PJI3LIC HEALTH SERVICE HOSPITAL. SEATTLE, WA. 324-7650. 1 12233 QUEUE,Suzy. 11Apr1979 Rx by:WOOD,Robert. Triprolidine-Pseudoephedrine REF: ...
P.iA,`IS PtiAlRAACY SYSTE I
Arthur 'L. Gurtel; Nialcolain A. Gleser; Alfred Fallavollita, Jr.; David R.
'oods
Health S0'ervices .iesearch and Pharolacy Departnents U.S. Public 'ealthl Service H3ospital Seattle, Wuashington services are planned for thie future.
A'3STRACT An autormated outpatient pharmnacy systemil is
Thtlere are aip)rox imatel], 6 0 0 outpatient visits per day at tuie .S'eattle hospital, includ ing visits to dental, occupational, clinics. and phll ys i c a l tnerapy Approxi-nately 175 patients contact thie pharmnacy each day with 345 prescriptiotis. The outpatient pharmnacy is staffedi on the average by 2 pharliacists and 2.5 pharamacy technicians. This staff is responsible for m;iaintaini ng pharamacy operations 50 hours per week.
desi,gned to serve the rliultifacility health
care system,l of CIlie U.S. Public Hlealth This syste;n allows entry and Service. infortmiation, retrieval of prescription patient mLledication profiles, mnainitains produces a variety of workload and drug utilization reports, and mi aintains the It coinputerized utilizes iniventory. and drug product prescriber patient, prescription infori.aation to simplify Thle systemn saves pharmnacy, processing. patient, and prescriber titne and enhances accuracy and patient safety. The benefits expected of system wide im,plernentation with integrated patient records include: better, more efficient care for highly mobile PUS beneficiaries, more effective of phariuiacy managenent central ized resources, andl a large, uniquely com,lplete and druu utilization for database epide!iiiological studies.
PHAR.iACY SYSTE.-I OPERATIONS Functions Available for The functions provi(ded by PIIAAIS day-to-day operation of the outpatient pharmnacy are describedi here.
1.
I NTR OD UC T I ON An automated outpatient phar macy system has been in operation at the Seattle U.S. Public Health Service Hospital since It has been well received August, 1973. physicians, personnel, pharmacy by adm,iinistrators and patients. This paper describes its use in the phar.nacy, the benefits achieved through its use within a comnprehensive health care systemn, and the special design features which simnplify its care health mllultifacility use in a setting.
Prescription information entry. Entry of a prescription into PHAA'IS requires the identification of the patient, prescribin-, clinician, and the exact Patient product. nedication identification is easily manag,ed by the patien t's hospital entry of identification number and verification Pl AMIS. of the namne retrieved by Since all patients mlust be registered a valid and PHAM IS have on identification card before receiving r;aedications, the pharnacy staff is registration the of relieved stand-alone activities required by automnated phar.nacy systems. Prescribers are registered in PI-IAiM IS and given provider identification nunbers. Prescribers are encouraged to include ID numbers with their on to prescriptions signatures to their identification simpl if y PliAtMIS and to alleviate problems of deciphering signatures. Either nra,mies or numbers inay be used to identify to Pharrnacy PI-HAM IS. prescribers own also enter their personnel identification when they use PHAMIS, internal which provides
The outpatient pharmaacy module described here is a comnponent of the Public lIealth Syste:m Automnated Informnation Medical (PHAMIS), which is described in detail at The pharmnacy this (1). symnposium component is not a stand-alone module. Its operation requires other components of PHAIMIS, particularly patient registration. At present, the pharm;acy nodule serves outpatients only, although it functions in a hospital setting. Inpatient pharmacy
885 U.S. Government work not protected by U.S. copyright.
and lot number of the miiedications lispensed,. This inforimiation is kept in a mt1anual log rather tihan or} comnputer for two reasons: (a) It is accessed rarely infor-nation which would be expensive to store on and (b) it is actually cormiputer, easier to fmaintain manually, since rmledications hiave .oost prepacked removable labels indicating mnanufacturer and lot numnbers which can be affixed to the mnanual log faster than they can be entered on co,iputer.
accountability. The m,ledication product to be dlispensed can be indicated by a,ny of three methods: (a) A product-specific code can be entered1 (e.g., AM'P500, for a:npicillin 500 ing capsule). These codes are emrployed for the rnost frequently used imedication products. (b) The generic or brand narne of the m,edlication, and itts strength and formii, can be entered ( e.g ., amnpicillin 500 ng capsule). (c) The generic or brand name can be entered alone (e.g., Valium). If only one dosage form is available, that forin will be assurned. Otherwise, PHhAiAIS will display the and request a available products ciho ic e o f the prod uc t to be d i s pen sed .
