Is there a Pharmacist in the House?
EXECUTIVE SUMMARY
Nationwide, healthcare IT leaders are beginning to recognize the need to bring pharmacists to the clinical informatics table along with physicians and nurses. In fact, say CIOs and clinical informaticists, the need for these professionals will only intensify in the next few years, particularly given pressures to achieve meaningful use organization-wide.
After working for 10 years now as a pharmacist informaticist, Johnanne Ross, PharmD, director of pharmacy IT automation at the University of Pittsburgh Medical Center (UPMC) health system, says she can see one obvious change that has taken place: she no longer has to expend as much energy explaining what she does every day. For one thing, in contrast to when she first arrived at UPMC as one of the first wave of full-time informaticists with clinical pharmacy backgrounds, there are more of her colleagues with similar backgrounds now. In fact, Ross heads up a team of seven such informaticists, who have been working on all the electronic health record (EHR) rollouts and implementation of other clinical information systems across the 20-hospital system based in Pittsburgh.
“It's changed a lot,” Ross says of the need to explain exactly what pharmacist informaticists do. “Initially,” she says, “some people didn't recognize the importance of having a pharmacist present at a meds integration meeting. It was actually sometimes the vendors who didn't get it. So I've seen that change over the years, that people do recognize the value of a pharmacist in this role.”
INITIALLY SOME PEOPLE DIDN'T RECOGNIZE THE IMPORTANCE OF HAVING A PHARMACIST PRESENT AT A MEDS INTEGRATION MEETING. IT WAS ACTUALLY SOMETIMES THE VENDORS WHO DIDN'T GET IT. SO I'VE SEEN THAT CHANGE OVER THE YEARS, THAT PEOPLE DO RECOGNIZE THE VALUE OF A PHARMACIST IN THIS ROLE.-JOHNANNE ROSS, PharmD
Indeed, nationwide, more and more healthcare IT leaders are beginning to do just that-to recognize clearly the need for clinical pharmacists to join the clinical informaticist teams in hospital-based organizations-teams that already include physician and nurse informaticists-as patient care organizations push forward with electronic health record (EHR), computerized physician order entry (CPOE), electronic medication administration record (eMAR), advanced pharmacy, and other clinical IS implementations. For when it comes to patient safety, clinical decision support, medication formulary, clinician workflow, and a host of other issues, leaving pharmacists out of the discussion-it's becoming clearer and clearer over time-is a recipe for implementation failure.
As an example of the kinds of involvement that pharmacist informaticists are engaged in, Ross cites a recent go-live with CPOE at one of UPMC's facilities. “We gave the people in the neonatal ICU things like dose-range checking for several medications; deployed a rounding report for them; were able to add head circumference and gestational age as data elements in the order entry system, in order to keep up with the babies' gestational ages; and developed new label codes for the babies,” among other things. “They were extremely happy with what they got, absolutely happy.”
Of course, with 20 hospitals in various stages of CPOE deployment, it's not surprising that Ross and her colleagues at UPMC would be kept perpetually busy. But even pharmacists who are rooted to specific areas of individual hospitals are becoming increasingly involved as “bridge people” between the pharmacy and IT. Mirjana Lulic-Botica, RPh, a board-certified pharmacist at Detroit Medical Center (DMC) in downtown Detroit, has for more than 10 years been involved in the interface between pharmacy and IT, though she declines to call herself a pharmacist informaticist (DMC does have several full-time pharmacist informaticists within the organization). But Lulic-Botica was intensively involved in working with a multidisciplinary team of clinicians, clinical informaticists, and IT managers, to prepare the neonatal ICU at Harper-Hutzel Hospitals within DMC for CPOE implementation there.
Lulic-Botica and her colleagues spent hours every week for nearly two years working on order preparation for the CPOE go-live in December 2006, both populating medication orders in the core CPOE system (from the Kansas City-based Cerner Corp.), as well as working on the interfacing needed between the CPOE system and the organization's pharmacy IS, which went live at the same time. “There was much pharmacy file-building leading to the implementation of CPOE in PharmNet,” she says of the medication order set development process. “We recognized that we didn't want the physicians going to the general catalog, where they'd see adult dosages and dosage forms,” she says, regarding medication order set development for the neonatal ICN. As a result, she and a nursing colleague built more than 600 order sets based on disease states, then developed tiers of sets based on medication types (intravenous meds, continuous infusions, orals, topicals), all alphabetically. On top of that, she says, “We built the orders so they could put in notes, and clinical decision support on dosaging and with regard to formulary compliance.” She and her colleagues also developed an online tutorial “to assist in the training with order entry and verification in training production,” she adds.
YOUR AVERAGE PHARMACIST WON'T BE ABLE TO DO THIS JOB. IT'S JUST LIKE YOUR AVERAGE PHYSICIAN, WHO WON'T BE ABLE TO DO THE CMIO JOB.-RICK SCHOOLER
The key to her success in all this, Lulic-Botica says, is having experience in and understanding of both medication distribution and clinician workflow, as well as, of course, the ability to work together with the other disciplines (medicine and nursing) and IT in order to create successful order sets and bridge gaps in understanding among groups.
