Data Management and Security

Strategies for Pharmacy Integration and Pharmacy Information System Interfaces

Bruce W. Chaffee; Josephine Bonasso

Posted: 03/12/2004; American Journal of Health-System Pharmacy. 2004;61(5) © 2004 American Society of Health-System Pharmacists

Introduction

In recent years, a great deal of attention has been focused on the potential advances in medication safety that could occur with the implementation of computerized physician order entry (CPOE) in hospitals. Tangible improvements have been demonstrated in the areas of quicker medication turnaround time,^[1] better compliance with institutional medication-use policies and formularies,^[2] more appropriate prescribing,^[3] and reductions in medication errors,^[4]with clinical decision support (CDS) systems serving a significant role in the latter three.

Modern CPOE systems are a component of a larger entity called the clinical information system (CIS). For purposes of this article, a CIS is considered to be an inpatient information system that at a minimum provides health care professionals with CPOE, CDS, medication administration documentation (i.e., an electronic medication administration record), and clinical views of data provided by ancillary information systems, such as pharmacy, radiology, and laboratory. These clinical data may appear in the application via a direct interface with an ancillary system or from a database source, such as an institutional clinical data repository (CDR). There are many additional features that could be included in a CIS, such as discipline-specific task lists, clinical documentation, patient scheduling, and outpatient functionality.

In most hospital settings, the medication delivery system is an amalgamation of activities provided by a number of different health care providers. A simplistic construct of the workflow is that a physician diagnoses the disease and prescribes medication treatment; a pharmacist reviews the medication order for clinical appropriateness, prepares the medication, and ensures its timely delivery to the nursing staff; and a nurse ensures that the patient receives the medication at the appropriate time. Technology, such as a CIS, must be integrated within this workflow to ensure that there is a safe and efficient medication delivery system. A further complication is that technologies originally designed to be independent of each other are often expected to work together.

Information systems used to support ancillary departments, such as the laboratory or pharmacy, can be integrated with the CIS if (1) the functionality required by ancillary departments to conduct their business is included within the CIS (i.e., an "all-in-one" system) or (2) provisions have been made to electronically connect the CIS with the ancillary system via an interface.

There is a definite need for the CPOE component of the CIS to integrate with pharmacy department operations to ensure that health care professionals have accurate and complete access to patient data and that conflicting data do not exist in different information systems. Since most hospitals have a pharmacy information system, this means there needs to be integration of the CPOE component with the pharmacy information system. This article reviews the various options available for such integration.

Pharmacy Integration Options

There are four basic options for integrating the pharmacy department with the CPOE system. These include an integrated all-in-one CPOE and pharmacy system, a bidirectional interface between the pharmacy system and the CPOE medication-ordering system, a unidirectional interface between the CPOE system and the pharmacy information system, and not using an interface. Depending on the capabilities of the CIS vendor, there may be other potential solutions, such as the use of the CPOE system for order verification by pharmacists with subsequent automated transmittal of the order across the interface to the pharmacy information system.

Integrated All-In-One System

When hospital leadership makes the decision to implement a CPOE system, one of the key struggles pharmacy managers have is the choice among using their existing pharmacy information system, switching to a best-of-breed pharmacy information system, or using the CPOE vendor's integrated pharmacy information system, if available. A change to an integrated pharmacy information system may be the preferred option if the integrated system contains robust functionality or is an improvement over the legacy pharmacy information system. In some situations, managers may be required to select an integrated solution, especially if the pharmacy department has little input in the organization's information technology decisions, has little internal knowledge of and experience with technology, or has little support for independent technology initiatives.

Advantages

If the hospital elects to use an all-in-one solution and the pharmacy already uses the integrated pharmacy information system for the selected CIS or CPOE system, there are no disadvantages. By definition, integrated systems share the same architecture, database structure, and CDR. At the time of system configuration, the pharmacy products are linked to the CPOE medication orderables and are, therefore, configured to meet the needs of the recipient pharmacy system. This eliminates the need for personnel to develop interface specifications, match database fields, and support the interface during production, as is necessary with interfaced solutions. Further, an integrated solution offers the potential for integration of decision support and interdisciplinary communication.

Risks and Disadvantages

Many issues arise when pharmacy needs to implement a pharmacy information system where none existed previously or when a change from an existing pharmacy information system to an integrated system is required. The decision to use an integrated CIS containing a new pharmacy information system should compel the pharmacy to undertake a number of tasks prior to system launch ("go-live"). First, the pharmacy department should perform a complete "gap analysis" comparing the existing pharmacy information system with the new, integrated system. Next, the department leadership must make decisions regarding any deficiencies in functionality that are discovered. The department can either develop procedural work-around solutions or request software enhancements.

Finally, it is imperative that the system be fully tested and operational in the pharmacy prior to CPOE implementation. Medication delivery systems are complex, and the potential for error is relatively high. If go-live for CPOE is initiated prior to or simultaneously with pharmacy information system go-live, then the mapping of pharmacy orderables to pharmacy products can be compromised by the simultaneous changes that are occurring in the two systems. In this event, the source of problems related to medication order communication can be very difficult to diagnose, require substantial time to resolve, negatively affect departmental efficiency, and potentially create significant patient care risks.

Bidirectional Orders Interface

This solution offers the ability for orders to be electronically transmitted to an existing pharmacy information system, such that the majority of ordered items would be able to be matched to pharmacy products used in the system. Conversely, orders generated in the existing pharmacy information system would also be populated in the orders, medication administration, and work list sections of the CIS.

