Pharmacy Integration is Starting to Make Sense

I’ve been writing about the need for pharmacy integration for years. Most of it negative, and deservedly so because it’s been lousy.

With that said, things appear to have changed in recent years. Integration, it seems, has slowly become a thing. Maybe because I’ve been out of general pharmacy practice for so long that it seems decent, or maybe it’s getting better. Hard to tell, honestly.

Pharmacy systems aren’t really talking to each other better than before, per se, but the number of disparate systems seem to have decreased over the years. Once there were many, now there are seeming few. Once, everything was “best-of-breed”, now things are moving to one system to rule them. Case in point, electronic health records. (EHRs).

I always thought pharmacy integration would take place from the inside out, i.e. pharmacy systems would integrate with other systems and drive information sharing across the hospital. Not even close. Instead, pharmacy systems have become more integrated by being consolidated and sucked into the EHR.

The advent of EHRs has done more for system integration in healthcare than just about anything else. I have plenty of negative things to say about EHRs, but it’s clear that they’ve changed the way we practice, forever.

The way I see things – at least now – most healthcare systems have fallen into two large buckets: 1) documentation – clinical and other; and 2) operational logistics.

Clinical Documentation: Clinical documentation used to take place in “the chart”, among many other places. The chart was nothing more than a binder filled with dividers, separating one bit of information from another. Think of a Trapper Keeper, minus the cool picture on the cover. Paper was everywhere. If you wanted to read something about a patient, like a progress note or radiology report, you had to go to the chart, which wasn’t always easy. They had a way of walking away with physicians and not making their way back to the nursing station.

This all changed when EHRs hit the scene. Everything from demographic data to notes, lab values, medication information, and so on is at your fingertips. If you need information, all you do is log into the EHR and go hunting. Admittedly, it’s not as easy to navigate as a paper chart, but it’s a heck of a lot more data rich and never walks away.

Most of the information coming out of hospital pharmacies these days can be found in EHRs. That includes medication distribution information, pharmacist notes, barcode archives, and so on.

Operational Logistics: Think Amazon warehouse. That’s the easiest way I can explain pharmacy logistics. You buy something from a third party, store it in the pharmacy for a period of time, and send it to a patient when it’s ordered. Simple, really. We’re still not very good at it, but that’s the gist.

For the most part, pharmacy logistics has maintained its distance from the influence of EHRs. Instead, inventory management has been driven largely by a other, non-EHR companies: CareFusion, Omnicell, and to a lesser extent, Swisslog. These companies have grown and expanded over the years, increasing their portfolios to cover more and more areas of the pharmacy.

I’ve mentioned the “four areas of pharmacy” many times: standard storage, refrigerated storage, controlled substance storage, and the iv room. The first three areas are still dominated by these companies. Carousels, inventory software, refrigerators, various cabinets controlled by remote locks, and automated packagers can be found in most large pharmacies. All of which are offered by the aforementioned companies. There was a time when it was common for any number of these products to be supplied by different vendors. Not so much anymore.

These days, it’s all about integrated systems from a single vendor. When given a choice, pharmacies are deciding to purchase from a vendor that can “do it all”. For example, CareFusion offers Pyxis ES ADUs for medication distribution at the point of care; Pyxis Logistics software and hardware for medication distribution from the pharmacy; Pyxis CII safe to manage controlled substances; BD Cato for the IV room; and so on.

With that said, the IV room is in a state of flux. The nature of this area lends itself to both operational logistics and documentation, the latter of which seems to be more important now more than before. It may be the only area of the four where inventory management means less than documentation. I expect this trend to continue.  

Surprisingly, I really have seen better integration amongst pharmacy systems these days. I fully expect it to improve even more as EHRs expand and eventually creep into operational logistics. At least one EHR vendor has already made a significant impact in the IV room. Eventually, pharmacy will be just another department within the EHR’s web of control. I see both good and bad in such a future, but that’s a blog post for another time.

First time using Epic – initial thoughts and impressions

Epic is an Electronic Health Record (EHR) used in hospitals all over the country. If you work in healthcare you know who they are. Epic is the top EHR system in the U.S. and they continue to gobble up market share.

According to the Epic website, the pharmacy information system (PhIS) inside Epic is officially known as the “Willow Inpatient Pharmacy System”. However, I commonly hear it referred to as simply Willow.

Over the span of my 19 year career I’ve used several pharmacy information systems, but never Willow. For whatever reason the hospitals I’ve worked in have used other EHR and/or pharmacy system vendors; GE, Siemens, MEDITECH, IDX, etc. Recently I had the opportunity to spend a couple days learning how to use Willow. I was pretty excited. I’ve heard a lot of good things about Willow, and some bad. I’ve been wanting to get firsthand knowledge for quite some time.

Disclaimer: These are my initial impressions. Two days of training isn’t nearly enough time to learn all the ins and outs of a pharmacy system. I’ve recently accepted a position where I will be using Epic, albeit not in a full-time capacity, so I’m sure that my thoughts and opinions will evolve over time.
Continue reading First time using Epic – initial thoughts and impressions

The benefits of an EHR may or may not be real

I’ve had reason to think about Electronic Health Records (EHRs) these past few weeks. There is a lot riding on their success or failure. There’s no question that EHRs will be the future of all documentation in healthcare, but I’m not convinced that healthcare is ready for the transition. At least not yet.