FIGURE 1
PRESCRIPTION CONTAIINER AN[) CONTROL LOG LABELS
After the identifying patient, prescriber, and aledication product, personnel enter the p,harmiac y directions for use, the afnount to be dispensed, the number of refills, and the nuimber of container labels to be printed. This a cornpletes prescription Additional entry. prescriptions entered imnmediately do not require of reidentification patient or prescriber.
(Facsimile) -------------------------------------------
U.. PJI3LIC HEALTH SERVICE HOSPITAL
SEATTLE, WA 324-7650 1 12233 QUEUE,Suzy 11Apr1979 Rx by:WOOD,Robert Triprolidine-Pseudoephedrine REF:O tablet
Total disp: 30 tallets TAKE 1 TABLET BY-MOUTH THREE TIMES A DAY FOR CONGESTION
Refills are handled simnilarly. The and the medication to be patient refilled are identified. PHAAIS retrieves the previous prescription informnation and it displays for If inspection. a refill is authorized, pharmacy personnel need only enter any changes in the amiiount to be dispensed or the number of labels to be printed in order to complete the refill transaction.
MAY CAUSE DROWSINESS OR NERVOUSNESS ALCOHOL CAN IPICREASE THESE EFFECTS
CAUTION:FEDERAL LAW PROHIBITS THIE TRANSFER OF THlIS DRUG TO ANY PERSON OTHER THANJ, T HE PATIENT FOR WHOM IT WAS PRESCRIBED.
When a new prescription is to be entered for a medication the patient has been taking, pharmacy personnel may issue a represcribe transaction. This preserves the directions for use the from. previous prescription, simnplifying entry and reducing the potential for introducing errors. 2.
#112233/1 1APR1979/GUR Triprolidine-Pseudoephedrine tablet 30 tablets Fill /Ck
Container label generation. PHAMIS produces at least one container label for each prescription entered. Labels are printed in a uniform formnat in two parts (figure 1). The top section contains identification of the facility, patient, prescriber, and the medication; amount dispensed; number of refills; directions for use; and a group of preprogrammed warning messages. This t'op section is affixed to the medication container. The bottom sections of labels are kept in the pharmacy as a control log. The log is used to record the manufacturer
3.
MA1N.
-/CON. ____
A receipt of medications. is required to do a final check of each filled prescription and verify to PHAi1IS that it was received This pharfaacist is by the patient. responsible for giving verbal instructions and product 'drug information to the patient, and is identified in PHAMIS as the pharmnacist of record for the prescription. After the patient's receipt of medication has been recorded, PHAMIS decrements the automated inventory.
Patient
pharmacist
4
886
.
Return
to
stock.
PHAM4IS
can
list
allerg,y
i nforrnation and spec ial notes drug therapy, and enter refill requests. A technician uses a second CRT to enter new prescription inforination. Pharmnacy personnel fill the prescriptions, print, separate, and affix the container log . labels, and initial the control Filled prescriptions are chlecked by a pharmnacist, who also initials the control log. Finally, this pharmlacist dispenses meJications to patients, with directions for use, using the third CRT to record the actual receipt by patients.
mleJications wnich have been filled but not picked up by patients, and can p)erform a return to stock transaction. th i s In case, the prescription information is retained in P1AAIIS but the inventory is not decremnented. The pharuiacy can notify the prescribing clinician of patient failure to pick up niedications. 5.
kllergy itnforination entry. Ph! artna c y enter drug allergy personnel mnay inforination onto the patient' s medical record. Allergies to specific or arnpicillin) rnedications (e.g., (e.g., classes of inedications penicill ins) may be entered.
