Electronic Medication Ordering: An Awkward Work in Progress

Fairview Health Services, a healthcare system in Minneapolis, is ahead of the pack when it comes to electronic medication ordering and management. Three of its 10 hospitals have had computerized physician order entry (CPOE) systems for the past three years, and its outpatient clinics have had electronic prescribing capability in their Epic EHR for a decade. But because the Epic system does not communicate with Fairview’s Eclipsys inpatient EHR system, outpatient med lists must be entered manually into the patient EHR as part of the reconciliation process. And because the CPOE and pharmacy systems come from different vendors, pharmacists must print out orders and enter them manually into the pharmacy system. That poses a risk of errors in data entry and also means that medication alerts are not synchronized between CPOE and pharmacy.

We recognize that’s a risk we want to get rid of,” says Ray Gensinger, MD, CMIO of Fairview. So when Fairview migrates to Epic’s inpatient EHR at seven of its hospitals next summer, it will switch to Epic’s pharmacy system, he says.

Incompatibility between systems also is a problem at Concord Hospital in Concord, N.H. About half of Concord’s staff is using the GE Centricity EHR on the outpatient side, so the intake nurses know that their med lists are fairly accurate and up to date. But after the nurses interview patients to double-check their meds and the physicians decide which ones they want to continue, Concord’s pharmacists must still enter them manually into the hospital’s McKesson EHR. However, Concord CIO Dean Morrison notes, McKesson and GE are now testing a prototype interface at Providence Health System in Portland, Ore., after Providence and Concord requested it. The same interface, he says, will enable physicians to send a summary of inpatient allergies, meds and problems to the outpatient EHR when a patient is discharged. Morrison believes vendors will respond positively to such provider requests as the 2011 deadline for hospitals to start showing “meaningful use” of their clinical systems approaches.

CIOs and CMIOs face many other challenges as they implement and continue fine-tuning their CPOE systems. And, as Morrison points out, ordering is only half of medication management in hospitals. The rest includes pharmacy verification of orders, dispensing of medications, and medication administration at the bedside. Here’s a tour of some of the key issues.

Clinical decision support has limits
Only 14 to 18 percent of hospitals are currently using CPOE—and a third of these institutions are not utilizing clinical decision support (CDS). If the CDS features of CPOE are turned on, the alerts and reminders in these systems require such data as current medications, allergies and problems. They also should be able to highlight relevant lab results for providers before they order a medication. But as Gensinger points out, this is easier said than done: Fairview is still developing such a process in its 3-year-old CPOE system. Finally, while CPOE is regarded as an essential part of an inpatient EHR, fewer than 6 percent of hospitals have complete EHRs that include physician and nursing documentation, as well.

Because CPOE does not necessarily have all the data it needs for CDS, physicians cannot rely solely on these systems to make ordering decisions, points out Michael Zaroukian, MD, CMIO of the three-hospital Sparrow Health System in Lansing, Mich., which is about to launch a CPOE system. “There’s an increased risk of making the wrong decision with regard to CPOE if you’re counting on having data that helps inform the decision. You may have decision rules, but you don’t have enough data in the system, or the systems you have don’t talk to each other.”

Gensinger stresses the need to maintain human communication. For instance, before a Fairview pharmacist makes any changes in an order, he must phone or page the provider who placed that order. “CPOE systems aren’t meant to take the place of communication between providers. In many cases, you want to make sure the pharmacist feeds back that information to the provider. They may not know about a new renal function test or about an allergy from five years ago.”

Alert fatigue can easily set in
Medication alerts may be generated by drug-drug, drug-allergy, therapeutic duplication or dosing issues. A patient’s age or condition, such as renal failure or pregnancy, may also trigger some warnings. The importance of these reminders varies greatly, and some systems fire alerts too often or in inappropriate situations, notes Jane Metzger, principal, emerging practices, for CSC in Waltham, Mass. When that happens, some physicians may simply ignore the alerts, raising the risk of adverse drug events. The key is to customize the alerts so that they neither lead to alert fatigue nor endanger patient safety.

“That’s something that most organizations struggle with,” observes Kevin McNamara, a CPOE consultant with ECG Management Consultants in Seattle. “Most hospitals err on the side of caution. In consultation with their providers and pharmacists, they reset alert levels based on what they’re seeing in the hospital.”

That’s good advice, but CPOE systems allow only certain kinds of adjustments. Gensinger points out that at the University of Minnesota Medical Center, one of Fairview’s facilities, student doctors are working side-by-side with attendings, some of whom wrote their textbooks. “I want to make sure the alert fires every time the medical student writes an order—whereas the guy who wrote the book might not want to see those alerts. But the systems don’t have the ability to differentiate.”

Concord Hospital has taken a slow, deliberate approach to turning on alerts in its new CPOE system, Morrison says. “We want to make sure that if we send an alert, there’s general agreement that everyone needs to pay attention to it.”

