Closed-Loop Medication Management with an Electronic Health Record System in U.S. and Finnish Hospitals
Abstract
:1. Introduction
2. Closed-Loop EMMSs in U.S. and Finnish Hospitals
2.1. Development of Closed-Loop EMMSs in U.S. Hospitals
2.2. Helsinki University Hospital Introduced Closed-Loop EMMSs to Finland
United States (Hospitals with 200 or More Beds) | Helsinki University Hospital, Finland [10] |
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Medication Reconciliation: home medication list obtained using two sources | |
Medication reconciliation and nursing or pharmacy staff obtain the best-possible medication history (prior-to-admission medication lists) and compliance rates are monitored. External medication history information is pulled into the EHR from outside sources such as retail pharmacies. Pharmacists and pharmacy technicians are frequently involved [32,33,34]. | Medication reconciliation and nursing or pharmacy staff obtain the best-possible medication history (prior-to-admission medication lists) and compliance rates are monitored. Medication reconciliation and a structured home medication list are mandatory for in-patient medication. The EHR home medication list is integrated into the national Kanta system [35], which holds electronic prescriptions. Pharmacists are involved in many units. |
Ordering/prescribing with computerized physician order entry (CPOE) | |
Provides ordering support, through structured order and prescription forms, for most common doses/frequencies. Order panels and order sets developed for specific diagnoses or situations (e.g., admission) [36]. | |
Clinical Decision Support System (CDSS) | |
Sophisticated CDSS, e.g., with dose warnings (including dosing with older patients and renal impairment), duplicate medications, and electronic best practice advice (BPA) [37,38]. | |
Dispensing and automated dispensing cabinets (ADCs) | |
ADCs are widely used, integrated with EHR, and enable the dispensing of medicines according to verified electronic orders on many units. Medication removal by override is limited to urgently needed medications (e.g., antidotes, medications for intubation) [39]. ADC overrides display in EMR to be reconciled with prescriber order and allow BCMA. While some barcodes include lot number and expiration date, scanning technology in use is reading a medication’s National Drug Code (NDC) number. Starting in November 2023, barcodes must include lot numbers and expiration dates [40]. | ADCs are in use in many units and integrated with EHR, which enables the dispensing of medicines according to electronic orders. Medication removal by override is not yet limited. Nurses do the dispensing in a timely manner (max. 2 h before administration) by using the eMAR and scanning the barcodes of the medicine secondary packages (unit doses are not available yet). Barcodes include a lot number and expiration date [41]. A manual double-check is used when the barcode is not available and for HAMs. |
Preparation outside of the pharmacy | |
On units, intravenous preparation is limited to emergencies, drawing medications into syringes for IV Push or IM administration, or the use of vial and bag adaptor technology [42]. Efforts are made to dispense most medications as ready-to-use and unit-dosed by the hospital pharmacy | Ready-to-use medications are not widely available and preparing is commonly done by nurses or pharmacists. EHR provides the documentation with barcodes and instructions for preparation. The manual double-check is used when the barcode is not available and for HAMs. |
Administration | |
Medication administration is recorded promptly at the bedside using BCMA confirming the right patient, medication, dose, time, and route. | |
Most hospitals use smart pumps, some hospitals utilize IV pump interoperability with EHR [39]. High-alert titrated infusion medications may include a MAR calculator to assist with titrations (e.g., heparin or insulin). Some HAMs may require a manual independent double-check process documented in EHR. | IV pump interoperability with EHR is not yet in use. |
Patient Monitoring | |
Interfaced when technology allows. Monitoring data included in dashboards; patient scoring tools, or machine learning used for early identification of diseases such as sepsis and acute kidney injury [43,44,45,46]. | Interfaced when technology allows. Monitoring data included in dashboards; patient scoring tools used for early identification of diseases such as sepsis. |
Communication | |
EMR allows for secure electronic instant communication between members of the healthcare team using secure instant messaging. Order communication between pharmacy and nurse. Follow-up communication between shifts. Epic users have the MyChart phone App for patients to read their charts and laboratory results, communicate with healthcare professionals, and report their home medications and allergies, for example. |