Effects of Automiiation on the Pharmacy
retrieval. retrieve a su;mmary of a patient's drug allergies and all active and recent inactive mnedications. In addition, thie y can review a patient's entire record of use of a particular drug.
7.
Prescription discontinuation. W'hen a a no longer requires patient medication, the discontinue function cnay be used explicitly to remove it froma the patient' s active nedication profile. Error detection.
pres6rip tion
PHA:1 IIS insure
checks
Ttie Accuracy and patient safety. automnatic allergy and dosage checks and warnings built into thie PIIAI.,IS phar.nacy systern increase the pharimiacy staff's accuracy and promnote patient safety. Availability of up-to-date patient nedication profiles helps both pharm1iacists and clinicians to manage and mnonitor drug therapy and to detect problems.
2.
A titne study Patient waiting timne. and after conducted before of automnated the implernentation outpatient pharmnacy system at the Seattle hospital shows that automation has the processing of expedited prescriptions and decreased patient With timne 2). waiting (figure approximately equal prescription loads and staffing, overall patient waiting timne was reduced fromii an average of per minutes patient before 49.3 automnation to 21.6 minutes per patient after automation. Obviously, patients to have responded enthusiastically thiis change.
each
that it does not exceed a pre-specified mnaxim urn daily adult dosage or conflict with an As known patient allergies. additional safety feature, patient the for allergies are displayed whenever infornilation pharmnacist's or are prescriptions entered dispensed. Currently, PIlAiAIS does not drug-drug automaatically detect or interactions, incomnpatibilities though the availability and fornat of patient mnedication profiles facil itate their detection. 9.
1.
profile iMle;dication personnel !nay Phar,imacy
6.
8.
regarding
to
3.
Pharmnacy user acceptance. facilities
comnpared to Automnation
Governmnent
are generally understaffed
institutions. tirne. filing, Repetitive transcribing, and manual jeneration and retrieval of tnedication profiles have been elimninated, decreasing the average prescription processing time . Before implementation, the Seattle pharmacy personnel considered their work to be very routine and stressful. a After staffing autornation, indicated questionnaire preference for their desire to be scheduled longer rotations in the outpatient pharmacy. In addition, there is a subtle but genuine elemnent of prestige in working with an innovative computer system.
Inventory and utilization. A record of each dispensed Tnedication is used to decremaent a perpetual inventory. produces narcotics PHAAM IS daily monthly utilization reports, utilization reports of all mnedication products, and a variety of workload
statistics.
Pharm aacy Procedures Pharmacy personnel use three cathode ray tubes (CRTs) and one label printer to process prescriptions. At the reception a window, phar;nacist accepts prescriptions. This pharmacist uses one CRT to determnine patients' eligibility, record pharmacy visits, review patient medication information on-line, enter drug
887
private
saves staff as tasks such
care, incflding prescri)tions filled in the pharaacy, is provided without cost for most Therefore, patients. most benieficiaries receive all their prescribed mnedications at PiIS pharnacies, allowing innovations in aonitoring dru- therapy which greatly expand tne benefits derivedl from!i the phar-iiacy systemn.
FIGURE 2 l 'IME STIJDY RESULTS QEFORE ANqD AFTER AUTOr-IATIOf4
BEFOR E
AFTElR
Average # patients per day
171
18C)
Average I! prescriptions per Jay
345
340
2.0
1.9
The Patient dedication Profile
Breakdown of Prescription
Each night after the pharmacy closes, a printed version of the patient medication profile is prepared for all patients who received medications that lay (figure 3). The patient medication profile is arranged in three sections:
Processing Time (minutes per patient):
1.
Average
Rx/pt
Pt wait in- tirne for service at reception window
3.2
2. 3 2.
Tirme between receipt of prescriptions and com,1pleted typing/ entry of label
13.9
Time between completion of label and filling and labeling container
27.3
3. 5. 3
6.3
Total pt waiting timne
4
PR N
inedications: Medications to the patient as needed.
be
takfen by
Medications medications: Inactive the last seven within prescribed nonths which are not currently beinig used by the patient.
