Ask any pharmacist that’s been around for a while and they’ll tell you about the headaches associated with faxed medication orders. I can’t tell you how inefficient a fax machine can be for order retrieval, storage and sorting. In fact, fax machines really can’t do any of that. Well, you no longer have to deal with fax machines in the pharmacy if you chose not to.

Pharmacy, or physician, order management systems like OmniLinkRx offer a software only solution designed to reduce the influx of faxed orders to the pharmacy. Not only do systems like this reduce confusion, they also reduce paper waste. I suppose that makes OmniLinkRx “green”. Consider OmniLinkRx a digital fax machine that sends the order to your computer monitor instead of a fax machine.

According to the OmniLinkRx datasheet (PDF):

“OmniLinkRx runs on a standard server with user access via workstations using Microsoft Windows Internet Explorer. Orders may be sent via analog fax and/or digital sending devices. Nurses simply place the physician order into the sending device and indicate STAT or routine. The scanned document image is sent to the OmniLinkRx server where it is immediately viewable by pharmacy for order entry. The orders can be viewed remotely.

Nurses may view the orders sent to pharmacy at any internet enabled PC and/or at Omnicell Color Touch cabinets. Nurses are able to view the status of the order to allow them to know when to expect new medications. “

Some of the features that I like about OmniLinkRx are that it is web-based, it creates an audit trail based on user annotation, it offers pre-defined and customer generated stamps, it creates bar code association of the order to the patient and it can automatically associate the patient’s name to the order based on an OmniLinkRx to ADT system interface.

The one thing I don’t like is that the OnmiLinkRx technical specifications state “Web-based application, requiring Microsoft Windows Internet Explorer 7.0 Web browser.” While I appreciate the web-based part, I would like the option to use other browsers. It may still work in other browsers like Firefox and Google Chrome, then again it might not. If you’re savvy enough you can use one of the plugins for Firefox or Google Chrome that allows you to run a native IE window inside the browser, but most IT departments frown on this type of freedom.

Overall pharmacy order management systems like OmniLinkRx offer a great advantage to acute care pharmacies. They’re especially useful with a dual monitor set-up with the pharmacy information system up on one monitor and the order management system up on the other.

With proper use this technology can decrease turn-around time, allow easier order management and create a easy method to search for and locate orders already processed. Believe me, it’s much easier to search through electronic document files than it is to rummage through 400 paper faxes.

Other pharmacy order management systems:

• POMS from Integrated Informatics
• Pyxis Connect from Care Fusion
• Siemens EDM
• InterChange from AmerisourceBergen

Then I noticed a trend at a lot of the web sites that I frequent: Microsoft has slowly, and quietly, been positioning itself to jump into the healthcare market.

Consider the following:

• Microsoft has been plowing forward with their cloud and Software-as-a-Service model: Azure Platform, Office Live, etc.
• Microsoft is offering American scientific researchers free access to their new Window’s Azure platform. This should allow centralized data collection for scientists to collaborate on research projects.
• HealthVault is one of the key players in the personal healthcare record (PHR) race. Google Health is the other big boy on the block. Sure, there are other players in the game, but even they recognize the need to acknowledge the dominance of Microsoft and Google.
• Microsoft announced HealthVault Community Connect, which is designed to help hospitals and patients control the flow of data stored in multiple systems.
• The Cleveland Clinic and Microsoft partnered to use HealthVault with the hospitals EMR to track patients with chronic conditions.
• EHR vendors are starting to get on board with the Microsoft platform.
• Microsoft already offers a health information system, i.e. Amalga Hospital Information System. Why isn’t anyone talking about it?
• Take a look at some of Microsoft’s activity at HIMSS 10.
• Microsoft Surface – what a great tool for physician interaction with patients.

• Mobility – at the moment, the only real player in the tablet computer game is Microsoft. I’m encouraged by the iPad and the Adam, but for now there is only Microsoft and Windows XP tablet, Vista and Windows 7. Microsoft will have to do a better job with their smartphone platform, but take notice that they continue to push forward with the concept even though they’re getting trounced by the iPhone and Android devices.
• Microsoft and Philips are collaborating to build clinical decision support tools (CDST).
• Microsoft is already entrenched in numerous healthcare systems across the country, perhaps the world, as an enterprise partner. Windows is still the dominant operating system found on desktop computers in hospitals, and how many millions of healthcare providers already use a Microsoft productivity application, i.e. MS Office, Exchange Server, MS Outlook, MS SQL Server, so on and so forth. This gives Microsoft an extensive user base from which to build an incredibly integrated system.

