New & Improved!

Physicians Order Management Systems: Workflow Efficiency
December 2007 - Vol. 4 No. 12

How do you measure the time it takes your pharmacy to perform order entry? The clock should not start with the physician writing the order, as pharmacy does not have yet access to it. Rather, the clock should start when the order is made available to the pharmacy. The starting point may be when the nurse or unit secretary pulls an order from a patient’s chart and places it in the outbox or sends it via vertical drop tube, pneumatic tube, fax machine, scanner or another delivery method. Of all of these systems, there is one that can give you the most accurate measure of your order entry turnaround time, from the start of process to the completion of order entry: a scanner-based physician order management system (POMS) that can time stamp each medication order upon being scanned and sent to a pharmacy computer, being reviewed by a pharmacist, and upon completion of order entry.

 
These capabilities allow you to accurately measure how long it takes to perform each portion of the order entry task. You can also run reports by nursing station or the overall hospital to uncover trends related to medication order turnaround time. With this information, you can present hard data to administration, nursing, and physicians regarding how long it takes to enter orders, improving pharmacy accountability for medication order turnaround times, eliminating the need to discount estimated turnaround times, allowing pharmacy administration to respond to complaints that pharmacy caused a delay in therapy.
 
How Does a POMS Work?
An individual on each nursing unit, either a nurse or unit secretary, is responsible for scanning orders to the pharmacy. Scans are sent over a computer network to a server or computer, where they are stored. The server informs pharmacy of the number of orders and the locations they have been sent from. Scans can be sent to particular pharmacy satellites or to the main pharmacy. A system that allows orders to be directed to pharmacy satellite areas, when they are open, can also improve workflow and order turnaround time. For maximum visibility and workflow efficiency, pharmacy can use a dual-screen monitor to view both the electronic order and the pharmacy information system simultaneously. Pharmacy links orders to patients in the pharmacy information system, and when all of the orders on the order sheet have been entered, the sheet is marked as completed and the system presents the pharmacist with the next electronic order sheet on the computer screen. Completed orders can be retrieved electronically for further review.

The Benefits of Using a POMS
The pharmacy stands to benefit from investing in a POMS in numerous ways. First, as orders are sent directly to the pharmacy, staff no longer needs to visit each nursing station to pick up orders. The time saved can be used to improve the efficiency of other pharmacy functions, such as medication deliveries and unit dose packaging. Second, these automated systems can provide pharmacists with quicker access to medication orders. Third, the organization can realize immediate costs savings by eliminating the need for carbon or NCR order sheets.
In addition to improving workflow efficiency, these systems can pay significant patient safety dividends. A POMS can provide clearer orders than those sent to and printed in the pharmacy from fax machines. The scans pharmacy receives are 300 to 600 dpi (dots per inch). This high resolution gives the pharmacist the ability to enlarge portions of the order to clarify what has been written; you can more easily determine if a mark on the order is a decimal point or a minute smudge, for instance.

The system should also allow pharmacists to document problems with orders on the electronic file, creating a trail of documentation. Using the POMS, pharmacy can then send “problem” orders back to the originating nursing unit, where they can be printed on a scanner/multifunction printer, for clarification. Electronic orders can also be printed to local printers to create a paper trail, if necessary.

A highly functional system enables pharmacy to enter keywords to report on the occurrence of unsigned and illegible orders, which can be helpful in reporting on these issues to your physicians. For example, the POMS should have a field that allows the pharmacist to enter a few words that clarify the problem (i.e. “no signature”, ”illegible,” etc.) so that any pharmacist answering a call to the pharmacy can quickly identify the issue and work with the caller (physician or nurse) to resolve the problem. The system should also allow pharmacy to run reports, sorted by keyword, to identify prescribers whose orders frequently have a particular problem.    

Using a networked computer, nurses are also able to access the pharmacy’s work queue, cutting down on “order tracking” phone calls between nursing and pharmacy that can distract pharmacists during order entry and ultimately lead to errors.

Furthermore, since orders can be retained online for years, current orders can be compared with previous orders for patients with extended and recurring stays, such as patients on oncology protocols. This capability alone can save time by allowing the pharmacist to enter orders without having to call the prescriber for clarification.