Within these three maajor divisiors, drug by arranged are products categories; phar'nacological/therapeutic anti hista;ni ne s in the PRN two e.g., section would be printed next to each other. The profile is filed in the patient's medical record. It provides a cornplete overview of recent prescriptions fromn all prescribers, serves as a backup for the comnputer profile (in case of down communication facilitates and timne), between phar,nacists and prescribers. When a patient returns to clinic, the physician uses the updated profile in the chart to can Providers therapy. review drug reorder mnedications simnply by filling in the amount to be dispensed and signing this formn . New prescriptions can also be written on thie profile.
Filling and labeling
timne
Medications Continuous medications: or chronic conditions and prescribed acute for prescriptions recent conditl Fions.
49.3
Down ti-ne
When PlIAMIS is unavailable because of hardware or software failures, the pharmacy staff continues to receive, and fill dispense ned ications as usual. If down time is short (less incoming rninutes) , than 10 prescriptions are queued until PHAM.IS ApproxiTnately is again available. once every two weeks, down time is sufficiently long to require backup are Labels processing techniques. and prescription mnanually typed information is saved to be entered when PHAi4IS is available. Although such disruptions are irritating to the pharmnacy staff, manually processed information can usually be entered during periods of low workload without requiring extra staff or overtime.
After
six
mnonths
of
operation
of
the
pharmnacy systemn, printed profiles will be found in the chart patient visits.
for
the
inajority
of
A questionnaire was developed to determnine Seattle hospital prescribers' opinions and use of the patient inedication profile indicated Prescribers 4). (figure overwhelming satisfaction (95% satisfied; 5% neutral). They indicated that they use the profile to evaluate drug therapy and detect detertmine patient comnpliance, allergies and drug interactions, and write and estimated that the prescriptions; profile saves themn an average of 3.3 minutes per patient.
COMPREHENSIVE HEALTH CARE ASPECTS The Public Health Service hospitals and clinics provide total health care benefits This to the majority of patients served.
888
FIGURE 3 SAIlPLE PATI';:NT :IEDICArI ol PROFILE
12 34 56
Page 1
JEFFERSON,Sandy D. SEATTLE,WA 98116 12 Elm St. sex:M born:21Sep1928 benecode:USAER This profile was printed on 9-Apr-79
Allergy
Allergy
to PENICILLINS to
phone:999-1234
Prov#-
))) CONTINUING MEDS
Diazepam C-IV LRX by MATTHEWS,Meredith] (Valium) DISP: 23Jan79 5 mg oral tab; REFL: 3Apr79. D/C
1 tab po tid "FOR SEVERE PAIN";
ReRX dispensing*
with
90tab Ref: 1 90tab Ref: 0
refills. Prov#_
Hydrochlorothiazide [RX by MATTHEWS,Meredith] (HCIL,Oretic,Hydrodiuril) DISP: 23Feb79 50 mg oral tab; D/C
180tab Ref: 3
1 tab po bid;
ReRX dispensing#
with
refills.
Prov#_
))) PRN MEDS
Acetaminophen W/Codeine 30Mg C-III [RX by MATTHEWS,Meredith] (TIlenol W/ C DISP: 23Jan79 oral tab;
D/C
lOOtab Ref: 0
1 tab po q6hr prn;
ReRX dispensing*
with
refills. Prov#_
))) INACTIVE MEDS
Indomethacin LRX by MATTHEWS,Meredith] (Indocin) lOOcap Ref: 0
DISP: 23Feb79 25 mg oral cap; 2 cap po tid;
Inactive
Date
ReRX dispensing#
with
refills. Prov#_
Signature
_Prov#-_
Signature
_Prov#*_
889
r
FEATURE3 TO SIIlPLIF Y MIIULTIFACILITY UCIJ
I&U IE 4
PHA'MIS dedication For.1iulary
M'EDICATION PROFILE PATIENT QUESTI'ONN-1AIRE RESULTS
Operation of the p'harlnacy systeaii requires access to drug product inforination froua a comnputerized formnulary. The for-inulary contains an entry for every drug product stocked by t.he phar;;iacy. These entries include product dlescriptions and inventory informiiation, cross-references to a drug's official (generic) name, status codes for desi,3nating legal classes of drugs and thieir dispensing restrictions, and product codes which classify drugs in various pharmnacological-therapeutic categories.