Further consider that software like our pharmacy information system (PhIS) and BCMA system from Siemens is built on the .NET framework using Visual Basic.NET. Yep, another Microsoft product. How long do you think it will be before other vendors begin partnering with Microsoft to develop and integrate products that will work in the healthcare arena? I’m betting not long.

I’d love to spend a few days in Redmond running around playing with all their toys. I can’t imagine the research and development that goes on behind those walls, but it must be pretty cool. I’m sure we only see a fraction of what they’re working on.

Microsoft may be aging and their bite may not be as vicious as it used to be, but they are still an 800 pound gorilla in the the software industry. And what can an 800 pound gorilla do? You got it, anything it wants.

As mentioned by the authors in the article the currently available pharmacy-related applications are limited when compared to devices like the iPhone, but the numbers are growing. Drug information resources like Lexi-Comp, Skyscape and ePocrates are now available for use on the DROID as well as some medical references like Merck Medicus, Unboud Medicine and UpToDate (via mobile browser). Unfortunately I don’t have a list of available medical applications for the Android operating system nor do I know of a site that does, but the popularity of the Android operating system is growing and it’s only a matter of time before other medical references start popping up.

One piece of advice in the article that I found interesting was to “begin by selecting the telecommunication service that is most reliable and has the best connectivity coverage for voice and data in the community where you live.” Imagine that, selecting a mobile phone that first and foremost keeps you connected. I’ll make sure to keep that in mind the next time I feel the need to purchase another smartphone. Then again maybe I won’t. I guess that depends on how badly I want the device.

Our facility went live with out first BCMA unit last week. It’s still early, but my initial take is that things went fairly well. We had a few minor issues, but nothing that couldn’t be handled easily and quickly. No matter how well you plan for something there will always be some bumps in the road, and that is important to note.

Below are some things that I picked up along the road to implementation. Some of these things we did well and some we didn’t do at all. This list is my opinion and not the gospel on BCMA implementation by any stretch of the imagination. Please remember that as you read through it.

And now, on to my list of recommendations for BCMA implementation:

