A seismic shift in the healthcare landscape has accompanied the consolidation of hospitals and health systems. Hospital pharmacy directors now face the task of tackling interoperability between pharmacy automation and electronic medical records (EMRs).
Chad AlvarezWhile the dwindling number of vendors of EMR and pharmacy automation may make their lives simpler, pharmacy directors confront many challenges, including connectivity and standardization issues, a shortage of resources, and funding problems.
"We are living in a big data world, and being able to pull data quickly, stratify it, and then use it at the point of care becomes difficult when you are pooling data in automated systems and EMRs," said Chad Alvarez, PharmD, senior director of Retail Pharmacy/Pharmacy Systems and Support at Carilion Clinic in Roanoke, Va., a not-for-profit healthcare organization that includes a comprehensive network of hospitals and primary and specialty physician practices.
At Southampton Hospital in South Hampton, N.Y., a new Siemens Computer System was implemented more than a year ago. Jerard West, PharmD, director of Pharmacy, said the EMR comprises three integrated systems: Soarian computerized physician order entry (CPOE), medication administration check (MAK), and Siemens Pharmacy.
"One of the many challenges we faced is that the hospital's old legacy computer system was not able to transfer information to the new system," said West.
For example, predefined common orders (PCOs) had to be built from scratch, using a 1,600-medication item master.
The pharmacy department, said West, had to design its system with regard to current workflow practices, perform a Pyxis conversion to the new EMR, implement bar-coding technology, and assist with order set development for the medical staff. And it had to accomplish all this with limited resources, he said.
Less staff, more work
Southampton Hospital is not alone. Lack of resources remains a huge challenge for hospitals. Some industry insiders contend that IT departments in health systems are continually being downsized, while larger portfolios of projects are added to their plates. "From a pharmacy standpoint, one of the most common things we see from an interoperability challenge is getting IT resources to prioritize pharmacy projects. That’s a constant theme we see across the country," said Kraig McEwen, CEO of Aesynt Inc., a technology company that offers tools for medication management.
On the plus side, McEwen added, technical complexity has eased somewhat, as many automation vendors and EMR providers have developed better standards and better integration.
Economy of scale
"In order to achieve standardization across health-system pharmacy operations, which involves aligning disparate practices across multiple facilities, our workflow and related systems must be redesigned, and that was the reason behind the MedStation Enterprise System and the MedStation ES System," said Dave Swenson, vice president of Clinical Strategy in the Medical Affairs division of MMS (Medication Management Systems) for Carefusion. Becton, Dickinson and Company acquired CareFusion in March of 2015.
A key component of Carefusion's enterprise approach, said Swenson, is to allow health systems to standardize using one formulary and to manage users across a health system instead of on a hospital-specific basis.
"This undertaking involved five years of effort and was necessary to enable pharmacists to take advantage of the economy of scale of a health system," he said.
"To do that, I need to be able to aggregate data from across the community. I need to be able to run analytics on this population, have care coordination that sits across the community, and engage patients in their behavior," said Rich Berner, president, International and general manager, Allscripts' Sunrise business unit.
According to Berner, medication management is a huge component of this, because it's a way to increase the quality of population management by reducing errors. It could also provide savings and prevent fraud.
"The challenge that we see when it comes to interoperability is that if I'm managing this patient proactively and predictably, I need to do it no matter what system they're using — whether at home, in the doctor's office, or at the hospital," said Berner.
"We want to be where the patient is and through technology, have the opportunity to engage the patient and collect meaningful information to direct patient care, no matter the system or device," said Carilion's Alvarez.
Workflow, patient care
Alvarez pointed out that the landscape is more challenging as new mobile healthcare rolls out. "EHRs are a piece of the solution, but I think the largest challenge is the facilitation of new physician workflows and care management structures needed in order to create the synergy with the technology," said Alvarez.
Ray Vrabel, president and principal consultant, Vrabel Consulting Inc. in San Diego, Calif., contends that there are two levels of interoperability.
"One level of interoperability deals with just the data about drugs that are maintained in all of these different systems," said Vrabel, adding that in a perfect world, there would be a single database to which all the disparate systems having anything to do with medication management would refer, so that those responsible for maintaining the drug databases in all these systems would only have one touch point. "That does not exist today. It should."
The other type of interoperability, said Vrabel, a former pharmacy director at several hospitals, is clinical interoperability, which addresses the problem of clinicians such as nurses who have to use different systems in the hospital.
"Sometimes they have to repeat the same task in a second system, just because the two systems don't effectively talk with each other," Vrabel, also a former executive at a pharmacy automation vendor, said. "Interoperability drives clinical benefit for practitioners."
