With the adoption of the E-Prescribing standards this year (2008) the healthcare team is taking a close look at how to implement this technology. Provider, payors and pharmacies alike face many challenges if they transmit prescriptions electronically. This article calls out many of those challenges, including: financial cost, workflow changes, and hardware/software selection. In 2006, CMS funded a pilot study to look at the feasibility of implementation in the US. You can review the materials at the CMS E-Prescribing Portal. The final rule called for the adoption of three standards by April 2009:

Formulary and benefit transactions: gives prescribers information about which drugs are covered by a Medicare beneficiary's prescription drug benefit plan.
Medication history transactions: provides prescribers with information about medications a beneficiary is already taking, including those prescribed by other providers, to help reduce the number of adverse drug events.
Fill Status notifications: allows prescribers to receive an electronic notice from the pharmacy telling them that a patient's prescription has been picked up, not picked up, or has been partially filled, to help monitor medication adherence in patients with chronic conditions.

One of the major criticisms by the pharmacy community has been lack of inclusion in the pilot study. Pharmacies were not extensively used in any of the healthcare sector tests, yet play a major role in implementation and compliance with the rule. Although CMS is targeting Providers with this rule, we know E-Prescribing has at least 2 parties involved: a sender and a receiver. In many cases, the Pharmacy will be on either end of that transmission, requiring compliance.
However, there are a few respites from the rule. If your healthcare system transmits prescriptions from orderer to pharmacy over a closed, protected network (such as HL7), you do not have to comply. In addition, prescriptions issued to Long Term Care facilities that are then forwarded to a pharmacy for fulfillment need not worry. The final exemption originally included computer-generated faxes, currently commonplace for transmission of refill requests from pharmacy to provider. Unfortunately CMS rescinded this exemption, putting the burden on pharmacies to be compliant with E-Prescribing if they generate facsimiles via computer applications.

A few observations are worth mentioning. First, the overall intent of the legislation is to improve patient safety and push a very divergent patient care sector in healthcare to standardization. E-Prescribing will help bring together the almost 100 prescription order entry and management computer applications in the US. It forces vendors to conform to said standards, whereby helping create universal electronic communication of health information.
While it is a worthwhile endeavor, implementation will be challenging and costly for many entities.

As posted by the Wall Street Journal:

Article

My comments:

Christus SPOHN Hospital Systems in Corpus Christi, TX recently released information concerning an overdose of 17 neonatal patients in their intensive care unit. The error was identified at the preparation step in the pharmacy, whereby the pharmacist or technician used the incorrect concentration of Heparin to mix intravenous doses. As a result, the patients received a much higher dose that necessary for clinical efficacy.

The article questions currently available technologies in healthcare and starts with Computerized Provider Order Entry (CPOE). Appropriately noted, CPOE does nothing to prevent a preparation error directly. However, tremendous value lies in reviewing hospital wide medication use practices when implementing a CPOE system. Standard concentrations of medications, an evaluation of currently used medications per unit, and order properties are among many important factors.

Bar Code Medication Administration (BCMA) is mentioned as a possible solution, but quickly realized to have little impact on a medication that was made incorrectly. Automation for the creation of IV solutions presents a potential fix as well. In the end, pharmacy informatics professionals know a system is only as good as the pharmacists that build it. Humans are required to check the medications being loaded into all automation, and as with these preparation errors are subject to potential error.

Healthcare consumers are looking for a black/white fix to these potentially harmful human interventions, but today none exist. In the end, as pharmacists it is our professional obligation to ensure medications are ordered, prepared, delivered, administered, and monitored as accurately as possible. This is a great article to reference when you feel rushed to get those medications up to the unit. Take your time and double check. It could save a life.

A research firm announced the results of a recent survey of the nation's top healthcare systems.

The top 10 list:

The Top Ten HIT List is as follows:

1. Electronic Health/Medical Records

2. Disaster Recovery/Business Continuity

3. Medical Archiving Systems

4. Storage Consolidation and Virtualization

5. Backup (disk-based and online storage)

6. Business Intelligence

7. Picture Archiving and Communication System

8. Infrastructure for Health Information Systems

9. Compliance

10. Securing Electronic Protected Health Information

After the July 1st deadline for adoption of NDC, administered quantity, and unit of measure to the Centers for Medicare and Medicaid Services (CMS), ASHP continues to request reprise.

ASHP is urging us to contact our state representatives and explain the challenges of adoption. We plan on following this with a few in-depth.

http://www.ashp.org/s_ashp/article_press.asp?CID=168&DID=2037&id=26364

Nothing surprising here. Many hospital systems continue to allocate lackluster funding for Health IT. In fact, consideration for Electronic Health Records, Electronic MARs, and Barcoding are lacking in over 30% of hospitals.

http://www.healthcareitnews.com/story.cms?id=9487&page=1

So who were the top dogs?

-Midland Memorial Hospital (320 Beds) in Midland, Texas;
-Clarian North Medical Center (170 Beds) in Carmel, Ind. ;
-Newport Hospital (148 Beds) in Newport, R.I. ;
-Evanston Northwestern Healthcare (858 Licensed Beds for the System) in Evanston, Ill. ;

As stated by the Washington Post, the nations two largest vendors for E-Prescribing solutions in the public sector are merging. This could help standardization of information between the hundreds of currently available pharmacy and provider systems on the market. Less than a week after the July 1st enforcement date, we see this important announcement.

http://www.washingtonpost.com/wp-dyn/content/article/2008/06/30/AR200806...

David Bates is one of the pioneers of healthcare informatics in the US. He was recently asked how the US has progressed over the past 15 years. A link to the interview is below.

http://webmm.ahrq.gov/printviewperspective.aspx?perspectiveID=59