• Pick a strong person to lead your implementation team. They’ll have to shoulder quite a bit and they need to be able to make decisions, stick to them, and hold others accountable.
• Create an empowered multi-disciplinary team to work on the project.
• Create an empowered multi-disciplinary team to work through issues following implementation.
• Only meet when you have to. I hate meeting to decide when you’re going to meet.
• Involve nursing early and often.
• Make sure you have enough resources assigned to the project. I believe this is one of the most common mistakes that leads to project failure. If you don’t assign the proper resources to a project people will get spread too thin and things will get missed.
• Remember: you’ve added something to your healthcare system and it will require maintenance and optimization. You need to have resources assigned and available to handle these two things. Don’t short change the BCMA system.
• Identify key people to take ownership of the system once things start flying. In other words figure out who can help troubleshoot something once you go live.
• Assign someone to analyze data coming from the BCMA system. If you chose not to have the data analyzed don’t even bother collecting it.
• Only speak positively about the system in public. If you have to complain about something do it behind closed doors. People believe what they hear and a positive attitude goes a long way.
• Be aggressive with your implementation timeline. Don’t sit on a project too long; it costs money and people get board.
• Don’t “over plan”. You can’t plan for every possibility. Some people think you can, but I don’t think that’s realistic. Do what you can and implement. You’ll learn more during the first 3 months after implementation then you could ever learn by sitting around a table talking about what could go wrong. We agonized over our pharmacy automation much longer than we should have. A few months after implementation we ended up scrapping our original workflow in favor of a better one. Two years later and we’re still tweaking things. Be diligent in your preparation, but don’t go overboard. All you’ll do is make everyone uptight and drive yourself crazy.
• Don’t be afraid to scrap something and start over. Not every idea translates well from paper to practice.
• Don’t marry yourself to an idea. Just because someone else is doing something a certain way, doesn’t mean you have to. It’s always a good idea to get opinions from other facilities, but don’t force it into your system if it doesn’t makes sense for you.
• Train nurses and pharmacists together prior to go-live, but not too far in advance. People tend to forget things soon after being taught when the lessons aren’t reinforced; out-of-sight, out-of-mind. I think it’s important for the pharmacists to see how the system works from the nurses point of view; it helps when barcode issues come up.
• Create a list of FAQ for end users. These are typical questions that come up during training. It’s basically a list of “what ifs”.
• Have lots and lots of “super users” available to help nursing during the initial implementation phase. This prevents people from getting frustrated with the system before they’ve had the change to use it correctly and efficiently.
• Have a good downtime plan including a way to generate a paper MAR that isn’t too far out of date. We print a MAR to a holding queue every 60 minutes. Each time the MAR is generated it overrights the previously stored version. If the system goes down we can print the MARs from the holding queue and the oldest they can be is 60 minutes.
• Decide how to best use clinical prompting in the BCMA system, if available. There’s no need to give nurses alert fatigue with a new system. If you currently use a system to define sound-alike-look-alike meds, black box warnings, etc then consider not forcing the nurse to deal with it again in the BCMA system. For example: we use our ADCs to alert nurses of drugs with black box warning. When the nurse removes a black box med from an ADC they receive a pop-up window alerting them of what to look for. They acknowledge the alert and chose to remove the drug or not based on the information presented. It makes no sense to add the same pop-up message to the BCMA system. All you’ve accomplished by duplicating the waring is ensure that nurses will start ignoring the warnings.
• Decide if you will chart in the BCMA system or elsewhere, not both. I’m talking about blood pressures, HR, finger sticks, etc. If your nurses already use a separate system to chart vitals don’t force duplicate documentation somewhere else. For example: our blood glucose monitors synch to our clinical nursing system. It makes no sense to have nurses enter the same blood sugar value in the BCMA system prior to administering insulin.
• Don’t let just anyone re-print patient wristbands. If anyone can re-print a wristbands, then you’ll find them attached to clipboards, IV polls, guardrails on the beds, etc. Make it hard to do the wrong thing.
• BCMA Hardware for nursing
• I’m not a big fan of “hardware fairs”. Put a thousand nurses in an area with 20 different vendors and you’ll get 500 opinions on what hardware configurations should be used. On the other hand, use a small group of nurses to select a few vendors to evaluate and you’ve got something to work with.
• Look at various solutions, i.e. in room devices mounted on the wall, laptops, tablets, computers on wheels (COWs), etc.
• If you decide to go with COWs or tablet PCs consider: 1) your storage needs for the devices, 2) battery life and replacement, 3) your protocol for cleaning the devices that go from one room to another, and how to handle patients in isolation
• Evaluate several types of barcode scanners, i.e. wireless, bluetooth, tethered. Look at different manufacturers. I’m a fan of Code Corp scanners myself, but would also recommend Honeywell.
• Don’t skimp on the barcode scanners; this is the center piece of the barcode scanning workflow after all.
• I still believe that the scanner you chose should be the same as the one used in pharmacy. I’ve received some negative feedback regarding this opinion, but I’m sticking with the recommendation. A single vendor means one support system to deal with, one set of hardware configurations, fewer questions trying to decide if it’s the hardware or the barcode and the ability to instantly pick up a scanner and use it anywhere in the hospital.
• Evaluate your wireless coverage throughout the hospital if you chose to go with wireless devices. Nothing is worse than pushing a wireless COW into a patient care area only to find out you can’t connect to the hospital network. I don’t care how great the system is, at that point the COW becomes a doorstop.
• Make sure you have enough electrical outlets and network access points.
• Take the opportunity to clean up your pharmacy formulary
• Standardize the nomenclature in your pharmacy system, i.e. tablet, capsule, etc
• Take a long hard look at your latin sig file. Pharmacists tend to use a lot of unnecessary latin sigs. Create a standard list along with standardized administration times. You should already have standardized sigs and administration times, but if you don’t get it done now.
• Get rid of as many non-formulary items as you can.
• Consider how you’re going to handle the following:
• pediatric syringes. are you going to use dose specific barcoding or drug identification only.
• insulin. patient specific vials or pens or a third option
• premixed IVs. Are you going to have nursing scan the product barcode or the pharmacy generated barcode
• chemotherapy
• Get everything in the pharmacy barcoded. This is key. You may have to use a combination of systems. You will need a way to barcode everything from bulk tablets to injectable vials to pediatric syringes. We use a complete automated packaging and labeling solution from Talyst, but there are others out there that offer similar services. Medical Packaging Inc offers a simple label solution; m:Print bar code label software from PearsonMedical is another. Even with all of our high-tech labeling equipment we ended up using Microsoft Word, a bunch of Avery return address labels and a free on-line linear barcode image creator at IDAutomation.com, Inc for certain items. That simple solution actually worked better than our multi-thousand dollar system in a couple of situations where we needed a barcode image without the lot and expiration data on the label. Go figure.
• Think about oddball medication in the pharmacy that may require a unique solution like unit dosed respiratory therapy drugs, levalbuterol, budesonide, etc, ampules, bulk tablets, etc.
• Scan everything in the pharmacy to make sure they are in your system. In fact, I recommend you do it twice.
• Scan everything in the automated dispensing cabinets on the pilot unit a few days before you go live. I thought we had everything well in hand until I scanned the items in our ADCs and found a couple of meds by manufacturers we hadn’t purchased in several months. The meds were still in date, but not in the system.
• Develop a system to deal with medications that have no barcode, won’t scan or scan as the wrong drug. No matter how diligent you are items will slip through the cracks; better to have a system in place than to be caught with your pants down.
• Cross train everyone in the pharmacy to troubleshoot barcoding issues. Trust me, you’ll regret it if you don’t.

