Hospital and pharmacy

information systems
Pharmacy Informatics
 Introductory to Information System (IS)
Definition
• In broad scope, the term information system is defined as “A system whether automated or manual that
comprises (involves) people, machine or methods organized to collect, process, transmit, and
disseminate data that represent user information” or in broad sense as “ A scientific field of study,
addresses (deals with) range of strategic, managerial and operational activities involved in gathering,
processing , storing , distributing and use of information”. In other words, it is an organized combination
of people, computer (i.e. hardware and software), communication network and data resources that
collects, transform and disseminate of information in an organization.
It obvious from the definition that people had relied on information systems to communicate with
each other using a variety of physical devices (Hardware), information processing instructions
(software) , communication channels and stored data (Data resource).
Types of information systems
There are various types of information systems. These include:
• Transaction processing systems
• Decision support systems
• Knowledge management systems
• Data management systems
• Office information systems
• Health information systems (hospital information system & pharmacy information system)
Here we would like to concentrate on health information systems.
Terminologies
The following are some of the common terminologies that help to understand functions of IS:
• End user is anyone who uses information system or information it produces, with exception of
information system specialist (such as system analyst s or computer programmers).
• Information system specialist is a professional who develop, implement and operate a computer-based
information system
 Hospital information systems
Definition
• In broad scope, the term information system is defined as “A system whether automated or
manual that comprises (involves) people, machine or methods organized to collect, process,
transmit, and disseminate data that represent user information” or in broad sense as “ A
scientific field of study, addresses (deals with) range of strategic, managerial and operational
activities involved in gathering, processing , storing , distributing and use of information”. In other
words, it is an organized combination of people, computer (i.e. hardware and software),
communication network and data resources that collects, transform and disseminate of
information in an organization.
It obvious from the definition that people had relied on information systems to communicate
with each other using a variety of physical devices (Hardware), information processing
instructions (software) , communication channels and stored data (Data resource).
• The term hospital information system has been used similar to that definition.
• Potential benefits of hospital information systems include:
a. Efficient and accurate administration of finance, diet of patient , engineering and
distribution of medical Aid. I t helps to viewed a broad practice of hospital growth.
b. Improve monitoring of drug usage and study of its effectivness. This leads to reduction of
drug adverse effect and drug interactions while promoting more appropriate drug
utilization.
c. Enhances information integrity, reduces transcription errors and reduces duplication of
information entries.
d. Hospital software is easy to use and eliminate errors caused by hand writing.
• System is a group of interrelated components, working together towards a common goal by accepting
input and producing output in organized transformation process. Any system has four basic interacting
components. These include:
- Input: Involves introduction of data result from recording events, or an inquiry of
information, or massage to other user in the system etc.
- Processing: involves transformation of input to output e.g. Storing , retrieving , recording,
updating or manipulation of mathematical calculation
- Storage: the information system has the capability to store data, text, image etc.
- Output : Involves transforming elements that has been produced by transformation
process to their ultimate. The finished product may be printed documents, terminal
screen, or instruction to automated devices to perform task. Today's end users relay on
many types of information systems. They may include simple manual (paper and pencil) ,
hardware devices and informal (word of mouth) communication channels. However, we are
going to concentrate on the computer-based information system that uses, hardware,
software, communication networks , computer based data management techniques and
other form of information technology.

Components of information systems

The following the main components of computer systems:
• Hardware or central processing units (CPU) .
• Software this refers to computer programs , these are machine readable instructions that direct the hardware of the system
to function in a way that produce useful information from the data.
• Communication networks are connecting systems that allow different computers to distribute resources.
• Data are discreet facts that are used by the programs to produce needed information.
• Procedure are policies that govern the operation of computer system. Procedure is very vital to people as software to
hardware.
• People every system needs people if it is to work or function. Trained personal are the key that influences the success or
failure of the information system.
 Health information system: Hospital information system
Include : Medical , chart and health records which are different terms used to
describe the documentation of a patient medical history and care
1. Medical record

. Translation of ancient Egyptian hieroglyphic and papery from 1600 to 3000 BC

indicate the use of medical record.

. Paper medical records was not steadily used until 1900 to 1920.
. Medical record describe the documentation of patient medical history and care.
. Traditionally health records were written on paper maintained in folders divided
into sections based on the type of notes.

. Now the meaning of medical record has been changed drastically from one
being a paper record intended to contain the universe of care provided to a
patient in a given setting, is transformed into fluid electronic portal that
described not only local care but also the interactions between health providers
and their patients. The record now encompasses the broadest possible
definition of data aggregation centered on the patient care.
2. Chart:

. Register of current medical history and care

- Patient medical record : paper-based records
• The patient medical record (PMR) is the primary written communication tools for all health care
professionals. The following constitute the patient paper-based records :-
1. Written interventions or progress notes of Health care providers after each patient visit at
outpatient setting ,
2. Written interventions or progress notes Health care providers in patient chart at inpatient setting

• Writing in or access to a patient medical record (charting) is license granted by each institution to
physicians and other professionals. However, recently many institutions allow clinical pharmacists
charting license, although this practice is yet immature and far from universal. The medical record
usually is used to:
1. Document and communicate information about the patient interventions and progress.
2. Assess, retrospectively, the quality and appropriateness of patient care
3. Document patient care activities and serve as data for charging.
NB.
• Those utilizing papers-based medical records should adhere to legal, ethical and
professional standards when documenting patient information. These ethical and
professional standards required that :
• Handwriting should be clear and readable using black ink.
• Errors are dealt with by crossing out the error with one line and then initiating the error.
• Label the notes with specific descriptive headings and time and date
• Sign at the end of the document with name and title.
- Electronic Medical Records (EMR)
• Nowadays, many institutions changing from handwriting medical record to electronic medical
record [EMR] in a way to avoid errors result from handwriting.
• The first EMRs were aggregations of observations laid down on paper either through a full
narrative entries or scanned copies on notes is usually created in the clinic, in hospital settings
and ambulatory care environment, where it deals of records of disease and interventions as well
as serve as data source for electronic health record system.
3. Electronic Health Record systems (EHRs)
. Traditionally, HERs were written on paper maintained in folders divided into sections based

on the type of notes and only one copy was available.

• The electronic record system is known as electronic health record system (EHRs), developed as
an identity in the early 1960s with pioneers developing programs to assist in documenting
patients’ history, physical examinations, laboratory and radiology reports etc. in USA, for
individuals or population.
• In general EHR systems are designed to replicate the information found in patient paper or
electronic medical records (EMR) but often takes on additional functionality.
• EHR systems are tools that provide secure, real time , and patient centered information for all
health care providers at the point of care and when ever needed.
Functional components of the HER and their relationship to other healthcare
systems
1. Integration and results review
HER is tightly integrated with other practice managements tools that allow for patient
identification , patient tracking and patient financial managements through master
patient index (MPI), which identify all patients cared for in a given institution and their
key demographic characters. The MPI is often hosted in registration system that
inform HER of new patients or change to demographic patients or additions are
propagated across the hospital they are called admission , discharge and tracking (ADT)
message.
The newer generation provide access to image need in the course of care. e. g. radiologic
images. EHRs can also create to third-party document management system so that
scanned images of documents from outside the institution that can be viewed in the
patient’s record.

2. EHR system can help to mange other multiple aspects of patient care such as :
a. Documentation (Manage clinical documents, order management, medications and
allergy managements as well as laboratory results tracking.)
b. Medication ordering [Computerized provider order entry ( COPE) ]
c. Promote better decision making by providing accurate and timely clinical information.
d. Support administrative functions related scheduling patient admission or
appointments.
e. Organize information according to what is needed and when it is needed.
3. Documentation
the most actual outcomes from provider visit is often the “note “ that emerges from a
meeting with a clinician summarizing the findings and assessments o office f that visit in an
office or inpatient setting. The note is used as a record for legal purposes to :

. Describe the care provided

. Act as a communication tool to other providers

. Serve as justification for charges attendants to the patients, because ensures art e
often as k for copies of the document as a part of checking to ensure that the
services were done .
To achieve these multiple needs of clinical documentation the vendors of many HER products
provide tools to facilitate documentation. Apart from a patient’s history written in a narrative
style the notes often contains:

. Current medications.

. Diagnostic information about a patient.

. Current laboratory values and recent vital signs.

• Other functionality of EHR is to improve and promote the quality of care
This is usually done in the same manner as in clinical decision support system when
associated with medication ordering. The thoughtful use of alerts and reminders is
intended to promote the physician to take an action in a manner consistent with
established evidence based guidelines. To illustrate the way in which EHR has come to
improve and promote quality of care, let’s take the following scenario:
Scenario: a provider seeing a patient with identified coronary artery disease on the
problem list. The EHR knows the most recent lipid levels as well as whether a patient is
taking medications to lower lipid level, if the patient is not currently on antilipemic agent or
does not have a serum level consistent with evidence based guidelines an alert will display
to promote the physician to take an action. In the same manner other screen will promote
the prescriber to order appropriate lipid-lowering therapy.
• EHRs’ records are designed in digital formats that are capable of being shared across
different health care settings.
• Sharing either occurred through network connected enterprise wide information systems
or other information network.
• Access to electronic medical records using EHRs should be limited to those who need it and
control must be exercised by using a security method (e.g. approved passwords and
electronic signature and/or biometric identification fingerprint or retinal scanning);
however access to other information is allowed to anyone within the password-protected
system. The computer automatically label entries with the date and time of entry and may
link the entry to the password.
Components of comprehensive EHR system
HER generally contains several essential components as follows:
• A patient data repository: it is generally a type of database that contains a patient information,
including lists of information, such as allergies, radiology and laboratory testing results, clinical
documentation, demographic information (e.g. age, gender, address and orders). These
information can be displayed in or inform the functioning of other tools within HER system.
• User interfaces: these tools allow the health care provider to interact with data in:-
1. Patient data repository
2. Promote entry of new order or prescription
3. Viewing recent laboratory results
4. Scheduling visits and admission and managing lists of diagnosis.
• Clinical decision support tools: provide guidelines or knowledge-based information to
health care providers as they generating clinical order to improve the decision making. The
knowledge and content that inform decision support tools come from several sources (See
diagram 1). Decision support can be simple as providing list of dosage forms while health care
provider entering the dose or complicated as therapy advisors for TPN or chemotherapy.
• Clinical note capture tools: assist health care provider in documenting their decision making
and patient interactions.
• Rules engines tools : apply specific algorithm to data available from any of theses systems to
ensure it is conform (obey the rule) to the system standards and to derive additional function (such
as decision support) For example, comparing microbiological culture and sensitivity data with
patient antibiotic regiments and disease, monitoring certainties clearance in relation to drug
therapy.
Documentation in clinical note capturing tool

the most actual outcomes from provider visit is often the “note “ that emerges from a
meeting with a clinician summarizing the findings and assessments o f that visit in an
office or inpatient setting. The note is used as a record for legal purposes to :
. Describe the care provided

. Act as a communication tool to other providers

. Serve as justification for charges attendants to the patients, because ensures art e
often as k for copies of the document as a part of checking to ensure that the
services were done .

To achieve these multiple needs of clinical documentation the vendors of many HER products
provide tools to facilitate documentation. Apart from a patient’s history written in a narrative
style the notes often contain:
. Current medications.
. Diagnostic information about a patient.
. Current laboratory values and recent vital signs.
 Core components of Comprehensive EHR system
Patient Data Repository
Patient information: Medications, Clinical Decision Support User Interfaces
allergies, laboratory & radiology Tools Provide guidelines or Allows Interaction with patient
results, clinical documents, knowledge-based information data Permit entry to new order
demographic information, from local medical library , /prescription; Laboratory reports;
address & orders. vital signs, associations & government Scheduling; Admission; Managing
personal statistics lists of diagnosis among others

EHR System

Rules Engines
Clinical Note Capture Apply specific algorithms to data
Tools to all systems to ensure that it
Assist health care providers in conform to system standard and to
documenting their clinical derive other functionality such as
making and patient interaction CDS
 Medication Distribution systems
• In the past , the pharmacist primarily role in medication use cycle was to purchase or prepare the desired drugs to be
used by the nursing unit. The physician would prescribe medication and administer it to the patient. The pharmacist rarely
decides:
1. whether the therapy was appropriate for the patient or not , they would simply make sure that: the nurse had a supply
of medication for the patient.
2. If this required repackaging or compounding of the medication , the pharmacist accepted responsibility for this function
with the exception of being IV admixture.

• By the time, in pharmacy evolving responsibilities, the above activities seems to receive more attention, among the main
responsibilities of the pharmacist:
1. in institutional settings , is to provide the patient with an appropriate medication in an acceptable dosage to facilitate
easy administration.
2. The hospital pharmacist working with other professionals, accepted responsibility to purchase or prepare drug products
approved for use in the hospital by pharmacy and therapeutic committee .
3. These drugs were then distributed by the pharmacist so they were available to the nurse to administered to patient as
prescribed by the physician.
4. Finally, the drug’s therapeutic effects were monitored to assure the desired effect were achieved, and undesirable
effect were minimized.
5. What transformed the hospital pharmacist into an integral member of the health care is the unit dose system. The
system require the pharmacist to receive individual patient medication order s. The pharmacist would prepare patient -
specific doses in a ready –to– administer form by reviewing the medication order. This allowed that the hospital to
accept responsibility for a patient drug therapy.
6. Over the past decades there have been many improvement in the unit dose system , mostly through advancement in
technology.

