It’s time to disrupt pharmacist order verification

Several years ago there was a debate over the long-time practice of having pharmacists review all medication orders prior to administration; referred to as nearly universal prospective order review (NUPOR).(1) At the heart of the debate was whether or not such a process was still relevant in the changing face of healthcare, i.e. do pharmacist really need to see every single medication order prior to that medication being administered to a patient?(2)

The argument in favor of universal medication order review is obvious: ensure complete, accurate orders. The argument against universal medication order review is that it’s expensive, time-consuming, and unnecessary in most instances. My own personal belief is that the practice is antiquated and should be changed.

The introduction of electronic health records (EHRs) has changed the medication order entry landscape. No longer do pharmacists interpret and enter orders from hand-written orders on paper faxed to the pharmacy. Those days are mostly behind us. These days, medication orders are generated electronically from pre-defined, pre-built entries in the EHR. Providers simply check a box and bam, order entered. Or as one pharmacist put it in a discussion forum recently “I mean an order set that has been checked by pharmacy, checked by a physician, checked by nursing, approved by P&T / Medical Ethics ….how many times do we need to verify it?”. I feel the same way.

In the rare case that no checkbox is available, today’s EHRs are intelligent enough to provide directions for the user. Not to mention that a majority of medication orders processed in a hospital are simple, routine, and require no critical thought. It is the exception rather than the rule to see an order that requires any deep thought or intervention.

There are those that argue that taking pharmacists out of the order verification role is dangerous, but nothing could be further from the truth. Having pharmacists verify orders is retroactive, at best. What percentage of orders require a pharmacist’s intervention? 10%? 5%? Hard to say, but the percentage is small.(3) The same pharmacist mentioned above said it best: “I did a cursory look and for one month out of 150,000 orders verified, only 5,000 had an intervention performed on them. So 3% of the time we are actually doing something significant enough to warrant an intervention.” So current best practice has pharmacists — a highly trained, expensive professional — looking at 100% of orders in an attempt to find the 3% that have problems. Seems kind of silly.

I often look to the model used in poison control centers for support of my opinion. Non-pharmacists screen calls at poison control centers. If the call can be handled via a well-thought-out algorithm, then it’s handled. If not, the call is escalated to a pharmacist. In other words, pharmacists are only getting the calls that require their particular brand of expertise. That’s poison control! Think about it.

The days of having a pharmacist look at each and every medication order entered into an EHR are over. It’s an antiquated process that’s long overdue for an overhaul. The time has come for healthcare systems to make better use of their personnel.

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  1. People love their acronyms. I’ve always called it “order verification”.
  2. The answer is obviously no, pharmacists do not need to review every single medication order before that medication is given to a patient. But, people like to argue.
  3. I’ve said many times that a monkey could do my job. While my comments are flippant, the sentiment rings true. I could train an intelligent teenager to do 80% of my job in a couple of short weeks. On a side note, I’ve never had a single person challenge me regarding my monkey comment. Seems odd, don’t you think? I mean, it’s insulting.

Saturday morning coffee [September 16 2017]

Why do you look at the speck of sawdust in your brother’s eye and pay no attention to the plank in your own eye?” — Matthew 7:3 (NIV)

So much happens each and every week, and it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts…

‘It’ was #1 at the box office last weekend, bringing in more than $120 million. Expect it to stay there for at least one more weekend. I won’t be seeing it any time soon. Not my kind of movie. Expect more scary movies to hit the box office as we approach Halloween.  

Deadline Hollywood: “It’s an age-old excuse, but, yes, blame this summer’s box office depression on too many tired tentpoles that underperformed. That’s what happens in a product-driven business.” – I feel like this is true. Some of this year’s franchise movies weren’t very good, i.e. Pirates of the Caribbean: Dead Men Tell No Tales, Alien: Covenant, and Transformers: The Last Knight to name a few.  

The FDA recently released a safety alert calling for “separating the dosing of sodium polystyrene sulfonate from other orally administered medicines by at least 3 hours…  A study found that sodium polystyrene sulfonate binds to many commonly prescribed oral medicines, decreasing the absorption and therefore effectiveness of those oral medicines.”. Sodium polystyrene sulfonate (SPS) is commonly used to treat hyperkalemia — a potassium level that’s too high. It’s kind of an odd alert as I would have thought this was common sense. It’s a freaking binding agent that preferentially exchanges sodium ions for other ions for Pete’s sake!