Order sets require consensus
The other CDS ingredient in CPOE is order sets, which encourage physicians to prescribe certain medications in particular circumstances. Order sets may be designed for conditions or procedures. Sometimes, they are confined to specific medications, such as heparin, Coumadin or sliding-scale insulin, that a physician wants to monitor as a patient’s condition changes.

The big issue with order sets is that they don’t work unless physicians agree on them. That’s a tall order, since doctors often practice differently, notes Concord’s Morrison. “When you bring in a CPOE system, and there are already 20 different [paper] order sets for the same condition, because 20 doctors want to do it different ways, it raises a red flag: If somebody is admitted for hip surgery, why do we have 20 different ways of treating the pain afterwards?”

Fortunately, each of Concord’s departments has been able to agree on a number of evidence-based order sets. Physicians can order medications outside of an order set or, if they’re working in an order set, they can replace a medication, notes Morrison. They don’t have to justify it unless the formulary committee has restricted that drug, he adds.

Because order sets speed medication ordering, he says, doctors tend to use them in the appropriate circumstances. “Time is king for docs. So if the order set is there and they’ve all agreed to it, they don’t make many exceptions, because it takes too much time. It takes less time to do the right thing and go with the evidence.”

McNamara points out that physicians tend to use order sets for admissions, discharges and post-operative care. But they don’t use them when they’re rounding and just want to order or adjust the dosage of a particular med. For these a la carte orders, Metzger says, good CPOE systems allow physicians to create “favorites” lists that pop up their most commonly used meds.

Discharge orders cross boundaries
At discharge, medications must be reconciled and discharge meds ordered. The default in many hospitals is to print out prescriptions for the patient as part of the discharge orders. But the Joint Commission wants hospitals to do this electronically as part of medication reconciliation, and it will be required for meaningful use in 2013, Metzger points out.

One problem with going online, she notes, is that CPOE is not directly connected to outpatient pharmacies; even if it were, the orders would not look the same as ambulatory-care prescriptions do. So to write orders that can go online to a community pharmacy, a physician must be able to send the order through an outpatient e-prescribing system, she says.

There are alternatives, however. Discharge med orders may be sent from CPOE to a hospital pharmacy or paper-faxed or computer-faxed to a community pharmacy, McNamara says. And Zaroukian observes that in a robust enterprise EHR, a physician could use the ambulatory-care e-prescribing module to send med orders to pharmacies via Surescripts.

To satisfy medication reconciliation requirements, patients and their outpatient physicians also are supposed to receive discharge medication lists. Typically, discharge summaries are completed after the patient leaves the hospital and may take days or weeks to reach the primary-care doctor. (McNamara, however, says that that’s changing in hospitals with electronic systems.) An inpatient EHR can generate a clinical summary that includes medications, Metzger says, but not many CPOE systems can do this on their own.

The art of medication management
As noted earlier, the ability to send orders directly from CPOE into pharmacy systems is important for safety and efficiency reasons. The consensus is that integration of these systems is superior to interfaces between systems from different vendors.

There are instances where the interface approach works pretty well, and Metzger says she knows of hospitals that use integrated software that’s so poorly designed that pharmacists have to enter orders in their system by hand. But on the whole, says Zaroukian, “best-of-breed” systems create far more problems than integrated ones do. In his view, “the unintended consequences and the cost to build and maintain those kinds of interfaces” argue against them.

Once orders enter the pharmacy system, the pharmacist must verify them, check for possible contraindications, dispense the medications, and send them up to the floors to be administered. Many hospitals have adopted an electronic medication administration record (EMAR) to help ensure that the right medication gets to the right patient at the right time. Separate from CPOE but connected to the inpatient EHR, EMAR is a form of nursing documentation. Physicians who want to track administration—which they might want to do for a variable-dose medication—can check in the EHR. At Concord, which doesn’t yet have a full EHR, physicians can go to an inpatient web portal and click on the EMAR tab.

However, as Gensinger points out, it is still possible for the nurse to administer the wrong med by accident. The best way to prevent that, he says, is by bar coding the medications. A study by Beth Israel Hospital in Boston showed that bar coding reduced dispensing errors as well as mistakes in medication administration. Adverse drug events fell by 63 percent in the study population.

Bar coding, however, also has its issues. The biggest one, notes Gensinger, is that it requires the bar coding of unit doses of medications. While the FDA requires that bulk packages of medications be bar coded, unit doses of the drugs must be repackaged and bar coded manually for the system to work with EMAR.

Since Concord has used bar coding since 1993, its pharmacists regard unit-dose repackaging “as a way of life,” Morrison says. McKesson, Concord’s vendor, also is a drug wholesaler, and it’s working with the hospital to bar code the products it distributes, he adds. But manual bar coding at the unit level is still required.

Some very advanced health IT solutions have been developed for electronic medication ordering and management. Yet, despite the sophistication of many of these tools, CMIOs still must address a host of issues—both technological and medical—in this complex area. Only by using the best available systems and solving a number of knotty problems can hospitals achieve their goals of using information technology to boost efficiency and improve patient care and safety.