Great integrations

Failure to address key workflow issues can make for a disastrous EMR implementation. Consider these tips for integrating EMR and radiology systems.

Anyone who's been involved in an electronic medical record (EMR)-to-radiology integration knows full well that the process doesn't begin and end with HL7 interfaces. Unresolved workflow issues can cripple an EMR implementation.

Part of the problem lies with the ambiguity of the term "EMR." A true EMR combines several key functions in the modern health care setting: computerized orders for prescriptions and tests, reporting of test results and physician notes. Sometimes problems occur when the EMR vendor's product forces an organization to make workflow choices that work for one ancillary and not the other (lab systems vs. radiology systems, for example). A good EMR vendor understands the different technical and workflow considerations of these two ancillaries.

Data integrity plays a large role in EMR-to-PACS or EMR-to-RIS [radiology information system] integration. What happens on one system must be communicated to the other systems. To achieve this communication, HL7 interfaces should be bidirectional for radiology orders, status changes, cancellations and result updates.

For the full article click here: http://imaging-radiation-oncology.advanceweb.com/Archives/Article-Archives/Great-Integrations.aspx

Electronic medical record jobs

Major Industry Job Websites

EMR and HIPAA Job Board - EMR and EHR Related Jobs

Healthcare IT Reps - Healthcare IT Jobs (sales and non-sales jobs)

justEMRJOBS.com - EMR Jobs Career Web site for all EMR related jobs. Best Place to find EMR Jobs.

EMR Jobs - Focused website on EMR Implementation, software development and sales jobs.

Healthcare IT News Job Listing - A website listing a number of Healthcare IT jobs and many EMR jobs available. The site is run by Healthcare IT news.

HIMSS JobMine - Job list sponsored by HIMSS with a bunch of HIT categories of jobs.

med IT jobs - The best set of search features of the ones listed. Categorized by job, company, etc.

Healthcare IT Jobs - Great set of features and a beautiful design.

Healthcare IT Central - Healthcare IT Career Center with Job Board, Content, Candidate and Employer resources.

MedReps.com - Nice place for IT/EMR sales jobs

HISTalk Jobs - Forum for HIT related jobs

Major Job Search Engines
EMR Jobs on indeed

EMR Jobs on Monster

EMR Jobs on Simply Hired

Hospital EMR stages

The majority of US hospitals are in the early stages of EMR transformation. Currently 19 percent of US hospitals have not achieved Stage 1 and are at Stage 0, 21 percent have achieved Stage 1, 50 percent have achieved stage 2, approximately eight percent have achieved stage 3, approximately two percent percent have achieved Stage 4, and less than one percent of hospitals have achieved stage 5 and stage 6 (see Figure 3).

There are a total of 754 acute care hospitals that have not fully implemented a base of major clinical ancillary department applications (e.g., laboratory, pharmacy, radiology) to qualify for stage 1 designation. This represents approximately 19 percent of the hospitals in the database. Most hospitals occupy the stage 1 and stage 2 levels of the EMR Adoption Model. The combined percentage of hospitals in these two stages is approximately 71 percent.  At this time, there are only 414 US hospitals that are stage 3-6 of the EMR Adoption Model. This shows the tremendous amount of work and investment that must be done by US hospitals to implement clinical systems to enable their participation in EHR initiatives. More importantly, further implementation of higher stage EMR applications will enable the reduction or elimination of medical errors, while providing the digital environment . The higher stages of the model represent the facilitation of not only improved patient care, but also improvements in efficiency and effectiveness with which patient care services are delivered by clinicians. Once we begin to deliver these capabilities within the healthcare organizations, we can begin to focus on sharing patient care information among all of the healthcare stakeholders. Currently, the hype surrounding healthcare IT has the cart before the horse. How can we discuss the potential of EHRs, much less implement them, until we have implemented effective EMRs, not only in hospitals, but in all care delivery organizations including physician practices? 

Click Read More for figures

Difference between EMR and EHR

The market has confused the electronic medical record (EMR) and the electronic health
record (EHR). Government officials, vendors, and consultants have propagated this
confusion, in some cases unintentionally. The definitions that HIMSS Analytics proposes
for these terms are as follows:

Electronic Medical Record: An application environment composed of the clinical data
repository, clinical decision support, controlled medical vocabulary, order entry, computerized
provider order entry, pharmacy, and clinical documentation applications. This environment
supports the patient s electronic medical record across inpatient and outpatient environments, and is used by healthcare practitioners to document, monitor, and manage health care delivery within a care delivery organization (CDO). The data in the EMR is the legal record of what happened to the patient during their encounter at the CDO and is owned by the CDO.

Electronic Health Record: A subset of each care delivery organization s EMR, presently
assumed to be summaries like ASTM s Continuity of Care Record (CCR) or HL7 s Continuity of
Care Document (CCD), is owned by the patient and has patient input and access that spans
episodes of care across multiple CDOs within a community, region, or state (or in some countries, the entire country). The EHR in the US will ride on the proposed National Health Information
Network (NHIN).

EMR Adoption Model: A New EMR Penetration Assessment Tool

Understanding the level of EMR capabilities in hospitals is a challenge in the US healthcare IT
market today. HIMSS Analytics has created an EMR Adoption Model that identifies the levels of
EMR capabilities ranging from the initial CDR environment through a paperless EMR
environment. HIMSS Analytics has developed a methodology and algorithms to automatically
score the approximately 4,000 hospitals in our database relative to their IT-enabled clinical
transformation status, to provide peer comparisons for CDOs as they strategize their path to a
complete EMR and participation in an EHR. The stages of the model are as follows:

Stage 0: Some clinical automation may be present, but all three of the major ancillary
department systems for laboratory, pharmacy, and radiology are not implemented.