7. The evolving drug distribution system used by the pharmacists reflects the expanding pharmacist’s role , advance in technology and the
increasing complexity of drug products.
Types of method used in medication distribution systems
There are at least three distinct distribution methods the pharmacist would utilize for the nurse to obtain
medications for the patient use. These include

. Floor Stock System

This the most common method . It is
1. considered a duplication of small pharmacy in the nurse where the drugs were stored prior to be
administered to the patient. The pharmacist
was responsible for stocking the nursing unit. The pharmacist would place bulk containers with multiple doses on the unit often
called the drug room.
2. The nurse was the professional responsible for preparing specific medications for both oral and intravenous use.
3. If a medication needed to be refilled or a patient started on a different drug the nurse would request new medication to be restocked.
4. In such system the pharmacist would likely never see the physician order , but would stock medication the floor solely from
request.
. Patient prescription system ( for inpatient and outpatient)
The patient prescription system involved the pharmacist to a greater extent by requiring a review of the patient order. For inpatient and
outpatients; For inpatients’ orders
5. After the physician wrote the order, would send the order to pharmacy for preparation and dispinsed
6. The pharmacist would prepare a 2 - 5 day supply for the patient and charge the patient for medication
dispensed .
7. The nurse will store medication on the nursing unit.
8. This system still require the nurse to prepare the individual dose for the patient.
9. When the drug need to be refilled, the nurse would contact the pharmacist who would prepare it, and send it to the for continued
use.
10. When the drug was discontinued or patient discharged , the prescription bottles were returned to the pharmacy and used drugs were
credited to the patient account. By this way the pharmacist had opportunity to review the patient order.
11. The pharmacist would place limited decision on whether the dose was correct or appropriate to the patient or there is a drug or food
a drug or food interactions, because has no access to the patient information

. Verbal order : in some situations the prescription order is requested verbally by physician
• Unit Dose System
The unit dose system is defined as “the pharmacy coordinated method of dispensing and control medications in health
care institutions”. The system characterized by the medication being :
1. Available In unit dose packages.
2. Dispensed in ready-to-administer form and not more than 24 hours supply being delivered or available on the patient care
unit at any time.
This method is very different from the previous methods. Studies showed the unit dose system has the following
advantages:
3. Cost reduction / less expensive
4. Safer for the patient
5. Place the pharmacist in a better position to be involved in patient care, by reviewing the medication order and could
intervene before the first dose is administered if any mistake is dicoverd.
Methods of unit-dose
There are two main ways that a pharmacy provide unit dose services. These include:
• Centralized model or location: this originates from the main pharmacy. The medication order is received in
the central pharmacy and all processing for patient order occur there: order processing, drug packaging,
cart fill, and medication dispensing. The advantage of this method is that all resources are localized in one
area and inventory can be minimized. The disadvantage is that the pharmacist is not available in patient
care area to provide clinical services.
• Decentralized model or location: is characterized by pharmacy satellites distributed evenly throughout the
institution. A physician order is sent to the satellites, where the order is processed by the pharmacist and
then send the first dose directly to the nurse to be administered. In addition, to pharmacy satellites, a
central pharmacy still exist to provide cart fill and service the decentralized satellites. The advantages of
decentralized model is that reduce turn-around time, increased physician and nurse satisfaction, expansion
of clinical services, reduced dispensing errors and decreased floor stock.
• The use of technologies and computers had a drastic impact on manual system. New ways emerged to
make drug distribution more safer and less manual. This will be discussed in details later.
Medication _use process
Medication use in Hospital setting may be described simply in several steps referred to
as The medication-use process which include the following :
1. Purchasing / inventory control
2. Prescribing: Assessing the need for/selecting the correct drug, individualizing the
therapeutic regimen and signing the desired therapeutic response.
3. Verification and reviewing: the order for correctness of the dosing and indication
for use, drug—drug interaction and drug-food interactions and IV incompatibilities .
4. Processing the order: compounding/preparing the drug and dispensing the drug in
timely manner
5. Administration: Administering the right medication to the right patent, at the right
dose, right time and right route, informing the patient about the medication, and
including the patient in administration.
6. Monitoring: Monitoring and documenting the patient’s response, identifying and
reporting adverse drug reactions and reevaluating drug selection, drug regimen,
frequency and duration.
7. Systems/management and control: Collaborating and communicating among
caregivers, reviewing and managing the patient complete therapeutic drug regimen

Information is used and generated at each step in this process and pharmacy information system
must be able to provide information needed as well as to communicate and document the
information generated.
Rise of technology to assist drug distribution
The use of technology and computer had a drastic impact on the manual that was in use. New ways emerged to
make drug distribution more safer and less manual. For example:
the first attempt to automate the drug distribution system was Brewer system which introduced in 1961 in the
nurse unit to provide individual doses with labels and charge slips.
Another automatic dispensing unit was the Baxter. This machine located in central place. Package d individual
doses upon demand.
Another device that has Widespread utilization is the use of the robots
NTP All this will be discussed later in more details
 Informatics
Objectives
After completing this chapter, the student will able to

. Define the term informatics.

. Identify different types of informatics
. Define data, information and knowledge.
. Identify information retrieval and knowledge sources.
. Identify different types of informatics

. Define the terms informatics security and confidentiality

. Describe different methods used for security and confidentiality of

health information electronic transfer

. Identify several topics that pertinent to the application of informatics in

pharmacy practice.

. Describe clinical applications and system integration and interfaces.

• Describe the advantages of electronic resources

. Describe the roles and responsibilities for those who specialized in informatics

. Describe options in education and training of informatics

 Informatics
Introduction
In 1870s, pharmacists invented modern telemedicine as the first telephone
exchange, connected a drug store with 21 local physicians. Since then, medicine
continue to incorporate technology through years, and In 1955 when less than 250
computers were existed, early articles were published on electronic digital
computers and health. Soon thereafter, the term informatique medicale (medical
informatics ) was invented in France and then adapted worldwide. A medical
informatics became a identified term, the debate start on how best to educate
inspiring medical practitioners.. However in 1974 , a forward looking group of
experts published, one of the first guides for teaching medical informatics (entitled
education in informatics of health personals). Although, informatics, may have a
relatively recent presence, it does possess a strong history over the last half
century.
Pharmacies have often been in forefront of using technology to improve medication
dispensing, ordering, record keeping and billing. Pharmacies have been using
computers for profile management for many years. Computerized profiles improve
the efficiency and safety of medication use systems by reducing legibility and
transcription errors. More recently dispensing technologies have advanced to
include devices such as automated dispensing cabinets and robots, IV
 What is Informatics
Informatics:
• Informatics can be defined as “ the application of computer and information sciences to the management and
processing of data, information and knowledge”.
• Broadly one can define informatics as “the science concerned with the gathering, manipulation, classification,
storage and retrieval of recorded knowledge”.
• In other words Informatics can be defined as the “use of computer to manage data and information “ and
represents the nexus of people, information and technology.
Data Information and Knowledge Management
To understand informatics one must understand the difference between data, information and
knowledge. Because informants focus on technology to improve data, information and knowledge

- Data are simply discrete and objective facts about a subject or event. Example,
patient laboratory values, drug order, patient weight. Data are easy to capture and
store in Media (such as databases or files and has no meaning. Good example of data in
health care are patient’s laboratory values drug orders for a patient or patient’s weight.

- Information is often defined as data that has relevance and purpose. Information has a
meaning because it can be contextualized categorized, calculated, corrected or
condensed. Example patient weight defined in kilograms or pounds, Cholesterol vale
expressed in mg/dl or knowing that a particular laboratory results lower or higher from
reference values.

-Knowledge is combining information with framed experience, norm and contextual

understanding. information is transformed to a knowledge through: comparison
between the current situation and another similar one, knowing how information
connects to other information, understanding the consequence of information or
understanding what people think about information. Knowledge is difficult to capture as
Types of informatics
The terms for Informatics contain numerous major areas (domains) i.e. affect many areas
such as:
• Bioinformatics (i.e. cellular and molecular biology, genomics, pharmacogenomics, and bio-image),
• Public health informatics” (i.e. application to surveillance and health promotion) Engineering,
• Health care informatics (clinical informatics), which can be subdivided by specialty into medical
informatics, pharmacy informatics, nursing informatics, dental informatics, and other specialty areas.
These include :
1. Medical informatics limits the definition to support medical research, education and patient care., while
pharmacy informatics limits the definition to those areas involving the medication management system
(medication use process) within the health care environment.
• Pharmacists has often been on the head of those using technology to improve medication dispensing,
ordering, record keeping, safety and billing as well as profiles management for many years.
• More recently dispensing technologies have advanced to include the use of computing devices such as
automated dispensing cabinets, robots and compounding machines.
• Advances in technologies also, have been seen in IV compounding machines and inventory management
of pharmaceuticals.
• Further many different computing are used in health environments such as personal desktop computers,
laptops, tablet PCs, personal digital assistants (PDAS) and cell phones.
• Introducing computerized prescribing in many health care organizations, has greatly assist in eliminating
the manual hand-writing of prescriptions and hence greatly enhances the pharmacist’s ability to partner
with physician in providing care.
Technology
Technology can defined as “ anything that used to replace routine or repetitive task previously
performed by people or extended the capability of people.
 Bio informatics ( i.e. Cellular ,
Informatics molecular, Biology &
Genomics)

Business & engineering

Informatics
Medical Informatics
Public Health Informatics ( i.e.
application in surveillances
and health promotion )
Dental Informatics
Health Informatics
) i.e. Clinical informatics (
Nursing informatics

FIG 1: TYPES OF INFORMATICS Pharmacy informatics

Security and confidentiality :
• Information security can be defined as “ reasonable protection from risk of loss, risk of inappropriate access, or
doubt regarding authenticity of information”. Data security concern can be referred to as confidentiality (i.e.
ensures that the data is readable only by intended recipients), authentication (i.e. protection against unauthorized access
or forgeries ) and non-repudiation (i.e. ensures someone cannot deny having conduct a transaction). Vulnerabilities and
threat to information security may consist internal failure of software or hardware, deliberate (intentional) attacks of
information security and natural catastrophes (disasters). Informatics specialist must ensure security design in all pharmacy
information systems support the pretension, detection, and correction of these vulnerabilities and threats.
• Security can be achieved by one or more of the following method (s) :
_ Passwords: such as smart cards, and/or biometric (i.e. fingerprint recognition or retinal
scanning) identification.
_ Back-up data sets is accomplished by replicating in an alternate medium or site. Media that is used
may include hard drives, tapes CDs or DVD. This system is intended to protect against natural
disasters as well as hardware or software failure.
_ Another key security issue that has get up with advent of electronic transmission of prescriptions between
physicians and pharmacies (internet pharmacies) has been the authenticity (legitimacy , truth) of involved
parties or electronic signature .
_ Systems as VeriSign are available to encrypt (encode) to encrypt prescription or other protected
health information during electronic transmission of these data. This system prevent the
interception (interruption), and unintended disclosure of confidential patient information during
these transaction (operation).
_ Encryption a technique used when handling protected health information . This technique
involves replacing identifiers that are traceable to an individual with another set of number or
letters which cannot be linked back to individual patients. This technique may be useful to protected
health information

- Fire wall
Information retrieval,/ knowledge sources:,
• Historically pharmacists have used hard copy references to access drug information and other resources.
• Today pharmacist are increasingly utilizing electronic information resources.
• The advantages of electronic information include:
1. Availability of information from almost any where within the health care system at the point of services.
2. Reduce space requirement for storing information.
3. Significant advances in the efficiency of information retrieval.
4. Increased availability of information leads to better decision making and improvement in the quality of care
provided.
• A wide verity of information retrieval and knowledge sources are currently available (reached about 100,000
websites provided health information)
• Electronic database and search engines, Medline , electronic journals, electronic books, electronic drug
information resources such micromedex, laxi-comp, facts and comparison etc..
• Several generations of knowledge systems allows to return information that specific to particular
patients or clinical situation or scenario . For example instead of reporting the usual dosage range
of particular drug , the information provided might be a dosage recommendation specific to a
patient of given age and creatinine clearance.
• Presence of the internet enabling more educated patients than ever before. It has been estimated that over 9
million individual in United States and Canada , use the World Wide Web on daily basis, one third of them to
find information on health . This allows patients to present health professionals with heap of printed
materials about their conditions from the internet . This raised concerns about the validity and reliability of
information available online. Because individual is able to serve as author, editor or publisher of information in
the Intranet, there is no safeguard on quality of information to be provided.. Therefore, the Commission of
the European Communities has published criteria to assure quality in health related Web sites.
 Practice application of informatics in pharmacy
Nowadays, informatics has a wide application in the daily functions in healthcare pharmacy. The following are the
most important functions in which informatics play a crucial role in hospital pharmacy:
A. Daily Operation in pharmacy
Informatics plays various roles in the daily operation of the pharmacy . For example :
1. Computer systems mange drug profiles and histories for patients allowing the pharmacist to better mange care.
2. Label generation and patient billing of charged medication are tied to computer system to automate many of tasks required for
providing pharmaceutical care.
3. Filling of patient order.
4. The complex health care systems used a number of interfaces to control the information stored in a multiple systems. interfaces allow patient’s Interfaces
formation to flow directly in the pharmacy, thus eliminating the needs for manual entering of data in the computers. For example interfaces to laboratory
systems, and addition of rules, allow easily retrieval of patient’s laboratory results to help in save and effective use of drugs.
5. Interfaces for electronic prescribing used in daily operation practice greatly reduce medication errors and improved patient safety as well.
6. Interfaces to external devices such as IV compounders, automatic dispensing cabinets and robots rises the efficiency of overall operation of the pharmacy.

