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1939Am J Health-Syst PharmVol 66 Nov 1, 2009

c a s e s t u d i e s

Implementation of home-based medication orderentry at a community hospital

AliciA Thorne, SArAh WilliAmSon, TArA JelliSon, And chriS JelliSon

AliciA Thorne, PhArm.D., is Sta Pharmacist, Cleveland Clinic,Cleveland, OH; at the time o writing she was Postgraduate Year1 Pharmacy Resident. SArAh WilliAmSon, PhArm.D., is ClinicalPharmacistInternal Medicine; TArA JelliSon, PhArm.D., is Clini-cal Pharmacy Manager; and chriS JelliSon, PhArm.D., is PharmacyManager, Parkview Hospital, Fort Wayne, IN.

Address correspondence to Dr. Thorne at 9500 Euclid Avenue,

Hb-3, Cleveland, OH 44195 ([email protected]).The authors have declared no potential conicts o interest.

Copyright 2009, American Society o Health-System Pharma-cists, Inc. All rights reserved. 1079-2082/09/1101-1939$06.00.

DOI 10.2146/ajhp080545

Problem

Factors contributing to the provi-sion o optimal patient service by

the pharmacy are order turnaroundtime, accurate order entry, accuratemedication dispensing, and provid-ing amicable, helpul, and exemplaryoral communication.1-3 The largevolume o medication and clinicalconsultation orders requested othe pharmacy can hinder the con-tinuous provision o excellent patientservice.4,5 Thereore, a relationshipmay exist between quality o phar-macy services and overall medication

order volume. A spontaneous surgeo medication orders, deined asperiods when the rate o incomingorders signifcantly exceeds the ratein which orders can be processed,can overwhelm the pharmacy staand lead to less-than-optimal patientcare.

One option or maintaining op-timal patient service during thesesurges is the use o remote medica-tion order entry in which a pharma-

cist enters medication orders awayrom the work site. Home-basedorder entry is one type o a remoteorder-entry process. Telepharmacyand home-based order entry are

similar, yet there are some key dier-ing characteristics. Though there is

no set defnition o telepharmacy, itis considered to be a practice wheresupervision o nonpharmacist staby a pharmacist is perormed byteleconerence.6-8 Telepharmacy is

typically an outsourced purchase opharmacist services, which decreases

or eliminates the need or an onsitepharmacist. The use o telepharmacymay require the purchase o auto-mation to support such unctions.Similarly, with home-based order

Purpose. The implementation o a home-

based order-entry program at a community

hospital is described.Summary. Parkview Hospital is a 600-bed,

community-based acility located in Fort

Wayne, Indiana, that provides 24-hour

pharmacy services. The main purpose or

establishing a home-based order-entry

program was to provide extra pharmacist

coverage during the event o a spontane-

ous order surge in an eort to maintain

excellent customer service. A virtual private

network (VPN) was created to ensure the

security and conidentiality o patients

health care inormation. The names o

volunteer pharmacists who met specifc cri-

teria and who were capable o perorminghome-based order entry were collected.

These pharmacists were trained and tested

in the home-based order-entry process.

When home-based order-entry is needed,

the lead pharmacist contacts the pharma-

cists on the list by telephone. I available,

the pharmacists (maximum o three) are

notifed to log into the Internet, access

the VPN, and perorm order entry with the

same vigilance, confdentiality, and care as

they would onsite. Home-based order en-try is discontinued when o-trigger points

are met. Pharmacists entering orders rom

home are paid by the time spent conduct-

ing order entry. Pharmacists reported that

the program was easy to contact home-

based order-entry volunteers, there were

no problems with logging into the VPNs,

and turnaround time was close to our tar-

get o 25 minutes.

Conclusion. A community-based hospital

successully implemented a home-based

medication order-entry program. The

program alleviated the shortage o phar-

macists during spontaneous surges omedication orders.

Index terms: Computers; Hospitals; Inter-

net; Manpower; Medication orders; Phar-

maceutical services; Pharmacists, hospital;

Pharmacy, institutional, hospital

Am J Health-Syst Pharm. 2009; 66:1939-

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entry, the presence o an onsite phar-macist is not needed, but it is not anoutsourced purchase o pharmacistservices. Instead, home-based orderentry uses the current pharmacists

available within a pharmacy depart-ment. Depending on the acility,the purchase o extra automationmay not be necessary. Remote orderentry does not include any techni-cian supervision, only order-entryunctions.

There are outsourcing companiesand institutions that have imple-mented o-site or home-basedorder entry.9 Examples o such a-cilities are health maintenance orga-

nizations, the Department o Veter-ans Aairs (VA) Health System, andmail-order pharmacies. Aside romthe VA Health System, the com-monality o a hospital-established,home-based order-entry process isgenerally unknown.