Stage 1: All three of the major ancillary clinical systems are installed (i.e., pharmacy,
laboratory, radiology).

Stage 2: Major ancillary clinical systems feed data to a clinical data repository (CDR)
that provides physician access for retrieving and reviewing results. The CDR contains a
controlled medical vocabulary, and the clinical decision support/rules engine for
rudimentary conflict checking. Information from document imaging systems may be
linked to the CDR at this stage.

Stage 3: Clinical documentation (e.g. vital signs, flow sheets) is required; nursing notes,
care plan charting, and/or the electronic medication administration record (eMAR)
system are scored with extra points, and are implemented and integrated with the CDR
for at least one service in the hospital. The first level of clinical decision support is
implemented to conduct error checking with order entry (i.e., drug/drug, drug/food,
drug/lab conflict checking normally found in the pharmacy). Some level of medical
image access from picture archive and communication systems (PACS) is available for
access by physicians via the organization s intranet or other secure networks outside of
the radiology department confines.

Stage 4: Computerized Practitioner/Physician Order Entry (CPOE) for use by any
clinician is added to the nursing and CDR environment along with the second level of
clinical decision support capabilities related to evidence based medicine protocols. If one
patient service area has implemented CPOE and completed the previous stages, then this
stage has been achieved.

Stage 5: The closed loop medication administration environment is fully implemented in
at least one patient care service area. The eMAR and bar coding or other auto identification technology, such as radio frequency identification (RFID), are implemented
and integrated with CPOE and pharmacy to maximize point of care patient safety
processes for medication administration.

Stage 6: Full physician documentation/charting (structured templates) is implemented for
at least one patient care service area. Level three of clinical decision support provides
guidance for all clinician activities related to protocols and outcomes in the form of
variance and compliance alerts. A full complement of radiology PACS systems provides
medical images to physicians via an intranet and displaces all film-based images.

Stage 7: The hospital has a paperless EMR environment. Clinical information can be
readily shared via electronic transactions or exchange of electronic records with all
entities within a regional health network (i.e., other hospitals, ambulatory clinics, subacute
environments, employers, payers and patients). This stage allows the HCO to
support the true electronic health record as envisioned in the ideal model.
The majority of US hospitals are in the early stages of EMR transformation. Currently 19
percent of US hospitals have not achieved Stage 1 and are at Stage 0, 21 percent have
achieved Stage 1, 50 percent have achieved stage 2, approximately eight percent have
achieved stage 3, approximately two percent percent have achieved Stage 4, and less than
one percent of hospitals have achieved stage 5 and stage 6 (see Figure 3).

Job twitter feeds

http://twitter.com/HealthIT_Jobs

http://twitter.com/integrity_jobs

http://twitter.com/getmedrecorjobs

https://twitter.com/GerryWiederRN/healthcare-technology

Dashboards in radiology highlights

Source: http://www.diagnosticimaging.com/practice-management/content/article/113619/1664518

The pressure to get faster, more efficient, and more productive is mounting. Healthcare reform, increasing regulations, and declining reimbursements are bearing down. Radiology departments and imaging centers are looking for ways to improve performance. Dashboards are lighting the way.

Dashboards that analyze data going back months or years show where a facility or department has been. Executive dashboards show whether a facility is aligned with the goals of the facility. They are actually reports, prepared by hand, from data laboriously pulled from PACS or RIS and assembled in a spreadsheet. They provide a retrospective on the past quarter or year, laying the foundation for trending analyses, which can be used to predict the future path of an organization.

Tactical dashboards are different. They uncover problems that need to be fixed and the details necessary to put those fixes in place. They are the glitz of healthcare analytics, displaying information in real-time about key indicators such as scanner volumes or report turnaround times.

Tactical dashboards hold the potential to make daily operations transparent, defining them in terms of metrics that quantify staff productivity, the utilization of scanners, and wait times. The complexity of these processes obscures them from view.
Siemens offers its syngo Portal Executive. This dashboard tool works in concert with syngo software to keep track of referral patterns, analyzing, for example, whether patient flow from key referring physicians is continuing, increasing, or decreasing. Portal Executive can also be used to look for—and find clues to remedy—inefficiencies that are holding back exam volumes. This, however, is retrospective. Kurt Reiff, vice president of image knowledge and management for Siemens Healthcare, is driving the company toward a more ambitious future.

“What we really need is perspective,” Reiff said. “If my business develops in a [particular] direction, how do I have to invest my money? Do I buy a CT or an MR? Where is my best return on investment? I think this is where this is heading.”

In the meantime, the real-time feedback possible with some dashboards offers the opportunity to spot problems in their earliest stages. Needles, bars, or numbers moving into red, yellow, or green provide an instant read on what’s happening in the department or facility.

Carestream’s Digital Dashboard monitors server performance, user volumes, and storage utilization. The dashboard supports Carestream’s RIS/PACS, but also can verify that other vendors’ devices are connected and operating on the network. The data can be presented onscreen or through e-mails and text messages that alert recipients to problems such as a failure in network connectivity or storage issues.

Leslie M. Beidleman uses the Carestream dashboard to ride herd on PACS at about a half dozen hospitals and clinics in the Mercy Health Partners network in Toledo, OH. As regional PACS administrator, Beidleman uses the dashboard to keep tabs on the amount of space available on the facilities’ several servers, as well as to check processes such as archiving and study backup.