B. Clinical activities
Informatics today's plays a curtail role in areas of clinical pharmacy activities as follows:
. Improve access to the information
• Other clinical area that important to the clinical pharmacist, or drug information specialists, and pharmaceutical care
specialist is the documentation of clinical pharmacy activities about patients care as well their interventions.
Methods of documentation
• Advances in technology provided the pharmacy with computerized methods that allow the clinical pharmacist to document the collected
data about his or her the patients’ care as well as their patient interventions‘ through one of the following ways :
1. Manual Documentation : Using paper forms and hand written notes. This is a troublesome method, time consuming and lost or unreadable and difficult
to complete.
Computerized documentation .
2. Record interventions on paper and latter enter them in computer. This is still hold the disadvantages of the paper
documentation, but it did make data interpretation more efficient
3. Use personnel digital assistant devices (PDAs) , and tablets PC. To document clinical activities and latter introduced into
computer for further data evaluation and analysis. Its advantages include reduce time needed for documentation,
improve ease of use, accessibility, time efficiency and general acceptance.
C. Administrative
The management of pharmacy services greatly improved since the introduction of technology and informatics. The
Informatics offers managers, information tools that:
1. allow them to better assign resources to meet workload requirements .
2. identify chances for cost saving and defend (justify) new services.
3. Invent of Medication systems such as automation dispensing machines have allowed pharmacy managers to
redistribute their pharmacists to do more clinical activities.
Administrative application of informatics
Use of informatics in administration helps managers in:
4. Drug usage reporting : in order to insure compliance with policies and standard practices.
5. Workload reporting: in order to measure efficacy and productivity of the process within pharmacy.
6. Inventory management systems to control inventory costs and turns, monitor purchasing activities, mange recall and drug shortage,
and monitor controlled substances methods of dispensing to insure that they comply with regulatory requirements.
4. Scheduling systems to mage employee schedules, employee recruitment, retention and compensation (i.e. mange
personnel costs ).
5. Portals to . disseminate information and create knowledge sources regarding drug therapy.

D. Workflow and medication process improvements

Informatics has a great impact on workflow and medication use process within pharmacies
6. Technology and automation has changed historically important pharmacist functions such as dispensing, by permitting
these functions to be performed by robots and cabinet dispensing machines thus increased safety and improved medication use process by
freeing more pharmacists to apply their clinical knowledge for patient care.
7. Improvement also often seen through improving and allowing knowledge sharing, for example Invent of web sites and internet allow the
user to access information easily and at a lower cost . Clinical guidelines, disease management approaches and formularies also become
more and easily accessible to the pharmacist.
8. Portable clinical computing advances in the forms od PDAs ( e.g. wireless laptops and tablet PCs) have brought the knowledge closer to the patient
and care plan.
9. Perhaps one of important improvement in technology and automation is increased patient safety by using of bar coding that help to ensure five
rights (i.e. right medication, for right patient , through right route at right time, and right dose) as well as dispensing machines and robots
Systems integration and interfacing and Pharmacist computer interactions

. There are many different types of software that are used in health care informatics and
pharmacist have varying ways in which they work with software, as follows:
1. Simple unchangeable fixed system program solely designed to operate a piece of equipment or
medical device (e.g. automated machines)
2.. Complex application designed for data entry, storage, exchange and retrieval.

. Usually, most of the pharmacists generally do not involved in software designing and
programming, especially for complex application required in health care environment . However,
the interaction of the pharmacist with different types of software is primarily to direct these
software to perform various tasks via either the user interface or the display screen of the
computer or device. This interaction can involve activities , such as programming infusion rates,
entering orders and extracting reports for various equipment, devices and systems such as p
pharmacy information system or computerized provider order entry (CPOE).
Opportunities in pharmacy informatics
• Pharmacist positions in clinical informatics had bee evolved in response to pharmacy
practice needs rather than positions which have a clear academic and training path.
• Nowadays informatics education appear often in curricula at colleges of pharmacy in many
countries and offered master degree in pharmacy informatics.

Roles and Responsibilities for those who specialized in informatics

Pharmacist who specialized in informatics generally are responsible for one or more of the following
activities:
• In patient pharmacy information systems
• Outpatient information systems.
• Robotic unit –dose dispensing machines. Automated dispensing machines.
• Point-of-care bar-code medication administration.
• Automated intravenous admixture devices.
• Inpatient and outpatient computerized provider order entry (CPOE) and electronic prescribing,
respectively.
• Clinical decision support system.
• Packaging machines
• Programming
• Pharmacy intranets
• Reports writing.
• Inventory control systems
• Desktop and application support.
• Staff training and education and so on
Education and training
Pharmacists who wish to hunt a position or impark in pharmacy informatics accomplish this in
several ways:

. One option is to take specific courses or obtain degree in computer science , information
systems and/or business information technology. Useful coursework would include areas
such as net work administration, basic programming, and database management.

. Second option is to an advanced residency in pharmacy informatics. Informatics Many

sites for informatics residencies available today.

. Third option is to volunteer to assume informatics roles at one current place of

employment and /or on the-job experience as possible including taking coursework through
local community colleges, attending certified training courses, attending vendors training
courses, attending informatics related conferences and learning from colleagues.
 Pharmacy informatics
Objectives
After completing this chapter, the student will able to

. Define the term Health informatics.

. Define the term medical informatics.

• Define the term pharmacy informatics.

• Describe the several subdivisions of pharmacy informatics

. Identify the responsibilities of pharmacy informatics specialist

. Describe practice, educational and training opportunities for clinical

pharmacists and pharmacists who are interested in informatics

. Describe Integrating information systems with pharmacy work activities

Background
• Despite the fact that pharmacy informatics is a relatively new specialty within the practice
of pharmacy, however it created an existing path for the pharmacist who is keen for forcing
information technology to support pharmacy activities.
• As medical informatics became a recognized term, dated back the late 1950s. The basis for
formal education on the subject was conceived by a forward-looking group of experts
almost 42 years ago. In 1974, they published one of the fist guides for teaching medical
informatics, "Education in Informatics of Health care Personnel". However, Pharmacy
informatics may have a relatively recent presence in the curricula at many colleges of
pharmacy, .
• Pharmacist positions in pharmacy informatics have evolved in response to pharmacy
practice needs rather than positions which have a clear academic and training path.
Historically, this has taken several ways or options to be achieved as follows:
1. Take specific courses or obtain a degree in computer science, information system and/or
business information technology. However, some colleges offer master degree in pharmacy
informatics.
2. Attend an advanced residency in pharmacy informatics.
3. Assume an informatics role at one's place in institutional setting. This can be done by
volunteering to take the responsibility for one or more aspects of informatics and/or
obtaining as much on-the-job experience as possible, including taking coursework through
local colleges, attending certified training or vendor training courses, attending informatics-
related confekrences and learning from colleagues.
Definitions
Health informatics
• The National Library of Medicine (NLM) defines health informatics as “the interdisciplinary of design,
development, adaptation and application of information technology (IT) based innovation in health
service delivery management and planning”. Health informatics is a discipline at the intersection of
information science, health care and computer science that design and delivers information to
improve individuals and public health care and biomedical research. ASHP believes that the
pharmacists have the unique knowledge, expertise and responsibility to hold a significant
role in health informatics.

• The broad definition of health informatics and of the discipline involved, present an opportunity
of growth of subspecialties within the field. Among these subspecialties is pharmacy informatics.

• Medical informatics sometimes used interchangeably with health informatics. It is defined as

“a more specific application of the use of people information technology and techniques in an
attempts related to the infrastructure, development, and delivery of optimal health care. Medical
informatics limits the definition to informatics involving the support of medical research, education
and patient care.

• Pharmacy informatics has been defined as "the use of integration of data, information and
knowledge, technology and automation in the medication-use process for the purpose of improving
health outcomes.
• The American Society of Health-System Pharmacist (ASHP), also, defines pharmacy informatics as
“an important subset of medical informatics in which pharmacists used their knowledge of
information systems and medication use process to improve patient care by ensuring that new
technologies lead to safer and more effective medication use”.
• In other words, IN PRACTICE the term pharmacy informatics can be clearly defined as the
application of technology and information system to medication use process to improve the health
outcomes and safety and efficacy of medication use process.
• To simplify the term pharmacy informatics can be defined as “a pharmacy specialty that dealing
with pharmacy computerization, but when used in integration with other current hospital
technologies relevant to medication use process.
• In contrast to medical informatics pharmacy informatics limits the definition to those areas involving
the medication management system within the health care environment.

• Today, informatics affect all areas of emphasis in pharmacy including: basic

pharmaceutical science (e.g. pharmacogenomic, pharmaceutical chemistry [Chemo-
informatics] and pharmacokinetics), pharmaceutical technology and managements (e.g.
pharmaceutics, pharmacoeconomics and study design) and clinical pharmacy practice
(e.g. therapeutic, drug information and patient counseling) and hospital pharmacy
practice (e.g. medication use process). See Fig-2.

• Pharmacy informatics was actually part of practice long before it was a cogent term or
discipline. In fact, even the study of computers and technology to improve pharmacy practice
dates back over 20 years. As technologies evolved that impacted the delivery of medication
therapy, they permitted a reengineering of the medication use process. Just as informatics
impacted the medication use process, it has also impacted pharmacy education.
Application of software in pharmacy informatics
Pharmacy informatics used a variety of software to perform different tasks within the pharmacy. This software is
typically divided into:
1. Application software
• Application software is designed for data entry, storage, exchange and retrieval.
2. System software
System software is a fixed system exclusively designed to operate a piece of equipment (e.g. Computers or
automated devices).

Role and Responsibilities of pharmacy informatics specialist

Pharmacists who specialized in pharmacy informatics typical are responsible for the following roles
and abilities:
• Help to support the concepts of pharmaceutical care by improving the efficiency and increasing of workflow.
• Increase access to patient-specific information and medication literature through technology by remote site
availability.
• Strong knowledge and understanding of pharmacy practice.
• Ability to have a clear understanding of the elements of automation that affect practice, including robotic unit-
dose dispensing machine, automated medication dispensing machines, automated intravenous administer
devices and automated packaging and compounding machines. Also, have a clear understanding of basic
approach to the adaption of information management and knowledge of technology that helps identifying
other technologies that are likely to benefit the medication use process.
• Acquired skills in manipulating computerized provider order entry (CPOE), electronic prescriber and clinical
decision support.
• Ability to adopt a careful and realistic planning for infrastructure, resources, time and materials in order to
ensure that all bases are covered.
• Ability and skills to speak two language fluently the professional language of the pharmacist and
programmatic language of the system designer. The drug informatics specialist must be able to interpret
• Ability to recognize and plan for the temporary sense of displacement that all health professionals will
feel as they adopt to change in workflow due to implementation of the new technology.
• Ability to approach any given system and determine how to best achieve a particular end goal. Also has
the ability to access to databases perform queries, manipulate spreadsheets and perform statistical
analysis.
• Aware of automation tools currently available to the pharmacy and if possible those under
developments, in order to help direct the practice site to an appropriate automation plan.
• Familiar with technology initiatives that support medication use process. Also, knowing the informatics
standards exist and how they can be used to advance the development of automated solution.
• Ability to develop plans to alleviate hazards created by developing and implementing new technology.
• Ability to provide recommendations regarding vendor selection and to communicate requirements to
potential vendors during an acquisition process to assist RFP responses and to provide a rational and
complete comparison of respondents.
• Ability to communicate with others healthcare professionals and serve as link between pharmacy and
other departments as well as serving as resource for hospital staff.
• Ability to educate and train pharmacy students and staff and other health care professionals and
managers.
Pharmacy technician roles in pharmacy informatics
• ASHP statements on the technician’s role in pharmacy informatics indicate that especially trained
pharmacy technician can assure important support role in pharmacy informatics. These include
automation and technology systems management, managements of projects, training and education,
policy and governance, customers’ services, charge integrity and reporting. Such roles required
pharmacy technicians to gain expertise in information technology (IT) systems, including knowledge of
informatics, computer management techniques, and problem resolution and database maintenance.
This knowledge could be acquired through specialized training or expertise in health, science or allied
scientific fields (e.g. Health informatics) ( ). A well trained and qualified pharmacy technician may assure
a supportive role in the field of informatics.
Integrating information systems with pharmacy work activities
There are several methods for integrating information systems into the existing pharmacy
processes. The most important of these are:
1. Pharmacy information system (PIS), this is the most widely used method in pharmacy
practice. It is used to organize the work activities in the pharmacy by automating and
organizing the daily workflow. Printed cart fill list and intravenous medication labels,
generated medication administration records (MARS that can help nurses to organize
activities related to medication administration process.
2. COPE systems are also used to organize activities. Most CPOE contains the following:

. Patient list and demographic information.

. Electronic medication administration documentation.
. Order forms and other features. The order-format can be different from one hospital to
another depending on:
1. Workflow patterns and scope of technology utilized.
2. Physical size and layout of the hospital.
3. Types of facility and practice-base of the physician (e.g. independent, group practice,
hospitalist, or residents)

Pharmacy orders can be :

. Handwritten or electronic.

. Individual or grouped (e.g. single sheet of paper or order set).

. Entered by physician or other persons such as nurse or clerk.

 Informatics
Basic pharmaceutical science
)e.g. Pharmacogenomics(

Pharmaceutical Chemistry
) i.e. Chemo informatics(

Pharmaceutical technology & management

(e.g. Pharmacetics &
Pharmacoeconomics )
Clinical pharmacy Practice
e.g. Therapeutics, Counseling & (
)pharmacokinetics

Drug Information
) Drug informatics (

Hospital Pharmacy Practice

)e.g. Medication use process(
FIG 2: INFORMATICS
SUBDIVISIONS
 Technologies and Automated Devices for Pharmacy
Informatics Relevant to Medication-use Process
After completing this chapter the reader will be able to:
. Define computerized provider order entry (CPOE).
. Describe the goal of CPOE.
. Describe benefits and limitation of CPOE.
. Describe types of options for handling orders that electronically delivered.
. Describe barriers that limit uses of CPOE.

