CPOE Implementation: A Status Report

Back in 1999, the Institute of Medicine (IOM) published the article "To Err is Human: Building a Safer Health System," which focused on preventing adverse drug events (ADEs).

Computerized Physician Order Entry (CPOE) was touted as a tool to reduce ADEs. Subsequent studies pointed out how it would help prevent medication errors and improve patient safety.

The US government has pushed computerization, as well.

"To improve the quality of our health care while lowering its cost," President Barack Obama said back in January 2009, "we will make the immediate investments necessary to ensure that, within 5 years, all of America's medical records are computerized."

It has now been 6 years, and medical records are still not 100% computerized.

Implementation of CPOE has been slow due to its complexity and huge cost. To further entice hospitals to jump on board with electronic health records (EHR), the US Centers for Medicare and Medicaid Services (CMS) sends money to facilities that meet set goals.

EHR systems are not something that can be rushed, but for dollars, workarounds happen. There is also the threat of penalties if systems are not implemented.

As the EHR market has matured, the once-crowded field of vendors has narrowed significantly.

At the end of 2013, just 10 vendors accounted for about 90% of the hospital EHR market: Epic, MEDITECH, CPSI, Cerner, McKesson, Healthland, Siemens, Healthcare Management Systems, Allscripts and NextGen Healthcare, according to Becker's Hospital Review.

No CPOE standardization

CPOE systems are all different, so how are they compared? A hospital may have implemented a CPOE, but does that equate to a sufficient system? Do groups like Leapfrog take into account CPOE errors or just the percentage of usage by prescribers? Do we rate CPOE systems like we rate hospitals?

Data show vendor CPOE market share, but there are no rating systems to evaluate the systems after implementation, or even a list of hospitals that decided to change systems due to issues.

Limited medication profiles

Another issue with CPOE is its lack of a coherent view of a patient’s profile while entering medications. It is also difficult to verify orders without a comprehensive view of the medications that the patient is taking.

This lack of a full picture causes the user, whether prescriber or verifier, to rely on the software alone, rather than a comprehensive approach. Seeing the whole picture while entering and verifying orders would probably decrease errors.

Alert fatigue

When CPOE systems are used for other tasks aside from entering and verifying orders, there is more alert fatigue.

On the pharmacist verification end, it is common to see alerts of different significance with nothing to differentiate high importance from low. For example, the same type of alert may be used to discuss inventory, prior authorization, and other messages that take away from the verification role, even though many of these alerts previously happened at order entry.

Pharmacists should not have to think pharmacologically and pharmacokinetically about how a medication works along with alerts dealing with inventory, cost, and formulary status that once occurred at the front end. There should be a way to differentiate these alerts and have them fire at appropriate times, rather than during actual medication review. 

Tailoring the CPOE to be more user-friendly for the prescriber often comes at the expense of more frustration on the back-end with verification. For example, a CPOE may allow a prescriber to free type directions for medications taken irregularly (3 days a week, different strengths on different days), choose non-formulary medications rather than built-in CPOE formularies, and remove alerts that need to be seen at order entry.

In this way, verification becomes more of an order entry “fix” role that pulls attention from clinical aspects of verification.

CPOE software is also designed under the assumption that prescribers and verifiers are working in a quiet environment, but both sides are working in noisy environments. When a phone is ringing, a patient is yelling, and a nurse is asking a question, quick pop-up alerts may not be enough of a warning. Even the most focused individual will make mistakes.

More duplicate orders

The Journal of the American Medical Informatics Association published a study pre and post-implementation of a CPOE in an ICU and found that duplicate medication ordering errors increased after implementation (pre: 48 errors, 2.6% total; post: 167 errors, 8.1% total; p<0.0001).

Sometimes, there is a lack of integration between laboratory values, both inpatient and home medications, and other data or different modules that do not communicate smoothly.
 
Last but not least, if the staff is not happy with the CPOE software that is implemented, they are not going to use it as designed. - See more at Pharmacy TImes.

The Patient that Made the Difference

Her initials were the same as mine, and we greeted one another after a few phone conversations with "Hi, BB, it's BB." 

