Where Exactly Do My Med Orders Go?

Where Exactly Do My Med Orders Go?

Ever wonder where your orders go? One of the things I do when training a doc on CPOE is explain to them the basic medication delivery workflow in a standard hospital. When a doc "goes CPOE", he/she is suddenly confronted with some hard realities of the ordering process - Exactly what they order, and exactly how they order it, will largely determine their success in getting a drug at the right time in the right place.

(PLEASE NOTE WITH THIS DISCUSSION : YOUR MILEAGE MAY VARY GREATLY - This workflow is a general summary, but lots of other hospitals may do things differently, and for a very good reason - I'm just summarizing some general themes, but for specific information, ask your directors and informatics staff.)

 

So I usually start to frame the discussion with the basic unit of care - A doctor, and a patient. (You'll notice these slides borrow from my piece on "What is Med Reconciliation, anyway?", where the physician and patient lovingly spend time with each other in an area I call the "patient care cubicle") -

• Inside a hospital, this "patient care cubicle" is an "inpatient care cubicle".
• Outside a hospital (or in an ambulatory setting like an ED or day surgery), it is an "outpatient care cubicle".

Let's focus first on the inpatient care cubicles, where a lot of medications are ordered as patients are admitted into a hospital :

It's first important to consider how exactly an order is created. If the doctor and patient are sitting next to eachother, then the basic unit of care (from the physician perspective) is the physician order - On this slide, it's labeled the "MD ORDER".

First, let's look at this "MD ORDER" for a medication in the INPATIENT setting :

I. MD ORDER FOR A MED : THE INPATIENT SETTING

There are then basically three different ways a med order can come into existence :

1. As a written order - This is an acceptable way of making an order - Even the VA, during downtimes, allows written orders. Most hospitals with EMRs still allow some form of written orders for downtimes or other complicated orders. The problem : This type of order requires a nurse or pharmacist to transcribe it, so if the doctor has poor handwriting, this can result in a small percentage of error. 
2. As a telephone / verbal order - This is also an acceptable way of making an order, especially if the physician's hands are tied up doing a procedure or surgery. The problem : This type of order also requires a nurse or pharmacist to transcribe it, so if the doctor doesn't speak clearly, this too can result in a small percentage of error. ("Did you say Metoprolol 15 or 50mg?") Another problem : This legally requires a physician to go back and sign this order afterwards - This is very complicated and time-consuming for most physicians.
3. As a CPOE order (Computerized Physician/Provider Order Entry) - This is the entry method preferred by most hospitals, regulatory bodies, and the government. I suspect this is primarily because there's no intermediary who needs to transcribe the orders, so there is the common belief that this is less error-prone. I haven't seen really good data about this yet, but I do believe that good CPOE requires good training. There is also some data to suggest total medication turnaround time decreases with CPOE use - See this HHS piece on Medication Turnaround Time.)

So no matter how a physician creates the order on the floor, the order gets made. Let's say, for our little example, that the order is "Ativan 2mg IV x1 dose STAT".

Any idea where the order goes next? If you guessed "Pharmacy", you're right!

Whether you're in an electronic hospital, or a paper hospital, Joint Commission requires all inpatient medication orders for acute care hospitals to be "verified" by pharmacy. ("Verify" is basically a fancy word for "double check".)

So a pharmacist suddenly sees the medication order - "Ativan 2mg IV x1 dose STAT". And there are a few things a pharmacist can do to try to help ensure the safety of this order :

• They can check the allergy profile of the patient.
• They can check the dose of the drug.
• They can check for drug-drug interactions.
• In some hospitals, they can even sometimes do fancier checks, like check the renal dosing of the drug, weight-based dosing of the drug, etc. (this sometimes varies considerably, depending on the types of services offered)

What pharmacists can't really do well is verify the need for the drug - They usually aren't sitting in front of the patient, with the patient's chart - So if you order heparin on a patient with a bleeding ulcer, a pharmacist is probably not going to be able to prevent that type of error. (Nurses, usually right in front of the patient, are generally much better at finding that sort of error.)