“It gives a good quick view of things,” she said.

Those data points can also be manually captured in a spreadsheet for later comparison, a trick that came in handy recently when Beidleman noticed that the number of studies needing backup was increasing. This led to finding the problem on the servers, which brought the number down very quickly.

Productivity, finances, and quality are woven tightly together. If workflow improves, financials go up, as does the quality of services. Reduce the number of retakes by improving scan quality and productivity improves, as does the bottom line. Patient and referring physician satisfaction rise. Demand may rise. Workflow becomes more challenging. Pressure mounts for greater efficiency, which is achieved by optimizing scan volume and minimizing patient wait times.

Demand may vary across several sites of an enterprise, as referring physicians send more or fewer patients later or earlier in the day to one place or another. When managing that enterprise, scheduling changes smooth the flow. Proactive monitoring keeps services on track while trending analyses allow strategic planning to meet future needs through asset utilization.

Such introspection works well when the goal is to improve individual performance. But a myopic view of the world can lead to missed opportunities. With McKesson’s benchmark collaborative, radiology departments can see how they stack up against others that are similar in size, makeup, and procedures. Reports can be customized to include certain specific metrics that have meaning to just your radiology department. This, according to McKesson executives, produces business information about inefficiencies, which can be turned into models that illustrate how those inefficiencies can be fixed. These lead to strategies about how to use staff and equipment more efficiently and effectively.

“It is a gold mine of information about their internal operational performance that they simply did not have before,” said George Kovacs, director of product marketing in McKesson’s Medical Imaging Group.

McKesson’s report allows the user to drill down starting at the most general comparison, a piece of a bar or pie chart, and see what’s underneath. Users can follow evidence that leads to the root cause of an operational inefficiency and then see how different actions, such as those taken by others in the collaborative, may resolve the problem.

Such comparisons provide the context for making strategic decisions. But even such complex and contextual analyses are only that, analyses. The ultimate expression of the dashboard is as a means to solve the problems. The automation that goes into summing up operational data needs to be extended to automatically fix problems rather than simply alert administrators to their presence.

“We want to identify the problem and instantiate the appropriate business logic to fix it,” said Dr. Paul Chang, vice chair of radiology informatics and pathology informatics at the University of Chicago.

For example, rather than programming an electronic dashboard to flash red when patient wait times go beyond a certain point, software might automatically reroute patients among scanners to spread the load.

Business intelligence can play a major role in safety as well, for example, in radiation monitoring. Rather than documenting the number of patients overexposed to radiation and waiting for human intervention to change the protocols, Chang advocates building software that recognizes and then stops the overexposure before it happens.

Today’s radiology dashboards are informational at best. The widespread adoption of RIS and PACS provides operational data to be tapped. Ros believes there is tremendous opportunity for vendors to create dashboards that deliver comprehensive operational analyses. But Geis thinks it may be awhile before this opportunity is fully realized.

When they do arrive, dashboards will provide the means to several ends: information that can be used by radiology departments and imaging facilities to increase productivity, financial performance, and quality.

Info tech basics

Workplace technologies help hospital management control health
professionals in five ways:

1. Surveillance
Your employer has to know what you’re doing in order to control you.
Because managers can’t watch everything you do, hospitals adopt surveillance technologies.

Surveillance is one of the primary functions of electronic medical records (EMRs), the computerized version of patients’ paper records. Computers keep track not only of data entered, but also of exactly when each entry is made. This allows management to monitor work processes closely, analyze them, and force RNs to change them and work faster.

2. Division
Employees are easily controlled when they see themselves as individuals distinct from other employees. They’re much stronger and harder to control when they feel solidarity with their coworkers and act collectively. Hospital management knows this and uses technologies to divide RNs.

3. Routinization
Hospital management wants to control health professionals so it can routinize work processes
         • By simplifying them and fragmenting them into tasks, and
         • By standardizing the tasks.
Management would like you to think that “standardizing” work processes means raising quality standards, but it doesn’t. “Standardizing” really means making work processes uniform, or forcing everyone to do them in exactly the same way.  Making work processes simpler and more uniform allows management to speed up and intensify work. This is how routinization
increases technical efficiency.

4. Deskilling
Skill and Judgment
Routinization leads to the deskilling of work processes and health professionals. Skill is the ability, drawn from education and experience, to do something expertly. It can also be defined as the effective exercise of professional judgment in non-routine situations.

How Skill is Related to control
Highly skilled employees are harder to control than less-skilled employees. The most highly skilled employees are considered professionals. Professionals have significant responsibility and have conventionally had the freedom to design their own work processes in the ways that suit them best. They don’t need someone else to manage their time. A health professional’s judgment in deciding how to get work done should be respected by hospital management.

Automation
When work processes are sufficiently routinized, they can be automated. You can probably think of medical technologies that help health professionals do things they couldn’t otherwise do. Such a technology benefits professionals and patients because it’s skill-enhancing. But technologies that automate work are usually deskilling or skill-degrading because they’re designed to serve management by tightening its control of employees.

Much health information technology is skill-degrading. As the work of health professionals becomes increasingly automated, they lose the ability to do their jobs without HIT. To make matters worse, they’re expected to keep pace with machines. They serve the machines rather than doing the more gratifying work of patient care, and ultimately they’re compensated less well.

