Database Application Improves Service Delivery in Hospital Pharmacy

by Frank Yacano, Director of Business Development, SYWARE, Inc. (www.syware.com)

Database application reduces paper burden in pharmacy department of the 350-bed acute care hospital.

Hospitals vary in size and focus, but they are all staffed by a variety of professionals who walk around performing activities where data has to be captured, accessed, and analyzed. It's the type of environment that lends itself to handheld computers.

By eliminating the need to record data on paper forms, handhelds increase efficiency both for the user as well as the medical facility as a whole. Time saving techniques such as drop-down lists allow data to be captured electronically in a fraction of the time required using paper forms. Information can be entered into the hospital's central medical records system the same day it is collected, improving the quality of care and eliminating gaps between the time data is recorded and when it becomes available.

One major issue is application development. In contrast to a warehouse, for example, where all personnel might use the same order processing application, the nurses, doctors, therapists, and other professionals in a hospital could make use of dozens of different applications. However, application development for handhelds does not have to be a complex, expensive project. Software productivity tools are available that make creating handheld applications extremely easy, even without programming experience.

Geoff Lawton, Director of Pharmacy Services at the Medical Center of Aurora, Colorado, saw the potential for handhelds to reduce the paper burden in the Pharmacy department of the 350-bed acute care hospital. He is emphatically not a programmer - his background is in pharmacy, along with an MBA. However, despite his lack of development experience, he was able to use a software productivity tool called Visual CE® to create valuable applications that are in constant use by the 45-person Pharmacy department.

As far as Lawton is concerned, there's no turning back. "Why would you ever want to use paper? Anything that you do on a paper form is much easier on a handheld computer using point and click technology. The more you use it, the more opportunities you find."

Building Applications Quickly
Visual CE (from SYWARE, Inc., www.syware.com) allows users to quickly build forms and database applications for Pocket PCs and Windows CE handhelds using drag & drop controls. The intuitive design functions have allowed Lawton to create handheld applications without a major development effort. Visual CE synchronizes with any ODBC data source, allowing data to be readily exchanged between handheld devices and a central database application. Tables can be created in Microsoft Access on a desktop PC and downloaded to Visual CE on the handheld to provide content for drop-down lists on an electronic form.

"Now we can create a form and get it deployed on a handheld network so quickly that it's amazing," adds Lawton. His first application, which tracks pharmacy consults, took a total of six hours to build. The second, for managing customer service, took one hour, and the third, for tracking medication usage, took only 30 minutes. While these applications are relatively simple one-page forms, they more than meet the needs of Lawton and his department.

"I found that creating forms using Visual CE is absolutely painless, even for someone who finds the process somewhat intimidating," Lawton explains. "Even though I'm very Access naïve, it was easy to build a one-dimensional table and upload it to Visual CE. Then I created a form on my desktop, dragged the fields into place, and added some drop-downs and radio buttons. I uploaded the form to the handhelds and we were ready to go."

The Pharmacy department is using Compaq iPACs and HP Journadas handheld devices, which Lawton selected for their high processing speed and memory. He also wanted a Windows-based platform, since the department staff all use Windows on their desktops. As a result, Lawton reports that the learning curve was virtually nil. "Traditionally, when I have tried to implement new technology, folks would be adverse to the changes. However, the handheld computers are so convenient, liberating, and fun that my folks embraced them immediately."

Consultation Management
The hospital's pharmacists now use handheld computers and Visual CE to manage and document the consultative services they provide to physicians and nurses. According to Lawson, the new approach using Visual CE has made the documentation process far more effective than using traditional paper forms. Where it used to take 3-4 minutes to complete a consultation, it can now be done in seconds. "Just point and click on the fields you need to build, and you've got your consult."

The role of the hospital pharmacist differs from that of the traditional retail pharmacist. While doctor prescribe the medication, pharmacists are the experts in monitoring medication therapy, particularly the interactions that can occur when patients are taking multiple medications. The hospital pharmacist manages a patient's medication therapy as part of the medical team. They may recommend adjustments based on the patient's weight, age, or physical condition. They also have expert knowledge of what factors to monitor while the patient is taking the medication.

If the pharmacist makes an adjustment to a patient's medication therapy, the change must be documented in order to ensure continuity of care. Traditionally, these consults have been done using paper forms This is a labor-intensive exercise: writing forms by hand takes time, and when you're in a busy hospital setting, time is at a premium. There is a natural tendency to put it off, leading to potential miscommunication between pharmacists from one shift to the next as well as between pharmacists, physicians, and nurses.