Anyway, after a pharmacist does his/her best to verify the safety and dosing of the order, or adjust the order, they generally click a button to "verify" the order, and then the order travels back to the floor where it does two things :

1. It unlocks the Pyxis drawer (in this example the Ativan drawer)
2. It creates a blank entry on the eMAR (electronic Med Administration Record, aka Cardex, aka Codex)

This then allows a nurse to take the drug out of the Pyxis drawer, give the drug, and chart it on the eMAR. Once it's charted, that's generally when a hospital gets to generate a bill for having given the drug. 

So that's generally the way it works in the inpatient world.

Any problem with this pharmacy verification workflow? Having a pharmacist double-check the orders helps reduce errors, so ... Is there any drawback a doc should be concerned about?

Well, imagine if you had a patient seizing in front of you, and you had to give them the "Ativan 2mg IV x1 dose STAT". How long exactly does it take a pharmacist to verify those medication orders? 

The interesting thing is that there are actual guidelines about this (these are approximate - Your state/region may vary on this) :

• Priority = STAT : In many places regulations allow up to 30 minutes (in reality, most inpatient pharmacies verify STAT orders in about 5-10 minutes)
• Priority = ROUTINE : In many places regulations allow up to 90 minutes (in reality, most inpatient pharmacies verify ROUTINE orders in about 10-15 minutes)

So if the regulations are typically around 30 minutes, and even if your inpatient pharmacy can do it in 5 minutes, can you wait 5 minutes to give a seizing patient ativan?

The answer, of course, is obviously no. So what can you do? You generally have two choices :

1. OPTION 1 : Call the pharmacy and say "I just put in an order for Ativan - Can you verify it ASAP so the nurse can take it out?"
2. OPTION 2 : BYPASS the system. In most hospitals, a "Code Blue" (or "Rapid Response") is a perfectly acceptable reason for a nurse to hit the "Emergency Bypass" button on most Pyxis machines - This allows a nurse to get the drug and give it in an emergency. 

Note that most Pyxis machines actually TRACK the number of times they have had an emergency bypass - There should be a valid reason to bypass this important safety mechanism, so a unit where there are more emergency bypasses than needed/expected may be a cause for concern and investigation.

So that's generally the way medication orders get created, verified, and followed in an inpatient setting.

II. MD ORDER FOR A MED : THE OUTPATIENT SETTING

Here's where it gets interesting - That pharmacy verification thing? Joint Commission, on seeing the success of this in reducing errors, thought 'Wouldn't it be nice to have pharmacist verification in the OUTPATIENT setting (e.g. Emergency Department, Surgical Daycare, etc?)'

And do you know what happened? Most emergency departments, for good reason, argued "We can't handle the time delay of verification!" - And so, as of yet, it's not a mandate to have pharmacy verification in the Outpatient setting. (Perhaps for good reason - The delays it could cause could create a whole different set of problems.)

So how exactly *does* it work in the outpatient setting?

ORDERING : Generally the same process - A doctor can use either :

1. Written order (same as above)
2. Telephone / Verbal order (same as above)
3. CPOE order (same as above)

The difference is, however, that without pharmacy verification, where exactly does the order go?

In most hospitals with electronic systems, then, this order then will simply go to the eMAR. (It makes a space in the software for charting the administration of the drug.)

So then the typical workflow is this :

1. Nurse sees order in EMR or eMAR
2. Nurse opens Pyxis (in most EDs, the Pyxis will open up automatically)
3. Nurse gives the drug
4. Nurse charts the administration on the eMAR

Again, after charting the administration, this usually lets a hospital generate a bill for having given the drug.

So in most Emergency Departments (mostly for reason of avoiding delays), there is no pharmacist between the doctor and the nurse part of the workflow. There are still two people double-checking every order - The physician, and the nurse.