The potential advantages of EHRs are many. In theory they offer real-time information, integration of many systems across a single platform, the ability to store, access and manipulate massive amounts of data (“business intelligence”, analytics, “big data”, etc), they provide information that follows a patient regardless of where they go or who they see, the offer potential for patients to view, edit, use, and add to their own medical information, and so on.

These are all good things. If only the potential was reality. The current state of EHRs is far from their future potential.
Continue reading The benefits of an EHR may or may not be real

EMR software optimized for Windows 8

EMR & HIPAA: “Yesterday at the Digital Health Conference I had the chance to catch up with George Cuthbert from Medent. He’d emailed me a few months back about the potential benefit of Windows 8 in the EHR world and the deep integration of Win 8 that they’d been working on to leverage the unique abilities of Windows 8 for their EHR users.

I admit that since I’ve become more of a health IT blogger and less of a techguy, I haven’t kept close track of all that was happening with Windows 8. I knew that it was designed to incorporate touch as a major focal point of the new Operating System and I knew that it was Microsoft’s attempt to integrate the best of touch together with the advantages of data input using a keyboard and mouse.

Based on the short demo that George did for me of Win 8 and the Medent EHR, it has some real promise. In fact, as the title suggests, I think that if an EHR vendor does it right this could solve the issues that so many EHR vendors have of trying to create an iPad EHR application.”

I’ve always thought that the Windows OS would be ideally suited over iOS and Android for EMR/EHR use because it is the native platform used by a majority of healthcare systems in the United States. Why continually reinvent the wheel when all you do is delay innovation? That’s what’s been going on in healthcare for the last several years when it comes to using tablet technology. Everyone has fallen in love with products that offers less functionality today than my tablet PC did nearly a decade ago. It’s odd when things turn out like that. People tend to get easily distracted by shiny objects. It happens.

The EHR software described at the EMR & HIPAA site can be found in the Microsoft Store. It’s called EMR Surface. More information can be found at the Pariscribe website. It looks interesting, but one can never tell whether or not something is usable by simply looking at it. I’d be interested to hear whether or not anyone has used it and what their opinion is of the system.

Clinical documentation: composition or synthesis? [article]

A recent article in the Journal of American Informatics Association (JAMIA) takes a look at note-writing practices of medical residents while using an electronic health record (EHR) system. Through the use of time-and-motion studies the authors concluded that there was “a high level of fragmentation of documentation activities and frequent task transitions [when using an EHR].” Not really surprising when you consider that most EHR systems simply aren’t designed with the needs of the end user in mind. In addition it is difficult to use an electronic system in an attempt to mimic the act of taking notes using pen and paper. I’ve struggled with that for years. The thought process is different.

Clinical documentation: composition or synthesis?
Mamykina L, Vawdrey DK, Stetson PD, Zheng K, Hripcsak G.

Department of Biomedical Informatics, Columbia University, New York, USA.

OBJECTIVE: To understand the nature of emerging electronic documentation practices, disconnects  between documentation workflows and computing systems designed to support them, and ways to improve the design of electronic documentation systems.
MATERIALS AND METHODS: Time-and-motion study of resident physicians’ note-writing practices using a commercial electronic health record system that includes an electronic documentation module. The study was conducted in the general medicine unit of a large academic hospital.
RESULTS: During the study, 96 note-writing sessions by 11 resident physicians, resulting in close to 100 h of observations were seen. Seven of the 10 most common transitions between activities during note composition were between documenting, and gathering and reviewing patient data, and updating the plan of care.
DISCUSSION: The high frequency of transitions seen in the study suggested that clinical documentation is fundamentally a synthesis activity, in which clinicians review available patient data and summarize their impressions and judgments. At the same time, most electronic health record systems are optimized to support documentation as uninterrupted composition. This mismatch leads to fragmentation in clinical work, and results in inefficiencies and workarounds. In contrast, we propose that documentation can be best supported with tools that facilitate data exploration and search for relevant information, selective reading and annotation, and composition of a note as a temporal structure.
CONCLUSIONS: Time-and-motion study of clinicians’ electronic documentation practices revealed a high level of fragmentation of documentation activities and frequent task transitions. Treating documentation as synthesis rather than composition suggests new possibilities for supporting it more effectively with electronic systems.

J Am Med Inform Assoc. 2012 Nov 1;19(6):1025-31

EHRs may not be all that after all

The New York Times: “Computerized patient records are unlikely to cut health care costs and may actually encourage doctors to order expensive tests more often, a study published on Monday concludes.

…research published Monday in the Journal Health Affairs found that doctors using computers to track tests, like X-rays and magnetic resonance imaging, ordered far more tests than doctors relying on paper records.

The use of costly image-taking tests has increased sharply in recent years. Many experts contend that electronic health records will help reduce unnecessary and duplicative tests by giving doctors more comprehensive and up-to-date information when making diagnoses.

