Computerized prescriber order entry (CPOE) usage is certainly widespread in hospitals across the country, but it is not always universally employed throughout the hospital. Specialty areas, such as radiology and the ER, often lag behind medical/surgical units in the adoption of CPOE given these departments’ non-standard use of medications and unique workflows.
The Ohio State University Wexner Medical Center (OSUMC) has utilized CPOE for medication orders since 2000. In 2009, we began an enterprise-wide electronic medical record (EMR) implementation; the inpatient areas went live in 2011, with the radiology department following suit 2 years later. Incorporating as many departments as possible into a single EMR, including CPOE in radiology, was a goal from the beginning of the project.
Expanding CPOE into Radiology
When undertaking an expansion of CPOE into the radiology department, the first step is to establish a partnership between all applicable stakeholders, which includes at a minimum: radiologists, radiology technologists, and representatives from informatics, scheduling, billing, and pharmacy. As the key stakeholders, this group is tasked with determining the workflow enhancements desired from the switch to electronic ordering as well as the features that will be required from the system. In addition, this group is responsible for identifying any challenges that might be raised by moving into CPOE and evaluating the potential impacts such a change may have on current workflow.
Two types of CPOE tools are available for use in the radiology department: a stand-alone radiology system that applies CPOE to radiology orders, or a radiology-specific module within an existing EMR system. We have experience with both of these approaches, having taken the former approach initially, and then switching to the latter in the fall of 2013. We realized a substantial benefit by utilizing the radiology-specific module within our EMR system, as having all contrast and radiology-administered medications in the EMR allows for the identification of potential drug interactions. For example, should a patient be prescribed a medication that can interact with the contrast agent or with another medication, the system will flag the potential interaction. Likewise, the EMR simplifies the tracking of allergies and total contrast dose. This feature is particularly helpful to pharmacy in managing the dosing of renally administered medications.
Transitioning the radiology department to CPOE can be a challenging process given the many unique requirements within the radiology workflow. As such, we faced a few significant hurdles during this process. First, we had to decide and define who can officially write an order for contrast. At OSUMC, any general practitioner (both inpatient and outpatient) can decide that their patient requires imaging. At that point, a radiologist protocols (ie, reviews) the order. We elected to continue to use this protocoling step as the initiation of the radiology order. During this step, the radiologist determines if the scan is appropriate for the patient, if the contrast agent is correct, and establishes the dosage.
Defining when a medication order becomes an official order in the CPOE/EMR system was a similar challenge. Depending on the intricacies or limitations of the CPOE or EMR system, orders may be in a pended mode or sitting in a treatment plan, meaning an order has been placed (and signed) by a provider, but has not officially become an order in the system. This has a significant impact on workflows and system usability, because until it is officially deemed an order, many required actions that must occur in sequence, including pharmacist order verification, cannot occur.
In our current system, an order is not actionable (in normal pharmacy workflows) until it is released by the radiation technologist. Due to the workflow of the radiology department, the actual release does not occur until the patient is ready to receive the contrast medication and the scan, which typically is only minutes before the patient needs the medication. This timing—or lack thereof—has been quite problematic in realizing the full potential of the radiology CPOE system. An ideal approach would allow for verification of the pended or treatment plan order prior to its release and conversion into an actual medication order in the EMR.
Prospective Pharmacy Review
Prospective order review by a pharmacist can be difficult to accomplish for contrast orders. In the past, we have conducted pilot projects where we were able to prospectively review orders, but this approach required adding several steps to both pharmacy and radiology workflows and was not sustainable over the long term.
In one pilot project, conducted in a single unit within the hospital, the radiation technologist was tasked with entering a communication order for the pharmacist when reviewing upcoming contrast patients. Upon receiving this notification, the pharmacist accessed the patient’s record and reviewed the order for appropriateness. The pharmacist had the option of contacting the primary team to initiate pre-hydration to minimize the nephrotoxicity of the contrast when applicable. Ultimately, this project resulted in expanded education for radiation technologists and the development of a screening form to assist the technologist in identifying patients who require pre-hydration or another intervention prior to receiving contrast.
