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

“Download AJHP Abstracts to Kindle Reader – Users of the Kindle wireless reading device, from Amazon.com Inc., can now automatically download abstracts of AJHP articles as they become available.”

AJHP abstracts are delivered directly to the Kindle e-reader via Amazon’s Whispernet for a monthly subscription of $1.99. However, details are a little sketchy as there is limited information available at the Amazon website.

It’s nice to see AJHP embracing digital technology. It’s a little late in the game and only abstracts are currently available, but it’s clearly a step in the right direction. Hopefully this is the first of many new digital offerings from AJHP and ASHP. I would eventually like to see AJHP journal articles available in their entirety for all digital readers. Articles are currently available for download in PDF format, but that’s really not the same as having a document formated for use on an e-reader.

Additional information can be found at the Amazon website here.

Most read posts over the past 7 days:

1. An almost disastrous bar-coding mishap
2. Cool Technology for Pharmacy – Post from before I started putting the name of the cool technology in the blog title. This particular post was from September 10, 2009 and covered the capsule machine.
3. Cool Technology for Pharmacy – Another post from before I started putting the name of the cool technology in the blog title. This particular post was from June 18, 2009 and covered Alaris Smartpumps.
4. Best iPhone / iPod Touch Applications for Pharmacists
5. Quick Hit – Mobile devices in our pharmacy – This post elicited a couple of interesting comments.
6. Curriculum Vitae
7. “What’d I miss?” – Week of June 27
8. Cool Technology for Pharmacy –NDC Translator
9. About -People checking up on me.
10. Motion J3500 gets a wicked update – People are still interested in tablet PCs, even with that other device grabbing all the press.

Top searchterm phrases used over the past 7 days:

1. “ feton capsule filling machine ”
2. “ alaris pumps ”
3. “ cerner and pandora data systems ”
4. “ dell xt2 ”
5. “ alaris pump ”
6. “ capsule machine ”
7. “ alaris infusion pump ”
8. “ pharmacokinetics iphone ”
9. “ free lexi-drugs windows mobile free ”
10. “cloud computing”

Drug searches
A search for losartan using Google resulted in a link to the NIH’s United States Pharmacopeia as the first item listed. The site provides consumers with basic drug information from AHFS Consumer Medication Information. Not bad.

Bing produced similar results, albeit from a different source. Bing uses a tabbed user interface to provide consumers with access to drug information from Gold Standard and Wikipedia, of which I am not a proponent. Not bad either.

Disease states
A search for MRSA in Google resulted in a link to Google Health where I found basic information provided by A.D.A.M. The second item on the Google results page was a link to a page at the Mayo Clinic on MRSA.

The MRSA search in Bing resulted in the same tabbed interface that I saw with the drug search. The tabbed interface gave easy access to information on MRSA through Bing Health, provided by Healthwise , and also Wikepedia. The information at Bing Health was just as generic as the information found at Google Health. The second item on the Bing results page was the same as Google, i.e. the Mayo Clinic MRSA information page.

While none of this information is intended for professional use, both search engines provided enough information for the average consumer. I think it’s time for @kevinclauson to dig into this a little deeper.

Over the past couple of weeks I’ve had several complaints from the pharmacists; blue screens, lost wireless configuration, loss of bezel button functions, inability to rotate the screen when in slate mode, etc. Today the ICU pharmacist dropped off his tablet in my office because none of the buttons along the outer bezel would work (CTRL, rotation and tools buttons). It turned out to be an issue with the drivers, but what caught my attention was the condition the poor tablet was in. It’s only been in use for just over 6 months and it looks pretty beat up. Apparently the XT2 isn’t designed to take the rigors of a pharmacists daily routine.

With all the iPads we have running around our hospital now it got me wondering how they’re going to hold up once we start pounding on them day in and day out. I’m guessing not well. I suppose no device is perfect as is so eloquently described by James Kendrik at jkOnTheRun, but I don’t mind saying that I’m more than a little concerned. Oh well, I guess we’ll find out soon enough.