. Define decision support system (CDSS)

. Describe methods of conveyance knowledge information

. Describe the components of (CDSS)

Technologies and automated devices applied throughout the medication –use process
Prescribing & verficatio
Computerized providers order entry (CPOE)
Clinical decision support system [(CDSS)(software)]
Electronic prescribing (e-prescribing) or Electronic provider order entry
Verification
Decision support system
Several companies such as First DataBank and Multum provide electronic drug knowledgebase information
for clinical decision support. The content provided by these companies support such functions as electronic
prescribing, patient education leaflets, clinical alerts (drug-drug drug allergy etc.) within CPOE and pharmacy
information systems
Dispensing
Carousel technology
Centralized robotic for dispensing medication & inventory tracking devices
Decentralized automated dispensing devices
Centralized narcotic dispensing and record keeping
Intravenous and total parenteral nutrition compounding devices
Pneumatic tube delivery systems
Unit dose medication repacking systems
Administration
Bar code medication administration technology
Clinical decision support infusion pumps (smart pumps)
Monitoring
Electronic clinical documentation system
Prescribing and role of computerized provider order entry (CPOE)
CPOE
History and Background
. The high incidence of preventable ADEs and medication errors in ordering phase is one of the
major reasons for creating CPOE.

. First implementation of CPOE date back to the mid -1970s.

. Early systems allowed health care providers to enter their orders directly into the system, but provided little
decision support to alert drug interaction, allergy warning etc.

. Some factors limited early adaptation, these include CPOE system functionality, hardware limitation and
willingness of institutions.
. Over succeeding years, technical advancement and the needs for tools to assist in delivering
optimal patient care, have led to further adaptation of CPOE.

. Recent surveys and reports placed CPOE on high of agenda of many facilities.

Definition of CPOE
Computerized Provider Order Entry (CPOE) is the process by which health care providers electronically
Place clinical orders (such as prescriptions, laboratory and radiology requests), using information system
platform or interfaces, instead of handwriting or verbal requesting an order. CPOE systems are also used
to organize various work decision activities Most of CPOEs contain patient lists or profile, demographic
information, electronic medication administration order form support system etc. This means that
most of the aspects of hospital information systems were fully integrated into CPOE to achieve the
best results.
Integrating information systems with work activities
There are several for integrating information systems into the existing pharmacy processes. The
most important of these are:
1. Pharmacy information system (PIS), this is the most widely used method in pharmacy
practice. It is used to organize the work activities in the pharmacy by automating and
organizing the daily workflow. Printed cart fill list and intravenous medication labels,
generated medication administration records (MARS that can help nurses to organize
activities related to medication administration process.
2. COPE systems are also used to organize activities. Most CPOE contains the following:

. Patient list and demographic information.

. Electronic medication administration documentation.

. Order forms and other features. The order-format can be different from one hospital to
another depending on:
1. Workflow patterns and scope of technology utilization.
2. Physical size and layout of the hospital.
3. Types of facility and practice-base of the physician (e.g. independent, group practice,
hospitalist, or residents)

Pharmacy orders can be :

. Handwritten or electronic.

. Individual or grouped (e.g. single sheet of paper or order set).

. Entered by physician or other person such as nurse or clerk.

. Delivered manually or electronically from CPOE system to PIS.

The goals of CPOE
System implementation usually include the following
• Improve patent safety
• Increase appropriateness of care
• Facilitate the use of current medical knowledge via clinical decision support
• Increase the process of coordination of care
• Limit the missed opportunities for preventive care
• Research capability for epidemiological studies
• Control or reduction of cost
• provide structure to physician orders
• allow for rendering of decision support tools at the moment of ordering.

Features of ideal CPOE

• Ordering : Physician order are standardized across the organization , yet may be
individualized for ach doctor.
• The ordering process include a display of patient medication history and current laboratory
results and evidence based clinical guidelines to support therapy decision.
• Patient safety feature: the CPOE system allows real-time patient identification, dose
recommendation, adverse drug reaction reviews and check on allergies, tests or treatment
conflicts. Accordingly, physicians, pharmacists and nurses can review orders immediately.
• Intuitorive (sensitive spontaneous) human interface: The order entry workflow
corresponds to familiar paper-based ordering , to allow efficient use by new or infrequent
users.
• Regulatory compliance and security: Access to the system is secured and permanent
records is created with electronic signature .
• Probability to: accepts and manages orders from all departments at the point of care from
any location in the health care system (such as physician office , hospitals or remote
location), through a variety of devices, including wireless PC, tablets and PDAs’ devices.
• Management : the system deliver statistical reports online , to aid managers in analyzing
patients census and make change s in staffing and replace inventory, assessing utilization
and productivity throughout the organization.
• Billing: Documentation is improved by linking diagnosis to orders at the time of order entry
to support appropriate charges.

Benefits of CPOE
• Provide structures to physician orders and allow for rendering of decision support tools at
the moment of ordering (e.g. check errors for duplicate , incorrect doss or tests.
• Eliminate the potential introduction of transcription errors.
• Eliminate entry to the wrong patient as well as omission due to the order being lost.
• Quicker in medication turnaround time.
• Improves better compliance with institutional medication –using policies and formularies .
• Decrease delay in order completion and allow entry at the point of care.
• Simplifies inventory and reorganization of charges.
• Overall provides and improves patient safety through reducing medication errors from
poor handwriting and transcription.
Limitation of CPOE
• Slower entry of orders, particularly by inexperience staff that can lead to errors.
• Physician to nurse commutation can be worsen if each work alone in their stations.
• Failure to deliver software that meet clinician needs:, e.g. easy to use, intuitive software
can cause bad results.
• Automation can cause false sense of security, a misconception when technology suggest s a
course of action that “error are avoided”.
• Frequent alert warning can interrupt workflow and cause alert fatigue.
• Imperfect methods selection Vendors and incorrect implementation..
• Shortcut of default in selection can override nonstandard regimens for elderly or
underweight patients.

Barriers for application of CPOE

These include:
• Resistant from side of some physicians may lead to slower adaptation of the system.
• Loss of autonomy (independence) feel by some physicians.
• Product system or vendor immaturity.
• Technical and process complexities of implementation of CPOE with no grantee of success.
• Lack of standardization in practice across health care facilities.
• High cost of implementation and lack of capital.
Types of CPOE interfaces
CPOE can interface with a pharmacy information system in a variety of options:
• No integration of CPOE and pharmacy information system. In this option the pharmacist takes
printed copies of orders from COPE system and the pharmacy personnel reenter the order manually into the
pharmacy information system . This way introduces transcription error.
• Unidirectional interface: this option would allow order to be transmitted electronically from CPOE
system to the pharmacy information system via one-way interface , thus eliminating the ability of the
pharmacist to enter or take action on prescriber order. The main disadvantage of this option include: 1.
needs for prescriber to reenter problem order in CPOE when changes are required; 2. the appearance
of medication ordering information inconsistent with the manner in which physician typically order
medications; 3. need to elaborate procedures in the events of CPOE system downtime.
• Independent option is to transmit orders from CPOE to the pharmacy information system (PIS) and
back to CPOE via independent one-way interface.
• Bidirectional interface: this option allows orders to be transmitted back and forth between systems.
A bidirectional orders interface is a very complex starting , but it can offer some advantages over two
unidirectional interfaces . Bidirectional order interface allows orders to be transmitted electronically
to existing pharmacy system and entered directly into the system and transmitted back through CPOE
to populate other clinical systems such as automated dispensing system, special instructions ,
modified orders, discontinued orders, prescriber, patient etc., all must be match between both
systems. This functionality allows the pharmacist to take verbal or telephone from prescriber in
urgent situation , as well as order correction or entering the order instead of prescriber. In
bidirectional interface, if any change made in PIS can be sent back through interface and will update
information stored in the CPOE system, without the need for deletion of incorrect order and
reentering the order in CPOE system. Furthermore, if either the CPOE or PIS system is down for
significant period of time, the interface engine is capable of queuing the orders on the life system
until such time as the system that down is to be placed back into production. The major problem with
bidirectional is the possibility of downtime of any component of the system such as CPOE, PIS and the
interface itself.
Clinical decision support system (CDSS)
Definition
• CDSS is a communicating decision support system, computer software tools which is
design to assist physicians and other health care professionals with decision making task
at the point of care. CDS use information from patient , drug, laboratory to provide the
physician with integrated data to help guide or support decision making.
• In other words a clinical decision system is a set of tools (software) that facilitates the
decision making capabilities of the prescriber at the decision point.
• CDS brings together integrated information (i.e. patient, internal, externals, and algorithm) to
patient care provider at decision point to promote the correct clinical decision at decision
point as follows:
1. Patient specific information : include core “portable” summary: problems, allergies, meds,
Local electronic patient record, orders active/inactive
2. Internal (i.e. Local) knowledge: include , institutional policies & costs; drug interactions and
formulary system and physician preferences.
3. External (i.e. Global) knowledge: medical literature; diagnostic databases regarding diseases;
national guidelines; patient databank with outcome data and so on.
4. Algorithms: reminders; alert; quality checks; self-generated monitors; decision support
programs.
• Pharmacy systems have long employed clinical decision support systems (tools) . Its
functionality , traditionally included allergy checking , duplicate therapy checking, drug
interaction checking and dose range checking. These proven an important tools for the
pharmacists in managing even complex drug therapy.
• Acknowledging, that these tools must improve to be effective if utilized in CPOE. So all
systems will provide a basic level of CDS, even though this functionality varies greatly with
the products.
• Increasingly CDS is recognized as the cornerstone of improving quality and safety within the
CPOE system.
• CDS can be provided in a passive means or in a more active methods.
• Passive interventions generally present relevant patient –specific data , without
recommending a change in therapy, e. g. would include non- formulary alert, drug shortage
and order sets.
• Active alerts utilize specific patient information combined with other content knowledge to
recommend a change therapy. Example include recommendation of dosing, allergy warning ,
and safer therapy, or less expensive treatment options.
• CPOE vendors provide drug-content modules (e.g. First data bank, Multum, Micromedex )
with their products which serve as a core (center or hub) of medication CDS.
Methods of conveying information by CDS
The clinical decision support system (CDSS) represents features and functions of an information system
that passively or actively convey clinical Knowledge contents to health care professionals so that
choices can be made in the best interest of patient care. Basically, these methods can be illustrated
as follows:
1. Passive transportation of clinical knowledge. This can divided into two passive ways as follow:

a. passive method can include providing users with links to the knowledge resources (as
mentioned previously),
b. Another passive method providing basically CDS with list use of STRUCTURED DATA ELEMENTS for
medication ordering in PIS and CPOE systems. During system operation drug tables are presented
that allow drug order choices that users or system users can select during order entry. (see fig-1).
The advantage of this method is that:
1. by limiting the choices, a prescriber can make, will help greatly in preventing medication errors.
2. also, by this directing choices patient will receive safe, effective and cost- efficient therapy.
3. The use of structured order entry will ensure that key clinical information contained in PIS or CPOE systems
can be coded. Furthermore, coding of stretchered allowed CDS to expand its capabilities checking for drug
interaction, allergy problems, unusual dose, doses duplication, IV incompatibilities therapeutic indications
problems and other rules
2. Active conveyance of clinical content is actually provided through alert and warning screen,
but can also include notification of alerts via printed documents, electronic mail and pagers .
. CDS alerts can be imbedded as a part of most any clinical information system, but most frequently
appreciated in PIS , COPE systems or standalone expert system.
. The proper use of CDS needs experiences, understanding the capabilities, limitations and
deficiencies within their environments.
. Active convey include allergy checking, duplication therapy checking and dose range checking,
drug-drug interaction checking , drug-food interaction checking etc. Functionality for dose
range checking involves comparing several patient parameters such as height or weight age
against ongoing prescribed dose. The purpose of this functionality is to prevent overdose or
support detection of super therapeutic dose. Drug-drug interaction checking consist of
electronically comparing a new drug that is being added to the drug(s) that the patient is
currently receiving. Drug-drug interaction may produce excessive number of alerts depending
on the number and type of medications the patient is taking. Many of these alerts may actually
represent false –positive or insignificant interactions. Similar to drug interaction checking,
food-drug interaction comparing food and drug combination that are known to alter drug
absorption (increase or decrease) or potentiate the effect of a drug. Laboratory drug checking
can also prevent many errors. Errors were most often due to drug dosing and selection
problems related to laboratory parameters.
Types of alerts: There are two types of alerts:
• Synchronous alerts
Represent warning screen that appealed as a result of specific action done by the user e.g. the
appearance a drug warning dosing alert notification screen when the user attempt to enter an
excessive dose of medication.
• Asynchronous alerts
This generally occurs as a result of imbedded rule, for example reported laboratory result of
the rule, to see if they are included as part of a rule. If so, and if the rule criteria specify that an
alert should occur then the system will present an alert to the user or users. For example the
alert could a flag placed on electronic user work list, patient list or system inbox when
abnormal laboratory value is manually entered or electronically transmitted to CPOE SYSTEM
for blood chemistry.
Example of basic structured data elements:
• Generic drug name

• Dose amount

• Unit of measures (e.g. mg, units, mg/kg, mEq/L etc.)

• Route of administration

• Frequency or rate of administration

• Dispensing dosage form (tablet, capsule etc.)

• Dispensing strength

• Dispensing dispensed
Electronic prescribing (e-prescribing)
Electronic prescribing or e-prescribing or outpatient computerized prescriber order
entry, is an automated device by which a provider can electronically send an accurate
error free new prescription or renewal one, directly to outpatient pharmacy
information system or community pharmacy from point of care.
Characteristics of ideal e-prescribing system
The flowing are the main characteristics of ideal e-prescribing:
• Creating a complete active medication lists.
• Selecting medications, printings, transiting prescriptions and perform all
safety checks using integrated decision making systems.
• Providing information with lower cost and therapeutically appropriate
alternatives.
• Providing information on formulary medications.
• Reviewed patients’ current medication list and medication history
information within the practice.
• Capable of viewing details of information, removing medications from
active medication lists and change dose or rout of administration.
• Prescribing or adding new medications and select the pharmacy where the
prescription to be dispensed.
• Easley sending and receiving information related to prescription to or from the
transaction hub.
• Providing patient specific information capabilities such as current patient
medication lists , access to patient historical data and patient identification.
• Having integrating capabilities for example connection with various databases,
connection with pharmacy and pharmacy benefit managers.
• Providing educational capabilities, for example patient education and provider
feedback.
Components of electronic prescribing system
• Prescriber
is typically a physician , searches patient by password, register number etc.
• Transaction hub.:
provides common link between all components of electronic prescribing:
prescriber, patient index to access to the patient, route enquires to match
Pharmacy benefit managers (PBMs), list to enrolled pharmacies and route
prescription to the demanded destination.
• Pharmacy Benefit Maneger (PBM ) system
works as intermediate to ensure accuracy of information
• Pharmacy with implemented software
receives information from the transaction hub, it send a conformation message that
the prescription have been filled
Benefits
• Offers clinician a powerful tool for safely and efficiently managed their patients.
• Enhance patient safety, convince and medication compliance.
• Improving prescribing accuracy and efficiency and reduce errors associated with handwriting or
transcription.
• Reduces health care costs via eliminating drug adverse events, substitute for less expense alternatives and
improve formulary adherence.
• Decreases the risk of medication errors .
• Enhance an overall medication managements.
• Reduces oral communication regarding phone calls and call back to pharmacist.
• Most order is correctly mapped.
• Elimination for the potential introduction of the possibility of transcription error.
• Eliminate entry to the wrong patient .
• Omission due to the order being lost.
• Reduce over all design complexity.

