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Hospital pharmacy's future: More EMRs and CPOEs, fewer centralized pharmacies
Future looks like more of current trends
New hospital technology is helping to move health care systems away from the centralized dispensing pharmacy model to a more integrated pharmacy practice model, according to results from the 2009 American Society of Health-System Pharmacists (ASHP) National Survey.
Automated dispensing cabinets (ADCs) which are fairly ubiquitous among hospitals, as well as barcode technology, smart infusion pumps, electronic medical records (EMRs), and computerized provider order entry (CPOE) systems, are accelerating this evolutionary change.
"They're moving toward decentralized drug distribution systems, using automated dispensing cabinets, and that has continued to increase," says Philip Schneider, MS, FASHP, an associate dean for academic and professional affairs in the College of Pharmacy at Phoenix Biomedical Campus in Phoenix, AZ. Schneider spoke about the 2009 survey results at the 44th ASHP Midyear Clinical Meeting & Exhibition, held Dec. 6-10, 2009, in Las Vegas, NV.
ADCs bring medications closer to patients, which helps to cut down on delays and waiting periods, he adds.
"Nurses like this because they no longer have to call the pharmacy and wait for the pneumatic tube to arrive," Schneider says.
One major reason why the adoption of new technology in hospital pharmacies has exploded is because of safety issues, says Lynnae M. Mahaney, MBA, RPh, FASHP, president of ASHP and chief of pharmacy at William S. Middleton Memorial Veterans Hospital in Madison, WI.
"Technology is helping us do the right thing, so that's the other big reason we're implementing it everywhere," Mahaney adds. "The drug handling process has so many points at which human errors can occur."
The pharmacist's role in hospitals will continue to expand and advance in terms of their involvement with patient care, predicts Douglas Scheckelhoff, MS, FASHP, vice president of professional development for ASHP in Bethesda, MD. Scheckelhoff also spoke about the ASHP national survey at the recent ASHP meeting in Las Vegas.
"One thing we've focused on is a look at a pharmacist practice model," he says.
ASHP will have a summit this year with a focus on this topic, Scheckelhoff adds.
"The reason for attention to this is we have an evolving pharmacist workforce with the doctor of pharmacy degree and residency training, and we also have drug therapy and patient management needs that are becoming more complex with more high risk," he explains.
New technology contributes to this changing need, as well.
"We have a growing amount of technology that's available with barcode dispensing and robotics, so the pharmacist is less tied to dispensing functions," Scheckelhoff says.
So the focus is more on a practice model tied to how pharmacists spend their time and how technology and technicians are used in medication preparation and the distribution process, he adds.
This year's survey described the three most common models and asked survey respondents to say which of these best described their hospital. The models are as follows:
"When we ask directors about their vision of the future model, 4% say it will be a drug distribution model, 84% say it will be an integrated model, and 12% say it's a clinical specialist model," Scheckelhoff says.
"We asked pharmacy directors what their barriers were to changing their practice model, and the No. 1 barrier was the lack of pharmacist staff resources," he adds. "The second most common barrier was the lack of pharmacist staff with the needed training to take on some of these expanded roles, and the third most common barrier was resistance to training from existing staff."
Hospital pharmacies will continue to incorporate new technology in their facilities, the survey also suggests.
"We also see continual adoption of technology, which will support the pharmacist's role," Scheckelhoff adds.
For instance, hospitals increasingly are implementing CPOE systems, Scheckelhoff says.
Only about 2.7% of hospitals used these in 2003 and 3.6% in 2005. But now 15.9% of hospitals have switched to CPOE systems, the survey shows.1
The implementation of CPOE systems increases each year despite the obstacles, including a high cost and obtaining buy-in from medical staff, Scheckelhoff notes.
"Hospitals need to have software systems in place, and the workflow changes, so it's quite an involved process," he adds.
Electronic medical records have had a slower, phased-in adoption rate, the survey's results show.
For example, only 8.8% of hospitals reported a complete EMR in 2009, which is up from the 3.8% who had complete EMRs in 2007. However, there now are more hospitals with partial EMRs, meaning some documentation still is on paper, than there are hospitals that have all-paper medical records, the survey shows. About 47% of hospitals reported partial EMR implementation in the 2009 survey, compared with about 37% in 2007.1
"I think the federal government's emphasis on building an electronic highway for medical and health information has contributed to this trend," Schneider says. "We're seeing [electronic technology] really improving the efficiency of care and the ability of everyone, including pharmacists, to have access to the information they need to do their jobs."
For instance, 93% of hospitals have pharmacists with access to ready data, he adds.
In the case of barcode technology, there has been a rapid improvement in its adoption.
"That's a technology that went from being adopted in 1.5% of hospitals in 2002 to almost 28% in 2009," Scheckelhoff says.
"The ASHP has pushed for that for a number of years, and the FDA back in 2004 required manufacturers to add a barcode to their medication packaging," he says. "There still are issues where barcodes aren't readable, but it has improved significantly over the last five years."
Another trend noted in the ASHP survey is that small hospitals are starting to catch up in their use of barcode technology, he adds.
"In the early years of barcode administration, it was almost always the large hospitals who were adopting this technology, but now there's very little difference from small to medium to large hospitals," Scheckelhoff says.
Smart infusion pumps also are becoming more popular among hospitals, with 56% reporting their use, up from 32% in 2005.1
The 2009 ASHP survey did not collect data on the adoption of automated dispensing cabinets because these already are used in 90% of hospitals, Scheckelhoff says.
The decentralization of hospital pharmacies has led to both more efficiency and some drawbacks.
The chief barriers to adopting new technology are the high capital expenditures and the often complex logistics work that needs to be done, Scheckelhoff says.
Schneider has found in his experience that new technologies often create new problems in workflow, as well.
"So it's really important for people to not just acquire technology, but to also understand why they're in place and how to use them properly," he says. "Hospitals will buy barcode systems, Smart Pumps, and not explain why the technology has been acquired and why employees need to change the way they work."
This leads staff to find creative ways to defeat the technology, Schneider adds.
"The difference between the potential for pharmacy with new technology and the actual effectiveness is a gap that pharmacists need to be mindful of and help with," he says.
"One issue is the nurse may get the medication from the ADC before the pharmacist has an opportunity to review the order," Schneider explains. "A review of the order could reveal problems before the drug is administered to a patient."
This problem has led the Joint Commission of Oakbrook Terrace, IL, to require that pharmacists review all medication orders before they're administered to a patient, he adds.
Another issue is that some new technology, such as barcoded medication administration, actually are more time-consuming for nurses.
"Many times it may take nurses longer to administer medications when new technology is implemented, but it is a safer system," Scheckelhoff says. "So it can take time to align what's needed, including equipment costs and software costs and having support and buy-in from nursing."