priority for healthcare professionals around the world. The benefits of a patient administration system that allows physicians and pharmacists to work together to coordinate service delivery are therefore indisputable
No one can underestimate the role of technology in transforming healthcare or dispute its potential to improve communication, decision making, safety, quality and efficiency. Having a single, extensive point of reference for the crucial data that clinicians need to treat patients not only helps them to make informed decisions, it also facilitates a seamless service across the care process.
It was armed with this knowledge that a team from LifeBridge Health, one of the largest and most comprehensive healthcare providers in Baltimore, US, recently visited the UK. They came to hold a series of educational sessions on the significant benefits the Cerner Millennium healthcare computing platform has brought to hospitals in the US and how these are being translated in the UK.
LifeBridge implemented Computerised Provider Order Entry (CPOE) – which is built on the unified Cerner Millennium architecture – at its two acute care hospitals (Sinai Hospital in Baltimore and Northwest Hospital in Randallstown, Maryland) in 2006. Since then, they have measured significant benefits in terms of cost-effectiveness, time efficiencies and reduction in prescription errors. They have reported an 87% decrease in medication and prescribing errors (at Sinai), an 80% and 90% improvement, respectively, in the time it takes for pharmacists to verify medication orders and a 29% and 50% improvement, respectively, in radiology test turnarounds.
So in an ever-changing healthcare environment, where information technology is increasingly being used to support best practice, what impact will the system have on the pharmacist’s role in practice?
Dr Bill Jaquis, chief of the department of emergency medicine at Sinai Hospital, believes it has already had a tremendous impact at several levels.
“The first level, which is probably one of the most crucial, is getting pharmacists involved more with the real-time application of medications to patients. They are connected in a way, probably that they have not been before. More specifically, when we look to the pharmacists, and using their expertise in the delivery of medication, the ability to link electronically to that medication up to delivery has been greatly expedited,” he says.
“In our emergency department, most of the medications we had given prior to introducing our CPOE system, we prescribed and gave, and there was no pharmacy interface unless we had a question. Now, by doing it electronically, they can see the medication we prescribe as we prescribe them and within five or six minutes they are able to do first-dose review on those medications and assist us with making sure there is no possible error related to that delivery.
“In addition, it allows them to use their expertise to create better order entry. For instance, we create order sets for a lot of the diseases that we see. They can then research current best practice and the evidence for what types of medications might need to be given to a patient and plug that into the system. And so when I go to order, I can see what the recommendations are for giving medications based on the patient’s renal function, their allergy profile or what I think their particular need is.”
But the benefits of the system extend a long way beyond the confines of the pharmacy department. “They’re really across the board,” Dr Jaquis says. “There are benefits to our other services as well: to radiology in being able to see what’s ordered and why it’s ordered, and have a recommendation for what they were likely looking for when they look at it; for the laboratory, it may be able to, for instance, screen people for whom blood transfusions are being requested to see that they do have a need that meets the best evidence; and for the clinicians, we have the ability to look across all of the things that have happened with the patient and integrate it into our decision-making process. It also helps to drive some of the care that is being delivered.
“One of the things we talked about when I was in the UK was the British Medical Journal’s (BMJ) evidenced-based medicine. Being able to take what the BMJ produces and put it into an electronic ordering system helps us to make sure that we are getting the best evidence into the order entry process and therefore to the patient. So it benefits almost every provider or service that integrates into the system.”
In terms of the costs associated with the system, Dr Jaquis says these vary depending on where, when and how much is implemented. “It is in the millions of dollars, or millions of pounds either way, to implement such a system – not just for the purchase of the software, but the creation and implementation process, and the entry data acquisition. So there is a large cost that for us, probably was in the tens of millions of dollars over many, many years,” he says.
But are these costs justifiable? Dr Jaquis thinks so. “It’s just one of those things that we are starting to see that the answer is more concretely yes,” he says. “One big thing is on that whole medication order process and looking at the potential for error along the traditional process of handwriting an order, trying to read a prescription that a physician has written, supporting that physician in making sure the order is correct, and all the screens and checks and balances all the way from ordering through to patient delivery. It takes a while to know because very few errors reach the patient to begin with, but over time, what we’re starting to see now is that there’s definitely a reduction in errors reaching the patient as a result of the order entry process being more electronic. In addition, we could look at it for efficiency of practice and see that it has improved our efficiency. It’s just that a lot of these things take a little time to get the actual dollar amount figured out.”
Turning to some of the standout features of the multifaceted patient administration system, specifically in relation to pharmacy, Dr Jaquis says: “I think the biggest thing for us is the integrated process. We use the Cerner module for the physicians and the PowerChart and FirstNet in the emergency department where we are doing the order entry, and the pharmacy is also on a Cerner module – so that interface is integrated. We are able to create an order entry process with the help of our pharmacists that allows us to look at, for instance, correct doses and timing of medication. It also allows for drug monitoring to be automated.
“There is also a database that we both work with that allows us to do error or complication checking. So if I order medication in the emergency department, it will check against the patient’s known medications and any allergies listed and will prompt me if there are any potential contraindications. This way both the pharmacists and I have an opportunity to review the medication order and decide whether it is still correct to order it or whether I need to step to another medication. At their end, it also allows them to queue the medications that are being ordered according to how quickly they need to be given, follow how the medicines are being used and coordinate the microbiology of, for instance, an antibiotic with the medication that is given.”
Cerner Millennium is therefore a comprehensive system that, among its many capabilities, streamlines daily clinical and pharmacy functions and increases productivity. But what, for Dr Jaquis, is its main advantage? “To me, the key benefit is being able to create clinical decision support,” he says. “Traditionally, for instance, if I am trying to prescribe a medication, I may be writing it on a piece of paper, I don’t quite remember the dose – where do I go for that? Traditionally, I may have to find a physicians’ desk reference or, more recently, go into another system to look at a database like Epocrates. Now that decision support is built into the system. I might need some help in just determining what the best medication to prescribe is and now I can do that in real time with the pharmacist, so that we are both looking at the same thing at the same time.”
It is plain to see the significant benefits in terms of improved medication processes, reduced testing turnaround times and high-quality patient care. There are many positive lessons healthcare professionals in the UK could take from the experiences of their US counterparts. So, surely, the idea of knowledge sharing between US and UK clinicians is appealing? Dr Jaquis agrees. “There’s a lot of opportunity to participate in knowledge sharing. It’s helpful for me to bring back some of the things I saw in the UK and I think it’s helpful for some of the Trusts there to see what we’re doing here. We do a lot of information sharing in the US through either conferences or list serves – pretty much when we have a question, for instance, about the Cerner Millennium system, we’ll go to one of our list serves and get information on what other hospitals have done with the system to improve their effectiveness. And there is no reason why we can’t continue to do that internationally. I know it’s being done, but I think a continuation of that is very effective,” he says.
“In the end, despite how different the application of our healthcare systems is, it really does come down to what we do effectively for those patients. And I think a lot of the things we’ve talked about within electronic systems, although we may have different paths of getting there, we are trying to get to the same endpoint – which is efficient systems that people will use and that result in a delivery to the patient that has better outcomes.”