The handheld form allows the pharmacist to build consultation records for individual patients. Pharmacists can select from thousands of different medications, which are grouped by class (i.e., antibiotics, painkillers, and stomach medicines) and then alphabetically. Pharmacists can also specify the type of intervention required, such as screening for allergies or to ensure that an antibiotic is appropriate. Warning flags guard against duplicate therapy, which can occur when multiple physicians are taking care of one patient.

At the end of the day, pharmacists synchronize the consult and medication intervention information captured on their handhelds with the Pharmacy department's desktop Access database. Any changes to a patient's medication therapy are documented in the hospital's central information system. Through the efficiency and ease of the handheld forms, the number of pharmacist consultations has increased nearly 600%. "Because the process is so convenient, we have much more time to perform consults," Lawton explains.

He can also easily update the form as needed, for example to expand consultation categories, add a new medication, or add a new floor to the drop down list of locations. Forms are updated automatically using a Visual CE option that copies updates to the handheld during synchronization.

Tracking Customer Service
With the success of the consulting pharmacist application, Lawson has started using handheld computers and Visual CE to streamline some of the department's other functions. One example is an application he developed for collecting and processing customer service information. (In the hospital, "customers" refers to physicians and nursing staff.) The Pharmacy department conducts monthly customer satisfaction surveys and found that overall satisfaction with pharmacy services has increased about 25% since the tracking program began.

The application tracks service requests from the time medication orders are received through preparation, packaging, and delivery. As pharmacy technicians take orders and make deliveries, they document events on a handheld computer on their belt. "The user friendly forms capability on the handheld allows us to easily track our customer service data. If we had to write all that material down, we would never be able to do it," Lawton adds.

Technicians sync customer information to the central Access database, where average turnaround time can be measured by factors such as medical specialty, hospital floor, and type of medication. By tracking this data over time, the Pharmacy department can validate the quality of service as well as identify opportunities for improvement. For example, some medications take significantly longer to prepare, impacting delivery times - information that can now be shared in advance with caregivers.

With the ability to track performance over time, Lawton has found that the department is doing a much better job in terms of order turnaround. "Our technicians realize that quality service is important, and they're trying harder at it. They're taking real pride in trying to do a better job and turn medication orders around faster and provide good customer service."

Monitoring Drug Utilization Trends
The latest Visual CE application is being used to track drug utilization trends within the hospital. The Pharmacy department conducts studies to identify changes in medication usage that can improve the quality of patient care or provide more cost-effective treatment. Typically, pharmacists will visit patients taking a particular medicine, review their charts, and gather all necessary information to assess whether utilization of the medicine is appropriate. The application captures information such as why a particular medication was prescribed, the dosage, the patient's age and physical condition, and how the patient responded to the therapy.

At the end of the day, the pharmacist synchronizes the medication data to the Pharmacy department's central system at the same time as their consulting records. A medication usage database is aggregated over time, and provides the ability to generate reports by patient demographics and medical conditions. Lawton or his staff present their findings in the hospital's medical committee meetings, and recommend changes in the utilization of the medication when appropriate.

Branching Out
Lawton has become recognized throughout the hospital as the handheld expert, with numerous potential applications under consideration in different departments. For example, emergency room physicians are intrigued by the idea of using handheld forms to manage information and provide decision support. In a sample scenario, a physician seeing a patient with pneumonia would enter their age, weight, test results, and any pre-existing medical conditions. The application will then respond with the correct medication and dosage - saving valuable time and helping prevent errors.

Another application under consideration would assist triage nurses who see patients when they arrive at the emergency room. A handheld form together with decision support software would help the nurse assess how quickly each patient needs to be seen, and prioritize their care. The nurse would use a handheld form to capture patient information such as age, primary complaint, medications they are taking, and other medical conditions. The decision support software would then make a recommendation, such as whether the patient must be seen immediately by a specialist, or if their condition can wait while the medical staff cares for more serious cases.

Thanks to tools such as Visual CE, Lawton is convinced that handheld computers will become ubiquitous in hospital settings within a few years. "Visual CE helped open our eyes, and now we see that we can automate many routine tasks. There are all kinds of applications - the potential is huge."