On May 6, 2004, departing Health and Human Services Secretary Tommy Thompson appointed David J. Brailer, MD, PhD, one of the nation’s preeminent authorities on electronic healthcare, as the first National Health Information Technology Coordinator. Dr. Brailer’s duty is to execute the Executive Order of April 27, 2004, calling for the universal deployment of electronic medical records systems within ten years. Dr. Brailer has since indicated that a primary target will be electronic organization of the institutional pharmacy process within three years.

The urgency shouldn’t be surprising in that institutional pharmacy operations are among the most cumbersome and potentially dangerous management challenges in long-term care. The traditional process finds the pharmacy receiving often- handwritten medication orders from the facility via fax, manually entering the data into a computer system, verifying sometimes inaccurate or illegible prescriptions from far-flung physician offices, printing out orders and labels, and eventually shipping the drugs to the facility. With residents each averaging well upwards of a half-dozen prescriptions per day, the opportunity for error—and significantly life-threatening error, at that—is vast.

Enter the newest array of e-prescribing vendors and their products, many of which have been introduced to the market only within recent months. What do they have to offer? What do facilities need to bring to the table? What will it take to make a three-year adaptation anywhere near reasonable?

Recently, key officials from several such vendors answered questions along these lines posed by Nursing Homes/Long Term Care Management. Those interviewed included:

Gary Duty, President and CEO, Millennium Pharmacy Systems

Louis Hyman, Chief Technology Officer, HealthRamp, Inc., CareGiver and CarePoint mobile product suites

David Blackburn, Director of Specialty Care and Life Sciences, Cardinal Health, Pyxis Products

Rohan Coelho, President and CEO, Daverci Solutions, Inc., manufacturer of the Toccaré system

Product-specific statements are for informational purposes only and in no way imply endorsement by Nursing Homes/Long Term Care Management.

What general comment would you offer about the prospects for e-prescribing in nursing homes and assisted living facilities?

Gary Duty, Millennium Pharmacy Systems: It is long overdue. The paper-based fax transmission of physician orders has been, and continues to be, the first trigger point for error in the traditional provision of pharmacy services in skilled nursing and assisted living. Electronic order entry, the critical first step in a fully integrated medication management solution, has been accepted and embraced by our customer base in both sectors.

Louis Hyman, HealthRamp, Inc., CareGiver and CarePoint: A mobile, wireless electronic order entry system offers valuable transactional and communication extensions to traditional institutional pharmacy services, and serves as the foundation for an approach that begins at the point-of-care. Computerized physician order entry capabilities—including e-prescribing—fit ultimately within the broader context of a comprehensive information technology infrastructure for long-term care. A complete IT solution will encompass preadmission screenings and admissions management; wireless order entry; asynchronous order approval for attending physicians; electronic, HIPAA-compliant charting; tracking of activities of daily living; MDS editing and scheduling; care planning; automatic fee calculation based on regional rates and resident-specific scoring; and third-party billing.

Electronic prescribing can significantly enhance resident safety through the reduction of medication errors. Complications caused by illegible handwriting are prevented through the secure delivery of precise electronic prescriptions directly to the institutional pharmacy. Automatic checks for negative drug interactions will avert the occurrence of adverse drug events—a critical capability, given the prevalence of residents with chronic and acute conditions that require multiple concurrent medications. In addition, e-prescribing can reduce costs by improving workflow efficiency and eliminating the administrative burdens associated with prior authorization compliance.

David Blackburn, Cardinal Health, Pyxis Products: Because of cost reduction needs, as well as the benefits of standardizing behavior, I believe the prospects of e-prescribing bode well for nursing facilities. The challenge will be getting physicians to adopt this technology and align their institutional incentives correctly to accomplish this.

Rohan Coelho, Daverci Solutions, Inc., the Toccaré system: Previous efforts by other companies have not succeeded in practice because nurses and med-aides found that the earlier “solutions” didn’t add value and in fact increased their workload rather than decreasing it. The best way to make e-prescribing successful is to tie it in with the medicine administration process (eliminating the extra data entry steps). When this is accomplished, the prospects for e-prescribing are good, provided that the following ingredients of success are addressed:

• The system is easy to use by people with little or no experience with computers (because many med-aides fall into this category).

• The system is easy to learn (because it will need to be used in a high-turnover environment).

• The system must be easy to support in facilities that don’t have dedicated IT resources.

How would specific components of your products (e.g., bar coding, PDAs, computer carts, software) affect current pharmacy operations in nursing facilities?

Duty, Millennium: Our product offers an integrated process that incorporates wireless technology, Internet infrastructure, proprietary software, and robotic prescription fulfillment. Fully operational in both the long-term care and assisted living environments, the solution supports regulatory compliance, improves patient safety, and reduces cost and liability to both the pharmacy provider and nursing facilities. The solution’s automated order entry routes orders directly from nursing facilities to the pharmacist, which eliminates faxing, misinterpreted handwriting, and delivery delays, with real-time drug allergy, drug-drug interaction, and formulary alerts available at the point of entry. Nursing labor time is reduced through the elimination of order transcription, monthly physician order recaps, and MAR and TAR audits. The essential components for preventing medication errors during medication administration are integrated into the workflow with our proprietary software, bar-coded prescription packaging, and handheld bar code scanning devices providing immediate documentation of the medication event. The system operates in a secure Web-based environment, allowing real-time capture of patient data with 24/7 access.

