulary, drug dictionary, etc. is manually dropped into a Microsoft Excel spreadsheet and the pharmacist is supposed to spend several hundred hours making it “easier for the doctors to read” and adding several fields that don’t already exist in the pharmacy system. It seems that the Siemens Pharmacy System and Siemens CPOE System aren’t well integrated. While we can interface the drug dictionaries following the initial upload we cannot simply use the pharmacy drug dictionary for the CPOE system.

I can’t tell you the number of times that the pharmacist looked at me during a work session and said “when you’re working the spreadsheet…”. Stop laughing, it’s not funny. Ok, it is kind of funny, but stop laughing anyway.

It’s going to be difficult for informatics pharmacists to broaden their scope as long as vendors see them as little more than tools for data entry. Then again maybe I’m the one who has it all wrong. I’m just sayin’.

My thoughts on pharmacy informatics can be found in several places on this site.

• Where is pharmacy informatics headed (July 1, 2009) – “Many IT pharmacists are involved in much more mundane tasks such as maintaining pharmacy formularies or creating and maintaining billing reports. Calls to investigate “printer problems” or reset forgotten passwords are not uncommon. Many of these issues certainly do not require the knowledge base of an IT pharmacist and often times pull them away from other important tasks.”
• View on technology-enabled practice from ASHP (August 27, 2009) – In reference to an article¹ in AJHP “Turning these ideas into reality will be challenging. As a group, pharmacy has been unable to make significant changes to their practice setting for more than 30 years. I have no idea why, but it is a serious problem. Without forceful leadership pharmacy will be using the same practice model for another 30 years and nobody wants that.”
• Use of pharmacy informatics resources in hospital pharmacist (November 17, 2009) – In reference to an article² in AJHP that took a look at the use of pharmacy informatics in approximately 200 hospitals across the US. “Any facility serious about taking advantage of pharmacy technology, informatics and automation has no choice but to consider the services of a pharmacy informatics specialist.” I still believe that, although what role they will play remains uncertain.
• Requirements for a pharmacy informatics professional (December 14, 2009) – “I can teach anyone how to maintain a system. What I can’t do is teach someone logic and how to be intelligent and forward thinking. In my humble opinion, [employers are] looking at [hiring practices] all wrong. Focus on the key components and forget about the system requirements. If you happen to get it, great; don’t go looking for it.”
• Confusion and varying opinions regarding the role of pharmacy in informatics remains the norm (July 20, 2010) –  “Pharmacy informaticists should be intricately involved in making sure that systems are designed to include pharmacy workflow, that reports being written provide the necessary information to be clinically relevant, that current clinical standards are adhered to during implementation of new systems, be the representative at the table during discussions of integration and interoperability of hospital systems, provide insight into new systems that can help pharmacists enjoy more freedom from the pharmacy and so on. What they shouldn’t be is the guy sitting in a room plugging away at a spreadsheet all day or fixing the fax machine when it breaks.” Now you know why I almost laughed out loud.

1. Technology-enabled practice: A vision statement by the ASHP Section of Pharmacy Informatics and Technology Am J Health Syst Pharm 2009; 66: 1573-1577
2. Use of pharmacy informatics resources by clinical pharmacy services in acute care Am J Health Syst Pharm 2009; 66: 1934-1938