We had this connection. Two grown women. Both single and young. The big difference was that I was her home health pharmacist in charge of her pain pump and she had terminal cancer.

When you are halfway through your life (and maybe your career) there comes a time when you look back and remember the patients that change your life and maybe even validate the half-ass "I want to be a pharmacist" decision made by a young twenty-something with no idea how profound the decision would have on every aspect of your life. 

B wanted to go to Florida and be in the ocean one more time.  Her boyfriend was in Florida and since she knew her time was short, the ocean was on her bucket list... with the dilemma of a pain pump. That's where I fit into the story, finding a creative way to make it happen along with a couple home health nurses and some supplies. She was a nurse, too, and was a big part of her own end-of-life care.

It has been eleven years ago. B was 33 years old. I had been a pharmacist for only four years; a baby in the working world with little idea of how that year would change my life.

I had these biweekly chats with her concerning supplies she might need, including the intravenous pain medication itself but we often left the rigid discussion of how we were connected through pharmacist and patient to human conversation of "please do monthly self breast exams," to "live a full life and travel Beth!" to "who cares what people think about you, you certainly won't care when you are at the end of your life" and "I wish I could have been a mother." It was almost as if I had been granted insight into the world of a life ending way too soon and maybe learning my own lesson along the way. I sure did.

I finally went to meet her the last few days of her life. I waited much too long to meet my friend and that is my only regret. There is a professional line you have to keep in place with your patients, but sometimes that looks a little different patient to patient.  She squeezed my hand and had a picture of her vibrant former self before cancer ravaged her body sitting on her nightstand. "You are beautiful," I had said although wishing I had arrived months before.

Pharmacists and nurses along with other healthcare providers can make a difference. 

I witnessed the same thing with my father-in-law's nurse at the VA in Nashville caring for a man that had no family at bedside because of a lack of a relationship with his family. His nurse was amazing and was not only his nurse but his friend.  

I saw it again in Memphis on a hospice rotation where I saw different patients in different stages of terminal illness along with their families in different stages of grief. 

My life changed with each of these moments and patients who touched my life and maybe that young twenty-something college student knew more than I thought about selecting a career?

10 Rules of Email Etiquette at Work

One of the most frustrating things about pharmacy jobs today, for me at least, is the lack of email etiquette at work.  I know it sounds crazy to even bring this up, but I have been pondering this post for years.  You see, I have been guilty of not being the best at email, but over the years it is becoming crystal clear the errors people make every single day that not only make the sender look badly, but can actually fracture a team.  Without further ado, the email changes I would like to see in the pharmacy and hospital world with a disclaimer that since I have been practicing for almost 15 years, these examples go way back in time. 1.  REFRAIN FROM REACTIVE EMOTIONAL EMAILS.  If you find yourself getting worked up over what you are reading, do your best to avoid pressing reply and firing off a response.  Avoid sending emails when you’re feeling any type of negative emotion. These types of emails will ALWAYS make you look unprofessional and maybe even unstable.  Before you send off that email rant or reply to an email that angers you, try cooling off overnight.  Or, write an uncensored draft that you never actually send. Remember that all emails are forwardable.  If you don't want your whole department to read it, do not send it.

2.  RESIST THE REPLY ALL BUTTON.  This is the one that literally will make my entire head explode at work.  I have seen coworker after coworker make this mistake and it is not pretty.  This can make you look totally clueless all the way up the chain.  Coworkers don't let coworkers reply all.  In fact, I would love to see the day when reply all is no longer an option in Outlook, Gmail, or any other email client.  Why?  Because it creates mindless replies when all of the discussion could be tabled and then ONE single email sent out to a team.  Time after time in all of my jobs have seen emails go out - an official type declaration of what we are going to be doing - and someone else will reply all and jump in with something else essentially calling out critically all the things wrong with the initial.  Take the time to call the person that sent the email and give them the professional courtesy to make any corrections.  Don't shoot the messenger!

