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Implementation of a Telepharmacy Service to Provide Round-The-Clock Medication Order Review by Pharmacists Douglas S

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Implementation of a Telepharmacy Service to Provide Round-The-Clock Medication Order Review by Pharmacists Douglas S CASE STUDY Telepharmacy service CASE STUDY Implementation of a telepharmacy service to provide round-the-clock medication order review by pharmacists DOUGLAS S. WAKEFIELD, MARCIA M. WARD, JEAN L. LOES, JOHN O’BRIEN, AND LEEVON SPERRY ffective execution of all aspects of the medication-use process, Purpose. The implementation of a tele­ the pharmacist selects the appropriate Eincluding prescribing, dispens- pharmacy service to provide round­the­ medication to dispense from the CAH’s ing, and administration, is necessary clock medication order review by pharma­ formulary. If the medication order is not to ensure high-quality, safe medica- cists is described. made using the CPOE system, the order tion practices. Many regulatory, ad- Summary. Seven critical access hospitals is scanned into a document and sent via (CAHs) worked collaboratively as part e­mail to remote pharmacists. The pharma­ visory, and purchasing groups have of a network of hospitals implementing cist enters the necessary information into established numerous requirements the same electronic health record (EHR), the EHR and pharmacy information system. and recommendations for improving computerized prescriber­order­entry The medication order review process from medication safety.1-3 Chief among (CPOE) system, and pharmacy information this point forward is identical to that used these is the need for pharmacist system to serve as the health information for medications ordered via CPOE. The new review of medication orders before technology (HIT) backbone supporting medication order is then entered into the medications are dispensed and ad- round­the­clock medication order review EHR, and the CAH nurse can proceed with by pharmacists. Collaboration permitted the order. ministered to patients. standardization of workflow policies and Conclusion. The implementation of a Approximately half of all medica- procedures. Through the HIT backbone, telepharmacy model in a multihospital tion errors occur in the prescribing both onsite and remote pharmacists were health system increased access to pharma­ stage of the medication-use process given access to the medication orders, the cy services, allowing for round­the­clock and may be attributed to the pre- pharmacy information system, and other medication order review by pharmacists. scriber’s lack of knowledge of a drug, patient­specific clinical data in patients’ the prescriber’s failure to adhere to EHRs. Orders are typically reviewed within Index terms: Computers; Hours; Medica­ 60 minutes of when they are entered into tion orders; Pharmaceutical services; Phar­ accepted practices and procedures, or the system. The reviewing pharmacists macists, hospital; Pharmacy, institutional, general slips and memory lapses dur- have remote access to the EHRs in each hospital; Telepharmacy ing the ordering process.4 Pharmacist CAH. After completing the clinical review, Am J Health-Syst Pharm. 2010; 67:2052­7 review of medication orders reduces DOUGLAS S. WAKEFIELD, PH.D., is Professor, Depart- Address correspondence to Dr. Wakefield at the Center for Health ment of Health Management and Informatics, the Care Quality, University of Missouri, CE548, Clinical Support and University of Missouri Informatics Institute, and Education Building, DC375.00, One Hospital Drive, Columbia, MO Director, Center for Health Care Quality, University of Missouri, 65212 ([email protected]). Columbia. MARCIA M. WARD, M.A., PH.D., is Professor and Associ- Supported in part by Agency for Healthcare Research and Quality ate Head, Department of Health Management and Policy, College grant UC1HS016156, the University of Iowa Center for Health Policy of Public Health, University of Iowa, Iowa City. JEAN L. LOES, M.S., and Research, and the University of Missouri Center for Health Care RN, is Network Clinical Information Analyst, Clinical Practice and Quality. Informatics, Mercy Medical Center—North Iowa, Mason City. JOHN The authors have declared no potential conflicts of interest. O’BRIEN, M.B.A.; at the time of writing he was Chief Executive Of- ficer, Ellsworth Municipal Hospital, Iowa Falls, IA. LEEVON SPERRY, Copyright © 2010, American Society of Health-System Pharma- B.S., is Graduate Research Assistant, Center for Health Care Quality, cists, Inc. All rights reserved. 