United States | Helsinki University Hospital, Finland [10] |
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Pharmacist Medication Order Verification | |
Prospective pharmacist verification for all orders. Exceptions are emergent/urgent medication needs or medication in the presence of a physician [47]. | Retrospective pharmacist verification of specific orders (e.g., high-alert medications) in some units during weekdays and after the fact for weekends. |
Purchasing, storing, and inventory | |
Continuous inventory allows for as-needed purchasing and enhanced management of medication shortages facilitated by integration of her, ADCs, and in some hospitals, automated drug storage such as carousels or robots [39]. | There is integration between EHR and hospital pharmacy’s ERP regarding ADCs. Information on orders and patients comes from EHR to ERP and doses taken from ADC go to EHR. Storage automation and barcode scanning are in use with the hospital pharmacy’s ERP, which is in use for purchasing, storage, and inventory. |
Dispensing | |
Automated drug storage and retrieval (e.g., carousels or robots) may be used that coordinate patient orders with medication dispensing through an interface [39]. Dispensing and stocking are verified with barcode scanning. Unit-dose dispensing prioritized for medications (exceptions: bulk medications such as creams, ointments, ophthalmic/otic drops, and insulin pens). If not stocked in ADC, first doses are prioritized and sent to units regularly from the main pharmacy. Ongoing scheduled medications are dispensed to units at specified times during the day based on upcoming administration times. | Dispensing is integrated with EHR only regarding ADCs and multidose dispensing, which is in use in primary and social care, where the HUS Pharmacy also dispenses medications. Information on orders and patients comes from EHR to ERP and information on prepared doses (including lot numbers and expiration dates) goes back to EHR. Unit-dose dispensing is not yet in use, but HUS is planning and preparing it for its next new hospital. |
Sterile Medication Preparation | |
Use of barcode scanning of medication and diluent during preparation in sterile preparation facilities connected to order in EHR. Photo documentation and gravimetric confirmation are possible at many hospitals [39]. The final product is provided with a scannable barcode for BCMA. | Integrated into EHR system. Hospital pharmacy prepares patient-specific ready-to-use cytotoxic and biological medications, botulin toxin solutions, and total parenteral nutrition. Information on orders and patients comes from the EHR to the hospital pharmacy’s ERP and information on prepared doses (including lot numbers and expiration dates) goes back to the EHR. Preparation robots including gravimetric confirmation and barcode scanning are in use for cytotoxic medications. |
Communication | |
EHR allows for secure electronic instant communication between members of the healthcare team using secure instant messaging. Order communication between pharmacy and nurse. Follow-up communication between shifts. |
2.3. Comparing Closed-Loop EMMSs in U.S. and Finnish Hospitals
3. Functionality of Closed-Loop EMMSs across the Medication Use System
3.1. Medication Reconciliation
3.2. Ordering/Prescribing with Computerized Physician Order Entry (CPOE) with Clinical Decision Support System (CDSS)
3.3. Order Verification
3.4. Dispensing and Preparing of Medicines
3.5. Barcoded Medication Administration (BCMA), Electronic Medication Administration Records (eMAR), and Integrated Smart Pumps
3.6. Patient Monitoring
3.7. Inventory and Stockpiling
3.8. Communication with Healthcare Colleagues and Patients
4. Future Directions of EMMSs in the U.S. and Finland
4.1. Existing Challenges
4.2. Opportunities and Application Prospects
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Shermock, S.B.; Shermock, K.M.; Schepel, L.L. Closed-Loop Medication Management with an Electronic Health Record System in U.S. and Finnish Hospitals. Int. J. Environ. Res. Public Health 2023, 20, 6680. https://doi.org/10.3390/ijerph20176680
Shermock SB, Shermock KM, Schepel LL. Closed-Loop Medication Management with an Electronic Health Record System in U.S. and Finnish Hospitals. International Journal of Environmental Research and Public Health. 2023; 20(17):6680. https://doi.org/10.3390/ijerph20176680
Chicago/Turabian StyleShermock, Susan B., Kenneth M. Shermock, and Lotta L. Schepel. 2023. "Closed-Loop Medication Management with an Electronic Health Record System in U.S. and Finnish Hospitals" International Journal of Environmental Research and Public Health 20, no. 17: 6680. https://doi.org/10.3390/ijerph20176680