Healthcare software: Thoughts on usability

Yesterday at the Build developer conference, Microsoft unveiled the next version of Windows to developers from around the world.  Windows 8 has received a great deal of press over the past few months, with usability among the mantras.  I am always interested in finding ways to improve the user interface for consumers.  In the case of electronic health records (EHRs), organization and simplicity are thought to play a role in improving safety and productivity.  Reviewing the general layout of some of the top certified EHRs in the country has left me desirous of a cleaner user experience. 

We expect the systems to check for allergies, allow documentation of clinical impressions, or display critical lab values.  However, we haven't really provided input to the vendor community on how these things should be shown.  There are a number of lessons everyone in healthcare technology can learn from our counterparts in mainstream operating systems. This 90 minute developer video does a great job of showing just how much thought and resource IT companies are giving to the user interface.  Some might argue the certification criteria should include usability measures, and we will most likely see healthcare software migrate to this thought process in the future.  After all, it has taken the largest software company in the world over 25 years to gain the necessary experience.   

Certainly we need to understand more about who needs to see it, where/when should it show,  and what should it say.  The information has to be meaningful and actionable, but it also needs to be clear.  We try to show so much information to providers and clinical staff, sometimes we may be doing more harm than good.  In Pharmacy Informatics, missing one piece of information in a sea of text can have dire consequences.  it is our job to help vendor's understand just how important the user experience is to safe and effective patient care.  I personally am looking forward to the journey with our vendor and clinical partners. 

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When should we teach students about Pharmacy Informatics?

The timing of student Informatics exposure came up in a recent discussion with Doina Dumitru, an Informatics colleague and editor of The Pharmacy Informatics Primer.  We were approached by a well known college about the possibility of offering an elective Pharmacy Informatics course to students.  You can imagine our excitement and enthusiasm for this request.  We started charting out the curriculum and lecture topics, as well as appropriate class timelines.  Initially we hoped to offer this during the summer of the student's second professional year, but quickly came to realize some challenges.  

First, students lacked the pharmacy practice experience to understand much of what we taught.  Informatics is an extension of the clinician, a way to take our experience and build it into computers.  Students just don't possess the knowledge to absorb the implications or reasons for Informatics decisions.  Informatics is about our practice experience, not about being an IT person.  The IT skills are necessary, but secondary.  Pharmacy workflows, regulations, and clinical practice play a big part in our decision making process.  Paralleling the importance of these points to pharmacy curricula, we realized the students would not be ready for an entire Informatics course until a portion of their final clinical rotations were complete.  While there may be an exemplary example with years of pharmacy technician or externship experience, it was not enough to justify a course.  

Integrating a handful of lectures on Informatics topics into a required management course might be a better alternative, but what about the lecture content?  The topics should focus on well known, high impact subjects such as Meaningful Use, the HITECH portion of ARRA 2009, and the overall impact of technology on pharmacy practice.  How has technology shaped our profession over the past 30 years?  What does Meaningful Use "mean" to the practicing pharmacist?  How can pharmacists help their institutions and colleagues in healthcare with adoption of medication use methodologies in information systems?  What is an electronic health record and how do medications flow through them?  Topics such as automation technologies, downtime, data mining, and report writing came up in our discussions, but the group felt like they would be perceived as low impact lectures.  In student speak "we will watch the lecture on video and sleep in a few hours."  

The next topic was on how many hours of content the lectures would provide.  The topics need to be targeted, high impact discussions that spark interest in the profession.  They need to grab the student's attention and flip a few light bulbs to the "on" position.   This is still an open discussion, but I would estimate 6 hours to cover the high impact topics.  

Students are a precious resource, and represent our legacy.  It is important for us to develop their exposure to Informatics in an interesting and paced manner.  I welcome your comments and questions.  

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Do we see only what we want to see in EHRs?