5. Displacement
Employers would prefer not to have to control employees. It’s too much trouble. Machines are technically efficient, and they don’t join labor unions. From an employer’s point of view, the ideal workplace would be one where machines did all the work. Of course, in all industries, there are still many jobs performed by people rather than machines, but employers automate whatever processes they can. For health professionals, as for other employees, losing skills is a stage on the way to being replaced by machines.

Health care information technology blog

Want to stay up to date with some of the latest information?  Go to the feed:

http://healthit.hhs.gov/blog/onc/index.php/feed/

Health IT return on interest

• Organizations should look at technology as a "business solution" and not simply as a new tool.
• Measuring the ROI for health IT investment projects must include not only cost and quantifiable benefits, but also intangible or value-based benefits that organizations can derive from such projects.
• Some technology investments need to be considered as a cost of doing business. Organizations will not operate an office without electricity or water. Similarly, they should not operate an office without IT systems in this day and age.
• Implementing a health IT system may not reduce cost but will improve outcomes e.g., a surgical information system may or may not reduce operational costs, but it will result in better patient care outcomes.
• Some technology investments are necessary for compliance with HIPAA and JCAHO regulations, accreditation processes, and other state and federal requirements.
• Organizations should also assess the cost of not investing in health IT. For example, if appropriate tools are not implemented to support patient billing office, it could result in additional staffing, an increase in accounts receivable, and lower patient satisfaction.
• Organizations should look at a longer term vision and strategy when considering the acquisition of an EHR system. Use of the planned National Health Information Network (NHIN) and Regional Health Information Organizations (RHIO) will necessitate the use of an EHR system in order to exchange data with others.
• Finally, while it is important to calculate the expected benefits, it is equally important to measure realization of actual benefits a year or so after the system has been implemented.

The actual benefits can be summarized as follows:

• EHR Systems
  • It is estimated that over 5 years, EHR benefits will be $86,400 per provider and the benefits will be accrued by several stakeholders such as physician practices, ancillary services, pharmacies and most importantly patients
  • Ohio State University Health System reduced the time for getting medication to patients by 65 percent from 5.28 hours to 1.51 hours. They also reduced Radiology turnaround from 7.37 hours to 4.21 hours
  • Maimonides Medical Center reported 30.4 percent reduction in average length of stay from 7.26 to 5.05 days. They also realized organizational efficiencies by preventing duplicate ancillary tests
  • Heritage Behavioral Health experienced 70 percent reduction in cost of clinical documentation with EHR
  • University of Illinois at Chicago Medical Center gained significant benefits in reallocation of nursing time from manual documentation to direct care - estimated to be $1.2 million
• e-Prescriptions
  • Many errors occur because of handwritten prescriptions that can be easily misunderstood and can result in adverse drug events or complications. More than 3 billion prescriptions are written annually and according to an eHI report, medication errors account for 1 out 131 ambulatory care deaths and many deaths in acute care are also attributed to medication error.
  • Studies indicate that the national savings from universal adoption could be as high as $27 billion annually
• Computerized Provider Order Entry (CPOE)
  • The Center for Information Technology Leadership (CITL) estimates that implementing advanced ambulatory CPOE systems would eliminate over 2 million drug events per year; avoid nearly 13 million physician visits, 190,000 admissions and over 130,000 life-threatening adverse drug events per year and save $44 billion per year.
  • Brigham and Women's Hospital in Boston reported 55 percent reduction in serious medication errors and 17 percent reduction in preventable Adverse Drug Events (ADE) - average cost of an ADE was $2,595, resulting in projected savings of $480,000 per year. They estimated net savings from $5 million to $10 million per year.
  • Maimonides Medical Center in New York realized 55 percent decrease in medication discrepancies and 58 percent reduction in problem medication orders. They also eliminated pharmacy transcription errors.
  • Children's Hospital of Pittsburg has eradicated handwriting transcription errors completely and cut harmful medication errors by 75 percent.

My e-prescribing device proposal

My device would be called MAD Pad – (Medical Access Device)

• Electronic ink
• Web browser
• Multi-touchscreen
• Long life battery
• Low maintenance
• Built-in cameras
  • Forward facing (high-resolution)
    • Facial recognition access
    • Controlled substance compliance
  • Rear facing (low-resolution monochrome)
    • Patient ID scanning
    • Two-dimension barcodes

(Also done with PowerPoint 2010!)

 

Patient ID QR codes

On wrist band:
This has already been done!
http://salmapatel.com/healthcare/qr-code-on-hospital-wristband 

‘

Future EHR computing

Do you know where the future is headed for hospital computing?  This is what doctor’s can look forward to, a world of intelligent mobile computers. (Note: Done with PowerPoint 2010!)

With better diagnosis, better records, more data mining, can health care be improved?

According to Donald A. Young, chief operating officer and medical director of the Health Insurance Association of America, it depends.  Sometimes technology falls just short of the mark. Technologies don't always reach its intended practitioners and is often flawed. Technology is misused and services overused. We have these problems because it is a failure to apply what we know. You have to see who is using the technology and under what circumstances, not just its effectiveness. The flaw is in the application of the technology and the selection of individuals who are the right candidates for it. We have the necessary body of knowledge, but we are not applying it properly. By the time this is solved, a whole new generation of new technology is deployed, making the findings moot and we have to start all over again. The adoption and application of that knowledge by practitioners are the true flaws.

www.aaas.org/spp/rd/ch28.pdf

Meaningful use

Meaningful use: The government’s billion dollar gift to radiologists
http://www.diagnosticimaging.com/display/article/113619/1692637

In July 2010 the final rule on meaningful use was released, along with a new definition to determine eligibility classification. Eligible hospital (EH) and eligible professional (EP) assignments are based on a series of CMS place-of-service codes. A shift of code 22 (outpatient hospital) from EH to EP resulted in the majority of radiology professionals qualifying as EPs under the Medicare electronic health record (EHR) incentive program. Personal eligibility can be determined by a radiology professional’s patient mix and imaging practice scenario (See Table).