Limitations
• Higher cost of implementation.
• Change in management process.
• Erroneous of alerts.
• Hardware and software selection.
• Security and privacy.
• System downtime
Electronic prescribing
Another Computer-based prescribing for outpatient pharmacy
Online prescription entry created major changes in the process of handling prescription by physician
and Pharmacist.
First , physician enter their prescription directly into microcomputer located throughout the general
medicine practice (GMP) . After a patient’s hospital number is entered, a menu of actions is displayed on the
monitor. Among selections on the menu one for prescription medications. When the prescription order selection is
chosen, all active prescription medication for the patient are shown on the screen. Then, the physician can review or
modify an existing medication that has been previously stored or order a new medications. Prescription renewal is
simply, reviewing the field corresponding to medication’s dosage , sig and quantity to be dispensed. However, to
prescribe a new medication, the physician can quickly call a specific order by typing in of few letters of the
medication’s name or can examine a specific formulary class of drugs to look for alternative treatments. The
advantages of this process is improving practice by removing some of the practical ambiguities physicians have in
writing prescriptions (such as, which drug, strength, dosage, how supplied and costs) and also reminding physicians
how to effectively monitor patients’ drug therapy and avoid important drug interactions. After physician enters all
medications, an electronic copy of the patient’s prescription is sent to the pharmacy and a paper copy is printed for
the patient. The paper copy given to the patient serves two purposes :
1. first to store the copy in the pharmacy.
2. Second the paper copy brought to the pharmacy by the patient, serves to notify the pharmacist that the
patient is at the pharmacy and their prescription have already been written and stored.
To display the patient’s prescriptions the pharmacist enter a prescription access code or number specific to the
patient, physician and date. All patient’s prescriptions are then displayed to the pharmacist to accept, modify or
reject. The paper copy is field latter after the majority of patients have been served during the day.
Fig-3 Clinical decision support brings to gather the information
seen in knowledge sources links during decision making
2. Internal knowledge
1. Patient specific information
Problems, allergies, meds, local policies & costs, drug
Institution
electronic patient records, orders interactions & formulary,
active /inactive physician preferences

Patient care provider

3. External knowledge 4. Algorithms to enhance
at the point of care
care
Reminders, alert, quality checks,
Medical literature, Diagnostic
self-generated monitors,
databases, National guidelines,
decision support programs
Patient databank with outcome
data
Drug Administration Systems
Bar code medication administration (BCMA) technology
• The medication administration phase of medication – use- process is perhaps the most error-prone phase of any
process in all of health care except prescribing phase which is the leading (e.g. that error rates are higher as 19%).
BCMA technology can help to dramatically reduce this error.
• BCMA technology relatives to a number of hardware and software components combined together to display,
receive and chart real-time patient and medication information, thus, providing the nurse with tool needed to
accurately administer and document (record) the medication administration process.
• Before administering a medication to a patient, the nurse , performs three checks at patient’s
bedside:
First linking and checking bar codes on the nurse identification badge ( emblem, or device ).
Second linking and checking bar code on the unit- dose of medication at the bedside.
Third linking and checking bar cod on patient‘s identification wristband .
• By this way of triple checking, BCMA enables the nurse to administer medication safely and helps to ensure the five
right of medication administration i.e. the right medication is being given to the right patient, in the right dose, by
right route at the right time.
• When the nurse scans the medication, he or she planning to administer, then that medication is electronically
compared to the patient’s medication profile. The BCMA system then either:
1. Confirms the drug as a match with ordered drug and instantly documents the drug as administered in an
electronic medication administration record (e-MAR) OR
2. Warns or alert the nurse that the drug scanned does not match the drug that was ordered for that patient.
• Also, if there is inconsistency anywhere (i.e. drug, dose, time, route or patient) most BCMA systems alert the
nurse via visual and audible (easy to hear) alert that an error about to occur . All avoided errors are
documented in the BCMA software. Usually the BCMA system records the time of administration or reasons
for not giving the medication (if applicable) onto an Electronic Medication Administration Record (E-MAR)
Other functionality of BCMA
• Most various devices applied by BCMA at the point of care (such as laser bar code scanners and
wireless had-held computers) are linked to pharmacy computer system, via radio frequency and
real-time software interface to maximize portability and updated hand held scanners with patient’s
information and any new modified and discontinued medication order from the pharmacy
computer system. By this way the nurse can immediately be acquainted with the new modified or
discontinued medication in the order.
• BCMA provides real-time updates to electronic MARs that enables the nurse and caregivers to
view information about the current and past medications and make judgment about future
medications administration

Bar codes
• The bar codes are a way of enc oding numbers and letters by using combination of bars and spaces
with varying width stacked side by side & designed to be scanned by special optical scanners called
barcode reader and read into computer memory.
• Bar codes come in various sizes and shapes such as Linear, Rectcangular, dots, hexagons and other
geometric patterns in two dimension formats . But the most commonly used is the linear.
• The bar code type or symbol is commonly referred to as symbology, referred to language used in
bar code technology.
• Currently more than 20 different types of bar code symbologies exist, and each bar code
symbology presents specific benefits and limitation.
Benefits of BCMA
In general the overall benefits of BCMA include:
• Improve safety and accuracy of medication administration , via proofing the “5 rights”.
• Prevent preventable errors during the medication process of administration.
• Generate online records of medical administration (e-MAR)
Limitations
Although BCMA offers a dramatically reduction in the risk of drug administration errors, still there are major
limitations for use of BCMA. These include:
• High cost of implementation (related to hardware and software).
• All medication must be bar coded to achieve the optimal safety benefits.
• Commercially available BCMA products are still at early stage of development.
• Nursing workflow redesign issues.
• Complicated real-time interfaces between pharmacy and BCMA information system are necessary to
assure accurate patient records within the BCMA system.
• Instillation of dedicated radiofrequency network may be incompatible with certain devices in the hospital
The electronic medication administration records (e-MAR)
• The medication administration records (MAR) is one of the documents that uniting nursing and pharmacy in
the safe of medication administration process
• E-MAR is another key medication administration-related technology. It’s an electronic version of the
patient’s paper-based medication administration record performed by the nurse has the capability to
automatically generate Online records.
• Prior to advent the computer, pharmacy maintain manually a patients’ profiles in such the same manner as
the nurse, handling new medications and discontinued and deleted medications.
• E-MAR commonly lists a patient allergies, medication and standardized medication administration time, and
missed dose.
• Additionally, e-MAR may include specific administration (e.g. infusion within 1 hour).
• Now with the advent of the computer, it is becoming easy to provide printed MARs by the pharmacy. This
reduces manually transcription by nurses and gives the nurse chance to double check the accuracy of the
pharmacist as well as the nurses who transcriber the order in between printing.
• Today’s most advanced systems utilized computer-based MARs in which the nurse electronically document
medication via touch screen technology (or by bar code on the patient wrist and medication badge).
This functionality allows immediate feedback to the nurse, if he or she tries to administer inappropriate
medications (e.g. attempt to administer wrong drug, wrong dose, at wrong time by wrong route etc)

• So from the above-mentioned discussions it seems that combining E-MAR with BCMA to verify
patients and medications to be administered will better equip the nurse to meet the “5 rights”
of medication administration, correctly.
Computerized clinical documentation system (CCDS)
• Computerized clinical documentation systems provide for electronically documentation of patient care, for
example, the recording the vital signs directly from the respiratory monitors.
• Nursing documentation practice. is a medium used to record the care provided by nursing process and keep
track of change over time.
Reported benefits of CCDS. These include:
1. Nurse time saving
2. Improve of nursing documentation process.
3. Decreased medication errors.
4. Decreased time for results.
5. Ease the quality of assurance process.

Reasons for nurse documenting care, include:

• Communicating and providing continuity of care: to ensure that documentation presents accurate,
clear , comprehensive picture of client’s needs, nurse interventions and the client outcomes.
• Responsibility : nurses are responsible for ensuring an accurate, timely and complete document.
• Facilitate evidence-based best practice.
• Legal and professional practice requirements .
• Security: safeguard clients health information by : maintaining confidentiality and acting according to
procedure that consistent with standard and legislation.
Intravenous additive program versus Intravenous additive service
The difference cited is that intravenous (IV) additive program consists of policies and procedure for
both the preparation and administration of IV fluids to which drug are to be added under aseptic
conditions, on around-the-clock basis, and controlled to as location and person preparing the product.
Whereas, IV additive service usually refers to the preparation of the product by individuals who may not
be necessary involved in its administration and assume the responsibility for monitoring its clinical effects.
It seems from these differences that an IV additive service is a part of IV additive program.
In the past (and still) the preparation of intravenous solutions with their additive is a
task performed on the nursing floor by nurses or interns and resident. The concept that the
preparations of these products require the skills of the pharmacist has raised many other questions not
the least of which is the availability of the product at odd (unusual) hours, particularly if the preparation
of the product is done in the main pharmacy. Therefore, this assumption was solved by evolving the
stellate pharmacies that equipped with clinical pharmacist and technicians.
The responsibility of IV additive services, might be expected to achieve the following objectives
when preparing IV additives:.
1. The preparation of the final product is accomplished under aseptic condition.
2. Drug interactions and incompatibilities be avoided.
3. The final product should be appropriately labeled dispensed and stored.
Preparation of IV additive solutions: when preparing IV additives the pharmacist should work
from original order form or directly from a copy.
. The first step : is to prepare a label that covers the following information: patient Identification,
patient location, physician’s name, name of the drug with quantities added, date, date of
compounding, expiration date and identification of the pharmacist preparing the product. If any
additional labeling is needed, it should be prepared at this time.
. When applying the label to the container, it must be positioned in upside down order, to facilitate
reading when the container is hung from an intravenous solution pole on the patient bed.
. Preparation of the solution should always take place under laminar flow hood using sterile
needles and syringes or double ended transfer needles.
. When the transfer is made, the metal disc should be replaced, and new seal crimped on to the
container. As safety device, a different colored seal should used to guard against confusion and
warning individuals that the drug has been added.
. Before allowing the admixture to leave the counter, the pharmacist must carry out a final
inspection of the product. The inspection should involve a review of the label, clarity (clearness)
of the solution and mathematic involved in the preparation.
. For more information refer to ASHP guidelines for pharmacist preparing IV admixture
and parenteral nutrition.

Parenteral Hyperalimentation
Parenteral hyperalimentation is the intravenous administration of sufficient nutrients above the usual
basal requirements to achieve tissue synthesis, positive nitrogen balance and anabolism.
To prepare Parenteral hyperalimentation solution two method are used described as follows:
1. Wet method : this consists of mixing the dextrose solution from one flask and fibrin
hydrolysate in another flask using a solution transfer set.
2. Dry method : this consists of adding the appropriate amount anhydrous glucose to the fibrin
hydrolysate solution. Both methods should be carried out under laminar flow hood. The fished
product must be stored in refrigerator. Also, be cautious about caramelization of glucose during
sterilization.
 Computerized infusion devices
.
. Computerized infusion devices with drug errors reduction systems are now available to
improve safety of intravenous infusions of various types such as
continuous infusions;
patient controlled analgesia; total parenteral nutrition; epidural infusions
and intermittent infusions from syringes.
. To prevent confusions of dispensed product concentrations in order to reduce complexity
and improve patient safety, these technologies often inspire a combination of available,
dispensed drug product concentrations for the same drug from hospital pharmacies.
• Nowadays, intravenous technology has drastically changed from the former devices
that offer only one infusion channel and simple rate programming to devices with
multiple channels allowing infusion of several medications at the same time and
complex programming of dose calculation and dose delivery (e.g. smart pump).
• Smart pump is defined as “ Infusion device with clinical decision support software
and drug library that perform a test of reasonableness (realistic) at the point of
medication administration.”
• Devices today are provided with alert to signal when air is detected within the infusion line.
• The safety software in these devices contain multiple drug libraries that include intervenes
medications , concentration dosing unit, and doses minimum and maximum limits.
• Typically, regulated medical devices require pharmacists to develop or
validate drug library files listing the drug items that can be managed by
“smart” infusion pump.
Record Systems
Record systems in the hospital include :
1. Patient paper-based records
2. Electronic medical records (EMR)
3. Electronic Health Record systems (EHRs)
4. Administration electronic records (see the previous slide)

Patient paper-based records

• The patient medical record (PMR) is the primary written communication tools for all health care professionals. The following
constitute the patient paper-based records (charting):-
1. Written interventions or progrbess notes of Health care providers after each patient visit at outpatient setting ,
2. Written interventions or progress notes Health care providers in patient chart at in inpatient setting