I was recently informed of a situation in which a high alert medication was programmed incorrectly, causing a gross rounding error to occur. Certainly the system could have been checked more carefully before implementing the changes, but what about the physician, pharmacist, or nurse? In this case the physician missed the rounding calculation (although shown on the ordering screen below the ordered dose). The pharmacist, our medication expert in the hospital setting also checked the order in the EHR without question. Luckily the discrepancy was caught by a completely unrelated test order, or ADEs could have resulted. Have we become so trusting of what shows on a computer screen that we don't question the content?
The power of the suggestive mind is not new to humans. It helps us fill in the blanks on those fun crosswords and MadLibs, and with those difficult co-workers. However, when it comes to the power of suggestion in electronic health records, seeing what we want to see may potentiate errors. This lab order is always twice daily, why should I pay attention to it after ordering it 15 times? The TPN order has always defaulted to 2000ml, can't I just skip review of the field? On rotation, my students are informed of this critical vulnerability in the healthcare computing age. We must use our minds to be sure what we see in a computer, in a book, or on the news makes sense. In our profession, we cannot take the computer's word for it. After all, it was programmed by a human and we are all aware of our nature. As we continue to learn more about technology adoption in healthcare, we will become aware of these pitfalls. In the meantime, we must remain diligent and ever questioning.

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When does the journey begin?

To Meaningful Use, of course :)  

This piece on HCR Blog provides some wonderful insight into what it really means to use EHR technology.  Think of a long hall with a doorway at the end.  Although the implementation of EHRs might be that long journey down the hallway, and the door is golive..........   Once we step through we "see the light" and the real task at hand:  Turning this technology into better patient care.  

After golive your journey is just beginning, and organizations should put more emphasis on this than the implementation itself.  How do we make things more efficient and safe for healthcare providers?  How can we leverage technology to solve logistics issues and improve patient throughput?  How can the pharmacist use CPOE to communicate formulary and safe medication choices to providers at the right time and place?  

It was just an outstanding revelation for me to hear this again.  It is so important to this transition.  We must keep it in perspective.  

Should institutions wait to start Meaningful Use?

A very interesting post at Thehealthcareblog on Meaningful Use, and why it might be wise to take a deep breath before a mad rush for implementation.  Protima Advani has some very good points, may of which are relevant to pharmacists.  A week or so ago we talked about what Stage 2 and 3 could mean for the pharmacist.  Taking many key points from the article, it might be advisable to wait for more standardization and codification of data.  In fact, some might recommend waiting as long as you can before implementation to ensure better adoption by HIT vendors.  RxNorm is a current front runner for medication naming, and some data vendors are already supporting its translation database.  However, we have a long way to go for codified Allergies, SIGs, and other components of medication order transmittal.  

Most of meaningful use regarding medication use surrounds prescribing and actively maintaining pertinent information in patient specific lists.  Without codification, it will be very difficult to achieve what many pharmacists consider true meaningful use of medication information.  However, meeting the standard might be a few measures lighter.  

One of the more critical points in the article surrounds adoption timeframes, and suggests that because the "first" year does not necessarily have to be 2011 it might be prudent to wait to implement.  This is certainly a valuable agrument, but as a pharmacist I would challenge with advocacy for patient safety.  Many hospitals and health systems are integrating EHRs this year, and meaningful use goes a long way in helping guide them to better patient safety.  Providers and nurses are not accustomed to doing their work in computers, and this presents a risk to patient safety.  As a pharmacist the more I can do to prepare my EHR, CPOE, eMAR, BCMA, and supporting systems for appropriate use, the better off patients will be.  However, we should not sacrifice safety for speed of implementation.  If you need the time, take advantage of it to improve the deliverable.  