Once eligibility is determined but before incentive payments can be made, all EPs will need to have a national provider identifier; enroll in the CMS Provider Enrollment, Chain, and Ownership System; and have an active account in the National Plan and Provider Enumeration System. Details about these requirements can be found on the CMS website.

In July 2010 the final rule on meaningful use was released, along with a new definition to determine eligibility classification. Eligible hospital (EH) and eligible professional (EP) assignments are based on a series of CMS place-of-service codes. A shift of code 22 (outpatient hospital) from EH to EP resulted in the majority of radiology professionals qualifying as EPs under the Medicare electronic health record (EHR) incentive program. Personal eligibility can be determined by a radiology professional’s patient mix and imaging practice scenario.

Once eligibility is determined but before incentive payments can be made, all EPs will need to have a national provider identifier; enroll in the CMS Provider Enrollment, Chain, and Ownership System; and have an active account in the National Plan and Provider Enumeration System. Details about these requirements can be found on the CMS website.

Clinical use of barcode scanners

One of the paramount concerns of a hospitalized
patient is receiving the wrong medication. Yet
few patients know that they are 100 times more likely
to receive the wrong blood than they are to be exposed
to HIV and hepatitis through a blood transfusion and
that most laboratory specimen errors occur right at
the patient’s bedside.

All clinical processes are subject to human error,
and, where possible, bar coding is being employed to
provide critical double checks for patient safety. This
chapter describes several important clinical bar code
applications.

Medication administration verification

When bar coding technology is used, the nurse
scans his or her name badge and enters a secure password
into a bedside computer (laptop, desktop, or
handheld device). The nurse then scans the patient’s
wristband, which enables the patient’s medication
record, as ordered by the physician and transcribed
by the pharmacist, to appear on the computer screen.
The nurse then scans the bar-coded medication before
giving it to the patient. This medication administration
is recorded electronically, which makes it easily accessible
to physicians and other clinicians.

If the nurse has unintentionally violated one of the
“five rights” of medication delivery, a warning appears
on the computer screen before the patient receives the
medication. Some bar code medication systems provide
clinical alerts, such as reminding the nurse to take the
patient’s pulse before giving a medication or caution
the nurse that a particular drug is easily confused with
a similar-sounding or similar-looking medication. Bar
coding used in medication administration has reduced
medication errors between 71 percent and 86 percent.

Blood transfusion verification

When bar coding technology is used at the bedside,
the nurse again enters the system by scanning his or
her name badge and entering a secure password. The
nurse then scans the patient’s wristband, and through
a series of electronically displayed prompts, scans the
blood product, the blood product type, the patient’s
blood type, the blood unit number, and expiration
date. If all prompts are accurately executed, the nurse
is directed to start the blood transfusion. On the other
hand, if any of the prompts are inaccurately executed
(e.g., the patient’s wristband identification number
does not match the patient identification number on
the blood product bag), an alert is generated. Bedside
bar coding systems used in transfusion have resulted in
100 percent accurate patient identification and are
recommended by industry experts.

Laboratory specimens identification

Some laboratories print labels that identify the patient
and expected test in advance. As the phlebotomist
arrives on a clinical unit and proceeds from patient
to patient, the labels are attached after the sample is
placed in the test tube. It is at this point that most
blood specimen errors occur, as patients are transferred
to other units or discharged, test requests are
modified, and/or specimens are required on an urgent
basis. Using bar coding at the bedside to properly
identify the patient and test results in accurate specimen
labeling can prevent additional testing and
patient discomfort.

Respiratory therapy treatment at the bedside

When bar coding is used, the respiratory therapist scans his
or her name badge and enters a secure password into
a bedside computer (laptop, desktop, or handheld
device). The therapist then scans the patient’s wristband,
which allows the patient’s medication record,
as ordered by the physician and transcribed by the
pharmacist, to appear on the computer screen (e.g.,
Proventil 2.5 mg in 2.5 mL of normal saline every
3 to 4 hours via nebulizer).While nurses may be given
access to all of the patient’s medications, the system
can limit the respiratory therapist’s view to only the
medications and treatments that he or she will be
administering.

The therapist conducts a critical double check by
comparing the order presented on the point-of-care
system with the physician’s original order in the chart.
As the therapist confirms the order, an electronic signature
documents that the verification process was
completed. Next, the therapist scans the Proventil
inhalation solution. The software performs a series of
checks to make sure that the medication is scanned for
the “five rights.” The therapist then completes a final
review of the medication and dose about to be administered.
This step conforms to current standards for
reviewing documentation before an electronic signature
is applied.When the medication has been
administered to the patient, the therapist confirms in
the system that the dose of Proventil was given. As the
medication administration is confirmed, the electronic
medication administration record is updated. In addition,
all charge events can be sent to the billing system
to ensure timely and accurate patient billing and to the
cost accounting system to ensure that the cost of care is
accurately and efficiently captured.

Dietary management

When interfaced with a dietary management system,
a BPOC application using bar coding scanning
can automatically ensure that the right meals get to the
right patient in the right portions. At mealtime, the
caregiver identifies the patient by scanning his or her
bar-coded wristband. This pulls up a patient profile
that includes the latest diet order. A bar-coded meal
ticket on the tray is scanned and cross-checked with
the patient’s diet order. If the ticket and order match,
the tray can safely be delivered.