I won’t tell you where I think we failed in our implementation because that just wouldn’t be right, but needless to say we didn’t do everything perfect which is how I got the idea for some of the items on the list. If you’d like to talk about my experience with implementation in more detail feel free to contact me and we can chat about it one on one. I would like this list to become a living document and I encourage you to leave comments, good or bad, about the list above or about items you think should be added that could help others. There’s always someone out there smarter with better ideas and I’d like to hear about them.

Posted via email from fahrni’s posterous

- Shutter Island was #1 at the box office last weekend. My wife and I saw it last Friday. She liked it quite a bit while my thoughts on it were lukewarm. To me a movie is good if I would walk right back into the theater and watch it a second straight time, like I did with Star Wars back in the 70’s. Shutter Island wasn’t like that. So there you go, take it for what it’s worth.

- HIMSS 2010 was held in Atlanta this week. I wasn’t ablet to attend, but still managed to get some great information by following various FriendFeed and Twitter feeds. I’m definitely attending next year.

- There’s a great “Best and Worst of HIMSS Wrapup” at the EMR and HIPAA website. And here’s the flip side at the HISTALK website: “The emphasis was on money and business rather than patients for the most part (my low point: a session that rattled off dozens of government grant programs from ARRA right on down, which reminded me of that seedy guy with the Free Government Grants infomercial).”

- KevinMD.com has a great list of free iPhone apps aimed at physicians. There are a lot of lists like this floating around the ‘net, but it’s always nice to have another. The problem is trying to figure out which applications to use and which ones to dump. You can’t use them all, believe me I’ve tried.

- The Healthcare IT Guy has an interesting article on how the EMR industry can learn from the Customer Relationship Management (CRM) industry. According to the article the CRM industry has made great strides in developing their model based on previous failures. The parallels between the current EMR industry and the CRM industry prior to maturing are very interesting. The Healthcare IT Guy states “with the lessons learned from the CRM industry , and armed with the expert guidance, you can adopt an EMR that can probably meet your financial and healthcare objectives.” Take a minute to read the entire post, it’s worth the time.

- Rumors are surfacing again regarding Microsoft’s Courier tablet. According to electronista.com “The book-like device has had more concrete hardware details and should be powered by NVIDIA’s Tegra 250 and should be relatively portable. Despite the second touchscreen, it would be lighter than an iPad and weigh just over one pound and would still be under an inch thick; the footprint would be that of a 5-by-7-inch photo when shut.” Hmm, that’s too bad really. I was hoping for a slightly larger device with two 8-10 inch screens like the enTourage eDGe. Although the enTourage is taking some hits from GottaBeMobile where the device is reported as not being “ready for prime time yet.”

- Speaking of Microsoft, it looks like their pushing their way into the acute care healthcare system with HealthVault Community Connect. Hey, more power to them. Anything that can help improve data structure and storage is alright by me.

