Trends in health information systems technology.

Major trends in health information systems technology are described. The new paradigm for information systems is integrated, patient-centered computing. The computer system and files are designed around information-capture needs along the continuum of care instead of around charge capture or inventory. The need for patient information in the future will not be limited to the health system but will extend to work sites and homes. Health systems will move to full client-server architecture, higher-speed data transmission, and greater network capacity. Computing standards will be instituted nationwide. With changes in the economics of health care, physician order-entry systems are inevitable. Many health systems and system vendors are making progress in achieving the computer-based patient record (CPR); health systems will require the CPR if they are to be truly integrated. Trends in health care and health care information technology will require that pharmacists innovate and adapt as never before.

Preparing to implement an information system.

The factors that must be considered when preparing to implement a pharmacy information system are discussed. A major early decision is whether to locate the central processing unit (CPU) in the pharmacy department or the information services department. Other site considerations are the size of the CPU, environmental conditions, electrical needs, the presence of a backup CPU, and system security. System considerations include interfaces, daily management, preventive maintenance, other support functions, and printers. The system will affect all personnel in the pharmacy department; most jobs will have to be redesigned. Issues to address during implementation planning are forms and labels, the implementation schedule, benchmark development, system conversion, and problem resolution. Files must be developed with great attention to detail and accuracy, as they are the heart and soul of the system. Most departmental policies and procedures will have to be incorporated into the operations of the system. Other departments--in particular, information services, hospital purchasing, administration, nursing, and laboratory--may have requirements that should be considered. There may be legal requirements in the areas of drug order entry, file security and confidentiality, and retention of records. Extensive preparation and planning are necessary before a pharmacy information system can be implemented.

Hospital pharmacy in 1991: the year in review.

Issues and activities that dominated hospital pharmacy in 1991 are reviewed, and their relationship to political and economic trends of national and international importance is described. While rising costs, equitable reimbursement, and access to care continued to dominate the nation's health-care agenda in 1991, the growing interest in quality assurance was also noteworthy. Health-care reform will likely be a dominant issue during the current election year, and pharmacists are urged to play an active role in this restructuring process, both within their work settings and in their communities. Among the major concerns of hospital pharmacy in 1991 were the appropriate use of the new products of biotechnology, advances in computer and communications technology, and measuring and improving the quality of pharmaceutical care. Other issues highlighted in the literature included the need to articulate a mission statement concerning pharmaceutical care, the role of specialization in pharmacy practice, and the appropriate allocation of human resources. The literature of hospital pharmacy continues to provide insight into the progress of the profession and to serve as a benchmark that will gauge its future course.

Hospital pharmacy in 1990: the year in review.

The accomplishments of hospital pharmacy in 1990 are reviewed, and external and internal factors affecting the profession are described. Six issues were identified as having a major impact on hospital pharmacy in 1990: cost containment, productivity and leadership, patient safety, medical-legal and ethical considerations, human resource management, and computers and new technologies. Highlights of activity in each of these areas, as reported primarily in the American Journal of Hospital Pharmacy, are reviewed. Hospital pharmacy remains a vibrant and growing profession that is responding positively to external and internal challenges.

Pharmacy-controlled documentation of drug allergies.

The implementation of a pharmacy-enforced policy for documenting drug allergies is described. After two incidents at a 600-bed teaching hospital in which patients experienced severe allergic reactions to drugs, an audit was conducted to evaluate the existing drug allergy documentation policy. Physicians documented allergies in medical charts and treatment orders for 68% and 78% of patients, respectively; no initial drug orders contained this information. Nurses documented allergies in admission assessments, medication records, and charts for 71%, 61%, and 15% of patients, respectively. Only 2% of pharmacy computerized drug profiles contained allergy information. A new policy for drug allergy documentation was instituted. Physicians provide allergy information on the first written drug order. Nurses independently solicit allergy information and check it against that provided by the physician. Pharmacists enter the information into the patient's drug profile. If the information has not been obtained, the drug is not dispensed. Repeat audits two months and one year after the policy was put in place showed significant improvements in the completeness and accuracy of drug allergy documentation by pharmacists and physicians. In general, documentation by nurses did not improve to the degree found for pharmacists and physicians. A policy that gave pharmacists the primary responsibility for ensuring that drug allergy information was obtained before drugs were dispensed was effective in improving allergy documentation by physicians and pharmacists.

The application of computerized clinical files to hospital pharmacy practice.