Gamete tracking in the fertilization process

Throughout
the process, the bar code scanning system is used
to verify the correct union of appropriate components.
The technology stops scientists from fertilizing eggs or
transferring embryos to the patient unless the identification
bar code matches. Likewise, the grown embryos
will be transferred to the patient only after the system
has successfully matched the embryos’ ID with the
parents’ ID.

E-prescribing and show your work

At our institution, we have constructed a method to annotate prescriptions automatically, called ‘‘Show Your Work”
(SYW). This process adds notes below each medication order to describe any decision support warnings that were displayed at the
time of prescribing, any overrides to drug alerts provided by the prescriber during the session, and any dose calculations for pediatric
prescriptions. Show Your Work also notes when specific tasks
were done manually or could not be accomplished.

Although qualitative data presented here were in support of the
continued exploration of SYW functionality in e-prescribing systems,
we found no significant change in the callback rates in our
randomized trial. There are several factors that may account for
this.

Case Study: E-Pharmacy At Chelsea And Westminster Hospital in the UK

*Full name of the hospital: Chelsea and Westminster Healthcare NHS Trust
*Location: London, UK
*Type: Integrated acute care teaching hospital
*Year of foundation: 1993
*Number of beds: 522
*Number of employees: 2,200
*Income in last financial year: £190 million (~280 million euros)(2004-2005)
*Area from which patients are drawn: Mainly central and West London

Chelsea and Westminster Healthcare Trust is an acute care hospital in West London. Its
pharmacy department was modernized during 2002 and 2003, including the introduction
of an electronic prescription system, a new dispensary, a computer-controlled dispensing
robot and pneumatic tubes to distribute medications to the ward or unit where they are
required. The new dispensary was designed to meet the needs of new pharmacy
processes using electronic prescriptions. The electronic medication management system
encompasses the whole chain of an electronic pharmacy system, that can be described
as e-prescribing, e-dispensing, e-distribution, e-stock-management, and e-procurement.
The new system led to more accurate prescriptions, more accurate dispensing, reduced
stock holding, reduced waiting times for patients, reduced workload in the dispensary,
and fewer visits to pharmacy by nursing staff, allowing more time to be spent with
patients.

In 1993, C&W started planning to introduce electronic patient records (EPRs). In 1999 the
hospital introduced its EPR using a software system called Lastword. It was produced by
the IDX Systems Corporation1 to replace the old patient administration system. After a
period of piloting and development, Lastword was also used from 2001 for e-prescribing
for the hospital’s outpatients and discharged inpatients. The general view was that e-prescriptions
were easier to read than hand written ones and the Lastword system
provided useful electronic records of medication for particular patients. This reinforced a
parallel development in the hospital pharmacy that aimed to modernize its services. A
driving force was the long patient waiting times for both outpatients and discharged
inpatients. There had been an increasing number of formal complaints regarding these
waits. There was also a need to reduce the number of dispensing errors, increase the
number of pharmacists working directly with patients as part of the healthcare
professional teams, improve stock control, and improve the generally low staff morale
caused mainly by hectic working days and late hours when on late duty.

In May 2003, C&W installed the Rowa dispensing robot, constructed by ARX Ltd.
The robot screens show stock orders from prescriptions that have been prepared by the
robot, but not released by the pharmacy staff. This ensures that prescriptions can be
prepared by the robot, but not executed until the system is explicitly told to do so by the
pharmacy staff.

The new system improved dispensing accuracy, reduced stock holding, reduced waiting
times for processing and dispensing outpatient and discharged inpatient prescriptions,
enabled earlier finishing times for late duties, reduced workload in the dispensary, and
reduced the number of visits to the pharmacy by nursing staff, allowing more time to be
spent with patients on the ward. The impact has been evaluated using the methodology
of the EU’s eHealth Impact project.

Lessons learned:

*C&W has the following lessons to offer by introducing ICT into its prescribing, dispensing
and stock management chain:

*Investing in ICT across the whole chain from e-prescribing to e-procurement offers
significant net benefits to patients, healthcare professionals and the organization.
Access rights to robot programs should be restricted according to job roles to
prevent miscoordination errors and misuse.

*Stock levels should be reduced several weeks before the system’s “go live” date in
order to facilitate the task of capturing all stock records in electronic form, as well
as physically “feeding” the system with articles.

*At an early stage of planning, the managers involved should investigate existing
solutions by visiting sites where similar systems are already running, as C&W
managers did. Managers should seek support from people and teams who have
experience in implementing such systems.

*Training curricula should be tailor-made to the needs of particular professionals,
especially physicians, nurses and pharmacists. This is vital for motivating and
ensuring the support of all staff members. The success of implementing a
medication management system that requires a thorough re-organization of
workflows depends on the willingness of staff members to accept and use the
system.

*The C&W experience has already been successfully utilized by other NHS hospitals in
the London area, with more sites in the process of implementing similar systems

E-prescribing frequently asked questions

Step 1 - Assessing Your Practice Readiness

1. Are there other tools that will help me determine my practice readiness?

 

There are a number of tools available that allow you to assess your practice

readiness. The American Medical Association provides a readiness

assessment tool. Texas Medical Association also offers an

assessment tool.

 

2. I am not sure if I can determine my practice readiness unless I know

more about e-prescribing. Where can I find more information about what

e-prescribing is and what changes it might require?