MedicalXpress: “In recent years, researchers have identified substances in coffee that could help quash the risk of developing Type 2 diabetes. But few of these have been tested in animals. Now in study appearing in ACS’ Journal of Natural Products, scientists report that one of these previously untested compounds [cafestol ] appears to improve cell function and insulin sensitivity in laboratory mice.” – It’s coffee time! Coffee, coffee, coffee, coffee…

Bloomberg: “Here’s a fact you have to write down to believe: Over the past 10 years, during which the world has adopted smartphones and social media, sales of fountain pens have risen… Retail sales, in particular, have grown consistently. In 2016 they were up 2.1 percent from the year before, making fountain pens a $1 billion market, according to a report by Euromonitor International.” — I enjoy using fountain pens, and have several. My most recent acquisition is a Pilot Vanishing Point. Neat pen. Retractable nib. 

Jalopnik: “Tesla briefly sold a 60 and 60D trim level of its Model S and Model X vehicles. These models had 75 kWh battery packs installed, but were software limited to have less range to artificially create a more affordable entry-level tier for buyers….With category four Hurricane Irma headed straight for Florida, Tesla unlocked the full capacity of 60 and 60D model owners in Florida to give them about a 30 mile range boost while evacuating.” – Tesla is getting a lot of praise for doing this. On the surface that makes sense, but why would you put an artificial limit on the car straight off the production line. Can you imagine if Chevy or Ford said, “here’s our new V6. It gets 30 miles per gallon, but we tune it down to 22 miles per gallon unless you pay us more”. Think about it.

Xiaomi announces the Mi Mix 2 and Mi Note 3, a better bezel-less flagship and mid-ranger for the end of 2017. With the price of smartphones at or above $1000, it’s time to search for an alternative. 

Looks like Google is ready to drop the curtain on the Pixel 2. “Google hasn’t yet sent out invitations to its next event, but it is beginning to tease it. After sightings of a billboard in Boston suggested that we “ask more of our phone,” Google has thrown up a homepage for the entire world with the same notion — the Pixel 2s are coming.” (source: Android Central). I have to admit, the Pixel and Pixel XL just didn’t do it for me. My wife and daughter both carry the Pixel XL. Meh.

Healthcare IT News: “AMA demands EHR overhaul, calls them ‘poorly designed and implemented’…Latest study confirms typing and clicking consume more than half the workday for doctors.” – Ya think?

Ars Technica: “The situation at Cooley Dickinson is not unique; patients nationwide are being potentially misled about the quality of their care. According to data collected by the [Wall Street] Journal, hundreds of hospitals with federal safety violations continue to boast accreditation and a “Gold Seal of Approval” from the Joint Commission, a nonprofit that the government relies on to accredit almost 80 percent of US hospitals.” – This really isn’t a surprise. The Joint Commission is a joke. They give hospitals tons of warning prior to their “inspections”. And of course, they do a superficial job of looking around. I think they should just pop in without warning and do a deep dive. I could certainly tell them where to look. 

I watched a slew of college football games last weekend. A couple of minor surprises, like Oklahoma over Ohio State — for which I am eternally grateful — and how much trouble Washington State had with Boise State. The PAC-12 looks pretty solid as does the SEC, as usual. Looking forward to watching a few this weekend as well: USC vs. Texas and Louisville vs. Clemson, for starters.

As far as NFL games from last weekend, I didn’t watch a single one. That’s the first time that I can remember that I didn’t sit down on a Sunday and watch the NFL. You want to know something? I don’t really miss it.

I gotta’ go to work now. Have a great weekend, everyone.

EHRs are an untapped, but almost impossible to use, health resource

We’re all familiar with the promise of “big data” in healthcare. Crud, I’m a huge fan of using data. I think the amount of information inside an EHR has the potential to do a lot of wonderful things, not only for healthcare in general but specifically for a pharmacist. How many kinetic consults have been done by hand, tracked manually, and refined by voodoo magic? Thousands, I can assure you. The number of things pharmacists still do manually is staggering. “Monitoring” should no longer involve rummaging through charts — electronic or otherwise — looking for tidbits of information that need to be “fixed”. The days of dosing medications like vancomycin, warfarin, phenytoin, and aminoglycosides — just to name a few — should be long gone. We can contemplate building a Hyperloop, but we can’t figure out how to get someone’s INR to a therapeutic level within five days? Seriously, think about that for a second.