- The iPad is scheduled for launch on Saturday April 3rd. Pre-orders will begin March 12th. I’m trying to decide if I really want one of the first generation devices or if I should wait 6-8 months. I’ll let you know on March 12th.

- medGadget: “PEPID, one of the big names in clinical information for mobile devices, is gearing up to release an Android version of its popular software suite.” – PEPID is very popular among a certain subset of physicians. I’m sure they’ll be very excited to have it on their Android devices.

- I found it interesting that Engadget posted an article questioning the survival of the Android platform in the same week that Computerwold wrote about the growing Android market share.

- It looks like e-prescribing might actually catch on after all. Medsacape is reporting that “the number of prescriptions that were routed to pharmacies electronically increased by 181% in 2009 compared with in 2008.” Wow, that’s significant.

- Archetypical: “I first heard about openEHR nearly 10 years ago. I didn’t understand openEHR at all initially, but there was something in the commonsense of getting the foundation data defined and standardized that resonated with me. Over time I have become convinced that openEHR provides an orthogonal approach to eHealth that has a very reasonable chance of success, and more importantly, of making a difference. I no longer believe that the traditional application-driven approach to electronic health information management is effective, economic or sustainable.” – This is a great article that goes on to explain more about the openEHR movement. Check it out.

- Medical News Today: “Yuksel and her research team did a study involving 262 patients at various Alberta pharmacies. Patients in the control group were given an information brochure then asked to come back in 16 weeks for a follow-up meeting. Those in the intervention group went through a more in-depth process. They spoke with a pharmacist about osteoporosis, the risk factors of the disease and screening processes for assessment of osteoporosis. When the pharmacists met with the patients 16 weeks later, they found that those in the intervention group were two times more likely to get a bone density test or start an osteoporosis medication, meaning the pharmacist intervention was beneficial in helping more people receive further assessment and a diagnosis from their doctor.” – Pharmacists continue to make a positive impact on healthcare. I’m just sayin’.

- Isoniazid is a common therapy for the prevention of active tuberculosis in patients with latent disease. Unfortunately treatment can be accompanied by some fairly undesirable side effects, including liver injury. AHSP is reporting that the CDC is now urging increased awareness of liver injury during isoniazid therapy. To that I say, Duh!

- SiliconRepublic.com: “Google believes that in three years or so desktops will give way to mobile as the primary screen from which most people will consume information and entertainment. That’s according to Google Europe boss John Herlihy who said that smart phones enhance Google’s mission to make information universal.” – That’s a bold prediction, but one that I don’t think is too ridiculous. I really don’t think desktops will become obsolete, but I certainly think mobile computing will overtake them. 

- The Five Rights website takes a look at a common situation in every actue care pharmacy in America; been there. 

Have a great weekend everyone, I know I will because I’ll be at Universal Studios Hollywood for a cheer competition.

However, the ATP-71 (PDF) from Swisslog is a bulk packager that can hold up to 71 canisters in a relatively small footprint: 31.5 inches wide x 29.6 inches deep x 30.6 inches high. For comparison, a Pyxis MedStation 4000 2-drawer main unit is 22.8 inches wide x 26.7 inches deep x 27.7 inches high. I would say that makes the two units comparable in terms of size, and I can tell you from personal experience that a 2-drawer main isn’t very big up close.

According to Swisslog: “Swisslog’s high-speed packaging and barcoding solutions are not only fast and efcient, they provide many levels of patient safety. Color coded fll-to-light trays, locking canisters, and accurate labeling with barcode capabilities enable pharmacies in any size hospital to make patient safety the highest priority. Many additional accessories and interfacing capabilities complement the packager and provide gains in workfow effciency.”

For those of you that aren’t familiar with bulk packagers you should take a look at the technology; it’s very interesting. Loose tablets/capsules are placed in a medication canister that is fitted with a computerized chip that uniquely identifies the medication contained inside. Once started the packager drops tablets/capsules one at a time from the canister, down a shoot and into a hopper where they are packaged and labeled with the medication name, strength, dosage form, lot, expiration, barcode, etc. We’ve found it to be a very efficient way to unit-dose and barcode large numbers of bulk tablets/capsules.

I still like the idea of having a small unit like this on the nursing units. Maybe I could talk Carefusion into adding something like this to their line of Pyxis products.