• Writing in or access to a patient medical record (charting) is license granted by each institution to physicians and other professionals.
However, recently many institutions allow clinical pharmacists charting license, although this practice is yet immature and far from
universal. The medical record usually is used to:
1. Document and communicate information about the patient interventions and progress.
2. Assess, retrospectively, the quality and appropriateness of patient care
3. Document patient care activities and serve as data for charging.
NB.
• Those utilizing papers-based medical records should adhere to legal, ethical and professional standards when
documenting patient information. These ethical and professional standards required that :
• Handwriting should be clear and readable using black ink.
• Errors are dealt with by crossing out the error with one line and then initiating the error.
• Label the notes with specific descriptive headings and time and date
• Sign at the end of the document with name and title.
Electronic Medical Records (EMR)
• Nowadays, many institutions changing from handwriting medical record (handwriting chart) to
electronic medical record ([EMR] or electronic chart) in a way to avoid errors result from handwriting.
• The first EMRs were aggregations of observations laid down on paper either through a full narrative
entries or scanned copies on notes is usually created in the clinic, in hospital settings and ambulatory
care environment, where it deals of records of disease and interventions as well as serve as data
source for electronic health record system.
Electronic Health Record systems (EHRs)
• The electronic record system is known as electronic health record system (EHRs), developed as
an identity in the early 1960s with pioneers developing programs to assist in documenting
patients’ history, physical examinations, laboratory and radiology reports etc. in USA, for
individuals or population.
• In general EHR systems are designed to replicate (duplicate or repeat) the information found
in patient paper or electronic medical records (EMR) but often takes on additional functionality.
• EHR systems are tools that provide secure, real time , and patient centered information for all
health care providers at the point of care and when ever needed.
• EHR system can help to mange multiple aspects of patient care such as :
1. Manage clinical documents, medications and allergy managements as well as laboratory results
tracking.
2. Promote better decision making by providing accurate and timely clinical information.
3. Support administrative functions related scheduling patient admission or appointments.
4. Organize information according to what is needed and when it is needed.
Components of comprehensive EHR system
HER generally contains several essential components as follows:
• A patient data repository: it is generally a type of database that contains a patient information,
including lists of information, such as allergies, radiology and laboratory testing results, clinical
documentation, demographic information (e.g. age, gender, address and orders). These information
can be displayed in or inform the functioning of other tools within HER system.
• User interfaces: these tools allow the health care provider to interact with data in:-
1. Patient data repository
2. Promote entry of new order or prescription
3. Viewing recent laboratory results
4. Scheduling visits and admission and managing lists of diagnosis.
• Clinical decision support tools: provide guidelines or knowledge-based information to health care
providers as they generating clinical order to improve the decision making. The knowledge and content
that inform decision support tools come from several sources (See diagram 1). Decision support can be
simple as providing list of dosage forms while health care provider entering the dose or complicated as
therapy advisors for TPN or chemotherapy.
• Clinical note capture tools: assist health care provider in documenting their decision making and
patient interactions.
• Rules engines tools : apply specific algorithm to data available from any of theses systems to ensure
it HisHH h conform (obey the rule) to the system standards and to derive additional function (such as
decision support) For example, comparing microbiological culture and sensitivity data with patient
antibiotic regiments and disease, monitoring certainties clearance in relation to drug therapy.
• Other functionality of EHR is to improve and promote the quality of care
This is usually done in the same manner as in clinical decision support system when
associated with medication ordering. The thoughtful use of alerts and reminders is intended to
promote the physician to take an action in a manner consistent with established evidence
based guidelines. To illustrate the way in which EHR has come to improve and promote quality
of care, let’s take the following scenario:
Scenario: a provider seeing a patient with identified coronary artery disease on the problem
list. The EHR knows the most recent lipid levels as well as whether a patient is taking
medications to lower lipid level, if the patient is not currently on antilipemic agent or does not
have a serum level consistent with evidence based guidelines an alert will display to promote
the physician to take an action. In the same manner other screen will promote the prescriber
to order appropriate lipid-lowering therapy.

• EHRs’ records are designed in digital formats that are capable of being shared across different
health care settings.
• Sharing either occurred through network connected enterprise wide information systems or
other information network.
• Access to electronic medical records using EHRs should be limited to those who need it
and control must be exercised by using a security method (e.g. approved passwords and
electronic signature and/or biometric identification fingerprint or retinal scanning);
however access to other information is allowed to anyone within the password-
protected system. The computer automatically label entries with the date and time of
entry and may link the entry to the password.
 Core components of Comprehensive EHR system
Patient Data Repository
Patient information: Medications, Clinical Decision Support User Interfaces
allergies, laboratory & radiology Tools Provide guidelines or Allows Interaction with patient
results, clinical documents, knowledge-based information data Permit entry to new order
demographic information, from local medical library , /prescription; Laboratory reports;
address & orders. vital signs, associations & goverment Scheduling; Admission; Managing
personal statistics lists of diagnosis among others

EHR System

Rules Engines
Clinical Note Capture Apply specific algorithms to data
Tools to all systems to ensure that it
Assist health care providers in conform to system standard and to
documenting their clinical derive other functionality such as
making and patient interaction CDS
Benefits of EHR Include:
• Assists in minimizing number of times health care provider unacquainted with patient’s
history, because of clear readably corrected data provided by EHR systems.
• Support clinical decision making
• Greatly support administrative functions and quality improve monitoring due to wide
covering nature of EHR systems.
• Support clinical actions and verify that the right therapy administer to the right patient.
• Allows physicians to access patients records from remote locations.
• Improve accuracy of diagnosis, outcomes and coordination between health professionals.
• Increase practice efficiencies , cost saving and quality of convince and patient care.
Increase patient participation in care.
• Provide a clinical documentation tools.
• Help to improve compliance with healthy regulatory standards in institutional settings.
• Connection of EHR systems to medical devices such as infusion pump or other
technologies can active alerts warning about any change in status or encounter medication
problem can greatly enhance the quality of care.
• Assist gathering information necessary for research protocols.
 Automated devices & Technologies applied throughout
medication-use process (i.e. Dispensing)
Automation
Objectives
When completing this chapter the reader will be able to:
. Identify the use of automation in patient pharmacy practice, particularly
medication use process
. Define the term automation
. Define adverse drug events and medication error
. Describe advantages and disadvantage of automation
. Describe centralized robotics for dispensing medications
. Describe decentralized automated devices
. Describe carousel technology as example of storage cadent
. Describe centralized narcotic dispensing and record systems
. Describe pneumatic tube delivery systems
Introduction
• Pharmacies has been automating their supply chains for several decades in an effort
to achieve optimal, continuous inventory management.
• Automation is now used to improve the safety of the supplied chain by inserting
barcode confirmation steps as product are received , stored, retrieved and
dispensed.
• Today’s, all automated counting machines, packaging machines, inventory
management technologies and dispensing machines, rely on the use of barcodes as
medications move from the pharmacy to patient.
• Automation is designed to improve and make more efficient of the medication use
process.
• Technological advancements are constant which pharmacy departments must cope with all these
development in order to successfully implement them to provide optimum quality services.
• All automation are technology, but the opposite is not necessary true.
• The automation demand for unit dose method continued to be increased .
• The use of technology and automation had a drastic impact on the manual distribution system that
was in use, as well as supporting the ongoing transformation (alteration) of the health care
pharmacy profession to more clinical activities, and directly connected with patent, rather than
doing merely technical activities .
• New automated devices were emerged to make drug distribution system more safer
and less manual. Subsequently, nowadays, a wide array of automation is currently in
use in many health systems, within all phases of medication-use process. These intended to
perform different tasks including counting, inventory control, packaging, compounding , labeling ,
distribution, prescribing, dispending, and proof of accurate medication administration, while
electronically documenting all transactions.
• Demand for using robotics in pharmacy practice continued to be increased. For example
more than one type of automated individualized syringe-filling robot has been marketed.
Goals of automation include:
. Improving patient, customer services.
. Resource utilization
. Improving patient safety by reducing adverse drug events and minimizing medication errors.

Definitions
• Technology can be defined as “Any thing that is used to replace routine or repetitive
tasks previously performed by people or which extend the capability of people.
• Automation can be defined as “any technology machine or device linked to or
controlled by computer and used to do work
• Adverse drug events (ADEs)___ An injury from medication or lack of intended
(planned) medication. Reported ADE rates vary in the literature depending on the detection method
ranging from 0.2% (using a voluntary , self-reporting system) to 10% (when chart reviewed and a computerized
screening was used).
• Medication error___ Any preventable event that may cause or lead to inappropriate
medication or patient harm while the medication is in the control of the health care
professional, patient or consumer. Also, a medication error may be defined as “the failure of
a planned action to be completed as intended or the use of wrong plan to achieve an aim” .
Medication errors are preventable, do not always cause patient harm, and that they may be cause by errors in planning
(e.g. Prescribing), not just errors in execution (e. g. dispensing the wrong drug for a patient) Majority of medication
errors do not result in adverse drug events (ADEs). Reported medication error rates in the literature reach up to 19%.
Medication errors resulting in ADEs (preventable ADEs). This result in significant consumption of resources in the form of
increased lengths of stay, increased cost of care, rework time, malpractice claims and patient costs (suffering and lost of
productivity).
History
• The application of automation in pharmacy practice dated back to the year 1960s.
• Historically, pharmacies have been automating their supply chains for several decades in an effort
to achieve optimal, continuous inventory management.
• Nowadays several factors emerged that greatly increased demand for incorporation of
automation in pharmacy practice These include.
1. Changes in health care systems and profession’s transition to pharmaceutical care dramatically
increase the demand for incorporating automation into pharmacy practice over the past
decades.
2. Organizational goals: intended to reducing costs, improving operating efficiencies , growing
profits, enhancing safety and quality, integrating and managing data and providing outstanding
customer services, as well as
3. Pharmacy managers goals: which are aiming to Improve pharmacy efficiency ( i.e. reduce
pharmacy staff, reduce nursing workload) and quality (i.e. reduce medication delivery time,
improve patient safety and clinical programs). Both of which can be accomplished through
appropriate use of automation.
4. Increased emergence of new professional responsibilities for pharmacist, for example for
improving patient outcomes through implementing of pharmacist patient care services that
demand freeing the pharmacist to do more clinical activities, increased the necessity for
implementation of automation technology.
5. Shortage of qualified pharmacists and technicians
6. Strategic partnerships between health systems and pharmaceutical wholesalers are increasing
the rate of availability and development of new automation and technologies
.

Advantages of automation
In general, the goals and advantages of automation are to :
• Improve patient care via providing efficient and cost effective services.
• Maximize patients and customer services, through reduction of medication delivery time and improving patient
safety by reducing adverse reaction events and minimize medication errors.
• Promote efficient resource utilization by eliminating traditional technical tasks of pharmacists
• Promote efficient time utilization: pharmacists can have time to stay with costumers for consultation.
• Shorter waiting time for prescription.
• Reduce the need for storage space .
• Reduce on-hand drug product inventory, improving accuracy and labor efficiency and reduce drug acquisition cost .
• Reduce waste and pilferage by limiting access to drug inventory..
• Reduce pharmacy labor cost and free the pharmacists to do clinical activities.
• Reduce medication turnaround time and preventing missed doses.
• Remove confusion over sound-alike drug name, look-alike , skipping a medication or choosing the wrong strength.
• Improving medication dispensing accuracy and efficiency.
• Results in greater productivity of nurses and pharmacists.
• Enhance methods of tracking controlled substances
• Achieving pharmacy’s ultimate goal of provision of pharmaceutical care.
• Automation maximizes the safe and efficient use of medications and improving medication use process
Disadvantages of automated systems
These include:
• Expensive cost of implementation due to the expense of machinery
• Automated system can be braked down.
• Breaking rules e.g. Using another person’s identification or mix-up patient prescription
• Automated dispensing systems may introduce much potential of medication errors e.g.
nurses retrieving an incorrect medications.
Stock control systems
Computerized sock control systems were introduced to pharmacy during 1980s to provide machine generated label. Some of these
systems also, provided limited management information about what drugs had been used and by whom. Systems were further
developed to provide automated stock Control, patient medication records, and drug interaction warnings. Despite these advances
many systems are still not used to their full potential.

Purchasing/inventory :
Using Bar coding and scanners. Many pharmacy information system have the capability to manage pharmaceutical inventories.
Nevertheless, there is variability in the success of using such functionality in inpatient versus outpatient pharmacy environ
using software. Inventories need to account for use of each and every tables, capsule, bottle syringe and so on, in the system.
This may be problematic when inpatient pharmacy environment (Most inpatient pharmacies are refrained to support and use
of inventory software, due to :
1. Numerous access points in which medication are stocked.
2. Large number of personnel involved.
3. Continuous transferring of medication such stocking , pharmacy satellites, missing
doses and pilferage.

Traditional orders v s. Electronic data interchange (EDI)

Traditionally, orders from regular suppliers (such as wholesalers) relied on telephone conversations, sometimes supported by
faxed copies or posted hard copy of the orders. Perhaps In the earliest development was to use suppliers-specific hardware
that allow electronic transmission of orders, using products code (e.g. prosper), via a telephone link. While these systems
reduced miscommunication orders to some extent, but they are labor- intensive for both purchasers and suppliers.
The inventory system can be activated to reorder a medication when the inventory, based on actual usage drops below the par
level. When this occurs, an inventory order is then generated, and the order may automatically be sent to the drug supplier or
may place the order into a queue review by the technician before released
The ideal would be stock control system that determine what needs to be ordered; this would then be reviewed by a decision
support system which double-check that the order is correct and then the order would be placed electronically. The order when
received this can be checked by bar code against the delivery note and against the original order to minimize the delivery
errors. The electronic invoice would also be checked automatically against reordered delivery information, via a decision
support price checking system, validated invoices would then be paid electronically.
Systems of pharmacy automation
There are two automated systems used for medication distribution in pharmacy information
system.. These described as follows:
• Centralized system in which automated devices or machines are located centrally at any
location in the hospital, particularly, in hospital pharmacy department.
• Decentralized systems in which automated machines or devices are located in Wards or
nursing unit or station.
NB: Both systems are computer controlled and function into pharmacy computer which process
drug order entry, inventory and patient information.