3.  UNDERSTAND WHAT CC AND BCC MEAN.  The recipients listed in the To field are the direct addressees of your email. These are the people to whom you are writing directly.  CC, which stands for “carbon copy” or even “courtesy copy,” is for anyone you want to keep in the loop but are not addressing directly in the email. The person(s) in the CC field is being sent a copy of your email as an FYI. Commonly, people CC their supervisors to let them know an email has been sent/an action has been taken or to provide a record of communications. The general rule of thumb is that recipients in the To field are expected to reply or follow up to the email, while those in the CC field do not.  So many times I see the ones in the CC field adding in their two-cents and then the whole thing becomes a reply-all festival.

4. IF YOU ADD SOMEONE IN THE CC OR TO FIELD, LET THE OTHERS KNOW.  Guess what?  There are times when people are added willy-nilly for no good reason and you look back and notice it a couple of emails later.  Let people know.  Professional courtesy and politeness go a long way.

5.  BCC IS GOOD FOR ONE THING ONLY.  Let's say that only half in your department contributed to the annual walk fund.  Rather than sending out an email to all those that contribute in the TO field where each of them can see who did contribute and who did not, put your own name in the TO and the rest in the BCC.  That way, gossip about who gives and doesn't is stopped before it can even begin.  Don't use the BCC field to add someone random to eavesdrop on the email.

6.  PICK UP THE PHONE.  If you notice that you are going back and forth on an email and getting nowhere, the phone still works.  Guess what?  Voices can convey so much more than words and rarely are misinterpreted as much as typed words.  I remember an email I saw that was sent for the third time.  The second time it was heavily highlighted with quotes from the manager's email weeks before.  The third send apologized for resending the email yet again but someone was not doing it correctly.  Because of the sender's frustration, more time was wasted from the entire department reading about some small piece in the whole operation, and worse, half of the department had nothing to do with the infraction.

7.  DON'T PUT A QUOTE IN YOUR SIGNATURE.  There is no reason for it.  From The Wordsmith:

******Avoid quotes, witty sayings and colors in the signature.

8.  DON'T ASSUME EVERYONE READS THEIR EMAIL IMMEDIATELY.  If something is important and needs to be communicated quickly, pick up the phone.

9.  DO NOT FORWARD AN EMAIL UNTIL YOU ASK PERMISSION.  This is just plain common professional sense.

10.  DO NOT USE UNPROFESSIONAL FONTS OR BACKGROUND PAPERS.  They only distract.  This means NO comic sans.

Hope that helps.  And, by the way, I do mess up on some of these myself.

Doing What You Love

There is this paradox of thought that creeps in most days (if I allow it) and most of the time I will even ask a fellow coworker, "Do you love what you do?"  or "If you could go back in time, would you choose pharmacy again?" This article by Paul Graham found its way to my feed this morning through another reading, and though it took me all morning to read and digest the whole thing, I feel validated.  There are moments when I look at myself from another's point-of-view and think, "Is she happy?"  Happiness is the thing that I tend to search for... you see I couldn't tell you exactly how much money I make to the penny.  I have no idea to the hour how much PTO I have built up.  I can tell you I have been a drug expert since 1999 and only recently so feel I can use that term and MEAN it.

Would I do my job without pay?  That, according to the article, seems to be one of the qualifiers of finding and doing what you love.  Would I do right now for money for free?  Maybe.  I mean, I would definitely change the job.  First, I wouldn't sit in a room and just enter orders all day.  I would probably do more of a clinical job but not clinical that is defined in my current job today.

What would that look like?  More patient contact.  More ER contact.  More of a presence where knowledge is valued and needed in a moment's notice.  I have that to offer.  It would make me happy, even if momentarily in that the Sallie Mae bill I continue to pay monthly would see more worthy.

But, if I was really honest with myself I would stop and say I may find something else someday.  Even if it is something on the side.  Being in-demand was a lovely time when district managers valued your license (not so much your credentials) and would throw new cars, sign-on bonuses and time off your way.  They would appear like vultures outside the retail pharmacy with a suit on and ready to beg.

Today?  The students are graduating and learning the art of begging.

The creative life doesn't seem to coincide with making money.

"The most important thing a creative per­son can learn professionally is where to draw the red line that separates what you are willing to do, and what you are not.