FierceHealthcare: “For public health agencies, tapping into EHR data could augment the costly and time-consuming process of surveys….Data analytics has emerged as a key tool for providers to target high-risk populations with chronic conditions, although some have argued that health IT systems are still ill-equipped to adequately manage population health.” There’s the crux of the matter, data is valuable, but it’s tough to get. I’ve only recently started to request specific data from the EHR to look at some things I find interesting. Unfortunately, I’ve run into roadblocks. Apparently, the data inside an EHR — at least inside this particular EHR — isn’t easy to retrieve. At least that’s what I’ve been told. How hard can it be? Dude, just dump the raw data somewhere and I’ll build the queries myself. Again, apparently not that easy. 

In a nutshell, all patient data, from demographics and notes to labs and medication use should be easily accessible to anyone with appropriate credentials, i.e. a pharmacist that works for the hospital where an EHR is used, for example. Only when we, as healthcare professionals, can access data at will, and use that data to answer questions, will EHRs become valuable to patient care. At present, EHRs are full of potentially valuable information that no one can get. It’s like having a savings account that only allows deposits, no withdrawals. The balance might look great, but what do you do when you need a little money and the bank says “sorry, there’s no way to take your money out”? Throw in the fact that EHRs are a usability nightmare and you realize that we have a long way to go.

Allergies and Electronic Health Records, we’re doing it wrong

ACP Hospitalist: “About 10% of patients in the United States report a penicillin allergy, but most of these patients are not currently allergic, meaning that they could safely take drugs in the beta-lactam class. “The vast majority of patients who think they have penicillin allergies actually don’t when they undergo penicillin allergy skin testing,” said Emily Heil, PharmD, of the University of Maryland School of Pharmacy in Baltimore…. In fact, 96% of patients at one acute care facility who self-reported penicillin allergy had a negative skin test in a recent study by Dr. Heil and colleagues.”

I wrote about the problems surrounding patient allergies in the medical record several years ago. One would think that things have improved over time. Not even close. The proliferation of Electronic Health Records (EHRs) has only made things worse. The inaccuracy and incomplete nature of drug allergy information located in EHRs is causing more problems than ever before.

It might surprise you – or perhaps not – to find out that most patients don’t know whether or not they’re allergic to a medication, much less what the details are surrounding the allergy. Many perceived allergic reactions can be classified as an adverse reaction, intolerance, or simply an expected side effect.

Many of the allergies I see recorded in EHRs could easily be classified as intolerance, which in my mind means they shouldn’t be listed as an allergy. Having codeine listed as an allergy in the EHR because it causes GI upset is wrong. GI upset is not an allergy. GI upset to codeine does not preclude a patient from using any number of opioid analgesics. However, that little entry in the EHR will follow that patient around until the end of time, repeatedly rearing its ugly head whenever an opioid analgesic is prescribed. Each time a provider enters an order for an opioid analgesic, or a pharmacist verifies that order, or a nurse administers that order, they will have to contend with an allergy alert. The alert will fire, the provider will acknowledge it, quickly realize that it’s not really an allergy, and truck on. Not only does the alert provide worthless information with no value to the provider, it contributes to alert fatigue, which we all know is a very real and dangerous thing in today’s EHR-driven healthcare world.

Allowing poorly defined allergy information to appear, and remain, in the EHR should not be allowed. Facilities that allow it should be reprimanded. Providers that enter it should be educated. Improving the quality of allergy information found in EHRs benefits everyone. It should be a priority.

According to the ACP Hospital article cited above, accurate allergy information can lead to optimized therapy, decreased use of broad-spectrum antibiotics, and decreased costs. Is there anyone in healthcare that doesn’t want all of that?

Here’s the thing: it’s such a simple thing. Collecting better allergy information is so easy that it makes my brain hurt. It’s low-hanging fruit that often gets ignored. It requires no special education, training, or skill. No technology required. It cost nothing. This is one of those rare instances when a little common sense goes a long way.

Electronic alert overload

The Washington Post: “Something similar is happening to doctors, nurses and pharmacists. And when they’re hit with too much information, the result can be a health hazard… It’s called alert fatigue… Electronic health records increasingly include automated alert systems pegged to patients’ health information… The number of these pop-up messages has become unmanageable, doctors and IT experts say, because of reflecting what many experts call excessive caution, and now they are overwhelming practitioners.”

alert_overrides

I had to laugh when I read The Washington Post article quoted above. Pharmacists have been dealing with this for years. We’ve been getting hammered with unnecessary alerts since electronic order entry became a thing. I don’t know exactly when it started, but it’s been an integral part of my career for the past 20 years.