III. SO WHY DO I CARE?

The reason you, as a physician, might care about these workflows is that often, inpatient doctors are asked to admit patients from the Emergency Department.

And how exactly does a computer know which workflow to follow - The inpatient or outpatient workflow?

Let's recall - In both settings :

• The physician usually places the order via written, telephone/verbal, or CPOE methods.
• The nurse usually gives the drug to the patient
• The nurse usually charts the administration on the eMAR.

So how does the computer know whether to follow the inpatient or outpatient workflow for a medication order?

Q : "Dirk, is it by physician type? Like, orders from ED docs follow the outpatient workflow, and orders from Hospitalists or other inpatient docs follow the inpatient workflow?"

A : Usually not. If systems were built to do that, then a Hospitalist would have significant challenge in running a code on a patient physically located in the ED.

The answer is usually, as we say in New York, "Location, location, location." That is, the location of the patient determines which workflow most EMRs will use on the order.

So for example - A patient in a location, and the workflow :

• ED Room 1 = Outpatient
• ED Room 2 = Outpatient
• ED Room 14 = Outpatient
• ED Holding Unit = Inpatient *
• Room 125B = Inpatient
• Room 202A = Inpatient
• ICU Bed 3 = Inpatient
• ICU Bed 4 = Inpatient

* - Remember - Most holding unit beds are actually an inpatient level of care, and so they follow the inpatient workflow.

IV. AGAIN - WHY DO I CARE?
There are a few reasons why I teach this to the docs I'm training on CPOE. They are :

1. You are going to be a working doc - You need to know how to troubleshoot the system, just in case of emergencies.
2. You might admit someone from the ED to an inpatient bed.

Reason #2 is especially important for Hospitalists and other inpatient docs to understand. Why? Because if you are admitting a patient, and the computer still shows the patient to be in an ED bed (e.g. ED Room 1), then those orders entered into your EMR may not be verified by pharmacy - Orders not verified by pharmacy means the Pyxis machine won't open up when the patient gets up to the floor. This is when you get that call from the nurses : "Dr. ____________, remember those orders you put in while the patient was in the ED? For some reason, the Pyxis machine isn't opening up now - Can you re-enter those orders in the computer?"

This, of course, leads to delays and frustration. So what's the best thing you can do as an inpatient doctor, if you get called by the ED to admit a patient to your service?

1. First, go down to the ED and see and evaluate your patient
2. Look on the computer at their location -
     - If it says "ED Room 1" - Ask your registration to change their bed to an inpatient location.
     - If it says "ED Holding Unit" or "125B" or "204A" or "ICU 3" - Go ahead and start your orders.

Again, please remember - Your hospital's workflows may vary - This is a gross generalization for teaching purposes only. Please ask your local regulatory agencies, your local administrators and directors, and your local informatics people for more details about the workflows in your hospital.

Hope you enjoyed this post - Feel free to send questions, I love the feedback and I'm always glad to create posts to answer them!

Welcome to the new CMIO!

I was speaking with Mark Hagland today (of Healthcare Informatics magazine), who recently wrote some GREAT articles about Rowing Together (A GREAT summary of the embedded physician informaticist's struggle and rise), Revenge of the Clinical Informaticists and my favorite, my own interview a while back.

Mark was telling me, that he's spoken to recruiters recently, who had several things to say about CMIOs in general :

1. The CMIO role lacks formality in the industry (there is a wide variation of job duties among CMIOs)
2. The CMIO role lacks training in "how an organization works" (a valid criticism for some)
3. That most CMIOs start the job totally unprepared for the realities.

I will agree, there is a problem with formality. (See my last post about how hard it is to find a good job description, for both CMIO and for the Physician Informaticist).

