This blog is the second in a series on "Maintaining Disparate Systems." In the first post we reviewed the definitions and terminology commonly used in healthcare information technology and, more specifically, pharmacy information technology. This post focuses on the complex challenges of maintaining your formulary and synchronizing it across multiple databases.
The “ASHP national survey of pharmacy practice in hospital settings: Prescribing and transcribing – 2013” reported the following results:
- 60.4% of hospitals enforced strict formulary systems.
- 92.6% of hospitals implemented Electronic Health Records (EHRs) partially or completely [up from 67% in 2011].
- 65.2% of hospitals use computerized prescriber-order-entry systems with clinical decision support [up from 34% in 2011].
- 80% of hospitals have barcode-assisted medication administration systems [up from 50% in 2011].
- 80.8% of hospitals have smart infusion pumps [up from 68% in 2011].
- 93.9% of hospitals have electronic medication administration records (eMAR) [up from 67% in 2011].
- 60.7% of outpatient clinics use EHRs; 59.6% of these use electronic prescribing to outpatient pharmacies.
- 89% of hospitals used automated dispensing cabinets (2011).
- 11% of hospitals used robots (2011).
- 18% of hospitals used carousels (2011).
**(2013; n=1433 hospitals, response rate 28.9%; 2011 n=1401, response rate 40.1%):
This survey clearly illustrates that hospital pharmacies are embracing the use of technology to improve workflow, efficiency, and patient safety. The challenge is to maintain accurate drug information across all of these platforms. Each of these “disparate” systems contains its own drug database that requires continual maintenance. The “source of truth” is the formulary or pharmacy drug master embedded in the pharmacy information system (PIS). Any additions/deletions/edits to the PIS formulary, but be maintained across the downstream drug databases.
First Layer of Complexity – Maintenance of the Pharmacy Information System Formulary
The complexity starts with the maintenance of the pharmacy information system drug database (for ease of terminology, we will call this the “formulary”). Even if a hospital has only one location with one formulary, manual maintenance is required to add/delete/edit the content of that database. Sources of changes to the formulary include:
- P&T-approved additions and changes
- Source Drug Database (e.g. NDDF, Multum) monthly updates
- Changes/updates to evidence-based order sets
- NDC changes
- Management of drug shortages
This becomes more of a challenge with multi-entity systems. We had one client that consisted of 22 acute-care hospitals across the country. Instead of having a formulary, individually managed by each facility, the organization underwent the herculean effort of “standardizing” the formulary across all 22 facilities, with one person responsible for the maintenance of the formulary for all facilities. If possible or practical, this is the recommended practice in multi-entity systems.
Next Layer of Complexity – Maintenance of “Downstream” Systems
After the PIS formulary is accurately maintained, the challenge is to synchronize any changes to the formulary with the “downstream” systems, such as automated dispensing cabinets, robots, carousels, smart infusion pumps, barcode medication administration systems, electronic health records, and IV preparation devices.
Some vendors have created unidirectional interfaces between the PIS and their application (e.g. automated dispensing cabinets, robot, and carousels) to receive drug database additions/edits. Others have not. The challenge is that the data schema required by each of these systems may be different from the data available in the PIS formulary. Additional data may be required to populate the drug databases in these systems, thus manual editing of the drug database is required.
In a webinar hosted by ASHP, it was noted via online polling that 78% of participants rely on manual processes to support formulary maintenance, taking 10+ effort hours per week. Based on this survey, it could cost an organization ~ $10,000 - $29,000/year [10 hours x 52 weeks x $20/hour for a technician, $55/hour for pharmacist]. Extrapolating this across 5,000 hospitals nationwide, the cost is astounding ($52 – $143 Million).
Manual editing creates potential for errors. Brookins et al state the concern succinctly. Manual maintenance of drug databases has the following issues:
- Safety – Each manual keystroke required for formulary-database updating adds to the risk of data-entry error.
- Resource intensiveness – Highly trained personnel are required for the maintenance.
- Synchronization – Until all manual changes are complete, downstream systems are out of sync with updates, potentially leading to medication errors.
- Inconsistent matching – Manual synchronization may not be timely, creating the potential for medication-related errors in pricing or patient care.
What To Do Next?
At this point, formulary maintenance across disparate systems requires some level of manual maintenance of the requisite drug databases. With this, we must limit the potential for error by limiting the access to change/edit the drug databases to a limited number of highly trained professionals within your organization. These professionals are accountable for the maintenance of the PIS formulary and all other databases that are connected to this “source of truth.” In the meantime, ASHP has issued a Call for Action to the vendor community to place a priority on standardizing a formulary data structure that allows interoperability across all applications that depend on the PIS formulary.
You may also like: Definitions and Terminology - Pharmacy Database Management
ASHP national survey of pharmacy practice in hospital settings: Prescribing and transcribing—2013; Am J Health-Syst Pharm—Vol 71 Jun 1, 2014.
ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration—2011; Am J Health-Syst Pharm—Vol 69 May 1, 2012
Formulary and database synchronization; Am J Health-Syst Pharm – Vol 68 Feb 1 2011
Automation and improved technology to promote database synchronization; Am J Health-Syst Pharm – Vol 71 Apr 15, 2014
Section on Pharmacy Informatics and Technology, ASHP Webinar: Let’s all stay connected – Interoperability of Multiple Electronic Medication Formularies