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.

Are You Studying for the BCPS Exam?

A friend and colleague of mine created a study guide for the statistics part of the BCPS, and I wanted to let you know about it: 

Use discount code: Beth 

Get 20% off of the stats guide!

From MedEd101:

Everyone who's done some research on BCPS Pharmacotherapy certification understands that you have to know statistics to pass the exam. That fact is most certainly true.

Like most, I don't enjoy studying statistics. I wanted to create a BCPS Statistics Study Guide that gave you the critical pearls you need to know without overwhelming you with details, frivolous information, and baffling equations that you don't need to waste valuable time on.

I've created a 30+ page PDF full of the most important statistical principles that are relevant to medication therapy and the BCPS Pharmacotherapy Exam. I walk you through case examples and have included various graphs to try to aid those who are more visual learners. In addition, the Meded101 BCPS Statistics Study Guide also contains a 20 question self-assessment quiz to test you on the basics and give you a feel for the type of questions you will be asked on the BCPS exam.

Mike M. -  "I was surprised by the ease it took me to understand the key concepts while reviewing your study guide. It was very reader-friendly and well written. For someone like me who has not had enough exposure to statistics, let alone biostatistics, it was of tremendous value."

While this study guide was specifically designed for the BCPS exam, many of the BPS certifications like BCACP, BCOP, BCCCP, BCPP, etc. require a basic understanding of biostatistics principles for which this study guide may be beneficial as well.

Here's an outline of important statistical terms you need to understand and what's covered in the study guide.

• Hypothesis testing
• Independent and Dependent Variables
• The p-value (alpha) and what it represents
• The Beta value and what it represents
• Confidence Intervals
• Categorical Variables – Nominal and Ordinal
• Continuous Variables
• Ratio Scale
• Interval Scale
• Parametric Data Versus Non-Parametric Data
• Discrete Variables
• Statistical testing
• Statistical testing for nominal data
• Statistical testing for ordinal data
• The Normal Distribution
• Relative versus Absolute Risk
• Number Needed to Treat or NNT
• Number Needed to Harm
• Odds ratio
• Hazard Ratio
• Correlation
• Bias in Study Designs
• Three Types of Clinical Literature
• Study Designs – Listed In Descending Order of Strength
• Meta Analysis
• Confounding variables
• Survival Analysis
• Kaplan Meier
• Clinical Versus Statistical Significance
• Internal and External Validity
• The Basics: HIPAA, IRB, NIH, OSHA roles in conducting research

Pharmacists Wanting a Career Change?

If you could go back to the day you decided to become a pharmacist, would you do it again?

I will pause and give you time to think though if you are like me, you may not need that much time to say yes or no.

Someone in my family who I respect told me recently that pharmacists generally are a group of whiners with the inability to manage or lead very well. You cannot generalize the whole lot of us in one broad statement, but...

Why are pharmacists so unhappy?

Well for starters, pharmacists are not in the position to be power players of knowledge and expertise. Yes, we are players of knowledge but we cannot really bill for it, so all of the advice we give to those at the counter and prescribers at the hospital is free, thus we have no power. Consults are free. Telling someone how to take their medication is free and in fact is taking away from the 150 prescriptions per hour that the district managers and corporate leaders are needing to make a profit. We are no different in our billing structure than when I worked in a seed factory working a quota for money on the line and if I hit the magical 101% production, I could make a little more money.

Pharmacists don't make businesses a lot of money but are highly paid. In other words poor return on investment.

The best article I have read on the matter is written by Jerry Fahrni "Why Pharmacy Continues to Fail." I highly recommend it. It sheds light into all things pharmacy and how the profession continues to stagnate from business to leadership.

So, what to do. Stay or find a new career?

That is the question. Do we wait around for law to change, which it will eventually, or do we go ahead and research and find another way to make a difference in patients' lives? I still believe nursing would have been a better choice with expanded provider status, working hand-in-hand as part of the healthcare team with direct patient care and learning directly from physicians. Nurses can operate walk-in clinics with retail pharmacies and bring business while we are still getting paid for dispensing.