ASHP Releases Statement on Barcode Verification

ASHP recently released a statement on barcode verification of product in the pharmacy.  As many of us are aware, barcoding at the point of medication administration (BCMA) is a common, albeit controversial technology that many hospitals and health systems are installing or evaluating.  Barcode verification is considered by some to be a necessary precursor for successful BCMA implementation, as it adds a safety validation step to medications as they are put into pharmacy inventory, or removed to be used in auxiliary dispensing mechanisms.  This initiative can also improve BCMA compliance by forcing the pharmacy to develop a workflow for ensuring 100% of products that leave the pharmacy are accurately barcoded.  This type of barcoding process is an intensive undertaking for many pharmacy operations, requiring inpatient operations to re-distribute personnel to meet the demand of touching every product without a barcode.  Some medications are already barcoded for us by manufacturers, others get a barcode from our Pharmacy Information System when patient specific labels are printed, and the rest require the manual addition of a readable, standardized barcode by a human or automated device.  Pharmaceutical distributors many also offer barcoding/repackaging programs, allowing pharmacies to purchase repackaged and barcoded medications in ready to use containers for a fee.  

The inventory verification step is an important and often overlooked technology by many organizations that are faced with EHR adoption or meeting Meaningful Use.  Overall a very well designed position statement by my friends, colleagues, and ASHP.  If you would like a copy of this statement, please contact me.  

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How much longer can pharmacists distribute medications?

Every once in awhile stories about healthcare automation reach the mainstream media.  What better time to discuss the impact of automation on pharmacy practice!  

From USAToday.com 

Even administration of some medications is being done by robots in the US.  The entire supply chain for pharmaceuticals is the perfect opportunity for automation companies to develop robotics.  We have automation to prepare almost all meds that come from the pharmacy and package them in ready to use containers.  We have robots that can deliver (on time) medications to patient’s and document they received the drug.  There isn’t a great deal of the distributive process that can’t be done by automation. We continue to cling to an archaic practice that, although important is repetitive and mundane in many ways.  These are the types of processes that automation and robotics are great at reproducing.  We have seen it in other industries such as banking and automobile.  With the push of Meaningful Use and Electronic Health Records, how long before a hospital administrator figures out using robotics and technicians can allow him to lay off 70% of the pharmacists in central distribution?  How long before one of the large retail chains lobbies state legislatures to allow technicians to check prescriptions entered by a physician electronically?  How long before retail pharmacy is run by robotics and technicians?  

The longer we rely on pharmacists to run the entire supply chain, the higher our risk of obsolescence. 

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What is Pharmacy Informatics: Student Perspectives

Every once in awhile I am overwhelmed at the extent to which certain pharmacy students understand informatics.  Recently I had the pleasure of working with Ben Philip, an outstanding student from Texas Southern University College of Pharmacy and Health Sciences.  With minimal experience over a 4 week rotation, I asked Ben to put together a presentation to describe what he felt Informatics was about.  Attached is his answer.  

Personally I find the presentation to be well designed both aesthetically and didactically.  Ben did a wonderful job laying out what many of use continue to deliberate in our small circles.  Please join me in congratulating Ben for an excellent view of our profession.  

What is Pharmacy Informatics?  Let us know what you think.

What is pharmacy informatics 02-08-11.ppt Download this file

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AJHP Commentary on ePrescribing

E-prescribing: One giant leap toward pharmacy practice integration

Mark offers a very well developed piece on how legislation attempts to help, what types of barriers we need to overcome, and the importance of interoperability.  

In the past 10 years, one of my favorite words has become "interoperability".  It explains so much of what we strive to create in the healthcare technology sector, yet remains one of our biggest challenges.  One of the major design flaws with federal regulations regarding ePrescribing was the naivety of pharmacy practice.  Appropriate workflows and order processing steps in the pharmacy setting were not reviewed in the pilot study, nor were they addressed in the rule with gusto until the comment periods opened to the pharmacy community.  This leaves the pharmacy profession with questions and concerns about how to implement, utilize, and encourage our vendors to support ePrescribing.  A great example of this is ePrescribing for controlled substances.  We have a federal rule, but no vendors on the market can support the requirements to date.  My experience in technology tells me you don't typically want to create policies without really knowing what developers are capable of building.  Policy development is based on knowledge of practice and process.  This of course includes how pharmacies are using electronic prescribing technology, what they are using it to do, and where they need improvement in workflow.  