Automated devices or machines

The following are the most widely used automated devices in the pharmacy information system
and which thought to have the greatest potential impact on safety of the patient and improving
The safety of entire medication-use process
Decentralized automated devices
• The original automated distribution devices was the Brewer machine developed
in 1960s. This system was located in the nursing unit to provide individual doses with labels,
charge slips and an accounting report. It also, offers a reduction of medication errors by rates
of 30 to 51%.
• Decentralized Automated Dispensing Devices sometimes referred to as unit–
based dispensing cabinets. Or automated dispensing cabinets (ADCs), were originally
installed in hospitals in the early 1990s to provide increased control over floor stock
medications and controlled substances in patient care areas. Nowadays, over 60% of
hospitals in the United States use automated dispensing devices for dispensing
medications to in-patients, as well as storing and dispensing nearly all scheduled doses,
thereby, eliminating the manual medication cart fill and delivery process.
Decentralized automated dispensing Cabinets, sometimes referred to as unit–
based dispensing cabinets. Or automated dispensing cabinets (ADCs), which can
be defined as “secure storage cabinets capable of handling most unit doses and
some bulk (multiple-dose) medications, and connected via a real-time
interface to the hospital pharmacy computer system in an attempt to maintain
control over drug dispensing”. This automated dispensing cabinets (ADCs), had
greatest impact on medication distribution process.

• Likely, other decentralized devices such as Meditrol, Medistatin RX or Sure-

Med are located in the nursing unit and designed as an alternative to the concept of
manual distribution of medications within the ward, except that all drugs that
stored there, are not patient-specific. However, a single strength of medication
needed is stored in a discreet location within the drawer of locke d cabinets known
as pockets. To pick out the single dose, the nurse goes into the pocket which keeps
the specific medication needed.
• Nowadays, decentralized devices are increasingly incorporate bar code labeling
and scanning into refilling process, thus improving restocking accuracy, that leads
to potential improving of medications safety.

Advantages of ADC system

• Provides prompt, real-time availability of medications for the nurse and patient.
• Improves the controlled substance accountability ( or liability).
• Mini mizing pharmacy’s filling and delivery of medication cart.
• Provides the vast majority of medications needed for the patient.
• The pharmacy technician started to fill the ACD, instead of a patient specific cart.
• The dose is removed when needed , thus, provides more accurate patient charging
• Reduce pharmacy and nursing labor cost.

Disadvantages of ADC system

• Holds the old concept of floor stock methods which may lead to medication errors.
• Places more medication for the nurse to choose, between when giving a dose which
may leads to medication errors.
• Increases inventory.
• Potential for medication errors, because of open access pockets, and nurses may
access medication before the pharmacist review the order.
Centralized automated devices
• Centrally located automated dispensing devices are designed to automate the entire process of
medication dispensing which includes: medication storage, dispensing, restocking and accepting of unit
dose medications.
• Centrally located automated dispensing devices are designed to be interfaced with the pharmacy
information system and access to each patient’s medication profile.
• The following are the most used centralized automated devices:-
A. Baxter ATC-212
• The first automated dispensing machine that assist drug distribution is Baxter ATC-212. The machine is
located in a central place in the pharmacy and designed to package individual doses of medications
upon demand which is then loaded into unit dose cart. The system interfaces with the computer
containing the fill list. Then the information is transferred to the machine which instructed to package
and dispense medications in the order it is generated in the filling list. A study conducted demonstrated
that the system greatly reduce the technician time with cart fill but has no impact in reducing the
pharmacist time in cart checking.
B. Centralized robotics for dispensing medications.
Centralized robotic dispensing systems in hospitals were traditionally used exclusively to dispense unit
dose, and bar coded medications for scheduled medication cart filling. Also, now its use was extend to
include:
• Automation of first dose dispensing.
• Picked medication doses to be restocked in decentralized dispensing cabinets This has the potential to
reduce medication administration errors by improving dispensing cabinet restocking accuracy.
• When new medication can be ordered at the bedside through a radio computer link to nan automated
dispensary, where robotic system pick the new medications and dispatch them to the patient’s ward via
a pneumatic tube
How the robot works
• The robot usually contains a medication selected station, bar-code reader and packaging
and bar coding equipment. However, through the use of bar code scanning , an appropriate
medications and number of doses for medication drawer, will be identified and selected. after that,
computerized information from the pharmacy system will be automatically transferred to the robotic
dispensing system before filling. Once the system started, a bar code label for each patient was
generated from the system will be placed on medication bin (basket) for each patient. These bins were
then placed on a conveyor belt and the patient label was read by scanner, and the robotic filling device
would immediately recognized what specific patient’s medication needs were for this period, It would
then proceed to pick those medications for that patient and place them in the basket. Once completed
the conveyor belt would start and advance the next basket and the process would start all over again,
until the filling process cycle is completed .
Advantages of robotics, include: Reduce pharmacy labor cost; reduce storage space; eliminate
technical tasks in dispensing medication, therefore, allows pharmacist being able to offer a higher
quality of pharmaceutical care; improve medication dispensing accuracy; improve nurse
satisfaction due to less missing doses, fewer days for first doses and more control over day-to-day
medication distribution activities; it is removed confusion over sound alike drug names, skipping a
medication or choose wrong strength
Disadvantages, include: Possibility of causing a preventable errors and suboptimal therapy;
Incapable of accommodating all medications; because many medication did not come from the
manufactures bar coded so that pharmacy has to do it by itself or outsider this activity; saving cost is
questionable; the system may down time, if the system not functioning, this require the pharmacy to
hand fill the carts. .
The outpatient or community pharmacy robots
The robot was also used to dispense medications , to do this , the pharmacy staff type the name of
medication into the software and the robot will automatically find the medication and pass it through
c. Carousel Automation
. Is another technology, consists of medication storage cabinet with rotating shelves used to
automate medication dispensing. Like other centralized automated systems , the carousel must be
interfaced with pharmacy information system. The carousel utilizes bar code and pick-to-light software and
technology to increase the accuracy of the person who pick and restore medication. Rotating selves bring
medication to a person at one working level, whereas a light identifies the exact location from which
medication is to be picked.

. Assigning medications into carousel does not need to be in alphabetical order, thus eliminate or reduce
errors from sound alike or look alike medications. Carousel technology eliminate the fatigue caused by
frequent traveling time, bending to reach medication during filling and dispensing process. Also the rotating
shelves allow pharmacies to take advantages of rarely used vertical space to store medications, freeing up
space for other uses. The bar code can be used to identify medication and tracking inventory and expiry
date.

. Accurate inventory levels along with par levels (i.e. order-points) allow pharmacy to automate the medication
reordering process.

. Carousel can be integrated with automated dispensing cabinets to increase the efficiency of restocking and
eliminate the need for manual filling and picking process.

. Software within carousel allows: minimizing the number of carousel turns; prioritizing workflow and allowing
processing the most important order first. Also, software allow set up inventory location outside of a
carousel (e.g. on shelf s or refrigerator)
D. Centralized narcotic dispensing and record keeping
system
. Accounting for every dose of controlled substance is considered a tedious and most labor
intensive (exhaustive) process in central pharmacy. Fortunately, there are devices that can
automate this process, thus offering more improved efficiency and control to the system.

. Such system can account and record all doses dispensed from central pharmacy narcotic
room along with decentralized automated dispensing devices, by scanning manufacture’s
bar-code and provide a record of the individual performing every transaction..

. Also, this system can interface with decentralized automated dispensing devices to confirm
that every dose dispensed from the pharmacy is stocked in the planned device.

. Additionally, the system can generate bar coded nursing proof- of -use forms, for patient
care areas without automated dispensing devices.

. Finally the system can suggest reorder quantities based on past usage that provide useful
compliance reports and facilitate documentation of controlled substance waste
Delivery systems
• Pneumatic tubes are devices used to mechanically deliver the medications, lab specimens and
other materials from one department to another in the hospital, so eliminate the manual methods of
delivery.
• Due to increase and expansion of responsibilities of hospital personnel staff , health care managers
look to technology as solution to improve their ability to deliver expanding hospital service without
increasing the Staff. Thus pneumatic tube systems are found to be as an immediate answer to this
problem,
• Pneumatic tube systems are developed in recent years to be widely used in hospital to deliver
medications, lab specimens and other materials from one department to another in the hospital. It
By this way helps to eliminate the manful methods of delivery.
• Using pneumatic tubes save both money and time of caregivers and reduce staff.
How the system work
• The system simply (see figure-1) consists of a sending station and receiving. Let use imagine that the
pharmacy is the sending station that linked to receiving station in the nursing room. When the
pharmacist want to send an order of medications to floor stock in nursing station, the pharmacist
simply load the medications into containers (see the depicted picture), and place the container in
the tube and close the door, then he or she press on the send button, the air compressor will be set
to “suck” and sucking the air along the tube will create a vacuum in front of the container. So, the
container can reach its destination, at high speed, slowing down when reached its destination where
can be empted and return to the sending station via “blow” that made the air compressor push the
container through the tube by blowing the air behind it.
Different types of pneumatic tube containers
 Pharmacy information system
Introduction
• Pharmacy information system have been used in delivery of pharmacy services since the
early 1980s. Pharmacy information system support for automation has become vital to
optimize the safety of medication use process. Today’s practice of pharmacy incorporates
many technologies to assist the pharmacists in delivering care. These technologies
increased efficiency , reduces pharmacist time in preparing and dispensing medications
and allows increased time for clinical activities. The adaptation of these technologies
also allows placement of advanced safety measures .

. The pharmacy system incorporates patient specific clinical data to support review of
medication appropriateness, perform real time inventory management and interact
fully with other systems, including computerized provider order entry (CPOE), Bar code
medication administration (BCMA), billing systems automated dispensing systems, and
electronic health records (EHR).

. Pharmacy information system also exist in the ambulatory settings and serve to help
pharmacist to receive, process, fill and dispense prescription orders, track inventory and
pill insurance payers for prescriptions.
 Pharmacy information system

Objectives
After completing this section the reader will be able to:

. Define the meaning of information system

. Explain the importance of pharmacy information system to the management medication use
process

. Describe why many pharmacy departments in some institution not allowed to select their
own information systems

. Describe how pharmacy information system is selected

. Describe the role of selection and executive teams in pharmacy information system
selection

. Describe steps used in selecting a pharmacy information system

. Illustrate different methods used to select information system vendors

. Describe the most common type of interfaces received by pharmacy system from
various external sources

. Describe how information system is implemented

 Pharmacy Information System (PIS)
Introduction
• Pharmacy information system have been used in delivery of pharmacy services since the early
1980s.
• Over the past decade technology has been dramatically advanced that pharmacies would not be
sustained without the aid and assistance of information system.
• Pharmacy information systems provide the building blocks of medication use system.
• Today’s pharmacy information systems manage many basic tasks such as medication
administration record (MAR), managing inventory and managing prescribing process, assist in
decision making and choices at the point of care alerting users to dosage range checking drug
interactions and drug allergy checking, reporting etc.
• More advanced systems have rule engines that apply specific algorithms to set of available
data to ensure that it conforms to system standards ( e.g. high potassium lab value when
potassium supplements has been ordered or high cloistral level above the higher limit) and to
derive additional functionality such as decision support.
• Pharmacy information systems track the dispensing history of patients’ medications as well as
information summarizing the events. The information include prescriber’s demographic
information (name, license number place of practice etc.). The date the medication was
prescribed/order (number of doses, drug name, strength, dose, route etc.), patient demographic
(name, address, height , weight etc.), pharmacy technician responsible for entering pharmacist
responsible for review and approval nursing units and so on.
• In its earliest development and up the mid 1990s, pharmacy information systems were limited to
distributive, managerial. These include pharmacy billing, inventory management, report generation
consisting of medication labels, fill list, drug-use check and patient profiles
• With the advent of operating systems such as Microsoft Windows, graphical user interfaces, all of
these have improved the ease with which computer technology has been incorporated into pharmacy
practice.
• Other advances in technology including the evolution of personal computers (PC), hand hold devices
such as personnel digital assistant (PDAs), high-speed network connectivity (e.g. Ethernet, fiber optic
cables, local area networks) along with advances in processor technology have significant impact on
the progress and increasing capabilities of pharmacy information systems.

Pharmacy information system selection

• Changing from one pharmacy information system vendor to another is a significant and most
often one of the largest decisions a pharmacy department will ever make. This because a
significant amount of effort is required to select, purchase and implement pharmacy
information system.
• Some institutions, do not allowed departments of pharmacy to make independent choices in
the selection of their own system. This may be due to:
1. The need for integration of pharmacy systems with other specific systems in the institution
(such as lab, CPOE etc)
2. The elevated level of complexity associated with decision making.
• Nevertheless, despite this situation, some institutions allow departments of pharmacy to select
their own information systems, because pharmacists have a professional responsibility to share
and ensure the proper selection of a pharmacy information system.
Selection team v s. Executive team
• A multidisciplinary selection team should be established includes pharmacists, hospital
information technology (IT) experts and nurses and physicians in order to establish and obtain an
institution wide prospective
• An executive or decision making team may also be established with the aim to :
1. Convey the institution vision for future computerization and provided strategic plans to the selection team.
2. Sort out the important hardware, software, support, financial and operational decision for the selection team
3. Participate in executive managers’ meeting
4. Review the selection team recommendations for preferred VENDORS
5. Make final decision to the vendor and system choice.

Choice of best system versus one size fits all

Purchasing a group of information systems products from one Vendor provides the health systems with benefits of:
6. negotiating a lower purchase price than if all systems were purchased from separate Vendors
7. Allows an enterprise to reassure that service are supported for more than one product.