Just in case you were wondering, the Motion J3400 used by the pediatric pharmacist has held up much better and is still in good shape. That’s something to keep in the back of my mind for the future.

According to information I received, the PPMI Summit will:

Describe optimal pharmacy practice models that ensure the provision of safe, effective, efficient, and accountable medication-related care for hospital and health-system patients, taking into account the education and training of pharmacists, the prospect of enhancing the capacity of pharmacy technicians, and the current and future state of technology

Identify core patient-care-related services that should be consistently provided by departments of pharmacy in hospitals and health systems

Foster understanding of and support for optimal pharmacy practice models in hospitals and health systems by patients and caregivers, health care professionals, health care executives, and payers;
Identify existing and future technologies required to support optimal pharmacy practice models in hospitals and health systems

Identify specific actions that hospital and health-system pharmacists should take to implement optimal practice models; and

Determine the tools and resources needed to implement optimal pharmacy practice models in hospitals and health systems

This is a great opportunity for pharmacists to get involved with something that will affect the way we practice pharmacy for the foreseeable future. Approximately 100 hospital/health-system pharmacists will be invited to the Summit. To nominate a pharmacist to participate in the Summit go to the online nomination form and fill it out. Note that self-nomination is allowed.

For more information visit the ASHP Pharmacy Practice Model Initiative website.

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.

Looking for patient information wasn’t any less cumbersome. If you needed to read a patient’s history and physical, you went to the chart. If you wanted to look at lab results you had to wait for the lab, or the unit secretary, to print them out and attach them to the chart. If you wanted to see what time a medication was administered, you had to look in the medication administration record, i.e. the MAR. Data was scattered all over the place. Of course, no one thought it a problem because that was the most advanced system available at the time.
Healthcare technology has come a long way, and as pharmacists most of the information we need is much easier to find. Yet here we are still trying to figure out a way to create a unified patient health record that can be used by healthcare professionals not only across the street, but across the continent or world.

While technology has granted pharmacists the ability to fit everything they need in their pocket, the volume of data created, stored, manipulated and reviewed by pharmacists has grown to staggering levels. Unfortunately healthcare continues to struggle with the best way to handle storage of this information in a way that makes it universally accessible. Patient information is often times located throughout many systems; pharmacy, lab, radiology, nursing, ADCs, ADT, etc. While integration among various systems is improving, it’s still imperfect.

Pharmacy organizations like ASHP are working to remedy some of this by developing electronic standards for pharmacy and working to get various groups on the same page prior to moving forward.

In 2009 the ASHP Section of Pharmacy Informatics and Technology published a vision statement on “Technology-enabled practice”.  In the paper several technologies are discussed that can act as a springboard for development of a new and improved pharmacy practice model. My thoughts on the vision statement can be found here.

For this technology to work now and well into the future, pharmacy needs to consider a model that will provide the foundation for centralized data storage as well as easy access to information anytime from anywhere. A data hub that can be accessed via any web-enabled device makes a lot of sense. These things are central to the principles behind the cloud computing model.

One major misconception regarding cloud computing is that it is simply remote storage. While remote storage is a piece of the puzzle, there are many other components that make up the cloud computing environment; software-as-a-service (SaaS), infrastructure-as-a-service (IaaS), platform-as-a-service (PaaS) and some might say data-as-a-service (DaaS). The nomenclature continues with words like “private cloud”, “hybrid cloud”, and so on. It can get very confusing. However, the most important pieces of the puzzle for pharmacy are the ideas of centralized data storage and access to the information anytime, anywhere; IaaS and SaaS, respectively.

Regardless of the nomenclature used, it is clear that cloud computing will become very important to not only pharmacy, but the entire healthcare industry as a whole. Without saying “cloud computing”, the RAND Corporation presented testimony to the Senate Finance Committee in 2008 that addressed some of the benefits of a cloud-based healthcare system. According to the statement: “The hope of many is that the broad adoption of HIT systems with the aforementioned functionality in the United States will transform health care in terms of making it more efficient and effective simultaneously. Efficiency would be enhanced by reduced test duplication, improved drug utilization, better scheduling, reduced paper record handling, and improved claims processing and billing. Effectiveness would be enhanced by reduced errors (reduced handwriting-based errors, for example), reminders to improve preventative care, decision support for better evidence-based practice, improved management of chronic illness, and improved continuity of care for those patients seeking care away from their primary provider (such as was needed to support the mass evacuation that occurred after Hurricane Katrina). Effectiveness would also be enhanced by the quality of care assessment such systems would make possible and by improvements in the evidence base for best practices derived from the analysis of large electronic medical record databases.”