It’s a problem to be sure. A vast majority of alerts, conservatively 90%, have absolutely no bearing on the job clinicians are asked to perform. The article mentions receiving alerts for pain meds when it’s obvious that the patient needs them, such as in a post-op situation. Even more ridiculous is getting an alert for a duplicate fluid, or my favorite, lactation warnings for an 80-year-old female.

It’s difficult to say what the impact of these alerts is on patient care, but I think it’s safe to say that they cause more harm than good. They pop up so often that most simply get ignored. I know that I’ve clicked through my fair share of alerts without more than a glance.

And here’s the thing, physicians see only a fraction of the alerts seen by pharmacists. Many hospitals minimize alerts so as not to irritate physicians. We wouldn’t want to irritate physicians now, would we?

With all that said, things have improved in the past few years. Usability is on the radar of hospitals and healthcare systems. We can thank consumers for that. Healthcare workers are consumers first and their experience with software and hardware in their day-to-day lives has spilled over into healthcare. Today’s software is much better than it was a decade ago, even in the Bizzaro World of healthcare.

I can recall my experience with pharmacy information systems during the early years of my career. They were terrible, and I do mean terrible. The things were barely usable. They were often functionally rich and usably poor. It wasn’t until quite recently that pharmacy systems became more user-friendly, in part because of the introduction of EHRs.

Physicians wield a disproportionate amount of power within healthcare systems, so when they are forced to use EHRs with poorly designed user interfaces and ridiculous alerts, the vendors hear about it. The result of all that complaining has been improvements in usability. As the pharmacy system is an integral part of many EHRs, pharmacists have benefited.

I dare say that we are nowhere near the user experience of consumer products, but the improvements are nonetheless welcome. Given time, and enough physician whining, we may live to see the day when alerts are useful rather than annoying. Until then, I say to my physician brothers and sisters, welcome to my world.

Using data to build proactive drug error prevention models

Data is variously described as the oxygen of the digital economy or the new raw material of the 21st century.“-Nigel Shadbolt

There are more than a few issues with today’s medication order entry systems. However, in this post I want to focus on only two.

First, alert fatigue. As a pharmacist that has entered his fair share of orders I can tell you that alert fatigue is real. Order entry systems, including CPOE, are designed to indiscriminately alert users of every possible problem associated with the patient’s profile and the order being entered. When entering orders for a patient with complex medical conditions, this can become a bit frustrating because a majority of these alerts are of little to no value. After a while you begin to blow through alerts because so many are simply a waste of your time. Unfortunately, when this happens you will occasionally miss something important. It happens.

Second, the “perfect medication error”.(1) This occurs when a physician inadvertently utilizes CPOE to order the wrong medication for a patient – or the right drug for the wrong patient – but the order meets all the necessary checks and balances to end up on the medication profile, i.e. no allergies, meets all appropriate dosing parameters, there are no drug-drug interactions, labs are fine, and so on. This is an issue that appeared on my radar while performing an FMEA for a CPOE implementation when I was still working as an IT pharmacist.
Continue reading Using data to build proactive drug error prevention models

Saturday morning coffee [August 1 2015]

“True humility is not thinking less of yourself; it is thinking of yourself less.” ― C.S. Lewis,

So much happens each and every week, and it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts…

MUG_SMC
Continue reading Saturday morning coffee [August 1 2015]

Do patients in the U.S. really own their healthcare data?

Yesterday I was reading through my Twitter stream when I came across a brief exchange between Eric Topol (@EricTopol)  and Farzad Mostashari (@Farzad_MD). Both are big names in the digital healthcare space.


Continue reading Do patients in the U.S. really own their healthcare data?

Saturday morning coffee [March 14 2015]

“There is nothing in which people more betray their character than in what they laugh at.” – Goethe

So much happens each and every week, and it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….

The mug below comes straight from Voodoo Doughnuts in Portland, OR. My wife and youngest daughter were up North last week visiting colleges. They surprised me upon their return with a box of Voodoo Doughnuts and this mug. The doughnuts were delicious.

MUG_VoodooDoughnuts
Continue reading Saturday morning coffee [March 14 2015]

Saturday morning coffee [March 7 2015]

“Your reputation is in the hands of others. That’s what a reputation is. You can’t control that. The only thing you can control is your character.” – Dr. Wayne W. Dyer

So much happens each and every week, and it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….

MUG_SMC
Continue reading Saturday morning coffee [March 7 2015]