Computerized Prescriber Order Entry Changes Pharmacists' Roles
The CPOE system at Vanderbilt, which was launched in 1994 in one nursing unit, has evolved and expanded over the years. Today, physicians and authorized nurses who enter medication orders into computers at nursing stations can use built-in order sets, dosage checks, and other decision-support tools to guide in the selection of the most appropriate drugs and dosages.
Speeding up order processing. Once entered in the CPOE system, medication orders are transmitted electronically to the pharmacy computer system, said Mark Sullivan, coordinator for the adult medicinesurgery satellite pharmacy. There, the orders are stratified by priority, with stat orders appearing on the top of the processing queue. Staff pharmacists process each order, ensuring that the information automatically entered in the pharmacy system matches the specifics in the CPOE system and that the order is appropriate. Once an order is approved, an electronic link to the automated dispensing-cabinet system allows the nurse to remove a dose of the drug.
The dispensing cabinets contain about 70% of the drugs ordered, Sullivan said. Turnaround time for orders for these drugs has been reduced to less than 15 minutes.
Before CPOE, said Ralph DiPalma, staff pharmacist, there was such a delay in transporting written orders from the nursing units to the pharmacy that nurses would often call about a medication before the order had arrived. Now, he said, "we get the orders instantly [and] can actually read what is written. "
Sullivan estimated that pharmacists in the satellite pharmacies still spend 6070% of their time processing orders. Said DiPalma: "Im just processing more." The increased efficiency has allowed the pharmacy department to do more with less. Although the prescription volume at Vanderbilt has increased over the years, Gregory said, pharmacy staffing needs have not risen commensurately. A few satellite pharmacies have closed in recent years. Sullivan attributes this development partially to the boost in productivity brought by the CPOE system.
Freeing up time for other activities. With the CPOE system catching many of the problems up front, staff pharmacists have become more involved in cost-reduction issues, Gregory said. DiPalma has documented $50,000$60,000 in savings in the past year from his intravenous-to-oral conversion project, in which he alerts physicians to patients who are receiving intravenous doses of certain expensive drugs while taking oral doses of other medications.
During implementation of the CPOE and automated dispensing-cabinet systems, DiPalma said, staff pharmacists had been kept busy with "other problems" but are now beginning to spend more time on the nursing units. He hopes to establish an inpatient anticoagulation management program soon, using what he learned several years ago in the outpatient anticoagulation clinic during slow work periods in the pharmacy. Fellow pharmacists are working on other projects, he said, and they all anticipate spending more time outside the pharmacy providing the nurses with drug information and helping them to locate medication doses not in the dispensing cabinets.
Stepping up clinical services. The new system has been "a great time saver" for clinical pharmacists, Sullivan said. Instead of generating a computerized list of drugs for each patient, manually recording laboratory values, and obtaining vital signs from medical charts, pharmacists can now "just punch up" a report on each patients current medications and laboratory test results from the CPOE system. Time saved on paperwork translates into time available for clinical activities. "Our clinical program historically has focused on our special-needs patients," Sullivan said. "Weve been able to broaden that out to general medicine and other patient populations."
The decision-support tools in the CPOE system have allowed pharmacists to "be more proactive on the front end of orders," said Gregory. When a pharmacist identifies a common medication error, he or she can intervene by requesting a change in the system to prevent future occurrences of the problem. "We dont always have to be there," Gregory said, "because instead of writing handwritten notes in the chart," pharmacists can help build tools into the CPOE system so that physicians "can make the right decision up front."
Building up the system. One-and-a-half full-time pharmacist positions at Vanderbilt are devoted to maintaining the CPOE system, which is used in almost all patient care areas in the nearly 600-bed facility, and building Web pages that pop up during order entry to provide prescribers with information on specific drugs, Gregory said. A Web page may contain warnings, a dosage-guidance tool, a comparison of drugs within a class, or recommendations of preferred items. Input on the content of a Web page is solicited from physicians with the specialty service that primarily uses the drug, physicians from the informatics department, and pharmacists. The pharmacy and therapeutics committee has the final say on every page before it is incorporated into the system. Suggestions for new Web pages can come from physicians, nurses, or pharmacists. Often, Gregory said, the frontline pharmacist who processes an order identifies an issue and refers it to the information-system pharmacist, who then develops a Web page to deal with the concern.
But the Web pages have not eliminated the need for retroactive interventions, DiPalma said. The system "doesnt prevent [prescribers] from doing anything," he said, and physicians may override or ignore messages, necessitating a pharmacists involvement later.
Through the CPOE system, physicians and nurses have access to the pharmacys drug information resources, so "all the easy answers are already out there," Sullivan said. Consequently, DiPalma said, "a lot of the questions I get are more complex than before." He is commonly asked about issues related to pharmacokinetics, dosages for patients with compromised renal function, and antimicrobial coverage. DiPalma said he gets more requests than before from nurses, particularly for information about new drugs. "Theres such a turnover [in the nursing staff] that they dont know the full capability of the system," he said.
Even among physicians, the questions have not changed that much. As a teaching institution, Vanderbilt has an influx of new physicians each year. "By the time this group gets trained as to what they can find without calling us, weve got a whole new group," DiPalma said.