Johnanne Ross, Pharm.D., has been a full-time pharmacist informaticist at the 20-hospital University of Pittsburgh Medical Center (UPMC) health system for seven years. She has participated in the implementation of clinical information systems across that health system for several years, as one of a small number of full-time pharmacist informaticists nationwide. Ross spoke recently with Editor-in-Chief Mark Hagland about her perspectives on the implementation of computerized physician order entry (CPOE), the electronic medication administration record (eMAR), and other key clinical systems. She was one of several clinical informaticists interviewed for the magazine's July cover story on clinical informaticist teams and their implementation and support work. Below are excerpts from that interview.
Healthcare Informatics: What should CIOs know about pharmacist informaticists? It's an area that's been too long neglected.
Johnanne Ross, Pharm.D.: As CPOE rolls out and the prescribers start entering orders, they don't really understand all the subterranean things that go on. The analysts and the prescribers don't really understand the workflow process around pharmacy, to the extent that that process is not evident on a patient care unit. There are delivery issues, there's the routing of workflow, the filling of medications to make sure the meds get to the patients on time. And our focus is totally meds, because they're our focus, and that's where our strength is. We understand the meds, the dosage forms, how they're mixed. So when you're looking at a medication build, you have to look at three angles: one, how does the pharmacist view that medication when they're looking at it? They're looking at dosage forms (tablet or capsule), dose, allergies, when the medication needs to be on the floor, and drug-drug interactions. And then there's the nurse who has to administer it. So we think about how that medication shows up on the eMAR for the nurse — is the description good? We have look-alike and sound-alike warnings. And we have to work very closely with the nurses on their input, because, when we installed barcoded meds administration, we had to talk with the nurses.
HCI: What issues came up between the pharmacist and nurse informaticists during that process?
Ross: Workflow; and how the meds appeared to the nurses. And what becomes apparent is the diversity of ways in which informational tools can be used by clinicians. For example, even charting the administration of an IV medication on the ICU flow-sheet involves making different kinds of choices for how to document such things as IV flow rates, input and output, documenting the use of a new bag, and so on, and affords the opportunity to document such elements in different ways in the eMAR. So we end up talking about workflow a lot, about how meds appear in the record, and about what doses come up when the nurses scan meds, so that the warnings can be made clear. And we make sure there are barcodes in the system so when they get up to the unit for the nurse, the nurse doesn't get frustrated if something doesn't scan.
To take one example [of the back-end work needed to make such systems work optimally for clinicians], one of our major nursing applications involves the nurse scanning the patient's wristband and the medication at the bedside. And we have found that scanning medications prevents medications getting to the wrong patients. So when the medication comes into the hospital, we have already looked at that medication centrally to make sure that medication has been scanned, before it goes up to the floor. Of course, that means ensuring that every medication has a barcode on it. Our meds are 95-percent barcoded; in fact, we actually have a central packaging facility to make sure the meds are barcoded, and it's FDA-rated. And if someone orders something directly from the manufacturer, there's an advisory to the nurse. We even went back to the central warehouse and made sure everything was barcoded.
HCI: What should CIOs know about getting the right people and dynamics on a team?
Ross: If we need something, we pretty much support each other. I can't even recall a moment when we went to another e-record team and they didn't want to help. But we deal with multiple hospitals, including both community and tertiary hospitals, and if we're interested in looking at where meds show up, there will obviously be a lot of requests and wants. So being very clear in what the goals are and what we're trying to achieve, is very important. And while we'll try to work people's wants in, we have to stay clear on what we need to do, given the multiple projects we have going on at any one time.
HCI: Do you get strong support from executive management?
Ross: Yes, and you absolutely need that. Everything from the staffing levels to what the priorities are, what the barriers are. And we move like a freight train. But I've always found our executives to be very approachable, and you can pick up a phone and raise an issue. And honestly, if you look at our team, if you didn't have that kind of support, you couldn't get it done. It really helps to understand that to roll out this kind of e-record with this kind of depth, you have to invest in it. I feel really positive about what we've achieved.
HCI: Is there any special quality you need in a pharmacist informaticist?
Ross: When I'm looking to add to my team, I'm looking for a good pharmacist with experience in the hospital pharmacy; you have to understand a lot of the aspects of the pharmacy from drug safety to workflow to distribution and operational flows. So you really have to have experience as a pharmacist in order to be effective in a pharmacist informaticist position.