1079-2082/10/1201-2052$06.00. University of Missouri. DOI 10.2146/ajhp090643 2052 Am J Health-Syst Pharm—Vol 67 Dec 1, 2010 CASE STUDY Telepharmacy service prescribing errors, as the pharmacist attention directed toward the use of and implementation. This article screens the orders for incorrectly health information technology (HIT) describes the creation of a HIT-based prescribed medications (e.g., wrong to review medication orders when no process for obtaining round-the- drug, wrong dose, wrong frequen- onsite pharmacists are available. clock pharmacist review of medica- cy), interactions, and contraindica- A number of telepharmacy mod- tion orders in seven CAHs and a large tions.5-7 The potential advantages els have been implemented by rural hospital. These hospitals col- of medication order review in acute rural hospitals, the most common laborated in implementing the same care facilities have been previously of which is a “hub and spoke” EHR, computerized prescriber-order- discussed in-depth.2,3,8-12 system.11-27 The hub is the entity entry (CPOE) system, and pharmacy responsible for supplying the rural information system to serve as the Problem hospital with round-the-clock phar- HIT backbone supporting round- Despite the recommendations macist medication review. A hub is the-clock prospective medication and evidence of the benefits, very few usually a larger hospital that either order review by pharmacists. rural hospitals have sufficient phar- has contracted with the rural hos- macist coverage to ensure adequate pital or is a part of the same health Analysis and resolution prospective pharmacist review of system, though the use of outsourc- Mercy Health Network—North medication orders. A 2008 study ing to a telepharmacy organization Iowa serves 14 counties in north found that almost half (48%) of 410 has also been documented. The rural central Iowa with a combined popu- small rural hospitals had pharmacists hospital, through the use of informa- lation of over 200,000. This network onsite fewer than five hours per week, tion technology, sends orders to the comprises Mercy Medical Center— and the lack of pharmacist coverage hub pharmacy for review when its North Iowa (MMC-NI), eight CAHs was magnified on nights and week- own pharmacist is unavailable. The contract-managed by MMC-NI, ends, where approximately 90% of level of technology associated with and one CAH owned by MMC-NI. hospitals reported that nurses were a telepharmacy model may vary, MMC-NI’s contract management responsible for dispensing and ad- ranging from communication via activities principally include recruit- ministering the medications.13 With fax to two-way video conferenc- ing and hiring for key leadership such limited pharmacist availability, ing. Evidence of the effectiveness of positions in the CAHs and providing most rural hospitals do not use pro- telepharmacy systems in decreasing selected management services. Each spective medication order review. the rate of medication errors at rural CAH is its own legal entity with an Only 20% of rural hospitals review hospitals is sparse, but initial research independent governing board and orders before the medication is dis- suggests that telepharmacy systems separate medical staff bylaws and is pensed, and only about half review have been generally well received by organized as an independent hospi- orders within 24 hours after medica- patients and staff.12,18,24,25,27 tal with its own clinical services and tion administration.5,13 Other barri- There is also growing interest by support departments (e.g., nursing, ers to pharmacist review of medica- rural and critical access hospitals pharmacy, laboratory, billing). The tion orders in rural hospitals include (CAHs) to implement HIT-based majority of primary care physicians cost and lack of patient volume to solutions that allow the reviewing practicing in the seven CAHs studied support a full-time pharmacist.6 pharmacist, regardless of location, to are also affiliated with the primary have real-time access to the patients’ care practice network managed by Background electronic health records (EHRs) and MMC-NI. The dominant referral Small rural hospitals have devel- the hospital’s pharmacy information pattern is between primary care oped a number of ways to increase and ordering systems. However, high providers practicing in the network pharmacist availability through loan purchase and implementation costs, CAHs and medical and surgical spe- forgiveness and rural training pro- limited local expertise in imple- cialists working at MMC-NI. grams, as well as through contracting menting HIT, a need for significant At the time of initiating this proj- with community pharmacists or shar- process redesign to take advantage ect (2007), all CAHs had 25 or fewer ing a pharmacist with another health of potential HIT functionality, and acute care beds; one CAH included care institution.13-15 Despite these the limited number of pharmacists a 10-bed psychiatric unit, and two and other efforts, onsite availability make this approach particularly chal- CAHs had attached nursing homes. of pharmacists to routinely provide lenging. The shortage of pharmacists Annual CAH inpatient admissions medication order reviews before
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