As more hospital pharmacies move in the direction of computer access, the profession must identify more clinical applications for computer programming. The roles of the hospital pharmacist and pharmacy technician are changing, and the profession is moving in the direction of increased clinical involvement. The computer is becoming the mainstay of hospital pharmacy practice. Enhancement of computer technology is essential to assist the hospital pharmacist in assimilating all relevant data in order to provide optimal oversight of drug therapy. As more data become available on drugs, optimal use of drugs, and factors which place the patient at risk for developing reactions to drugs, we must place less reliance on committing all facts to memory and recognize that the computer is a necessary solution to optimizing patient care.

Bar codes and their potential applications in hospital pharmacy.

The technology and terminology of bar codes, the Health Industry Bar Code (HIBC) Standard, issues facing the pharmaceutical industry with respect to bar codes, and potential applications of bar codes in hospital pharmacy are reviewed. Bar codes consist of a series of parallel alternating dark lines and empty spaces. Commonly used bar codes include UPC (Universal Product Code), Interleaved 2 of 5, Codabar, Code 93, Code 128, and Code 39. There are several different types of scanners that may be used for scanning bar codes. Some of the variable features are portability, contact and noncontact, autodiscrimination, and the presence of numeric keypads. The HIBC Council (HIBCC) is a steering committee charged with developing bar-code standards for health care, assigning identification numbers to manufacturers, and providing information to interested individuals. The HIBCC Board includes representatives from health-care providers, equipment manufacturers, drug manufacturers, and wholesalers. Drug manufacturers are concerned about several issues with regard to bar codes; for example, who will pay for the cost of implementation, on what level of packaging will the bar codes be required, and are there legal implications if a poor scan results in patient harm? Bar codes have already been applied in some hospitals for coding blood containers, roentgenogram jackets, medical records, and capital equipment. The potential applications in hospital pharmacy include inventory control, verifying the accuracy of dispensing to both inpatients and outpatients, and record keeping for drug product expiration or disposal. Bar codes also offer pharmacists the ability to perform in-process dispensing controls that are not practical to perform manually. Bar-code technology offers health-care personnel the opportunity to improve work efficiency and increase the accuracy of data entry into automated systems.

Selecting a personal computer for the home and office.

Potential uses, reasons for purchasing, and principles in selecting a personal computer for the office or home are described. The decision to purchase a personal computer involves acquiring basic knowledge, determining generic software needs, selecting appropriate hardware, designing the system on paper, determining costs, selecting a vendor, and purchasing and implementing the system. The user should start with basic equipment and add to the system as technology and his own proficiency advance. A personal computer should be designed for growth (adaptability), because equipment can quickly become obsolete. Purchasing a personal computer requires an organized approach and a substantial time commitment both for research before selecting a computer and for becoming a proficient user.

Hospital pharmacy financial management: challenges of the 1980s.

This paper concludes a series on financial management of hospital pharmacies. A decade of expansion of health-care services is ending. Changes in health care are predicted by examining changes that followed deregulation of the banking industry. Pharmacists' need for training in financial management is reiterated, and the need for computerized financial reports is emphasized. Pharmacy departments should prepare for constant changes in reimbursement methods and fluctuations in workload that require flexible staffing. Marketing of pharmaceutical services and increases in productivity will be necessary. Health-care cost reductions can be achieved using the available technology, although hospital closure, restructuring, and staff reductions may occur. Pharmacist-managers need financial skills to remain competitive.

Developing reports.

The development and uses of reports for hospital pharmacy financial management are described. The source of the data and the availability, characteristics, and primary uses of each financial report are discussed. The reports deal with weekly, monthly, and fiscal-year-to-date drug expenses, monthly drug expenses by hospital cost center, monthly personnel expenses, and monthly revenue. Other reports that examine drug expenses, workload, and revenue in terms of patient days and number of hospital admissions are presented. A proposed drug use by diagnosis-related group (DRG) report is included. The development and use of hospital pharmacy financial reports will enhance the manager's ability to improve or maintain services.

Financial analysis.

Analysis of financial reports used in hospital pharmacy management is described. Financial data may be reported as numbers, ratios, or graphs. Drug expenses should receive the most extensive analysis because they constitute the largest expense for a hospital pharmacy. Monthly and year-to-date expenses of various categories of drugs and supplies are discussed in relation to the influence of such factors as time of year, workload, and physician prescribing patterns. Personnel expenses are analyzed in a similar manner. An example of a written financial report to hospital administration that discusses expenses, revenues, and the effect of various factors on the financial status of the pharmacy department is presented. Analysis of financial data by the hospital pharmacy manager provides insight into other aspects of the department and information on which to base future management decisions.

Developing a data-collection system.