Art suffers the moment other people start paying for it. The more you need the money, the more people will tell you what to do. The less control you will have. The more bullshit you will have to swallow. The less joy it will bring. Know this and plan accordingly.” - Hugh McLeod

And this one by him:

"The best way to get approval is not to need it.

This is equally true in art and business. And love. And sex. And just about everything else worth having.”

What about approval from myself because I am so excited to face the day and go to work because it is not work but my passion?  Is that possible?

Steve Jobs:

Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work. And the only way to do great work is to love what you do. If you haven’t found it yet, keep looking. Don’t settle. As with all matters of the heart, you’ll know when you find it. And, like any great relationship, it just gets better and better as the years roll on. So keep looking until you find it. Don’t settle.

What if that looking takes more than 20 years because quite honestly I am THERE.  20 years and able to say apologetically I am still seeking.

The bottom line is start doing the things you love.  What do I love?  Well, I do love medicine.  I would be lying if I didn't admit that.  I do like how convoluted and complicated it can get.  Throw in another disease state and another medication and a genetic tendency to metabolize differently and weight changes.  Throw in some food or no food or grapefruit juice (though in some medications you would have to drink about a quart a day maybe?) and complicate the black and white definition.

Then give it some time because years ago hormone replacement therapy was all the rage and now it's not.  Thank you Women's Health Initiative for that one.

Back to the question at hand...

The realization:  A 21-year-old chose this career path for me.  She, in her silver spoon mentality felt it was prestigious but not to a fault.  She could forsee perhaps having a family and not being on call.  Oh, and Todd Gean's house was close to the biggest house in Adamsville, TN.  He owned and still owns his own drugstore.  Guess what?  I never spent ONE SINGLE DAY in his pharmacy prior to going to pharmacy school.  I am not even sure I was aware what went on except he put pills in a bottle all day.

“If one wanted to crush and destroy a man entirely, to mete out to him the most terrible punishment,”wrote Dostoevsky, “all one would have to do would be to make him do work that was completely and utterly devoid of usefulness and meaning.”

Yes, I am searching.

US News 100 Best Jobs of 2013 | Pharmacist is #3

I am a little baffled at Pharmacist being listed as #3 on this year's US News 100 Best Jobs because it seems to me that many of the pharmacists I read about on the internet are not very happy.  Personally pharmacy has been good to me.  I definitely would rather be a pharmacist than a dentist or an RN. #1 - Dentist Overall Score: 8.4 | Median Salary $142,740 Ever heard the phrase "Your face is your fortune"? For dentists, our smile is their fortune. They earn their living diagnosing and treating teeth and gums, performing oral surgery, and counseling and educating us on maintaining proper oral health. The profession should grow 21.1 percent by 2020.

#2 - Registered Nurse Overall Score: 8.2 | Median Salary $65,690 The nursing profession will almost always have great hiring opportunity because of its expanse (from pediatric care to geriatric care, and everything in between). And as a substantial chunk of our population ages, the necessity for qualified RNs intensifies.

#3 - Pharmacist Overall Score: 8.2 | Median Salary $113,390 With excellent job prospects and a solid average salary, the pharmacist profession nabs the No. 3 spot on our list. Possessors of a Pharm.D can anticipate nearly 70,000 available jobs this decade—the brunt in physician offices, outpatient care centers, and nursing homes.

#4 - Computer Systems Analyst Overall Score: 8.2 | Median Salary $78,770 Think of a computer systems analyst as a tech project manager. He or she is often a liaison between the IT department and a client, and has influence over both the budgetary and technical considerations of a project.

#5 - Physician Overall Score: 8.2 | Median Salary $183,170 At the top of the medical food chain, physicians diagnose and treat patients, plus they instruct on proper diet, hygiene, and disease prevention. And like other jobs in the healthcare industry, physicians will see abundant job growth to 2020.

And because I love this link mostly because I am included on the page, I will repost.  You will notice though who #1 is:

The Angry Pharmacist: For opinionated posts about drugs, patients, and pharmacy in general, read through this blog and see how this blogger earned his name.

He's angry.  I bet he wouldn't say his procession should be listed #3.

Read more about the top pharmacy blogs out there.