The radiology department utilizes other medications beside contrast orders, including radiopharmaceuticals. Because our in-house nuclear pharmacy dispenses all radiopharmaceuticals to radiology, a nuclear pharmacist prospectively verifies all of these orders. In the previous stand-alone system, this was accomplished by transcribing the protocoled order into the nuclear pharmacy dispensing software and then including a note on the order. In the new, module-based system, a similar process must occur, as the new system cannot conduct the complex nuclear pharmacy dispensing calculations, and there is no interface between the module-based system and the nuclear pharmacy system. In the future, we hope to develop an interface between the EMR and our nuclear pharmacy dispensing system. This would eliminate a transcription step, while still allowing for the radionucleotide half-life dispensing calculations to occur.
Establishing a Distribution Model
Determining the best distribution model for your operation is an important step, as contrast distribution can be managed either by pharmacy or by the radiology department. Both of these models can be successful, so decision-making is contingent on weighing the benefits and drawbacks of each approach. Regardless of the distribution model chosen, both stakeholders need to be active participants in the system design, product selection, and contract management processes.
When pharmacy is responsible for distribution, this allows all medications to be managed by a single department, which easily meets The Joint Commission’s medication management standards and decreases the risk of receiving an accreditation recommendation or citation. For those contrast agents that require sterile compounding, there is a strong argument for pharmacy’s management of the process. Conversely, under the pharmacy management model, there is the potential for increased product waste and time for delivery.
Using the radiology model translates into increased autonomy for the front-line users and quicker turnaround time. Keep in mind that this model does increase the risk of non-compliance with medication management standards; however, this risk can be mitigated through effective pharmacy and radiology collaboration.
In our health system, pharmacy informatics is responsible for building the radiology medication orders, while creation and management of the imaging orders is the responsibility of a builder for the radiology-specific module. The creation of all orders was a collaborative effort between radiology, pharmacy, and informatics. This team approach was key to achieving our two priorities: ensuring that radiology workflows are maintained, while simultaneously addressing all pharmacy regulations.
Creativity was required to accomplish both of these priorities. For example, some contrast agents require an extremely broad range of doses, dependent on the type of scan being performed. Often range orders—particularly wide ranges—receive a great deal of scrutiny from compliance and P&T committees. In this instance, our radiologist protocoling process allowed for a prescriber to pick the actual dose within this wide range, eliminating the need for a range order. Because each organization has its own unique workflow, each hospital must determine how to best approach the varying doses of a single contrast medication. Building out a custom medication record for each type of scan could be a viable option, but may have downstream maintenance impacts within the EMR.
Because most radiology medications are contrast agents that are used alone, the creation of the imaging orders did not require a significant amount of grouping. However, it can be beneficial to group any pre-medications with the contrast order. Additionally, any medications that would be used in the event of a reaction to the contrast or diagnostic agent can be grouped into the order as well. It is important to note that many accreditation bodies have identified radiology orders as a high-risk area in terms of medication safety. Proactively grouping orders can be an effective way to demonstrate that radiology orders are managed according to medication management standards.
Perhaps the most significant benefit of implementing CPOE for radiology orders is its impact on post-dose drug-drug interactions. Consider the implications of proactively adjusting medications that require dose or interval adjustment in response to the patient’s renal function. Being aware of a recent contrast administration allows the pharmacist to prospectively adjust the dose and avoid an adverse event resulting from a supratherapeutic level. Ultimately, the expansion of CPOE to cover all contrast orders delivers a significant boost to patient safety efforts.
Ryan W. Naseman, PharmD, MS, is the assistant director of pharmacy and infusion services at The Ohio State University James Cancer Hospital in Columbus, Ohio, where he manages the ambulatory infusion program, investigational drug services, and nuclear pharmacy. Ryan received his PharmD from Ohio Northern University, and an MS in health-system pharmacy administration from The Ohio State University while completing a combined PGY1/PGY2 residency in health system pharmacy administration at The Ohio State University Wexner Medical Center. His professional interests include automation and technology, workflow/efficiency and productivity analysis, and hematology/oncology pharmacy practice.