Desirable characteristics for a hospital pharmacy financial data-collection system are described. Data collection should follow standardized methods, require minimum personnel time, monitor financial performance, high-light trends, and use standard reporting periods and nomenclature. When automated data-collection methods are not available for pharmacy departments, manual systems should be developed so that totals correspond to automated hospital reports. Data should be collected for expenses (drug and supply costs; personnel costs; equipment purchase, lease, and maintenance; and purchased services), revenues, workload, transfers, credits, drug use, and hospital indicators. For data to be useful as a management tool, they must be reported in a timely fashion and in a manner that is easy to analyze. Reports to hospital administration should emphasize summary data, and details should support the summary. An adequate system for collection, collation, and reporting of financial data is essential for sound management of a hospital pharmacy department.

Health-care trends influencing the financial management of hospital pharmacies.

Current trends affecting health care and the response of the health-care industry to these trends are described, and recommended actions for hospital pharmacy departments are presented. The effects of societal changes, technological advances, information collection and exchange, excess physician population, cost constraints, and competition are examined. Appropriate responses include programs to lower costs, improved financial-monitoring systems, creative methods for attracting patients and donations, specialization of care, corporate formation and restructuring, emphasis on ambulatory and preventive programs, partnership with medical staff, deregulation initiatives, and standardization of hospital statistics. More aggressive management, financial expertise, and greater accountability will be expected of hospital pharmacy managers.

Financial management of hospital pharmacies.

This paper launches a 12-part series of articles on financial management of hospital pharmacies. This series is designed to help hospital pharmacists develop expertise in financial management so that they can keep pace with changing reimbursement structures and shrinking departmental budgets. The objectives, responsibilities, and capabilities of the hospital financial department will be reviewed, and the need for pharmacy directors to develop departmental financial management systems will be stressed. Methods of collecting financial information and preparing financial reports will be reviewed, as well as how those reports can be used in managing the pharmacy. Budgeting techniques will be demonstrated, methods for analyzing expenses and revenues will be illustrated, and possible cost-containment activities will be identified. Methods used by hospital administration to control costs of all departments will be reviewed.

Controlling moxalactam and cefotaxime use with a target drug program.

A target drug program was utilized to prevent increasing costs associated with inappropriate use of moxalactam and cefotaxime. The cost saving abilities of pharmacists in this regard were calculated. Pharmacists consulted with physicians each time these drugs were prescribed to encourage cefazolin substitution when appropriate. Records of all cephalosporin piggyback doses dispensed were maintained along with quarterly purchase data. Excess costs of utilizing third generation cephalosporins in place of cefazolin were calculated for various usage levels. Actual third-generation usage was compared to usage predicted if no target program was in place, and cost saving was calculated. During the study period, combined moxalactam and cefotaxime use averaged 3.2% of total cephalosporin use at a cost of $4109 per month. Based on an expected predicted usage of 20% to 40%, an annualized cost savings of $91,071 to $202,815 was achieved. Clinical pharmacists were very effective in preventing inappropriate use of moxalactam and cefotaxime, preventing a rise in drug costs.

Computer systems planning, development, and impact assessment.

In this final installment of a 12-article series on managing computer systems for the hospital pharmacy department, contemporary issues related to the topic of the series are discussed. Assessment of institutional strategy for acquiring systems and determining the departmental direction is reviewed. The far-reaching impact of computerization on personnel staffing and job functions is discussed. The results of a telephone survey of 23 pharmacy computer system vendors that had at least one installation of a unit dose and i.v. admixture system are also presented. Because of the current and future widespread use of computers, pharmacists must acquire knowledge of computer systems.

Role of the director of pharmacy: the first four months.

Specific goals and tasks that should be addressed during a pharmacy director's first four months of employment are reviewed. Individuals must prepare themselves for the director's role, find the right job, and negotiate an acceptable benefits package. During the first two months as director of pharmacy, an individual should primarily work on gathering facts and assessing the department's operations without making many changes. Interrelationships within the hospital should be studied, and many pharmacy and hospital documents should be reviewed so that the director has an understanding of past history. The director should interview all employees of the department and work as a staff pharmacist for one to two days in each area. During the third and fourth months, the new director will need to determine the extent of authority, develop working relationships with key individuals, assess the pharmacy-management team, develop a data-collection system, learn the processes for making changes, and consolidate authority. A major document, containing a departmental-operations analysis, statement of philosophy, goals, and approach to goal completion, should be the culmination of the four months. The director of pharmacy must meld professional, administrative, and financial activities; the final determinant of success will be the director's ability to implement and follow through with proposed changes.