Hyman, HealthRamp CareGiver: Our solution is designed to dramatically improve the efficiency of the entire clinical ordering and fulfillment process. CareGiver enables point-of-care medication and treatment order entry by on-site clinicians, real-time access to a comprehensive medication library, remote physician order approval capability, automated renewal of standing orders (a feature that greatly reduces the cost associated with the complex monthly reconciliation process), and secure integration with the institutional pharmacy information technology infrastructure.Desktop PCs enable system administration and unit management from each nursing station, and Wi-Fi-enabled PDAs allow clinicians to access resident-specific medical records and to enter orders while on rounds. These “ruggedized” PDAs—compact, shockproof, moisture-resistant, and readily sterilized—can be carried in a lab coat pocket or mounted directly to the med cart.

CareGiver’s wireless PDAs feature integrated bar code scanning capability, which can be used for resident identification using bar-coded bracelets or bedside cards with bar codes and resident photos. Medication administration and inventory control are also logical applications of bar code technology.

CareGiver technology is based upon an ASP model: All data are housed at a physically and virtually secure off-site location; no patient data are stored on local client devices. Data transmission is 128-bit encrypted, ensuring that protected health information remains secure and private. The ASP model enables CareGiver to be a mobile, secure solution.

Blackburn, Cardinal Health: Pyxis® Envoy™, Pyxis Station™, and Pyxis MedStation® all significantly affect pharmacy operations in nursing facilities. We offer a decentralized medication management model that allows significant cost reduction. Pyxis medication products also help reduce medication errors, because automating the medi-cation use process allows for better control of medications, increasing patient safety. All product components play an integrative role in delivering these benefits.

Coelho, Daverci: Toccaré will eliminate a number of problems that exist at both pharmacies and facilities today, including med order faxes that don’t get through, facilities not knowing the status of their med orders, playing “phone tag” to resolve problems, and lost med orders. The product provides for screening of meds when the order is received and again when it is administered to ensure that the right drug gets delivered to the right person at the right time. The technology can reduce the amount of time spent on clerical and administrative functions, cutting the med-pass time in half and eliminating end-of-month MAR reviews, saving up to three person-days per month.

What would be the minimum size of an organization that would benefit from this technology?

Duty, Millennium: Considering the fact that a fully integrated medication management solution has financial, operational, compliance, and patient safety benefits, any size organization would benefit from this technology, as evidenced by our current customer base.

Hyman, HealthRamp CareGiver: Our solution can benefit long-term care facilities of any size. It is priced on a per-bed subscription basis, so monthly financial outlays are proportional to the client facility’s size. Our analysis indicates that cost savings resulting from improved administrative efficiency will more than offset the recurring subscription fees.

Blackburn, Cardinal Health: An organization of 30 beds or more would benefit from our technology offering. Cardinal Health offers a leasing and service program that makes the acquisition, maintenance, and service of our products easy and cost-effective.

Coelho, Daverci: Toccaré is intended to be sponsored (and paid for) by pharmacies, which find it cost-effective for facilities as small as 20 beds. Ultimately, we expect the technology to evolve to be used in home care, adult foster care, and hospice environments involving even fewer clients.

What sort of administrative skills, personnel, and attitudes would be important for facilities to have for this?

Duty, Millennium: The most important factor related to acceptance is administration’s awareness of the misconception that a technology-driven solution would be difficult to implement in their environment. Long-term care nurses and providers need to get involved with technology, not only for the sake of residents and staff, but to boost the industry’s ability to take part in increasing technologic public-policy decision-making initiatives. It is important that the organization partner with a solution provider that has a proven record of successful implementation and support of a fully integrated solution.

Hyman, HealthRamp CareGiver: The transition from a labor-intensive, paper-based, manual system to a comprehensive, fully automated, computerized point-of-care order entry and facility management solution may seem daunting, but the benefits are enormous. Understanding the facility’s specific workflow requirements and remaining sensitive to end-user adoption variables are a vendor’s keys to success.

While the decision to deploy an e-prescribing system within the nursing facility is the responsibility of executive management, nursing staff buy-in and active participation by the director of nursing during training and deployment are further keys to success. Where possible, facility management should endeavor to identify respected, technically savvy administrators and clinicians on staff to propagate excitement for the deployment of an e-prescribing solution among their peers. The support of attending physicians, consultant pharmacists, and technical support personnel is also critical; all stakeholders in the e-prescribing value chain should be involved in the process well in advance of technical implementation.

Product demonstrations and training for the nursing staff need to be patient, thorough, and empathetic. On-site support during implementation must be in place and adequate. Ongoing end-user insight should be carefully integrated into the product development feedback loop to ensure continuous improvement of the application feature set and user interface.

Blackburn, Cardinal Health: Pyxis products are feature-rich and easy to use for all end users. The best set of skills is an aptitude for and willingness to work with technology. An open mind toward change and a willingness to do things a bit differently are also important.

Coelho, Daverci: Toccaré is explicitly designed to be used with little or no training—as easy to use as an ATM.” Users of this system don’t need to know how to use computers, let alone Microsoft Windows™.