Why? Well if you ask me it’s relatively simple:

• The cloud is sold on demand, sometimes by the minute or by the hour which requires less initial capital from healthcare systems.
• The cloud is elastic, meaning a user can have as little or as much services as they want at a given time. In other words, it can expand like a balloon when necessary.
• The cloud service is fully managed by the provider, meaning the user needs nothing besides internet access. This is a huge benefit when it comes to resources to implement and maintain a system.
• It’s green. How many CIOs are sitting on excess server power waiting for a spike in activity that they’ll never need? I bet it’s a lot. People don’t like getting caught with their pants down. With cloud services, you only use what you need (see points one and two above). This means you aren’t using resources you don’t need.

Advantages of SaaS over the traditional software model include:

• Lower implementation cost
• Lower maintenance cost; no maintenance from the end user
• No additional hardware investment
• No additional supprt resources necessary
• Faster development cycles; no upgrades or patch uploads from the end user
• Access anytime, anywhere with only an internet connection.

And let’s face it, I would wager that customer service and support can have a significant upside in cloud based computing. When a business wants to succeed they do a good job and provide stellar support. If they don’t, they fail. Not the case with on-site IT support in the hospital. When support from the IT department in the hospital is slow or subpar, the only recourse is to fill out some paperwork and hope it improves. To quote from Michael Biehn’s character, Kyle Reese, in the Terminator “That’s what he does. That’s all he does! You can’t stop him!” That’s how a successful vendor will behave. I’m not saying that will always be the case. I’m just saying that it’s possible.

As we continue to develop both new desktop and mobile operating system, i.e. Mac OS X, Windows 7, iPhone, Android, etc, it’s going to become even more important to develop and utilize applications that can be used regardless of hardware or software architecture. This is where SaaS fits. In theory anything with a web-enabled browser can utilize SaaS. How? Well the software runs from a central location and is simply delivered via the browser. I know what you’re thinking, but Citrix is not SaaS; it’s a virtual desktop environment. They’re not the same thing.

IaaS and SaaS are not new concepts. Naming conventions may have changed, and technology has advanced the ideas to new heights, but everyone that has spent any time on the internet has, or is now, using some form of cloud computing. You may be aware of it, then again you may not, but I’m confident that most people reading this blog post have used some form of online storage, social media service, or online application like GMail or Zoho.

For those of you that doubt the importance of the cloud model, understand that companies like Google and Microsoft have invested heavily in cloud computing over the past several years. While this alone doesn’t guarantee that cloud computing will be the future, I would like you to consider this: who drives future technology? I would argue that technology development is driven by whichever way the market is swinging. The idea of cloud computing has spawned a wave of new software and hardware technology. In addition it has generated new ideas for how to store, manage and access large amounts of data like those seen in the healthcare industry. As lofty as the idea may seem, based on what is happening in the world the traditional model of data storage and software distribution is being pushed toward the cumulus.

Take a look at some of the happenings in cloud compuing:

- PHRs are exploding. As evidence take a look at Google Health and Microsoft Healthvault; these are cloud offerings. Information is stored on some far away data farm where you don’t have to worry about security or hard drive failure.

- Microsoft, in agreement with the National Science Foundation, is offering free cloud computing to NSF-supported researchers. Of course it’s via Windows new Azure cloud platform, but it’s still cloud based and it’s free. In addition Microsoft now has its Business Productivity Online Suite, including Exchange Online, SharePoint Online, Office Live Meeting, and Offic Communications Online offered via the cloud.