Wouldn’t this be a great application to use in healthcare? Imagine a patient rolls in through the emergency department; can’t answer your questions because of a language barrier, is unconcious, is too young or simply can’t speak secondary to injuries. The physician grabs his/her smartphone and uses it to “recognize” the patient and pull up their medical records. Now that’s some cool technology!

The blog speaks specifically to the ownership of personal data versus allowing companies to sit on it and possibly hold it hostage secondary to a lack of compatibility with other systems. The information you throw onto the internet defines who and what you are, more now than ever before, and you need to be able to move it around anytime from anywhere.

Louis calls for people to host their own data in a standardized format instead of having data stored by one service provider or another. He goes on to say:

If I chose to log in with GMail one day, I would authenticate who I was, and GMail would pull down my e-mail stream, complete with e-mail activity history (such as replies and forwards). The data would not be stored on GMail, but instead be more like a read-only process, whereby changes to data, including sent items, would not be stored in GMail, but written back to my personal “cloud”, if you will.

Hosting one’s own personal cloud with our own data is not an end run around large corporations in fear of Big Brother, but instead, for real, true, portability. In this situation, a longtime iPhone user could pick up an Android phone, enter my own personal ID (be it through OpenID or some other standard), and pull down my details into all of Google’s native applications.

My brother, Robert spoke of something similar back in June of 2009 when he questioned how to identify and distinguish oneself from all the other people roaming the internet.

I find it interesting that Robert and Louis both mention OpenID as a possible standard. OpenID is a decentralized standard for telling websites who you are. It’s a very interesting concept; one that healthcare could benefit from. Think of carrying your electronic ID with you from place to place. No more learning ten new user id’s and passwords each time you change jobs. How nice would that be? Another option would be to have only one user id and password that gave you access to all the data you were looking for from a centralized hub.

If you look a little deeper though, you’ll find that Robert and Louis stumbled upon a common problem in the healthcare industry; how to handle the stream of data coming form patients and how to standardize it and distinguish it from everyone else’s data. Let’s face it, pharmacy is all about data. We collect it, store it, mine it and analyze it. When you’re looking at a patient’s lab work you’re looking at data; when you’re looking at a patients medication list you’re looking at data. How about their medical history, allergies, radiology results, endoscopy report? Yep. Data, data, data and oh yeah, data.

The problem with healthcare in general, and specifically pharmacy, is lack of a standard to collect, house and access this mountain of data. Some talk about HL7 and XML, but that’s just the box that moves the data from place to place. It’s just a standardized shuttle craft.

Some organizations, like ASHP, are discussing the use of standardized nomenclature systems like SNOMED CT and RxNorm to control the structure of the information inside the shuttle. Like Louis’ GMail and smartphone examples from above, a patient should be able to access their data from any device at anytime in a format that can easily be read by any commercial healthcare system in the world. Of course healthcare would have to adopt some form of centralized data storage, but that’s just part of the solution. Imagine no longer transporting medical records to your physician or having to give your medication history to a pharmacist at the 24 hour Walgreens because the mom & pop pharmacy you usually go to is closed. It’s something to think about. With all the money the government is throwing around to increase the use of health information technology the timing is right to build a foundation like the one Louis writes about. Just a thought.

The Pixel Qi screen offers the quick refresh of an LCD screen with the low power consumption and direct sunlight readability of e-ink. I’m excited about the Pixel Qi technology and have been waiting for their screens to appear in consumer devices for quite some time. In fact, I’m holding off my purchase of a Kindle DX until I see a Pixel Qi screen for myself. I’m just not a fan of reading PDF files on a backlit LCD display, and reading them on a Nook or Kindle isn’t a great experience either.

The addition of the touchpad on the back of the Adam tablet is interesting. It gives the user the ability to move around the screen while holding the device in its natural slate configuration. It may take some getting used to, but overall the rear touchpad is a novel concept that I think offers value. Other nice features include a camera, the ability to multi-task and an SD card slot.

The Adam could rival the iPad if given a fair comparison. The one major downside to the Notion tablet will be the same disadvantage I’m finding with my DROID; a lack of software available for healthcare. Then again, if your software is delivered over the web and accessed via the device browser it won’t make any difference.

Some great photos of the Notion Ink’s Adam tablet can be found at Flickr.