Please do not mis-interpret my widespread support for the electronic prescribing initiative.  I understand and recognize its importance in creating a unified electronic health record.  However, we have to be very careful not to segment information even further by allowing data to run rampant and un-checked by professionals.  Often times humans are still accustomed to putting garbage into computer systems just to get to the next step.  With drug formulary checks, cross checking drug duplicates, and reviewing medication profiles it can get out of hand quickly.  

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Meaningful Use Stage 2 and 3 Comment Period Comes to a Close

On 2/25/2011, the HIT Policy Committee closed the comment period on Meaningful Use stage 2 and 3 standards.  

A few of the measures apply directly to what many Pharmacy Informatics professionals are dealing with today, including:

1.  CPOE for med orders - This objective is still fairly easy to obtain if you have any manner of CPOE in place.  It only requires 1 med order for 80% of patients to be electronically entered (not transmitted)

2.  Drug-drug/drug- allergy interaction checks - lack of standards among data vendors, as well as practice differences makes this one very difficult.  Luckily there are no real measurements, save stating they must be enabled on "appropriate evidence-based interactions".  I am assuming the interpretation of "appropriate" is up to the individual institution.  

3.  ePrescribing - Stage 3 is proposed at 80% of outpatient and discharge prescriptions.  Depending on current levels of adoption, this could be difficult.  

4.  Maintain active medication list - This is somewhat ironic, requiring 80% of medication lists to be up to date.  The irony entails the fact that most often the longer institutions have been live with physicians managing medication lists, the more inaccurate they become.  Therefore those adopting closer to the stage 3 requirements will actually have cleaner lists, unless major cleanup efforts are undertaken.  A great deal of work is ahead of institutions that have been live for years.  Of course we can interpret the "up to date" requirement to mean someone has looked at it, but personally I would take it one step further and state it must be both accurate and up to date.  

5.  Maintain active med allergy list - Similar to #4, this objective gets worse the longer you are live, unless corrective measures are in place.  Not to mention the lack of standardized allergy nomenclature in information systems.  I apply the same comments regarding "up to date" as in #4.  

6.  Implement drug formulary checks - ePrescribing is becoming more common at facilities, but as we have seen in recent commentary, it still presents a standards challenge.  If you would like a copy of Mark Siska's wonderful comments on ePrescribing in general, please email me.  

7.  [NEW] Inpatient med orders are tracked via eMAR - The proposed stage 3 requirement includes 80% of medication orders.  Take into consideration floor stock items, flushes, and those that even currently use eMAR may have to do some work to meet the requirement.  For those that still print paper Medication Administration Records, start talking with your IT department now.  

8.  Patient centered electronic access to medical information - Although not directly related to medication, Personal Health Records currently allow for medication lists to be viewed.  When you implement patient portals, be sure to work with your IT department to review the accuracy and usability of the medication information shown.  

9.  Medication Reconciliation - In Stage 3 the requirement rises to 80% for transitions of care.  The interesting verbiage here places the burden on the receiving provider during a transition of care, not the sending provider.  Some system re-engineering may have to take place if EHRs only support the latter.  

10.  Immunization data submitted to IIS -  Immunization records can be difficult to tame, and transmission of data entails some data quality measures to keep things in order.  Like # 3 and 4, the longer lists have been allowed to be populated without quality monitoring, the more cleanup required.  

Overall, the progression of objectives is fully supported by this Informatics Pharmacist.  However, the lack of standardization, challenges of EHR workflow in practice, and shear amount of work needed to meet the requirements is daunting.  Best of luck to us all, but we can certainly agree we are headed in the right direction.  

MU_Stage 2_RFC _2011-01-12_final.pdf View this on Posterous

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