CIOS LOOK AT THEIR ORGANIZATIONAL NEEDS
At the seven-hospital, 1,800-bed Orlando Health system in Orlando, Fla., vice president and CIO Rick Schooler reports that he has three full-time PharmD-credentialed informaticists on his organization's clinical informatics team, with their work particularly focused on order entry and on “workflow between the various care providers and the pharmacies and how the information tools can optimize that.” His pharmacist informaticists are also involved in pharmaceutical packaging issues, as well as in the implementation of a new pharmacy IS implementation: his organization is replacing a standalone pharmacy IS with the Allscripts Sunrise pharmacy component from the Chicago-based Allscripts, to match the health system's core Allscripts (formerly Eclipsys) EMR.
“Your average pharmacist won't be able to do this job,” Schooler says of his pharmacist informaticists. “It's just like your average physician, who won't be able to do the CMIO job.”
Todd Rothenhaus, M.D., senior vice president and CIO of the six-hospital, 1,552-bed, Boston-based Caritas Christi Health Care System, has three full-time pharmacist informaticists, led by a fourth team member, a director of pharmacy informatics, on his clinical informatics team. His organization's core EMR is from the Westwood-Mass.-based Meditech Corp., and, of his pharmacy informatics director, Dorcas Rushton, PharmD, he says she “knows Meditech Pharmacy better than Meditech does.”
As for what qualifications a pharmacy informaticist needs, Rothenhaus says the individual doesn't necessarily need to be a PharmD, but quickly adds that a pharmacy informaticist absolutely needs to understand clinical processes. What's more, says Orlando's Schooler, individuals who would go into this area “have to be aware of all the different people involved in delivering care, and to be able to relate to them.” In other words, he says, “They have to be people people.”
AWARENESS IS ONLY BEGINNING TO DAWN
Despite the major success that pharmacist informaticists have had in IT implementation and optimization work at organizations like UPMC, Detroit Medical Center, Orlando Health, and Caritas Christi, leading recruiters say that the pharmacist informaticist role remains little understood or appreciated across the U.S. healthcare system at this point. “It's really not a well-staffed position,” says Linda Hodges, senior vice president and leader in the IT executive search practice at the Oak Brook, Ill.-based Witt Kieffer. “There are definitely pharmacists who are in analyst or team lead role positions. It's not a high-profile job; it's one that we're rarely asked to recruit. We did one recent search and found it very difficult to find people of the caliber we were looking for.”
In fact, says Tim Tolan, senior partner at Sanford Rose Associates Healthcare IT Practice, Charleston, S.C., “We see more med tech and clinical radiology informaticists overall in the marketplace right now. However,” he adds, “their clinical knowledge base and the market's increased adoption of e-prescribing will likely help drive more demand for the role.”
MEDICATION IS A HUGE PART OF WHAT WE DO; AND TO NOT HAVE A LOT OF EYES AND OVERSIGHT OVER THE MEDICATION PORTION OF ORDER SETS IS DOWNRIGHT DANGEROUS.-Todd ROTHENHAUS, M.D.
For the time being, says Arlene Anschel, executive search consultant at Witt Kieffer, “Typically, when an implementation is about to happen, they either take someone from IT and put them on the pharmacy issue full-time; or they take a pharmacist from the pharmacy and put them on the project 50-50 or even 90-10.”
Still for organizations with intensive pharmacy informatics needs, such ad hoc approaches are already a part of the distant past. At UPMC, says G. Daniel Martich, M.D., vice president and CMIO, pharmacist informaticists-specifically for this organization, Johnanne Ross and her team-are critical to the “build, implementation, and optimization” processes in clinical IT. “On the build side,” Martich says, “they help remind us that, sure, you may have ordered 25 milligrams of atenolol in the past, but that medication is actually a 50-milligram tablet that needs to be cut in two, and here's a standardization of process that can be built; so they've built in a great standardization to medication ordering that hadn't existed.
And for those who would tend to think only of physicians and nurses when contemplating how to build their clinical informatics teams, Martich adds slyly, “This is the dirty secret that doctors and nurses try to keep away from you: and that is that medications are really the secret to the EMR, and most of the safety features are really related to pharmacy information. And where the pharmacist has to interact with nurses at the delivery side, and doctors on the ordering side, they are the linchpin of medication management.”
Indeed, with the rapid implementation of core clinical information systems being compelled forward by meaningful use, all those interviewed for this article agree that the pharmacist informaticist role is set to rocket to prominence in the next few years.
Put another way, says Caritas Christi's Rothenhaus, “If you're missing one of the [three core clinical] disciplines at the table, you're going to end up having to do rework. Medication is a huge part of what we do; and to not have a lot of eyes and oversight over the medication portion of order sets is downright dangerous.”
Certainly for many of those who have been most intensively involved in this work for some time, there are great satisfactions. “I really enjoy what I do,” says UPMC's Ross. “It's really fun to see that you've really improved a workflow for people, and you take away from processes that take away from clinical work, because it frees people up to do other clinical things, or if something you do improves patient safety, or simply reduces stress on clinicians. That's a rewarding thing.”
Healthcare Informatics 2010 December;27(12):18-24
