Laying the Foundation for a Successful e-Prescribing Implementation

With adverse drug events and prescription fraud climbing to alarming heights, and $19 billion dollars designated for healthcare IT through the economic stimulus package, hospitals are taking a serious look at moving forward with electronic prescribing.  The opportunities to enhance patient safety and drive down the substantial costs associated with medication errors and prescription fraud make the prospect very attractive.

For some, the timing may be right.  Others may need to first step back and assess their readiness -- examine current workflows, consider how e-prescribing will impact those processes, determine what changes will need to be made and how to address them.  

“Paper-based prescribing systems have evolved over time. Though the basic processes may have been documented somewhere, many small nuances have not been written down.  It’s the people side of the process – how you do it, where you place it on the chart, whether you use a label or a multi-part form -- that must be understood,” explains Jay Frerichs who directs Standard Register’s prescription programs.  His experience as a hospital IT insider has given him first-hand understanding of workflow management in healthcare.

“A primary goal of any technology-fueled clinical workflow change should be to replace paper forms with electronic forms that can be generated as needed.  However, you need to be aware and sensitive to the impact these changes have on patients and clinicians.  Make certain you understand the flow of the current process and what downstream activities have a dependency—especially diagnostic activities.  Few things can complicate your day more than a frustrated or worse irate nursing staff,” Frerichs said.

This article is aimed at enhancing understanding of the e-prescribing process and offering helpful suggestions to help ensure a successful implementation.

Understanding e-Prescription Workflows
The concept of e-prescribing seems simple enough. It combines a data-entry process with drug utilization review (DUR) software that checks the prescription against other medications the patient may be taking as well as known allergies. These e-prescriptions can then be printed and filled in the traditional manner or transmitted electronically to participating pharmacies.

The table below provides a high-level view of each phase of the e-prescribing process and the related workflows that will need to be examined in advance of automating processes.

The Ying and Yang of e-Prescribing
Each of the Prescribe-Deliver-Dispense phases impacts workflow and delivers value to different parties as outlined in the chart below.  At the same time, each phase presents new challenges which hospitals will need to address in their transition plans.  While your primary focus may be the prescribing process, the delivery and dispensing processes require collaboration between the hospital and outside pharmacists.  You’ll need to consider how you will facilitate the dispensing process for discharged patients and what controls may need to be put in place to maintain system security.

There is no one-size-fits-all approach to addressing the challenges. The final solution will be unique to each hospital system -- its layout and facilities, as well as its clinical and operational processes, the preferences of its leadership as well as local regulations.  And that’s why proper planning and preparation are vital to a smooth implementation.

Setting the Stage for e-Prescribing
Frerichs offers six suggestions to help set the stage for your e-prescribing initiative:

1. Simplify First.  Prescribing is a core function in a hospital.  You need to look at basic processes.  A lot of facility-specific practices have grown up around handling prescriptions and medication records. They’ve been honed to get the job done accurately and quickly in a paper-based world. Trying to make technology emulate an existing paper process that consists of multiple form sets is complex, and from a software developer’s perspective, it’s likely to have limited reuse from customer to customer.

   You want to first streamline the process, consolidate forms and replace paper with content delivered electronically by dynamically-managed business rules.  In doing so, you’ll build clinician familiarity with your future technology vision and positively impact clinical workflows. This gives IT an important foundation, building credibility and trust among stakeholders who are concerned about how technology will impact day-to-day operation of critical areas of care. 

2. Create a Team to Lead the Effort.  The desirable approach is to create a cross-functional team comprised of people who are willing to make the extra effort to solve problems that will arise without drifting from the core objectives.  Having the right people on the team will help you build consensus and drive adoption.  That means giving clinicians and support staff a central role.  They know the processes first hand and will be living with the changes that are made.  Current processes must be discussed in light of the technology that’s coming forward. You want to acknowledge all the things they’re doing today and challenge the team to find a way to do it without the heavy use of paper. One of the positives of involving all stakeholders in creating a solution is that when it comes time to implement, you have a core set of credible people who can help drive adoption among their peers.

3. Set Criteria for Decision-making.   As planning begins, there will be forks in the road where you have to make choices.  Decisions will need to be made to possibly eliminate a step in a process or find a way to address it with technology.  Those are decisions you have to make together lest you risk patient safety, someone sabotaging the process or slowing adoption. You need a set of criteria people agree on in advance, so decisions can be made swiftly and consistently.  Certainly, cost will be part of the criteria, but in addition, look at your hospital’s core value statement for guidance.  It’s likely to provide additional criteria to assure the decision-making processing aligns with the hospital’s mission and the goals it seeks to achieve, for example a desire to meet the Joint Commission’s National Patient Safety Goals.

4. Implement Department by Department.   Inpatient, Outpatient and Emergency departments, each have distinct workflows and are likely to present their own challenges. To keep the implementation manageable  focus on one department at a time.  Assess and streamline processes. Establish a two-for-one rule where for any one thing you make worse, at least two other things are improved in the perception of the majority of stakeholders.  You want to ensure that each phase of the rollout produces a net positive effect. Create the expectation that you will test and tweak to assure you have a new workflow that can survive peak hours.  With each success, you’ll gain champions, help build confidence and reduce resistance among those departments who are yet to be implemented. 

5. Get Good Sponsorship Early and Keep Them Updated on Progress.  There will be certain situations when you have a facility or department that’s heavily resistant to change and you simply must focus on the area where you have the most to gain and proceed with the implementation without their initial support.  That’s when you need strong, sponsorship, someone with the authority and respect to make it happen, such as the medical director, director of pharmacy or nursing officer. This relationship must be cultivated early and continually developed throughout the project and, candidly, your career.  The perspective and insight gained often is priceless.

6. Measure and Follow Up   Make it clear from the outset what you’re trying to achieve and what impact you expect it will have for that department.  Put metrics in place– quality measures such as adverse drug events, patient days in hospital as well as efficiency measures related to the time it takes to complete specific tasks.  Then track and share results with affected departments regularly. Likewise, review processes as problems arise.  When metrics fall short of expectations, get to the root cause fast.  Make sure the people impacted by technology change have a voice to the organization about the good, the bad and the ugly.  Follow up and make sure you address all the negatives even if they are related to a technology roadmap delivering in 18 months.  Share these outcomes broadly as your rollout continues.

The Journey Begins
“The path to fully-implemented e-prescribing is fraught with challenges, particularly in the delivery and dispensing phases which involve broader issues spanning the entire country,” Frerichs acknowledged. “However, a hybrid solution leveraging the DUR capabilities of e-prescribing while retaining the flexibility to print prescriptions as required by patients delivers considerable value.  It will enable you to positively impact prescribing errors and sentinel events while reducing opportunities for forgery and counterfeiting of prescription forms,” he concluded.

For guidance in your transition to e-prescribing, contact us now.  With experience in both paper-based and digital processes, and expertise in prescription security, our healthcare sales professionals can offer helpful insights and recommendations.