Pharmacist Provider Status Gains Traction

Acute Gout: Topic of the Day

From the Rheumatology Guidelines 2012:

Patient education on diet, lifestyle, treatment objectives, and management of comorbidities is a recommended core therapeutic measure in gout. Foods to avoid are organ meats, foods containing high-fructose corn syrup, and excessive alcohol use; foods to limit are large portions or concentrations of meat and seafood, naturally sweet fruit juices, sugar, desserts, and salt; and foods that are encouraged include low-fat or nonfat dairy and vegetables.  Of course also maintaining a healthy weight, exercising and smoking cessation are important in the management of gout.

Urate-lowering therapy (ULT) should be considered in patients with 1 or more tophi, ≥2 attacks per year, chronic kidney disease (CKD; stage 2 or worse) and urolithiasis:

First line: Xanthine oxidase inhibitor (XOI) therapy with either allopurinol or febuxostat is recommended as the first-line pharmacologic urate-lowering therapy (ULT) approach in gout).

Alternative: probenacid

Serum urate level should be lowered sufficiently to durably improve signs and symptoms of gout, with the target 6 mg/dl at a minimum, and often 5 mg/dl.

Allopurinol:

Starting allopurinol dose should not exceed 100 mg/day, and patients with CKD of stage 4 or higher should be started at 50 mg/day. Dosages should be titrated up every 2-5 weeks to achieve target serum uric acid and can go above 300 mg/day as long as the patient is educated and monitored for adverse events. 

• Caveat: Prior to initiation of allopurinol, rapid polymerase chain reaction– based HLA–B*5801 screening should be considered as a risk management component in subpopulations where both the HLA– B*5801 allele frequency is elevated and the HLA– B*5801–positive subjects have a very high hazard ratio (“high risk”) for severe allopurinol hypersensitivity reaction (e.g., Koreans with stage 3 or worse CKD and all those of Han Chinese and Thai descent).

Combination oral ULT with 1 XOI agent and 1 uricosuric agent is appropriate when the serum urate target has not been met by appropriate dosing of an XOI.

Pegloticase is appropriate for patients with severe gout disease burden and refractoriness to, or intolerance of, appropriately dosed oral ULT options. 

Drug Overdose Surpasses Traffic Related Deaths in Leading Cause of Death

The BMJ (formerly the British Medical Journal) reported that drug overdose has become the leading cause of death from injury in the US based on a report by the Trust for America’s Health. As prescriptions for opioids have increased the number of deaths from drug overdose has risen and has surpassed traffic related deaths as the leading cause of death from injury in this country. Half of these overdose deaths are due to prescription medications.

The report states that all injury related deaths in the US have remained stable in about half of the states, increased significantly in 17 states and stable in the rest. Injuries are the leading cause of death for Americans ages 1 to 44 leading to about 193,000 deaths per year.

Why Hospital Pharmacy Struggles

It is no surprise to hospital pharmacists that there is an internal battle going on. I cannot outline the struggle without first describing how hospitals get paid. Hospitals are a business and businesses cannot continue to function without money to pay its employees and generate profit.

Hospitals are paid by different methods depending on who is paying the bill.

Medicare: the federal program for the elderly usually pays the hospital a flat fee per case depending on the case. There are around 750 different diagnostic related cases (D.R.G.'s) that can be billed and each command a flat rate regardless of what happens in the hospital. These flat rates are changed due to lobbying and advice from commissions and other methods. Many times hospitals claim the payments received are below cost which causes the hospital to lose money.

Medicaid: the federal-state program for the poor, blind and disabled hospitals receive the same D.R.G's or a set amount of dollars per day (per-diem) or fee-for-service (F.F.S.) payments. These are set by state governments. Again, many times hospitals claim the payments received from Medicaid are below cost which causes profit loss.

Private insurers: purchased by consumers and pay hospitals on the basis of per-diems or fee-for-service. These usually exceed hospitals' costs and help override the losses from Medicare and Medicaid. Private insurers also help with net profits for the hospital and are negotiated yearly.

