Push technology in the pharmacy: clinical decision support helps the pharmacy department of a South Carolina medical center automate monitoring of medication effectiveness - Medication management: case history

Health Management Technology, Jan, 2003 by David Amsden

Patient safety and medication management are the hot healthcare topics of the new millennium. However, with all the attention to bar code systems and point-of-care medication administration by nurses, it's easy to temporarily overlook the hub of medication in a hospital system--the pharmacy department.

While the sophistication of medication management technology occurs at the point of care, a world of automated decision support capability also exists for pharmacy managers and pharmacy departments, critical players in every hospital's attempt to reduce medication errors and avoid adverse drug events.

Palmetto Health Richland is at the forefront as a critical player in the endeavor to reduce medication errors. Palmetto Health Richland in Columbia, SC, is a 655-bed regional community teaching medical center with 3,300 employees and 800 medical and dental staff. Our pharmacy department, consisting of 50 pharmacists and 50 pharmacy technicians, is responsible for medications for more than 30,000 inpatients and 400,000 outpatients annually. Teams of pharmacists provide clinical pharmacy services, covering all inpatient beds and our ambulatory clinics.

Three years ago, we transitioned from a manual process for identifying medication-related problems to an automated decision support system, which utilizes push technology that has streamlined our operation and significantly improved our efficiency.

Automated Decision Support

Hospital pharmacy departments are no strangers to the concept of decision support. Long before the spread of healthcare information technology, pharmacy departments have been charged with functioning as the decision support center for medication provision within hospitals and delivery systems. While the advent of clinical documentation, laboratory and radiology information systems has considerably streamlined the collection, manipulation and utilization of patient data by clinicians, pharmacy departments still remain the hub of medication review and evaluation.

Even with automated clinical documentation and laboratory systems, in June 1999 Palmetto Health Richland faced an uphill climb in this area before installing a clinical decision support system for its department of pharmaceutical services. Until then, the pharmacy department reviewed and managed medications manually on a case-by-case basis.

Pharmacists reviewed large volumes of data from three distinct sources to determine any potential medication problems. First, each patient's medication profile in the pharmacy system was individually re viewed. Next, a pharmacist would evaluate each patient's laboratory values from the laboratory system. Finally, a pharmacist would analyze each patient's medical history and progress notes from the paper chart. The composite of these three steps was necessary for a pharmacist to effectively monitor medication disbursement and effectiveness. This process exhausted a considerable amount of the pharmacists' time, and, of course, presented an opportunity for errors.

In the late 1990s, we decided to invest in an automated decision support tool to assist pharmacy staff in identifying medication-related problems, and to assist in routine medication monitoring of the effectiveness of medications and potential adverse effects.

We researched several options before deciding upon Clinical Event Manager, the product that has evolved into the more robust Insight from Misys Healthcare Systems. The product was brought to our attention at a time when we were trying to develop an interface between lab and pharmacy for the organization, in an attempt to provide the same functions we gained with Insight. This is a vendor-neutral product, able to integrate with clinical systems from other suppliers such as Cerner or McKesson.

In addition, Palmetto Health Richland already used Sunquest (now Misys) for its laboratory information system, so we had confidence in the company as a supplier. Functionality and capability were key factors in our decision-making process. Insight offers a 550-rules-based alerting system, supported by push technology and coupled with e-mail and pager options for delivering medication alerts to clinicians. Our goal in adopting the system was to spend very little time maintaining or troubleshooting the system, while being able to automate the functions we previously performed manually.

Here is an example of how it works. An adult trauma patient developed pneumonia while hospitalized. Initially, the patient was treated with an empiric antibiotic regimen while final culture results were being determined. Final culture results came to the pharmacist's pager while she was on rounds with the physician. The original antibiotic regimen did not cover the organism that was cultured. Receiving an alert on her pager, the pharmacist was able to make recommendations and attain a change in antibiotics orders within a few minutes of receiving the alert.

Installation

The system installed at Palmetto Health Richland utilized three HL7 interfaces: an interface with HBOC pharmacy (for medication orders), an interface with Misys Laboratory (for lab results), and an interface with our HBOC ADT system (for patient location information).