Parkview Hospital is a 600-bed,community-based acility located inFort Wayne, Indiana, that provides24-hour pharmacy services. The hos-pital decided to implement home-based medication order entry andassessed the local utilization o thisprocess through a voluntary elec-tronic survey within Indiana and itsneighboring states (Michigan, Ohio,Illinois, Wisconsin, and Kentucky)beore the implementation.

Approximately 850 communityhospitals within the local states wereidentifed via the American HospitalAssociations website. Hospitals withat least 25 inpatient beds were eligibleor inclusion in the survey. Hospitals

categorized as an outpatient acil-ity or associated with the VA HealthSystem were excluded. An estimated50 hospitals per state were randomlyselected or the survey.

The survey contained ques-tions about hospital characteristics,pharmacy-order-entry systems, andhome-based order entry. I an estab-lished home-based order-entry proc-ess was used, the respondents wereurther inormally questioned on the

purpose and overall satisaction withthe program, including any majorimplementation or current obstacles.Institutions with home-based or-der entry were also contacted by

telephone and asked nonstandardquestions to clariy their use ohome-based order entry and anycomplications encountered duringthe implementation and mainte-nance o the program.

O the 300 acilities surveyed, 66(22%) responded. Most o the par-ticipants practiced in hospitals withless than 350 inpatient beds. Twelvehospitals (18%) confrmed the use oa home-based order entry. The pur-

pose o the program varied amonginstitutions, including coverage dur-ing pharmacist shortages (e.g., ill-ness, maternity leave), spontaneoussurges in order volume, and ater-hours coverage. With respect to ma-

jor obstacles during implementation,only 4 o the 12 hospitals responded.All 4 stated that the major complica-tion was gaining system access romhome through the Internet. O thesesame 12 hospitals, only 2 indicatedthey were currently having complica-tions, specifcally regarding legal un-certainties and the proper employeepayment methods.

Analysis and resolution

The main purpose or establishinga home-based order-entry programat our institution was to provide ex-tra pharmacist coverage during theevent o a spontaneous order surgein an eort to maintain excellentpatient care. The ollowing provides

an overview o the implementationprocess o home-based order entry atParkview Hospital.

Utilization of technology. Thecreation o a secure virtual privatenetwork (VPN) is necessary inhome-based order entry. In situa-tions where a company or individualhas a legal obligation to keep inor-mation conidential, secure accessto that inormation is necessary. Toensure security, a VPN incorporates

cryptographic tunneling protocolsto provide confdentiality (blockingsnooping), sender authentication(blocking identity spooing), andmessage integrity (blocking message

alteration) to achieve privacy.10,11

At Parkview Hospital, the Cen-tricity Enterprise (GE Healthcare,Chalont St. Giles, United Kingdom)order-entry program is used inconjunction with the electronicmedication-order-management pro-gram Pyxis Connect (CardinalHealth, San Diego, CA). A VPNwas created in conjunction with theParkview inormation technologydepartment. The servers used are lo-

cated within the pharmacy depart-ment. To establish a VPN connectionor accessing the pharmacy depart-ment program, authentication isrequired. The delivery network usedto access these programs is a highlysecured system that uses multipleauthentication programs. Once theVPN is established, all processing ohealth care inormation is perormedwithin the systems located in thepharmacy department and cannot beretained by the o-site computer.

Determining pharmacist par-ticipation.Pharmacists were asked toindicate interest in voluntarily par-ticipating in the home-based order-entry program via e-mail. Individualsconsidered or the program had to bea Parkview Hospital employee, haveaccess to a computer with Internetaccess and a telephone in their home(both supplied by the pharmacist),have a computer that was capable orunning pharmacy-order-entry da-

tabases adequately, be a licensed In-diana pharmacist, and be establishedas an individual who could perormorder entry (not in training). Phar-macists who met these criteria weretrained in and tested on the home-based order-entry process.

When determining how to pro-vide home-based order-entry ser-vices, three methods were assessed:creating a list o on-call pharmacists,creating scheduled home-based


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order-entry shits, and developing anongoing list o willing participants.On-call pharmacists and scheduledshits would ensure the availability oparticipants at the time o program

initiation. The major disadvantageso this method are the fnancial obli-gation o paying or on-call time andtime and a hal or called in timeand the complexity o developingand creating scheduled shits. An on-going list o home-based order-entrypharmacists does not interere withschedule development and has lessfnancial obligation than does the useo on-call pharmacists. Some disad-vantages to an entirely volunteer list

may include lower pharmacist avail-ability and possible bias in pharma-cist selection. Ater evaluating thesemethods, we determined that a vol-untary list o pharmacists was pre-erred. Twenty fve o 46 pharmacistsagree to participate in this program.