Breaking down the particular fees agreed upon, it's fairly evident that the pharmacist's role in billable services is on the distribution aspect: the medication provided and the rest is dollars saved but not billed. For example, if I dispense 2 bags of IV vancomycin, the hospital can bill $XX for the medication. If I recommend changing vancomycin to an oral antibiotic, the savings are due to medication and delivery costing less. I am not billing the other aspects of the IV to PO change. The patient has less chance of infection with an antibiotic given by mouth than IV and is easier to administer. Maybe even the cultures drawn show equal sensitivity and the choice of by mouth antibiotic is an ideal choice over choosing IV. There are cost savings for the drug (still distribution in nature) and costs in drug delivery, but the consult itself to change a medication has no billable service to the pharmacy department but indirect savings to the hospital as a whole. There are also cost savings with preventable adverse drug errors in regards to length of hospital stay billed, but nothing billed on catching anything amiss on a patient's profile, rounding with physicians, billing a "consult" or anything tied to a clinical pharmacist directly as a provider.

In other words, pharmacists command high salaries but do not have a way to bill for the same amount in return. Pharmacists and pharmacies cost the hospital a lot of money.

Hospitals are starting to learn that using pharmacists to cut medication errors cuts down on readmission (financial penalties with reimbursement). They are learning that there are costs tied to a patient experiencing an adverse drug reaction and other indirect cost savings, but the hospitals still need a return on their investment. Perhaps that is where provider status for pharmacists will fill in the gap?

Not only do we struggle with what we bill and what we cannot bill, we also struggle with being segmented within our own pharmacy departments. Distributive pharmacists (order entry pharmacists) are looked upon as aging dinosaurs out-of-touch with the clinical aspect of rounding with physicians and making real-time recommendations at bedside and new graduates state, "I don't want an order entry job. I want to be a clinical pharmacist." There is a division that seems to be encouraged with residency programs, fellowships, and board certification leading to "clinical" jobs and none required for order entry jobs. Maybe you are one of the lucky ones in a more progressive hospital that tries hard to incorporate both models into staffing with pharmacists decentralized on the hospital floors interacting "clinically" with nursing, physicians and patients. Maybe you are still stuck to a computer monitor in the basement of a hospital barely interacting with anyone directly. The models are all over the place because of the lack of being able to bill for what pharmacists provide besides a bag of medication.

Another struggle is that clinical pharmacists do not want to be bothered by pharmacy operational problems or regulatory issues. Operational problems affect patient care as well and translates into costs for the department and hospital. 

The last struggle that I have observed over the last fifteen years is the lack of excellence in leadership. I do not have many peers who strive for leadership roles in pharmacy but are fine to sit back and just work as a pharmacist rather than a manager. There are not a lot of strong leaders teaching and mentoring others on how to lead within the pharmacy and because of that pharmacists do not have a lot of power or clout to make change happen inside the pharmacy. This also translates into the lack of leadership and power where change happens on a government level.

What is the answer? I am hopeful that provider status will open the door to pharmacists becoming a return on investment for hospitals rather than a huge expense, but I also believe that there should be more meshing with understanding the business side of hospital pharmacy with clinical pharmacy because the two together would benefit what should be the ultimate goal of a hospital: patient care and minimizing costs.

Intake at the Hospital... in a Perfect World

Source: Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165:424-429. [go to PubMed]

In a perfect world, a patient would be met by a pharmacist or a certified pharmacy technician asking them about their home medications at admission. The information, especially when a physician signs the blanket order to "restart home medications" with one click or swipe of the pen, would become as scrutinized as medications started in the hospital. I have been and will continue to be baffled at how no one wants to take ownership of home medications and in fact treat them as though they do not fall under the same protocols as the hospitals' orders. 

For example, I stumbled across a patient who had been admitted and had all home medications restarted on day 2. He had reported to intake that he took morphine 60 mg by mouth twice daily. The intake person chose morphine sulfate immediate release (MSIR) rather than the patient's actual MS Contin and the patient actually received the medication as immediate release for a couple of days. Another time I discovered intake had entered Lyrica for Lopressor, Isordil for Imdur and the common Lopressor for Toprol. We have confusion with Depakote ER vs EC and the list is really endless. Not only that, the patient could report they take anything they want, and it is not verified and a physician not really paying attention could restart all kinds of medications the patient has not ever taken.