The study showed, however, that doctors with computerized access to a patient’s previous image results ordered tests on 18 percent of the visits, while those without the tracking technology ordered tests on 12.9 percent of visits. That is a 40 percent higher rate of image testing by doctors using electronic technology instead of paper records.”

I can’t say that I’m surprised by this. I remember something similar when I was working as the night pharmacist at Salinas Valley Memorial Hospital in Salinas, California. Physicians that were using pre-printed order forms to admit patients – now considered the standard of practice – almost always wrote for more PRN medications than those that didn’t use pre-printed order forms. We used to call them “don’t call me orders” because they covered every possible what-if for the patient, i.e. what if they have pain, what if they get a fever, what if they get indigestion or constipation, and so on. And why did they do that? Because it was easy to check a box, that’s why.

Shareable Ink plus EHR equals interesting alternative

EMR Daily News: “Shareable Ink®, an enterprise cloud computing company that transforms paper documentation to structured data, today announced three new partnerships with leading EHR vendors that will further the company’s reach in delivering a reliable, portable and easy to implement electronic data capture solution that works with existing physician workflows. The agreements with Greenway Medical Technologies, Inc., NextEMR, VoiceHIT, and an existing partnership with Allscripts, signal the demand within the physician practice marketplace for a flexible technology that can be used in any care setting to help compliance with Meaningful Use (MU) requirements.”

I think highly of Shareable Ink. I like the concept and think it provides a nice bridge between where we are today and where we need to be. I first mentioned Shareable Ink back in November 2009. It was a good idea then, and it’s a good idea now.

EHRs may not be the panacea many are hoping for

Selected excerpts from post-gazette.com article:

More and more studies are questioning the efficacy of electronic health records, and the U.S. Food and Drug Administration has begun collecting reports involving electronic health and IT errors, some of which have resulted in death…

The thing about these systems is that it doesn’t really look like they’re getting any cheaper,” he said. “And the upgrades and the upkeep represents a very significant cost, especially in outpatient clinics.”

Of those, 163 contained mistakes that could have led to “adverse drug events.” Most errors were mistakes of omission — a doctor left out an important piece of data.

Notably, this “is consistent with the literature on manual handwritten prescription error rates,” the report said. But the larger point is computerized systems do not automatically outperform paper ones. [referring to: Errors associated with outpatient computerized prescribing systems. JAMIA, 2011; DOI: 10.1136/amiajnl-2011-000205]

For an industry that relies on data and evidence-based measurements to make decisions on the clinical and pharmaceutical side, there isn’t a lot of evidence supporting the notion that electronic health records produce cheaper care or better outcomes.

I think the article outlines some of the significant problems that need to be addressed before a truly effective EHR system can be utilized. We’re forcing the healthcare industry to implement a technology that they’re simply not ready for. The IT infrastructure in healthcare is built on marbles and is still years behind the consumer market in all but the most advanced facilities. In addition we continue to struggle to standardize information. We first need to understand what the information will look like before we begin forcing everyone to use it.

There’s no question in my mind that sharing information across the healthcare continuum is paramount to providing safe, efficient, cost effective healthcare. However, there are some key pieces of the puzzle missing. Without those pieces we’re not going to get the whole picture, and that’s a problem.

Patients still not diggin’ the idea of an EHR

EHR outlook: “Patients are still worried about how secure their data will be when stored in an EHR systems, a new study suggests. Xerox Corporation found that of 2,720 poll respondents:

  • 80% were concerned with stolen personal information
  • 64% were concerned with lost, damaged or corrupted files
  • 62% were concerned with the misuse of information”

I’m not surprised by the numbers. In general people are afraid of change and the unknown. With that said, I think all you need to do is walk a patient through the paper processes that we use now to give them some insight into how bad things really are. Stolen and lost personal and medical information is a major problem within the current healthcare system. It’s not uncommon in any given week to hear about patient records that have been lost or stolen. And as far as misuse of information, well lets just say that’s all too common as well.

The advantages to an EHR outweigh the concerns listed above. Just sayin’.

Practice Fusion EHR gets allergy alerts

I am a fan of web-based healthcare applications, including EHRs. I especially like the web-based EHR available from Practice Fusion. The application is full featured, easy to use and free. I spent a little time playing with it back in June 2010. One of the things I noted during my review was that “there appears to be no cross checking between allergies and newly entered medications.” As a pharmacist this was pretty important. Well, I’m happy to say that allergy checking no longer appears to be an issue.

EHR Bloggers: “We’re excited to bring you a major new feature for your EHR account today: drug-drug and drug-allergy interaction alerts. It’s a frequently requested enhancement and also a big step towards Meaningful Use. And, like all our features, this clinical decision support system (CDSS) is entirely free.

Drug Interaction Alerts
You will now be automatically alerted when a drug you are adding, prescribing or refilling interacts with another drug or with an allergy listed in the patient’s chart. The following video shows you how to set permissions, heed alerts and override alerts. “

To gain access and begin using the Practice Fusion EHR simply sign up for a free account here. I would encourage any practitioner that needs a robust, easy to use EHR system to give Practice Fusion a look. It’s a solid application.

I was going to try the new feature for myself, but forgot my credentials; how embarrassing.