As for Informatics training, there are certainly informatics training programs out there, the most popular being the AMIA 10x10 class, but there are lots and lots of other "informatics training" programs out there too. It's certainly valid, however, that many CMIOs don't have formal informatics training. My own guess : Many of these informatics training programs are targeted for non-physicians too (since Informatics is not just a -physician job - Nurses have informatics needs, respiratory therapists have informatics needs, dietitians have informatics needs, pharmacists have informatics needs - Anyone who works clinically and wants to manage a clinical process can benefit from this sort of training.)

And as for training about "how an organization works", I'm not sure where one would best get that training. It's not just the CMIO that struggles with this! Some people point to MBA programs, but in all honesty, anyone who has worked in business, student government, and maybe understands Microsoft Office really well has at least some idea about how organizations operate. (Is this really some national secret? Committees and paperwork are more than just conspiracy!) I think this is one of the reasons many CMIOs are Internal Medicine, Hospitalists, or Emergency Medicine docs - These are specialties that are very, very affected by "how the machine runs" - You learn quickly, as a Hospitalist/ED doc, about how an organization runs (or doesn't). :)

Finally - the statement that "most CMIOs are totally unprepared for the job they're getting into", I will admit there is probably some truth to that. (Although the same could be said about any job - Who walks in knowing their job on day #1??)

I suppose if there is a "stereotype" to most CMIOs when they start (myself included), it's that of the "tech-savvy doc", waving around his/her iPhone, talking about who they friended on Facebook last night, tweeting at Starbucks while they order some crazy drink and look down their nose at people who have voice-only cell phones. They read Wired magazine, and seem the most "tech-friendly" of all of the docs in their hospital, and like to see themselves as open-minded and friendly, chanting the mantra, "Think Differently". They're often the first to buy a hybrid car and the latest gadget at Apple, and show it off to all of their friends. And according to CMIO magazine's recent job survey, apparently many are Internal Medicine physicians, male, ages 51-55 years old. (Curiously, 9% are not licensed physicians - Did they not complete a residency? Or just not physicians? Hmmm...)

Anyway, I would say that I fit this stereotype to some degree, when I started, except I worked for several years in the software industry before I went to medical school, so I didn't walk in totally naive about how hard it is to maintain a network and software for a large company.

What I didn't realize, when I got into the position in healthcare, is that unlike private industry, healthcare is much more challenging to implement a large-scale IT project :

1. In private industry, budgets are much more forgiving about technical snafus that arise. In healthcare, budgets are tight all over.
2. In private industry, everyone works 9a-5p. In healthcare, employees work 24/7, in different shifts, so training is much more difficult.
3. In private industry, if you have to train all employees, it's not such a big deal to close a unit of a company for 2-3 days while you train everyone. In healthcare, you can't close the ED for 2-3 days while the doctors and nurses learn the software.
4. In private industry, it's acceptable if the system works 98% of the time. In healthcare, it's unacceptable if the system works 99.5% of the time. (Engineers will tell you how easy it is to make a system that works 95% of the time, and how hard it is to make a system to work 99.9% of the time.)

These are some of the lessons I learned in my first year performing my job.

So now there seem to be a LOT of CMIOs being hired (for good reason!), and after speaking to a bunch of them, I've been asked to help "train our new CMIO so they hit the ground running". And the first thing I try to tell them is : Yeah, the iPhone and Facebook and Twitter are all great, but you won't be using any of them in CMIO land.

(It's a crushing defeat to the ego, often, but it's the truth.)