Why aren't electronic records linked where hospital staff could see what the patient has taken in the past year regardless of where filled?

Why don't hospitals see the need for trained professionals to make sure home medications are entered correctly at patient admission?

Many medication errors and interactions can be found in home medication reconciliation. Personally, I feel a pharmacist or experienced certified pharmacy technician should be the ones to handle medication reconciliation, but with high salaries that pharmacists make and technician costs, the hospitals' financial leaders make the decision that since a pharmacist or tech isn't billing that time to medicare or another insurance, it is money loss EVEN THOUGH it results in better patient care and less mistakes and drug errors and increase in patient safety.

Medication Reconciliation in the Hospital: What, Why, Where, When, How, and Who?

Medication Reconciliation Supported by Clincial Pharmacists

The Pharmacist's Role in Medication Reconciliation

Pharm Technicians Praised for Spot-On Med Reconciliation

Medication Reconciliation (AHRQ)

Rejection Can Be a Good Thing

Have you ever thought of rejection as being something that can be utilized for greatness? While no one actively enjoys rejection on the job or in life, it is at least something that can propel you to another level in how you view its role in your expertise and willingness to continue moving forward despite what is usually considered a personal failure with the usual negative results.

Usually when most people face rejection the first impulse is to withdraw and criticize the methods; however, what if we turned it into an opportunity to learn? What if we sought out opportunities to be rejected to learn how to minimize the emotional reaction and criticism and turned it into something else?

Take for example the issue that comes up with a medication where you have to make the phone call to the prescriber about a prescriber’s choice in medication. How does a pharmacist approach it to not look like someone who is pointing out mistakes the prescriber made and at the same time can convince a change if you really believe it? I hear pharmacists in the field make comments about physicians’ personalities and how one physician always says no to any recommendation and another physician is just plain “not nice.” What one pharmacist may think as “not nice” another pharmacist may interpret in a different way. Hospitals many times are using clinical pharmacists to manage medications with a cost savings plan in mind and that aspect can sometimes clash with what the prescriber believes when medicine was more of an art and less money, or it could mean that the pharmacist is bringing a valuable piece of knowledge to the table that the prescriber will appreciate. Whatever the reason, learning how to approach the physician and using it as an opportunity to improve the approach and delivery can make rejection turn into a positive rather than a negative.

Overcome the fear of rejection: One of the reasons why we have such fear of rejection is that we take rejection personally. Rejections are not personal. The prescriber or manager did not reject YOU but the proposal or effort was rejected. Of course rejection should not make you feel less, but it somehow can. Don’t let it, dive in and ask why the recommendation isn’t accepted, move on. The more you ask and are rejected (or accepted!) the less it will sting. If a pharmacist can learn how to detach emotions from the results, whether a yes or a no, it will help gain real confidence in the face of possible rejection. Building a relationship with the prescriber by actually being physically on the floor and picking up the phone helps as well. Leaving a note on a chart doesn’t help build a relationship and can easily be ignored but asserting yourself helps not only improve your relationship with the prescriber but also gives the prescriber a chance to hear and respond in real-time to a request. And the more you are rejected, the less it will sting and in the meantime the prescriber is getting to know you better.

What if a prescriber responds with a no? What if you asked the right questions to find out about the no? You could learn a lot as to why your idea to change something was rejected or you could just learn it is the prescriber’s prerogative. If all of this is handled well, you could use that no to help build a relationship and eventually trust.

This is a study that reviewed inpatient pharmacy recommendations and their acceptance rate. Perhaps if we focused a little more on approach and building a relationship with the prescribers, the number of acceptances would increase and make more of a difference. In the meantime, don’t let a rejection keep you from asking and asking well. Those rejections help teach you how to handle rejection better which could be the very thing keeping you from excelling as a clinical pharmacist.