Home-based order-entry ini-tiation and discontinuation. Forthe purpose o this project, the termson-trigger points and o-triggerpoints are used to describe the cri-teria or the initiation and discon-tinuation o home-based order entry,respectively.

To determine the on-trigger ando-trigger points, two separate inter-nal studies were perormed. Hourlysnapshots o the medication ordervolume at Parkview Hospital werecollected over three to ive days.Based on the interpretation o thedata, including order volumes andthe pharmacys capacity to man-age orders during the studied time

rames, an initial set o criteria wasestablished. On-trigger points weredefned as having at least 120 ordersand either greater than 50 orders thathad been idle or at least 60 minutes orover 30 orders that had been idle orat least 90 minutes in the queue. O-trigger points were defned as havingno orders greater than one hour oldand ewer than 30 orders in the queueor over 45 minutes or ewer than 75total orders in the queue.

In the event that the on-triggerpoints are met, the lead pharmacistutilizes the list o home-based order-entry volunteer participants andcontacts them by telephone to deter-

mine their availability. A maximumo three participants can be utilizedat a time due to the limited numbero VPNs set up or the department.I available, these participants arenotiied to log into the Internet,access the VPN, and perorm orderentry with the same vigilance, con-fdentiality, and care as they wouldonsite.

The lead pharmacist or parti-cipant determines when the o-

trigger points are met and therebydiscontinues home-based orderentry. Discontinuation is confrmedby telephone.

Determining pharmacist com-pensation.There are two main meth-ods or determining compensationor pharmacists conducting home-based order entry. The frst method isto pay or the time spent perormingorder entry. An advantage o thismethod is that proper compensa-tion is easily calculated. Majordisadvantages include the potentiallimitation in technology available tothe participant (e.g., slow computer-processing time) and environmentaldistractions, which may lead to aless-productive order processingthan i conducted onsite.

The second type o paymentmethod is to pay per order processed.This requires the creation and cat-egorization o a library o orders inwhich each order is categorized and

given a monetary value. With thismethod, environmental distractionsand available technologies at a phar-macists home are not major con-cerns with respect to overpayment.Some disadvantages include thetime spent calculating proper pay-ment and possible biased selectiono orders to be processed (e.g., onlyprocessing orders o high value).

For Parkview Hospital, we con-cluded that paying per time spent

in perorming home-based orderentry would be utilized. Each par-ticipant must perorm at least 15minutes o entry to receive any pay-ment. Once home-based order en-

try is discontinued, the pharmacistcompletes an electronic timecardthat indicates the time spent enter-ing orders. This orm is submittedto the pharmacy administration,who evaluates it or agreementwith the home-based order-entryinitiation and discontinuationdocumented by the onsite phar-macist and incorporates it into theemployees biweekly paycheck.

Current complications. Han-

dling problem orders was a concernduring the implementation o theprogram. Contacting providers roma nonwork environment can be di-fcult due to the presence o amilymembers and riends or the com-plications associated with paging aphysician to a number outside o thehospital. Providing all participantswith a telephone or paying or theminutes spent or contacting pro-viders was not budgeted. The use oan instant messaging program maybe a viable alternative when physi-cians are employed by an institu-tion and available round-the-clock.Instant messaging is currently notavailable in our community-basedacility. I problem orders requireattention, the pharmacists enteringthe orders are instructed to notiythe onsite pharmacists using PyxisConnect and make a ollow-up tele-phone call.

Discussion

The Joint Commission standardsare constantly evolving in light obest practices and new technology.Remote order entry has been con-sidered an acceptable alternativeor meeting the requirement orpharmacist review or ater-hoursservices since 2004,12 given its inu-ence on improving pharmacys e-fciency during ater hours. It couldalso be used to maximize compliance


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with the current Joint Commissionstandards (e.g., MM 4.1, MM 8.1).13Therefore, home-baased order entrycould be used in a similar manner.

Though established, the Parkview

Hospital pharmacy home-basedorder-entry program is in its infancy.At the time of writing, home-basedorder entry was used several timesand onsite pharmacists reported thatit was easy to contact home-basedorder-entry pharmacists, that therewere no problems with logging intothe VPNs, and that turnaround timeremained close to our target of 25minutes. No formal evaluation ofthe programs effectiveness has been

conducted. Upon further utilizationwith positive results, the programsapplication may expand by provid-ing increasing pharmacist coverageduring predicted and unpredictedpharmacist shortages (e.g., openpositions, sick calls, family medicalleave).

Conclusion

A community-based hospital suc-cessfully implemented a home-basedmedication order-entry program.The program alleviated the shortage

of pharmacists during spontaneoussurges of medication orders.

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