Purchase and Implementation Tips
Once you have decided to install a POMS, what should you look for in the system? First of all, the entire system – from the scanners to the server software to the pharmacy interfaces – should be user-friendly. Invite team members into the discussion and gather their opinions of each system’s usability. The system should also be flexible enough to work within your pharmacy’s existing workflow. However, keep in mind that there will be changes to your pharmacists’ order entry tasks, including the following:

•Establishing a new workflow dependent on the nursing units that each order entry pharmacist is responsible for

•Working with two computer screens

•Linking orders between the pharmacy information system and the POMS (Pharmacy technicians can be trained to link the orders, provided it is allowable under state law.  Technician order-linking can improve patient safety by having two people – a technician and a pharmacist – look at the patient name and admission number. This is particularly important when you have two patients with similar names or the same name, as often happens in the NICU with twins.)

•Watching for STAT orders, even if they automatically go to the top of the work queue

•Switching to another work queue to aid other pharmacists during times of heavy order volume

•Using the “zoom” function to clarify handwriting

•Annotating orders 

•Sending problem orders back to the originating nursing station

After making the final system selection, there are several steps you can take to ensure a smooth transition to POMS-based order entry. First, determine the data sets for which you will want pre- and post-implementation information. Baseline statistics should be accumulated if possible, requiring you to first identify what should be measured, as well as the start and stop points for the study. In gathering baseline data, only include portions of the process that involve the POMS. For instance, instead of studying how long it takes for nurses to pull orders from patient charts, collect data on how long it takes pulled orders to make it to the pharmacy via your current delivery method.

Also begin thinking about the processes – in pharmacy and in other departments – you may need to review or change to accommodate the system. For instance, look at the physical layout of the pharmacy: It has probably evolved to accommodate your current, paper-based system. What changes can you make to give your staff the tools they need to do their jobs well? Can you move your order entry pharmacists to a quieter area? Since change is inevitable when implementing a POMS, look for ways to maximize the benefit you will derive from it. For instance, install the scanner in a location that facilitates the efficient scanning of orders. If the scanner is more than an arm’s reach away, the unit secretary may set orders aside and wait to scan them in a batch, thereby delaying order entry and negating the workflow efficiency benefits of the POMS.

It is also wise to appoint a project leader from the pharmacy department and involve stakeholders from nursing and IT early in the process. Policies and procedures must be developed that delineate the functions and responsibilities of each stakeholder, such as:

•Who will maintain the scanners?

•Who will order and replace the toner cartridges in the printers?

•Who will have primary responsibility for scanning the orders?

•Who will check the printer for orders sent back for clarification – and how often will that person do so?

•Who will be notified if a scanner malfunctions, and who will be responsible for rectifying the situation?

•Who will notify IT of a network or PC problem?

•Who will be the frontline person for problems in pharmacy?  It should not be a staff pharmacist who is entering orders, as this will delay the order entry process further.

•How will computer monitor problems be handled in pharmacy?

•Who will notify stakeholders of any system downtime – planned and unplanned?

•What is a reasonable response time for IT to respond to issues? Remember, they are not patient-care oriented and may feel that a printer issue on a nursing station can wait until morning.

Because your POMS may be in use 24/7, system support must be available on all shifts and in all departments.
Working with IT, determine where the POMS server will be located. It is also vital that you develop a back-up plan for system downtime prior to implementing the POMS. For instance, if fax machines are available on the nursing units and in the pharmacy, it may be easiest to use them to send orders to pharmacy, versus using a courier.

Also determine who will run the system’s reports and look for ways to make the process more efficient. Since pharmacy will be responsible for evaluating and disseminating most of the information in the reports, the report-generating system should be available in pharmacy. The system should also allow you to create or modify reports to provide activity and time values by nurse station or pharmacist. The time range for the reports should be able to accommodate any period, from one day to a month or more.

Training is also an important issue. Ask your vendor for in-services and designate a member of your onsite personnel as a system specialist for ongoing training and troubleshooting. And although scanning may seem to be a simple function, your nurses and their support staff will have to be adequately trained and understand what is expected of them – the timely scanning of medication orders. Everyone must be trained to remember the reasons for implementing the POMS: improved patient care and safety.

Conclusion
A POMS is a valuable, relatively easy-to-implement, and effective tool for benchmarking your success in providing timely order entry. By implementing a POMS, your pharmacy also stands to improve medication order turnaround times, as well as patient safety and overall efficiency within the medication order entry process.


 Most recently the pharmacy manager for informatics at Baptist Hospital of Miami, Harvey S. Fields, RPh, now serves as a consultant with Pharmacy Informatics, LLC, based just outside of Fort Lauderdale, Florida. Fields has also served as the pharmacy supervisor for Maimonides Medical Center in Brooklyn, New York. He earned a BA in biology from New York University and a BS in pharmacy from Columbia University College of Pharmacy. Fields can be reached at harveyf.llc@att.com.

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