When several hospitals merge, a key goal is standardization — especially when it comes to quality and cost.
"From our view, most health systems need to take 20% of their cost structure out over the next several years just to remain solvent, so standardization is one of the mechanisms they use to help become more efficient," said Aesynt's McEwen.
About 70% of the large health systems, according to McEwen, are dealing with multiple automation vendors when they merge. To achieve the goal of standardization is a journey of years for every health system.
"That’s the obstacle," said McEwen. "It's expensive and time-consuming for IT resources, and it's going to take a long time to standardize across those platforms. One of the key challenges that we see that goes a little bit under-recognized is the actual organizational readiness for standardization."
Adoptability of new technology is always an obstacle, said Carilion's Alvarez but making the transition from best-of-breed systems into a single, integrated platform presents unique challenges to the enterprise.
"You may have a site that has the best system for lab, while another possesses the best system for radiology. Teams need to understand that an integrated, enterprise-wide system does not always equal a system better than what was in place at the department level before."
Alvarez noted that loss of functionality in one area might be coupled with gains of functionality in others. Overall, integrated systems provide more information at the point of care to produce better patient outcomes.
It's not unusual for culture clashes to occur during acquisitions. Sometimes the staff of the acquired facility starts off feeling embattled, because they’re being asked to make changes from procedures and processes for which they had ownership, said Dennis A. Tribble, PharmD, director, Healthcare Industry Operations, a medication-management-systems arm of Becton Dickinson (BD).
"They're being told that it will all be changed, but it can't happen overnight; that there's a period of time, maybe years, when systems are slowly evolving and migrating from one to another. It creates an immense amount of uncertainty and confusion," said Tribble.
Interoperability is a massive challenge, according to Jerry Fahrni, PharmD, a pharmacy and informatics consultant in Fresno, Calif. He explained that interoperability could take a long period of time, and health systems could end up using multiple disparate systems — for three to five years, in some cases.
"Getting those disparate systems to talk to each other is an uphill battle. It’s a monumental task and major problem. It’s a patient safety issue, a time issue, and a money issue," said Fahrni.
In today's healthcare landscape, the funding available to hospitals often is directly dependent on how the hospital performs under the Affordable Care Act (ACA).
"We have to be able to do a cost justification, where it's either going to save us money or FTEs, or deliver a more superior service that will pay for itself somewhere down the road," said Jim Toohey, director of Pharmacy, Aultman Hospital, Canton, Ohio.
"One of the largest challenges is the mindset that automation should automatically bring about a reduction in the workforce. Most areas are challenged to show how the capital investment in technology should eliminate or reduce employment numbers," said Carilion's Alvarez.
In some cases that may be true, said Alvarez, but in most cases, the labor force is reassigned to other areas, such as clinical patient care, which from a pharmacy perspective is a much less tangible thing to quantify, yet more meaningful to patient outcomes.
Due in part to the rise of ACOs, offsite venues, and new technologies that include tablets and smart phones, health systems are encountering even greater obstacles when it comes to achieving interoperability and standardization.
"We want to be where the patient is, and through technology, have the opportunity to engage the patient and collect meaningful information that can direct patient care, no matter the system or device," said Alvarez.
"EHRs are a piece of the solution, but I think the largest challenge is the facilitation of new physician workflows and care management structures, in order to create the synergy with the technology," said Alvarez.
"This has been a big area of discussion this past year as I have spoken with pharmacy directors. They must expand services to include redeployment of their pharmacy resources into ambulatory care, without pulling back on inpatient services," said Swenson.
Many pharmacies are able to manage this extension into the ambulatory setting. They have developed systems to manage the pharmacotherapy of patients treated in the outpatient setting, he said.
"It’s a big redeployment and retraining effort," said Swenson.
Outside the wall
According to Fahrni, this is the first time in healthcare that consumers are driving a process.
“Integration and technology is better outside the hospital's wall. As consumers themselves, physicians, and other healthcare professionals see this and are starting to ask questions. They’re interested in having similar integration inside the healthcare system.”
Fahrni noted that in today's environment, not only are there new applications that link back to and are part of the EMR, such as mobile apps, but now there are consumer apps and products such as Microsoft Health that want to link back, along with other companies, so that that information is captured by the EMR.
To some industry insiders the addition of ACOs, offsite physician offices, and mobile apps doesn't make interoperability any easier.
"It took 20 years to attain real interoperability with automated dispensing cabinets. We're going to have to go through that same cycle with other disparate things that are popping up out there. It's a real challenge," said Vrabel.
Anthony Vecchione is a healthcare journalist based in New Jersey.