 

Earlier this summer the Health Initiative and the Center for Improving Medication Management

released a comprehensive report on e-prescribing. The report describes what

e-prescribing is, why it is important and the major e-prescribing initiatives. To

access the report go to: http://www.ehealthinitiative.org/assets/

Documents/eHI_CIMM_ePrescribing_Report_6-10-08_FINAL.pdf.

 

3. What should I do next if my practice is not ready?

 

If after reading this guide

you determine your practice is not ready to successfully implement e-prescribing

you should focus first on fixing those areas of concern. These issues are not

insurmountable, but they will take time and effort to correct.

 

Step 2 - Defining Your Practice Needs

1. What are the attributes of a successful practice leader?

 

Instilling and

creating prescriber and staff behavioral change in a medical practice is difficult.

It is extremely helpful when a respected physician, other clinician or practice

administrator steps up as a champion and educates his or her fellow colleagues. An

e-prescribing practice leader should possess the following qualities: 1) be a

willing innovator, 2) somewhat technology savvy, 3) active, high volume

e-prescriber, 4) strong e-prescribing advocate, 5) comfortable serving as leader

and facilitator amongst his or her peers and 6) dedicated to committing time on a

weekly basis for physician and staff training.

2. What are the key considerations when redesigning my prescribing

process for e-prescribing?

 

 The following issues should be discussed at this

stage. Although you might not have a final strategy for each issue at this time, you

should consider strategies for each:

– How to define the role of the front desk, medical assistants, and prescribers in

a redesigned prescribing process

– How to effectively implement prescriber preferences in the system

– How to provide appropriate hardware based on the prescribing roles and

responsibilities of the practice

– How to communicate with patients about electronic prescribing

– How to maintain and monitor error logs

– How to monitor electronic renewal requests from the pharmacy

– How to best engage with local pharmacies in mutual problem solving

 

3. What is the basic technology I need to begin e-prescribing?

 

Office configurations will vary depending on the e-prescribing system chosen. However,

regardless of the e-prescribing system, practices must have a good Internet

connection (preferably high speed) and desktop, laptop or tablets computers,

hand-held PDAs, or a combination. If PDAs or tablets will be the primary

technology used by prescribers, setting up a wireless network is recommended.

 

4. What if my practice’s needs go beyond improving the prescribing process?

 

Some practices decide that the prescribing process is too dependent on other

clinical information to isolate. If that is the case, you should consider

implementing an EHR system with e-prescribing capability. Most EHR systems have

e-prescribing capability and provide more functionality than stand-alone

e-prescribing systems. But EHR systems are more expensive and disruptive to the

practice. Again, you have to decide what your practice is ready for and what

operational and clinical needs you want to address.

 

Step 3 - Understanding Costs and Financing Options

1. How much does e-prescribing cost?

 

Costs vary depending on which kind of

hardware and software (EHR system versus a stand-alone e-prescribing system) a

practice chooses. Stand-alone e-prescribing applications range from free to

approximately $2,500 per year per prescriber. Be sure to look for local or state

initiatives that subsidize the cost of e-prescribing systems. There may be

additional fees to integrate patient demographic information from your practice

management system into the e-prescribing application; however, the alternative

means you will need to enter each patient into the system as you prescribe for

them, which can be time consuming and may be a barrier to using the system.

 

As mentioned in Section I, EHR systems offer more comprehensive functionalities,

but are more costly, complex and time consuming to implement. According to the

Congressional Budget Office, office-based EHR systems are about $25,000 to

$45,000 per physician. Estimated annual costs to operate and maintain an EHR

system (e.g., software licensing fees, technical support, and updating and

replacing used equipment), range from $3,000 to $9,000 per physician per year.

Be sure to ask vendors specific questions about any incremental fees related to

e-prescribing functionality as well as training.

 

These figures do not include initial costs for the hardware required to support

either an e-prescribing or EHR system, temporary decreases in productivity

resulting from training or workflow redesign, practice management interfaces,

customization, maintenance, upgrades, or data conversation. Whether you choose

a stand-alone e-prescribing application or an EHR system with integrated

e-prescribing, cost is only one part of the equation. You should compare the cost –

both direct and indirect, start-up and ongoing – with the expected benefits – such

as improved efficiency and productivity, decreased administrative expenses and

staff utilization – to fully understand the value of e-prescribing to your practice.

 

2. Are there transaction fees for e-prescribing?

 

Pharmacies pay transaction fees

based on the number of electronic prescriptions and electronic prescription

renewals received, and payers/PBMs pay transaction fees to deliver formulary and

pharmacy benefits information. The only time your practice would incur transaction

fees for e-prescribing is if the vendor you select charges your practice a transaction

fee. Most vendors do not charge practices a transaction fee, but be sure to ask

your potential vendors about this during system selection.

 

3. Are there subsidy programs available to help with e-prescribing costs? Yes.

 

There are a number of e-prescribing and EHR initiatives available at the national

and state level. Information about some of these programs is provided in

Appendix II.

 

4. Does e-prescribing cost patients more money?

 

Patients pay the same amount

in the same way for electronic prescriptions as they do for traditional paper ones.

With e-prescribing, however, prescribers will likely have information about the

patient’s formulary at the time of prescribing, which may allow prescribers to

prescribe a medication with a lower co-pay or cost to the patient if paying out of

pocket.