PiROVI)ERS' JSE OF PROFILES (IJ=58) Total reporting profile use
93. 5
,
Breakdown of reported use:
Lvaluation of therapy Allergy detection Drug interaction detection Deterimiination of comlpliance
93.5%
4L5.8%
50.0% 40. 3%)
Finally,
the drug formnulary contains and storage, general usage entries which print out automnatically on prescription container labels.
warning ,
MEAt TIME SAVINGS ATTRIBUTED TO USE OF PROFILES (MINUTES PER PATIENT)*
Determnination of current medication and dosage schedule
2.5
Prescription writing
2.6
Total tiine saved per patient
3.3
Whhen implemiiented as a IIIultifacility will emiiploy a global system, PHA;MI:; superset formlulary. All products stockecd in any PUS facility will be included in the global forinulary, along with com plete product inforniatiori. Each facility will also miiaintain a local form,lulary which simply the status of each specifies product at that facility; i.e., stocked, not stocked, or restricted in so ne way. Implementation of a new pharmiiacy facility requires only a review of the global fortnulary anid creation of the local
*Providerse
estienations in response to three separate questions
Health Care Audit
forrnulary.
Comnplete pharmiiacy informnation on a defined patient population perm its use of the
As all medications will oe prescribed fromn the sane global forrnulary, comnplete data cornpatibility across facilities will be ma in tained . Comparison of workloads and patterns of drug utilization between facilities will be possible. It will also be possible to simnplify and streamnline centralized purchasing and warehousing functions.
database for retrospective health care audit and epideiniological studies of drug use. To date, the realization of this l i nited potential has been but It has been possible to encouraging. identify the prescribers wtho choose an expensive, patent protected medication (Diazeparn, Ibuprofen) over less costly alternatives (chlordiazepoxide, acetylsalicylic It has been acid). to possible patients identify simnultaneously taking mood elevators and depressants. Chart review of use and indications for a variety of inedications has been simplified by retrieval of the chart numbers of patients taking those nedications. Such studies can be conducted because, in the Public Health Service setting, little or no bias is introduced by reviewing only prescriptions filled at PUIS pharmiiacies, since virtually all beneficiaries' prescriptions are filled there.
Integrated Medication Profiles More important is the ability to rmaintain integrated patient mnedication profiles across facilities. Melost PHS inedical care beneficiaries are eligible for care at any PHS facility, and may in fact receive care at several. This is especially true of patients who receive outpatient care at one facility and rmay be hospitalized at another. will PHAAIIS provide each pharmnacy (and prescriber) with comaplete information on a patient's PHIS prescriptions, regardless of where they were prescribed or dispensed. Patients will be able to refill a prescription at a facility other than the one where it was originally obtained. This obviously will be a In convenience to patients. addition, it will eliminate any potential for medication and "shopping"
890
An overutilization at PHS facilities. initegrated profile also will enhance the prevention of adverse drug events arising fromn lack of knowledge at the dispensing facility of wedications received at other sites. It is now conceivable, for example, that a patient receiving care for diabetes in one facility and lheart failure in another rnight be given the samne medications at both facilities, and take themn as if they were different. A system designed for mnultifacility use is essential to prevent such occurrences.
Ub1MARY The P'IAMIS outpatient phar;nacy system provides pharmacy users with the mnany an advantages of autormated mned ical informaation system. The computer generated patient nedication profiles save and pharmnacy staff time and provider promnote patient safety in the prescribing process. These mnedication profiles have been enthusiastically accepted by prescribers at the Seattle USPHIS Hospital. Automation allows the medical and pharmacy staff to provide more efficient, higher quality service. Pharmnacy staff report job increased satisfaction. Reports generated by the pharmacy module promote and effective control of inanagemnent pharraacy resources.
The multifacility formnulary will allow pharLnacists to offer expanded services to the tnobile patients who comnprise a large It will segmnent of PHS beneficiaries. enhance comaprehensive care, and create a database for inul ti fac il it y drug utilization and epidemiological studies. REFERENC E 1.
a Gleser MA, Lang D: PHA1lIS .nultihospital integrated mnedical informnation system. Proceedings of the Third Annual Symposium on Computer Applications in Medical Care of the of and Institute Electrical Electronics Engineers. Silver Spring, MD, IEEE, 1979
891