Advantages

Information generated by the CIS is quickly and electronically transmitted to the pharmacy, eliminating lost medication orders, illegible or incomplete medication orders, and the delays associated with other means of transferring orders to the pharmacy. Depending on interface specifications, specific dose form information and other product details could be transmitted as well. Since the bidirectional interface allows orders to be entered into the pharmacy system, pharmacy staff would not need to be as knowledgeable about the CIS order-entry pathways and could primarily interact with just one system. A bidirectional orders interface may also help minimize the detrimental effects of CPOE system downtime. Handwritten orders could be entered into the pharmacy information system and queued to cross the interface to populate the CPOE system once it is back online.

A bidirectional orders interface allows the pharmacy to retain the existing functionality available in its existing system. Typically, substantial time and effort have been expended configuring the existing pharmacy information system to function efficiently within the construct of existing pharmacy operations, and pharmacy staff has been trained in the existing pharmacy information system. The use of a bidirectional orders interface leverages the substantial efforts undertaken to optimize both the pharmacy information system and pharmacy operations.

Risks and Disadvantages

The biggest risk is system downtime. There are three areas where the integration could fail: the CPOE system, the pharmacy information system, or the interface. As a result, knowledgeable technical staff must be available 24 hours per day to resolve downtime occurrences. Procedures would need to be developed to manage the downtime using a paper-based system and to repopulate or enter the orders once the systems are back on line.

Ongoing formulary maintenance is another area of concern. In the absence of formulary synchronization software, drug entry, modification, and deletion activities would increase, as formularies in both the pharmacy information system and the CIS would need to be manually maintained and synchronized for each system.

The two systems may use different clinical reference databases (e.g., Multum, First DataBank, Micromedex, and Medi-Span). As a result, allergies, drug interactions, dose-range checks, and other clinical alerts may not appear to either the ordering clinician or the pharmacist, or they may appear with different information. It is probably best to use the CIS as the source system (i.e., master) for allergy documentation, since it most likely contains the CDR and since problems could arise from having two sources feeding other ancillary systems. CDS notifications could potentially be duplicative, since alerts would continue to fire in the receiving system and there is significant similarity between the clinical reference databases, resulting in some rework for the pharmacist or physician.

Clinical information available only in the CIS would not be available to the pharmacy staff. If the pharmacy information system has no messaging functionality or cannot interface with the CIS messaging system, then existing processes (telephones, paper, fax) must be used for communication of missing medications, time clarifications, refills, and so on.

Finally, a good process would need to be developed for notifying pharmacy staff of new orders in the system and prioritizing orders for verification. If the pharmacy information system vendor does not have order-queuing capabilities, it may require printing orders on paper for manual triaging by pharmacy staff. If a paper notification occurs, there could be significant added paper and toner costs. Some of these costs would be offset by the reduction in printing of paper medication administration records and decreased use of physician order sheets.

Unidirectional Orders Interface

The advantages and disadvantages listed for the bidirectional interface are similar to those of a unidirectional interface. The biggest difference is that the pharmacy would either have to reenter orders in the CPOE system that were incorrect or call to ask the prescriber to reenter the order. This could be considered a nuisance to the prescriber if the electronic order problem is related to product selection rather than a technical entry mistake or clinical problem. Downtime procedures would need to address who enters the orders in the CPOE system.

No Interface

Under this scenario, medication orders would be entered in the CPOE system and printed in the pharmacy. Information regarding any CDS alerts that were presented to the prescriber could be printed along with the response. Pharmacy would then enter the orders into the pharmacy information system and address any CDS alerts that occur in the pharmacy information system in conjunction with the printed prescriber response from the CPOE system. This solution does not provide any electronic linking of orders between the pharmacy information system and the medication profile or the medication administration record.

Advantages

Medication order delivery to the pharmacy would be immediate, medication turnaround time would likely improve, most orders would be complete, and the legibility of medication orders would be assured.

Risks and Disadvantages

Despite these advantages, the medication process would not be optimal because it would be difficult to ensure continuity of information between the systems. Orders entered in the CPOE system could be transcribed incorrectly or could differ from how they are portrayed in the pharmacy information system. The system would not notify the nurse that an order has been reviewed by a pharmacist, resulting in some uncertainty as to when the order is eligible to be administered to a patient. Some efficiency in medication turnaround time would be gained, but there could still be delays in order entry. As with the prior scenario, there could be differences in the clinical reference database used by the two systems that would require resolution, two formularies would need to be maintained, CPOE downtime could occur (requiring procedures to manage it), and paper and toner costs could increase.

Reaction

In the Integrated All-In-One System, the prerequisite for prior implementation of the pharmacy information system is likely to delay the CIS project by up to one year or more, especially if vendor-promised modifications are delayed. In addition, there are significant configuration, testing, deployment, and training costs for pharmacy when changing from one pharmacy information system to another. These costs may extend to other areas that may use pharmacy information for reporting or billing purposes. There is also a great possibility that this kind of system is not so applicable or not yet fully acceptable here in the Philippines due to lack of enough budget, training and skills of the pharmacists.

The other solutions are highly vendor dependent and may require extensive modification to the computerized physician order entry or CPOE system, the pharmacy information system, or both. All the other systems also may be applicable here in our country but cannot really answer our problems in terms of pharmacy information system.

Pharmacy managers and information technology specialists face many options when determining how to integrate a CIS or CPOE system into their medication delivery system. None of these provide a universal solution for all institutions. Ultimately, there should be greater system-wide integration and organizational efficiency with an all-in-one solution; provided that the vendor provides the required functionality and support to ensure that the pharmacy information system component meets the needs of the pharmacy department.