- Google of course offers Google Apps, which includes Mail, Docs, Groups, Sites, and Video. Who hasn’t used one of the Google offerings?

- DocStoc launched an “iTunes style” online store. Slideshare is another “document sharing” service.

- VMware entered the marked with the Zimbra Collaboration Suite.

- Rackspace and Amazon are just two popular companies battling to gain customers in the ‘cloud’ storage market. Rackspace has a great site if you’re looking for general information on cloud computing.

- IBM is offereing Infosphere, an analytics solution designed to integrated and analyze data from multiple healthcare sources.

- Not to be outdone by IBM, Oracle unveiled Oracle Clinical Development Analytics for life science.

- Earlier this year Fujitsu launched tsClinical, a SaaS based solution designed to support clinical drug trials.

- Humedica offers a clinical informatics platform similar to IBM Infosphere.

- Pharmacy OneSource offers several SaaS products including a clinical servellance tool (Sentri7), intervention tracking (Quantifi) and pediatric dosage software (Accupedia) among others.

- Practice Fusion has been gaining ground with their web-based electronic health record software.

The explosion of cloud based products is consistent with job trends over the past several years (image below). Someone thinks this stuff is a good idea.

Pharmacy is standing on the edge of opportunity to do something special here. We can build a foundation for healthcare that will live far into the future. Gone are the days when proprietary desktop software is the norm. Slow development cycles, the inability to be flexible and costly upgrades and support services are turning companies offering traditional software models into forgettable entities. It’s time to investigate technologies that will provide pharmacists with the information they need in a timely manner on any device from any place in the world. Just a thought.

Many people have speculated that the iPad will be a great device for healthcare. Whether or not that will be the case remains to be seen. One thing is for certain: everyone is banking on the iPad being a big hit in healthcare. Based on the success of the iPhone as a favorite among physicians and nurses, this certainly isn’t a wild prediction. Will this success translate to the pharmacy? Good question.

The iPhone made an impact with pharmacists, but certainly several orders of magnitude less than it did for other healthcare professionals. I have no explanation for why physicians and nurses universally accepted the iPhone while pharmacists did not, but that appears to be the case. With that said, the pharmacists at my facility appear to have a healthy interest in the iPad. I informed them about a week or so ago that the department was in the process of purchasing some new tablets for use on the floor. Would you like to guess what the first questions I was asked was? Yep, “are we getting the new Apple device?” That’s a positive sign as most of the time the pharmacists I work with could care less about what technology they’re using.

Being practical for a moment, let’s consider some things:

1) The iPad will provide a similar experience to the iPhone, with one major exception: it’s not a phone. The popularity of the iPhone lies with its ability to fit in your pocket. Cell phones are akin to car keys nowadays; they’re always with you. Even though it is a fascinating device, the iPad is not pocketable.

2) The iPad cannot run native Windows based applications directly installed on the device. Of course one can always use something like Citrix to access applications, or products offered as SaaS, so that isn’t a game changer. In fact, I’m a big proponent of moving away from locally installed applications. Maybe this is a positive. I haven’t decided yet.

3) Data entry will be difficult on the touch screen. As much as I like touchscreen devices, they really aren’t designed for typing. On the other hand, keyboards tend to work well for data entry. Go figure.

4) No multitasking. Hmm, that could be a problem for a pharmacist when they need to access multiple applications at once.

5) Application development. Apple controls the flow of applications. How’s that going to work if healthcare is serious about utilizing the device?

6) Ports are missing. This could be important for peripherals and compatibility with other devices in the hospital.

7) The iPad is an entertainment device. Let’s face it, this tablet was designed to fill a niche in the consumer market, which means some tweaks will be necessary to integrate it into healthcare.

Only time will tell if pharmacists will embrace the iPad, but as I’ve mentioned before, the height of pharmacy interest in technology was brought on by a consumer electronic device. I’m cautiously optimistic that the iPad will do the same and I’m looking forward to putting my skepticism to the test.

Oh and one more thing:  when I asked the director of our IT department in charge of computer hardware when I could expect our new tablets, he asked me if we would be willing to try the iPad instead. Unbelievable.