How the Evolution of Medication Ordering Reinforces the Importance of the CPOE Triangle

July 2017

Even with so much emphasis put on regulations and requirements in today’s mandate-driven society, several healthcare organizations are still simply skating by with the absolute bare minimum compliance when it comes to major areas of focus like computerized physician order entry (CPOE) utilization. These organizations may have (1) a “best of breeds” HCIS configuration, (2) an older system that they are upgrading or (3) a system they are simply trying to get by with as is. Regardless of the circumstance, it is interesting to look back at how CPOE has evolved over the years and how so many organizations are still struggling to use government mandates as a true springboard for optimization, as opposed to viewing an imposed minimum requirement as the long-term goal.

Before the “Big Bang” EHR implementation became the norm, it was typically looked at as a resource nightmare. Many times, the same group of core analysts would handle all of the different phases of an implementation, simply because the organization was too lean to allow for more people to be involved and could not afford outside help. The pharmacy application was often part of Phase 1 of the staggered rollout EHR implementation approach, which is what was most commonly used before the Big Bang trend gained traction.  Here, the pharmacy, along with an analyst assisting with the hands on build, would work together to ensure that the formulary worked in a way that made sense to the pharmacists and technicians. The main focus was on having the appropriate medication sizes be correct and ensuring how it was dispensed and charged for was accurate. The pharmacy department knew the formulary better than anyone, as when orders were faxed and/or telephoned in by the providers they were then entered in the system by the pharmacist to allow for printing of a label and charging correctly for that medication. If there was a medication shortage or non-formulary substitution, the pharmacy adjusted the order based on either an organization’s policy or phone call to the ordering provider.

Phase 2 of the staggered rollout implementation approach often involved the electronic medication administration record (eMAR) and even possibly electronic documentation by nursing. Again, the pharmacy application was often built prior to this, so there were many instances where the eMAR display was not clear to the nurse or other care provider. Tweaking of the formulary was required to ensure that what was entered by pharmacy on their side also worked and was clear for the nurse or other care provider on their end.  This period of adjustment was also necessary to ensure that the nurse or other care provider could use the five rights and safely administer medications. To effectively work through this phase, it quickly became clear just how essential it was that both nursing and pharmacy get involved in both the build and testing efforts to ensure the ordering by pharmacy and the medication administration by nursing was consistent and clear.  Also, more often than not, this type of Phase 2 approach introduced additional post-live editing considerations.

Once the first two phases culminated in nursing and pharmacy having an agreed upon workflow defined, then followed the initial implementation of CPOE which consisted of more or less “forcing” what had been built for both pharmacy and the eMAR on the providers and trying to get their buy-in after the fact.  The display of the medication, the available doses, routes, directions and schedules were all new to providers at this time. The providers were very accustomed to filling a form out and faxing it, having a nurse fill out the form for them or when in doubt calling the pharmacy. Having to access the system, other than viewing information in the electronic medical record (EMR), was a very new concept all together. Even viewing the EMR was cumbersome, and nursing would often access it for the provider and print out applicable information. At this point in time the act of ordering a medication was not only unappealing to the provider, but it was very messy, which resulted in a lot of pushback on organizational leadership and created a very tense environment for everyone involved.  The long lasting ripple effects of this approach consistently has resulted in less than optimal CPOE provider buy-in, which in turn frequently brings about bare minimum compliance of government mandates. It is much harder and takes much longer for an organization to reach the point in which they can truly start to do optimization work that takes them to the next level when they are consistently struggling to meet the bare minimum thresholds required of them. 

Over time, organizations have begun to realize that the Big Bang style of implementation is not only beneficial, but necessary in many instances such as the above outlined scenario. Having the CPOE medication “triangle” of pharmacy, nursing, and providers involved simultaneously in the process from the beginning not only encourages the providers to utilize CPOE more effectively, but it also reduces questions from pharmacy that needs to verify the orders, and nursing who has to administer the medication.

CPOE groups/committees are now a staple in hospitals countrywide and should, without a doubt, be comprised of representatives from all of the ancillaries and different hospital departments to ensure that all points of view are considered when implementing a new system and/or workflow. Ensuring that the appropriate feedback is received, the workflow discussions happen both collaboratively and concurrently, and that representatives from all necessary areas/departments are involved from the beginning will always prove beneficial.

About The Author: John Vergato has over 10 years of implementation, optimization, and sales experience with Healthcare Information Systems, specializing in numerous proprietary software vendors. He has a distinct understanding of the healthcare IT environment, assisting in the support and implementation of all sizes of organizations, from critical access hospitals through Independent Delivery Networks with as many as 14 facilities.  He has his CPhT Certification and has shared his knowledge through presenting at user conferences across the country.