These are the things, new CMIO, you should instead look forward to :

1. You will spend a lot of your time trying to strategize politically about how to get physician buy-in to your informatics platform.
2. You will spend a lot of your time trying to strategize politically about how to get administrative buy-in to your informatics platform.
3. You will spend a lot of your time reading CMS and Joint Commission and State laws about medication delivery, ordering privileges, and such.
4. You will read a lot about industry guidelines in building your front-line informatics tools : Policies, protocols, order sets, documentation, and templates.
5. You will almost certainly encounter technical boundaries that you'll have to explain to docs who may never be satisfied.
6. You will almost certainly encounter financial boundaries that you'll have to explain to docs who may never be satisfied.
7. You will almost certainly encounter political boundaries that you'll have to explain to docs who may never be satisfied.
8. You will often be asked to be responsible for large, complicated systems, and hopefully, you will also be given proper authority to make changes. (Many CMIOs I speak to say they are hired but not given real authority - See the administrative buy-in problem I speak about in #2 above.)
9. You will spend time reviewing workflows, and analyzing them, and mapping them on flowcharting software, and developing project timelines and managing your informatics team. (If you're lucky - Some CMIOs have no informatics team to work with.)

Yes, new CMIO, welcome to the role! Leave your iPhone at the door, and prepare to swim in the informational swamp that modern healthcare demands! But remember - The CMIO is actually a clinical position, (not a technical one as many people mistake) and it's probably the strangest trip you'll ever take as a physician. So sit back, take a deep breath, and prepare for the wonders that the job will bring you. Welcome!

Hospital Administrator Informatics Tools

So it's been almost a week now, and I'm still trying to find good definitions for :

1. Clinical Protocols (to help automate a clinical process, e.g. Heparin or Insulin drips)

2. Clinical Policy

3. Clinical Documentation

4. Clinical Order Set

5. Clinical Templates

6. Staff Education Module

7. Patient Education Module

8. Clinical Staff Schedule

Each of these tools requires a delicate process to build, develop, approve, and publish them.

And the interesting thing? We don't seem to have a standard policy definition! The SKTM Glossary (http://www.skmtglossary.org) seems to offer mostly technical definitions, and various other web sites seem to have different definitions/labels for this very common tool in healthcare. (Most of the other definitions are related to clinical trials.)

I'm honestly surprised The Joint Commission and CMS haven't stepped in to offer a definition that could be very useful in healthcare policy development and educating healthcare administrators internationally. (Is anyone from CMS or TJC a reader? Email me!)

There are also a bunch of automated software packages and companies that provide automated policy management - Just Googling the options will give you lots and lots of choices. (This must be a big business!)

In the meantime, I keep trying to keep the Wikipedia entry alive :

http://en.wikipedia.org/wiki/Health_informatics_tools

(Perhaps I should write the first "Healthcare Administrator's Toolbook", so I can use myself as a citation?) :P :)

Policy definitions for common front-line informatics tools?

First, this week, I thought I'd offer up an interesting problem. You can help solve the problem.

I put up what I think are "Nine common front-line Health Informatics Tools" on Wikipedia :

http://en.wikipedia.org/wiki/Health_informatics_tools

These are nine tools that almost every hospital uses, to accomplish their day-to-day operations.

The curious thing is that there seems to be little national consensus on the definitions of these tools.

I looked through the Joint Commission, CMS, AMIA, and HIMSS web sites, and was unable to find good policy definitions of these tools.

Most hospitals have as one of their primary administrative policies, a policy that spells out the use of one or more of these tools. But since there is little national consensus, it seems most hospitals have to write that first administrative policy from scratch. (Do I have any readers who can comment more about this?)

So I took my first stab at writing a middle-of-the-road definition of these tools, and put it up on Wikipedia. And within 5 minutes, the Wikipedia editors rightfully told me these entries would be taken down in 7 days if I could not produce proper citations for these tools.

I sought more sources, and was able to find some help on clinical order sets through the Institute of Safe Medication Practices web site (http://www.ismp.org) -

But unfortunately, I'm having significant challenge in finding additional sources.

If you have time, feel free to go to Wikipedia and contribute either sources or edits that could help shape the political, legal, and cognitive framework on which all front-line informatics tools may be built in the future. :)

(In the meantime, I've approached some big people in the Informatics Industry - We'll see where we can get in the next seven days. Talk about a challenge!) :)

Stay tuned - Next post will be the training post I promised. :)