Backbone of an EMR

June 24, 2011
Suresh Gunasekaran UT Southwestern continues our significant progress in the implementation of an electronic medical record system for our
Suresh Gunasekaran
UT Southwestern continues our significant progress in the implementation of an electronic medical record system for our University Hospitals. In 2008, the major implementation goals include: results reporting system (live in January), electronic pre-operative anesthesia documentation (live in January), an emergency department information system, an electronic unit clerk order entry system, electronic medication administration record, and pharmacy information system.

We are working simultaneously on multiple components of our electronic medical record. Each component project team faces its own unique challenges. In the emergency department, the team continues to design the patient throughput workflow from triage, and analyze the appropriate nursing documentation needs of ED nurses. On the orders team, the analysis is focusing on standard naming conventions for our orders and analysis of our patient charging workflows. Our eMAR team is designing the relevant flowsheet integration.

Across all of these implementation teams, many commonalities have emerged. More significantly, the component project plans have dependencies given the integrated nature of clinical care in an acute care setting and the single database, integrated product we have chosen.

The single greatest intersection point and the single greatest dependency in our EMR project is the implementation of a unified pharmacy system for our two hospitals. It was only after we had fully lain out our plans and began our execution that we realized the importance of this EMR component.

Traditionally, the pharmacy information system has not been thought of as a component of an EMR, but rather an ancillary system, such as laboratory or radiology. This follows the traditional role of these departments as clinical support departments for care delivered throughout the facility.

Increasingly, as healthcare organizations have grown in sophistication around standard best practices in care planning and care management, the pharmacy has moved “out of the basement” into the forefront as a partner to clinical departments. Many of our best practice standards include standard administration of pharmaceuticals, guidelines for a large number of therapeutics, and concurrent review by pharmacists of numerous ordering activities.

Paralleling the growing importance of the pharmacy to the healthcare enterprise, the pharmacy information system market has evolved. The pharmacy information systems of the past helped keep track of inventory and orders for pills, and helped automate the distribution of pills. Advanced functionality provided clinical pharmacists stand alone tools for clinical review, interventions and order sets. Many hospitals purchased best of breed systems to meet the pharmacy's needs because integration with the rest of the clinical enterprise was limited to receiving medical orders.

Recently, the tide has turned on pharmacy information systems. The major change is the preference of most hospitals to purchase a pharmacy information system from the enterprise EMR vendor. The desired integration is well beyond just an orders interface. It is crucial that the medication file, medication interaction files, communication around pharmacist reviews, and medication administration workflows all be tightly coordinated and integrated. It is difficult to accomplish these goals without a single vendor approach; hence the industry moves away from best of breed solutions.

At UT Southwestern, there have been many major components of our pharmacy system implementation plan that will have tremendous impact on the organization as well as the other EMR components. A few of the significant project components are detailed below:

1. Primary source for master medication files

The pharmacy information system will be the single home in our electronic world for all medications and therapeutics. The system will drive available nomenclature, doses, frequencies, routes and other medication characteristics so that there is a unified medication structure across all of our clinical systems. Though physicians and others will be able to create order sets and preference lists in other EMR modules, the available universe will be defined and driven through the pharmacy information system. The governance for this mechanism will be the hospital pharmacy and therapeutics committee.

2. Central content management for drug interactions

UT Southwestern has purchased medication content from First Data Bank (San Bruno, Calif.) and imported this information into our pharmacy system built to serve as the single content driver of our drug interaction checking within the system. Though the use of a third party content provider simplifies the process significantly, integration through the pharmacy information system ensures that there is pharmacist review before any content is used.

3. Charging workflow: integration with eMAR

UT Southwestern currently utilizes Pyxis Corp. (Cardinal Health Inc., San Diego) distribution cabinets, and has long used interfaces between our legacy pharmacy systems and Pyxis. With the implementation of the EMR, this integration will continue, but we will change the workflow for the charging of these drugs. In the past, without electronic documentation of the administration, the practice has been to charge upon dispensing; we will change this workflow to charge upon administration to minimize the work of returns and credits.

4. Integrated communication between pharmacists and physicians

Given the large number of interventions that pharmacists perform on a regular basis, one of the major goals of our EMR implementation is to improve the communication between physicians and pharmacists during this process. The EMR allows the possibility of a unified messaging platform for facilitating interactions. We are currently defining the appropriate threshold to produce system messages (so that there are not too many messages flooding physician inboxes). We are early in this process, but this is crucial to meeting our patient safety goals.

5. Integration with bedside medication administration and smart pumps

Though both bedside medication administration and implementation of smart IV pumps (pumps with software error checking) are currently beyond the scope of this year's work at UT Southwestern University Hospitals, they are on our roadmap to achieve clinical goals. The pharmacy information system design, and specifically the design of labels and medication identification, will be crucial to bedside administration. Similarly, the design of the medication master-file tables in the pharmacy information system must take into account integration with smart pump ordering and alerting software.

It is still possible to approach the pharmacy information system as a departmental system and each of these goals as individual interface projects. However, the responsible decision is to integrate the pharmacy system implementation under your overall EMR implementation and create tight integration and controls to ensure that medication safety goals are achieved and those gains are maintained into the future.

Suresh Gunasekaran is assistant vice president and CIO, University Hospitals & Clinics, UT Southwestern Medical Center, Dallas.

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