 

 

 

Step 4 - Selecting a System

 

1. Is there a certification system for e-prescribing systems?

 

Yes. E-prescribing

applications and EHR systems with e-prescribing are certified by SureScripts-Rx

Hub – the infrastructure that technology vendors, pharmacies, and payers/PBMs

connect to in order to exchange medication information electronically according

to industry standards. The current certification is based on compliance with

industry standards, specifically the NCPDP Script Standard. A complete list of

SureScripts-RxHub certified products can be found at http://www.surescripts.com/

certified. This list shows the functionality and connectivity of e-prescribing

systems. If your practice is looking for an EHR system with integrated

e-prescribing functionality, the Certification Commission for Heath Information

Technology (CCHIT) certifies EHR systems based on a large number of functional

criteria, including e-prescribing capability. CCHIT has plans underway to certify

e-prescribing systems. For more information on CCHIT, go to www.cchit.org.

 

 

2. Are there specific questions I should ask a potential e-prescribing system

vendor?

 

Yes, ask questions such as: 1) What is the cost? 2) What do I need to

purchase? 3) What are the monthly maintenance fees? 4) What type of training is

provided? 5) Will your system be able to access demographic information from my

practice management system? 6) Does your system allow you to manage both new

prescriptions and renewal authorizations electronically? 7) What is the support

process, and how long does it typically take for issues to be addressed? For a

complete Buyer’s Guide, see Appendix I.

 

Step 5 – Deployment

1. How do I know which local pharmacies accept electronic prescriptions?

 

A quick

resource to find this information is www.rxsuccess.com. Simply click on the “Find

your connected pharmacy” tab to find the list of pharmacies in your state or zip

code that are enabled to receive electronic prescriptions and send electronic

renewal requests to your practice. You still should contact the pharmacies in your

area directly to notify them when your practice will be e-prescribing and confirm

that they have actually started using e-prescribing and are prepared to accept the

prescriptions.

 

2. How will I know if pharmacies are properly loaded in my system?

 

It is best to

provide your vendor with a comprehensive list of pharmacies that your patients

frequently use. The vendor can then match this list with the pharmacy records

from the Pharmacy Health Information Exchange while loading pharmacy

information in your application. This will help ensure that your frequently used

pharmacies are appropriately matched to the master pharmacy file from the

beginning and thus enabled for electronic prescriptions. If your practice application

allows you to create customized pharmacy records (customized name, address

or phone and fax number) then it is also important to ensure that the application

system matches such records with the master pharmacy list provided by the

Pharmacy Health Information Exchange.

 

3. How can I prepare for training?

 

Personalized one-on-one training using a variety of

common scenarios seems to work best for most prescribers. It is important to ask

detailed questions during your training sessions, including:

– What happens if the patient is not matched in the system when a pharmacy

sends a renewal requests?

– Can I cover for my colleagues when they are on leave and under whose name

will the prescriptions be sent to the pharmacy?

– How does the system handle controlled substance prescriptions and pharmacy

renewal requests for controlled substances?

– How do I write prescriptions to the pharmacy when a patient calls in a request

via phone?

– How do I know whether the prescription was successfully sent to the pharmacy?

– How do I handle mail order prescription writing?

– How do I create my favorite medication list?

– How do I search pharmacies within the practice database?

 

4. May I work offline using my e-prescribing system?

 

Some e-prescribing programs

allow access offline, which would enable prescribers to prepare multiple scripts and

then transmit then when they have Internet access again. However, queuing or

“batching” prescriptions before sending them to pharmacies electronically is not

recommended. Sending prescriptions to pharmacies as soon as possible after they

are prepared ensures that the pharmacy has adequate time to receive the

prescription before a patient arrives to pick it up.

 

5. Will the pharmacy send me electronic renewal requests?

 

Pharmacies will start

sending e-refills once individual prescribers send five new prescriptions

electronically via the Pharmacy Health Information Exchange. This is to help

ensure that your practice has been trained on your e-prescribing or EHR system

and is ready to receive and respond to refill requests electronically.

 

6. Can I e-prescribe controlled substances?

 

Prescriptions for Schedule II drugs can

never be sent electronically or by fax. Hand-signed hard copies of prescriptions for

Schedule III through V drugs can be sent using manual fax technologies. Neither

computer-generated faxes containing electronic signatures nor totally electronic

prescriptions for controlled substances can be sent to pharmacies at this time.

Some pharmacies will continue to send refill requests for controlled substances by fax.

 

7. How do I communicate e-prescribing to my patients?

 

Communicating with patients

regarding e-prescribing and its benefits and implications is important. Some

patients may express initial reluctance in response to a new system; prescribers

can make patients more comfortable by explaining how e-prescribing works and

what its benefits to patients, providers, and pharmacies.

In the initial phases it is important for you and your practice staff to educate and

reinforce the benefits of e-prescribing with your patients. Talking points include:

 

• Fast - E-prescribing allows you to electronically send prescriptions directly to

the patient’s choice of pharmacy. The prescription travels from your

computer to the pharmacy’s computer before the patient leaves the exam

room, giving their prescription a “head start.”

• Convenient – The patient no longer has to make an additional trip to the

pharmacy to drop off their prescriptions.

• Safe and Secure - Prescription information is not sent over the open Internet

and is not sent via an e-mail. E-prescriptions are sent electronically through a

private, secure, and closed network – the Pharmacy Health Information

Exchange®.

• Legible – The staff in the pharmacy no longer has to spend time interpreting

your handwriting.

• Informed – Availability of formulary information from health plans allows

choice of medications that are more affordable and e-prescribing allows drugdrug

interaction checking and allergy-drug interaction checking for safer

choices.