Steps used for selection of pharmacy information system

• Assessment of pharmacy information needs including personnel, workload, physical layout, etc.
• Listing the strength and weakness of the current system.
• Develop a desire list of functions, as well as specifications and capabilities needed in the new system.
• Developing request for information (RFI) including a potential vendor list
• Developing request for proposal (RFP) see the fig.
• Finally set up demonstration and contract negotiation
Methods of identifying Vendor
The development of a functionality wish list and prospective vendor can often be aided and
identified by two methods as follows:
1. By performing on-site visit s and phone surveys of other institutions. The advantages of
these types of interactions can often provide approaching into vendor selection that RFP is unable to
clarify or shed light on it. Institutions should have standard list of questions they are interested in
asking their peers See table-1).
2. Attending exhibitor showcases at local states or national pharmacy society meetings. These
are valuable low cost method for identifying vendor.
• After research for system specification is completed , then the RFP is utilized to summarize the ideal
pharmacy information systems needed (See table 2). The RFP is released to vendors interested in
pursuing business with the institution.
• A time limit should be placed on vendors pursuing the imitation's business.
• Review the RFP carefully to ensure that questions are binging clearly answered.
• Depending on responses, vendors may be invited to the demonstrate (go-live) functionality of their
system.
• A multidisciplinary group should participate in the go- live demonstration. Also, members of the
executive team should be a part of demonstrations.
• Taking notes and video taping of demonstrations to service as a useful reminders when review group
completing analysis.
• A standardized review form or scripts (handwriting) should be provided to all demonstration
participants so that the institution can quantify and qualify likes, dislikes and concerns. Following all
these steps introduces a more scientific approach to vendor selection and reduces the
chance of a purely emotional decision.
Contract negotiation
The final step in system’s selection is contract negotiation, to reach to sound and unbiased
contract it is helpful to include:
1. Institutional experts in contract negotiation.
2. Subject experts in contract development such as purchasing agents.
3. Software and hardware experts.
4. Institution attorneys (e.g. legal representatives or lawyers) should participate in this process to ensure that the
pharmacy department is well protected in this purchase.
5. A checklist of items to be included in the contract should be developed to ensure that aspects are adequately covered
(see table-3).
6. After the contract is signed, all coverage and power with vendor rests with the contract.

NB In conclusion, contract development is critical to the successful implementation of vendor’s system and the
ongoing relationship with vendor post implementation.

Interface and Standalone vs. Integrated pharmacy information systems

• In many aspects, interfaces are the means of support for any information system .
• The strength of an interface rely in determining the quality, amount and type of information
received by pharmacy system from various external resources.
• The most common type of interface is the Admission, Discharge and Transfer (ADT) . This interface
passes along information such as name and address of the patient , sex, height, weight, medical
record number admission date, unit, floor, room n umber, transfer location information, discharge
date and time etc. Other interfaces may include laboratory, automation (i.e. created from the
pharmacy information system), patient profile (i.e. MAR).
• Integrated system are constructed in such a way that all individual systems (such as pharmacy,
nursing, laboratory , CPOE, etc.) all reside on top of one common database platform. So there is
System implementation
• The planning for implementation of information system start s with development of master plan (project plan).
• The master plan should cover all aspects of the project such as:
1. Resources: human resources are important to success of implementation of new information system.. The project
team should include Pharmacists, the hospital information system specialist or expert , reprehensive from
information system vendors, nurses and physician, Nurses and physician should be included if the system needed to
be interfaced with medication administration documentation system and/or CPOE.
2. Timetable with date of implementation.
3. Assigned roles: include assessment of human resource needed for the day of go – live. Human resources
needed for go-live should be clearly identified and committed very early. Staff should know their roles, location
and expectation.
4. Hardware instillation and software development: Database conversion or transfer is one of the most complex
aspects (features) of new system implementation. The ability to convert data relies on the format and
availability of corresponding (matching) fields from one database to another. However, with today’s advanced
systems all fields from one system’s databases could be simply copied to the new system’s databases much
the way that one can copy from Microsoft Access to Excel or vise verse. When a vendor is unable to
electronically convert database, the organization is then left to decide if a manual entry of data is worth the
effort. Care and consideration should also be given to the conversion of the historical data from the current
system. In many cases , conversion of historical data may be complicated, especially if you are changing the
vendors.
5. System testing: is one of the most critical steps in the development and implementation of pharmacy
information systems. This step should be given especial care in order to explore all aspects of system
functionality. Testing should include aspects such as:
• Operational testing: includes reviewing such functions medication batches, order entry flow , connectivity to
automation, interfaces and billing.
• Clinical testing: includes reviewing dose range checking, allergy checking, drug interaction checking etc.
• Volume testing: includes simulating a period of high volume activity on the system. This
allows testing the processor speed, and size and space of the disk. This is done by allowing
10 to 12 pharmacists working at the same time to half to one hour and at the same time
the interface is open to stress the system. While this occurring special attention should be
paid to size, disk space and processor speed .
• Training and educations: training early should be done in knowing how the system is
function.

Obstacles to implementation and development of information system

• Scope creep: is the addition of unexpected and/or unplanned functionality resulting in the
need for additional time, resources or funding.
• Incompatible databases format.
• Image of the pharmacy.
• Change: change for the change is not acceptable for the sake of progress is warranted.
• We and they syndrome format (e.g. We are scientifically oriented, but they are practicing
etc.
 Hospital pharmacy information systems
(Inpatient and outpatient pharmacy systems )
Activities provided by pharmacy information to hospital pharmacy department
include:
• PIS perform many clinical decision support functions such as dose range checking, drug -drug
interaction, food interaction checking and laboratory checking. Dose range checking involves
comparing several patient’s parameterizes such as height, age against prescribed dose in order
to prevent overdose or detection of super-therapeutic dose. Drug interaction checking consists
of electronically comparing a new drug that is being added to patients regiment to drug(s) that
the patient currently receiving. However, drug food interaction is different in that food is
unknown daily variable. Similar to drug interaction checking compare food and drug
combination that known to alter drug absorption or potentiate the effect. Interface with
laboratory can prevent many errors. Errors were most often due drug dosing or selection
problems.
• Prescription/Order managements for both inpatient and outpatients .
• Inventory managements.
• Patient profile.
• Report generation: Reporting medication use information may be utilized for medication use
evaluation (MUE), ADR/AE tracking and developing, drug budget forecasting, market share
management, and surveillance. Many tools are used for reporting, these include:
1. Internet websites.
2. Wireless portable and handheld devices.
3. Interacting and interfacing with other component systems.

. Dispensing e.g. automated dispensing systems.

• Medication administration record (MAR) is the one document uniting nursing and pharmacy in
safe administration of medication and standardize medication administration time. Today’s most
advanced systems used computer-based MARs in which nurse document medication
administration via touch screen or through reading a bar code on the wrist of the patient.

. Telemedicine and Telepharmacy information system, this describe the ability to share data
and information across long distance. Allow the pharmacist to review, clarify and approve
physician order or prescription and have access to patient profiles from different remote
locations. The information provided through the internet can be secured by encryption.

. patient-specific clinical data to support review of medication correctness, performing real-time

inventory management and interact fully with other systems including computerized provider
order entry (CPOE)

. Bar code medication administration (BCMA) system.

. Billing and charging systems

. Electronic health record (HER).

Information systems security

As information systems have evolved, so too has the requirement to have unique user ID and
password, when logging into the pharmacy system. By having pharmacist and technicians sign –
on to a system pharmacies may track who has received, approved and dispensed medication.
Components of pharmacy information system (PIS)
PIS must interface directly with other components of clinical information systems to
communicate data to and for prescriber, pharmacy, laboratory and nursing. This Integrated
communication can greatly enhance pharmaceutical care delivery and increases patient safety
by optimizing information necessary to ensure safe and appropriate medication use process
within a hospital or facility
These components can be discussed briefly as follows (figure-1).
1. Patient file or profile, including primary patient data such as patient demographics (e.g. sex,
age, allergies, diagnosis , medications) .
2. CPOE, used to send the order electronically.
3. ADT (i.e. admission discharge and transfer)., This information is essential for hospital setting
and pharmacy. Patients often change beds, wards, room or unit, therefore, up-to -date
information is critical for the pharmacy information system.
4. Prescriber file contains all authorized prescribers within the hospital . Data usually included
license number, prescribing , privileges medical specialties and pager number.
5. Drug file contains an actively maintained list of medications available for prescribing within the
hospital. A drug file may have many associated sub-files that contain vital drug information,
including doses, warnings , available root of administration, criteria for use, formulary status,
and additional dispensing comments.
6. Laboratory interface Laboratory interface can provide cultures and sensitivity test to help guide
antimicrobial therapy, selection and therapeutic drug levels necessary for accurately dosing
potentially toxic drugs having low therapeutic range such as digoxin etc.
7. Clinical Decision system (CDS)
CDS use information from patient, drug, laboratory, ADT and prescriber to provide clinician
with integrated data to help guide or support decision making. Interface of CDS with pharmacy
information system is vital to help guide medication use process, (particulary, the verification
step)
8. Drug distribution automation
An integrated pharmacy information system can also interface with drug distribution
automation to ensure the timely and accurate availability of medications to be selected,
dispensed and administered by nurses.
9. Drug administration program
pharmacy information system may also interface with medication administration programs
such as an electronic medication administration record (e-MDAR).
10. Coding and billing system
Pharmacy information systems may interface with coding and billing system to ensure accurate
documentation and billing for pharmacy resource consumption.
 Inpatient pharmacy information system
Medication use process
Medication use process in a hospital setting may be described simply in several steps as follows:
• Ordering (i.e. assessing the need for/selecting the correct drug , individualizing the
therapeutic regimen
• Verification (i.e. reviewing the order for correctness, e.g. checking for drug interactions
allergies , dosage range , duplication of dosage and so on)
• Dispensing (processing the order, involves compounding and dispensing the drug in timely
manner).
• Administering (i.e. administering the medication to the right medication to the right
patient, at the right time in the right dose via the right route) .
• Monitoring (i.e. monitoring and documenting the patient’s response. Identifying and
reporting adverse drug reactions, reevaluating the drug selection, drug regiment, frequency
and duration). Monitoring of ongoing drug therapies is anticipated to lead to further
improved prescribing by creating a cycle through which medication therapy outcomes are
better documented and therefore, more obvious to prescribers when determining
medication therapy needs.
Summary of methods of Processing of the order
. Once order are received by pharmacy, the order verification process begins with using decision
Support system if not applicable use other knowledge resource such as Micromeded
During this process, information from data sources provides the pharmacist with patient
demographics, allergy, laboratory, and other pertinent clinical data. Potential problems with
prescribed therapy including: drug-drug, drug-food and drug disease interactions are screened
and corrected or acknowledged by the pharmacist.

. Verified order may then be sent to automated dispensing or dose preparation equipment and
to BCMD systems for medication administration by nursing staff.

. Finally appropriate billing or charge date are generated and processed either at the time of
administration or dispensing.

. After administration, monitoring information from the bedside and laboratory will be
evaluated by the pharmacist to ensure safety and efficacy of therapy.
 Outpatient pharmacy information systems

Outpatient pharmacy information systems are complex computer systems used by community and
ambulatory care clinic pharmacies to process, fill and dispense prescriptions . Outpatient information
systems can integrated into hospital information systems or other points of care to allow transmission
of the prescription from the prescriber directly to the pharmacy.
The main components of outpatient pharmacy information system are similar to those of inpatient
Hospital pharmacy information systems, but function specific to outpatient pharmacy settings.
Generally Outpatient pharmacy information systems consist of the following components (see figure-
2):
• Patient file
The patient file consists of patient-specific demographic and clinical information, such as patient
name, date of birth, sex, address and telephone number, medication allergy and drug reaction
information, chronic condition , insurance information and a prescription profile.
• Prescriber file
The prescriber file includes demographic data identifying the prescriber , including the provider
name, address and phone numbers and number of providers etc.
• Drug file
The drug file contains all drugs that the pharmacy dispensed, including products names, dosage
forms, routs of administration, strength and inventory information.
• Insurance file and billing interface
The insurance file contains a list of all support insurance companies as well as billing interface.
• Dispensing automation interface
Automated dispensing equipment interfaces may send completed prescription data to a robotic dispenser for filling.
• Outpatient pharmacy information system may be similar in structure to hospital systems, but the process used
to verify (confirm) and fill prescription is quite different from start to finish. In hospital setting , medication order are entered by
provider in the computer system via CPOE. I n contrast, prescriptions in outpatient setting are most often handwritten or print
from printer by provider and carried by the patient to the pharmacy. New prescriptions can be faxed to the pharmacy or called in
by the provider’s office or send electronically to the outpatient information system. All these prescriptions must be transcribed
(copied out) into the pharmacy information system by pharmacy staff once prescription received. The pharmacy staff is required
to verify all relevant patient information, provider information, and insurance and benefit information and select the appropriate
drug.
• E-prescribing is the process by which a provider can electronically send an accurate , error-free prescription directly to
the pharmacy information system from the point of care. E-prescribing greatly enhances patient safety
• The prescription is ready for processing by pharmacist once it is entered into pharmacy information
system. It is during this step that allergy, drug-drug interaction and drug disease interaction checking automatically
occurs. With CDS and order checking processes, the pharmacy information system can determine whether the dose is
appropriate for patient’s weight, age or renal function.
• The pharmacy information system can also screen for potential problems with prescribing therapy, including
duplication therapies, drug –drug, drug –food, and drug –disease interactions and notify the pharmacist.
• Unlike hospital pharmacy information systems, real-time insurance claim processing and adjudication during
outpatient prescription processing. If the patient has prescription drug coverage on file, the pharmacy information
system will send the prescription claim to insurance company’s central computer through billing interface, when
prescription checked , the pharmacist is immediately notified, if the prescription is not covered or if it is too early to fill
the prescription.
• Once the prescription has been processed by the pharmacist , a label can be printed and placed on the
prescription or alternatively , the prescription sent to automated drug dispensing machine, which then fill and labeled the
order.
Thank you for your attention