case studies  Home-based medication order entry

case  studies

Implementation of home-based medication order

entry at a community hospital
Alicia Thorne, Sarah Williamson, Tara Jellison, and Chris Jellison
Problem
Factors contributing to the provi-
sion of optimal patient service by
the pharmacy are order turnaround
time, accurate order entry, accurate
medication dispensing, and provid-
ing amicable, helpful, and exemplary
oral communication. 1-3 The large
volume of medication and clinical
consultation orders requested of
the pharmacy can hinder the con-
tinuous provision of excellent patient
service.4,5 Therefore, a relationship
may exist between quality of phar-
macy services and overall medication
order volume. A spontaneous surge
of medication orders, defined as
periods when the rate of incoming
orders significantly exceeds the rate
in which orders can be processed,
can overwhelm the pharmacy staff
and lead to less-than-optimal patient
care.
One option for maintaining op-
timal patient service during these
surges is the use of remote medica-
tion order entry in which a pharma-
cist enters medication orders away
from the work site. Home-based
order entry is one type of a remote
order-entry process. Telepharmacy
and home-based order entry are
Purpose. The implementation of a home-
based order-entry program at a community
hospital is described.
Summary. Parkview Hospital is a 600-bed,
community-based facility located in Fort
Wayne, Indiana, that provides 24-hour
pharmacy services. The main purpose for
establishing a home-based order-entry
program was to provide extra pharmacist
coverage during the event of a spontane-
ous order surge in an effort to maintain
excellent customer service. A virtual private
network (VPN) was created to ensure the
security and confidentiality of patients’
health care information. The names of
volunteer pharmacists who met specific cri-
teria and who were capable of performing
home-based order entry were collected.
These pharmacists were trained and tested
in the home-based order-entry process.
When home-based order-entry is needed,
the lead pharmacist contacts the pharma-
cists on the list by telephone. If available,
the pharmacists (maximum of three) are
notified to log into the Internet, access
similar, yet there are some key differ-
ing characteristics. Though there is
no set definition of telepharmacy, it
is considered to be a practice where
supervision of nonpharmacist staff
by a pharmacist is performed by
teleconference.6-8 Telepharmacy is
the VPN, and perform order entry with the
same vigilance, confidentiality, and care as
they would onsite. Home-based order en-
try is discontinued when off-trigger points
are met. Pharmacists entering orders from
home are paid by the time spent conduct-
ing order entry. Pharmacists reported that
the program was easy to contact home-
based order-entry volunteers, there were
no problems with logging into the VPNs,
and turnaround time was close to our tar-
get of 25 minutes.
Conclusion. A community-based hospital
successfully implemented a home-based
medication order-entry program. The
program alleviated the shortage of phar-
macists during spontaneous surges of
medication orders.
Index terms: Computers; Hospitals; Inter-
net; Manpower; Medication orders; Phar-
maceutical services; Pharmacists, hospital;
Pharmacy, institutional, hospital
Am J Health-Syst Pharm. 2009; 66:1939-
42
typically an outsourced purchase of
pharmacist services, which decreases
or eliminates the need for an onsite
pharmacist. The use of telepharmacy
may require the purchase of auto-
mation to support such functions.
Similarly, with home-based order

Alicia Thorne, Pharm.D., is Staff Pharmacist, Cleveland Clinic,
Cleveland, OH; at the time of writing she was Postgraduate Year
1 Pharmacy Resident. Sarah Williamson, Pharm.D., is Clinical
Pharmacist—Internal Medicine; Tara Jellison, Pharm.D., is Clini-
cal Pharmacy Manager; and Chris Jellison, Pharm.D., is Pharmacy
Manager, Parkview Hospital, Fort Wayne, IN.
Address correspondence to Dr. Thorne at 9500 Euclid Avenue,
Hb-3, Cleveland, OH 44195 (thornea@ccf.org).
The authors have declared no potential conflicts of interest.
Copyright © 2009, American Society of Health-System Pharma-
cists, Inc. All rights reserved. 1079-2082/09/1101-1939$06.00.
DOI 10.2146/ajhp080545

Am J Health-Syst Pharm—Vol 66 Nov 1, 2009 1939

 case studies  Home-based medication order entry
entry, the presence of an onsite phar-
macist is not needed, but it is not an
outsourced purchase of pharmacist
services. Instead, home-based order
entry uses the current pharmacists
available within a pharmacy depart-
ment. Depending on the facility,
the purchase of extra automation
may not be necessary. Remote order
entry does not include any techni-
cian supervision, only order-entry
functions.
There are outsourcing companies
and institutions that have imple-
mented off-site or home-based
order entry.9 Examples of such fa-
cilities are health maintenance orga-
nizations, the Department of Veter-
ans Affairs (VA) Health System, and
mail-order pharmacies. Aside from
the VA Health System, the com-
monality of a hospital-established,
home-based order-entry process is
generally unknown.
Parkview Hospital is a 600-bed,
community-based facility located in
Fort Wayne, Indiana, that provides
24-hour pharmacy services. The hos-
pital decided to implement home-
based medication order entry and
assessed the local utilization of this
process through a voluntary elec-
tronic survey within Indiana and its
neighboring states (Michigan, Ohio,
Illinois, Wisconsin, and Kentucky)
before the implementation.
Approximately 850 community
hospitals within the local states were
identified via the American Hospital
Association’s website. Hospitals with
at least 25 inpatient beds were eligible
for inclusion in the survey. Hospitals
categorized as an outpatient facil-
ity or associated with the VA Health
System were excluded. An estimated
50 hospitals per state were randomly
selected for the survey.
The survey contained ques-
tions about hospital characteristics,
pharmacy-order-entry systems, and
home-based order entry. If an estab-
lished home-based order-entry proc-
ess was used, the respondents were
further informally questioned on the
1940 Am J Health-Syst Pharm—Vol 66 Nov 1, 2009
purpose and overall satisfaction with
the program, including any major
implementation or current obstacles.
Institutions with home-based or-
der entry were also contacted by
telephone and asked nonstandard
questions to clarify their use of
home-based order entry and any
complications encountered during
the implementation and mainte-
nance of the program.
Of the 300 facilities surveyed, 66
(22%) responded. Most of the par-
ticipants practiced in hospitals with
less than 350 inpatient beds. Twelve
hospitals (18%) confirmed the use of
a home-based order entry. The pur-
pose of the program varied among
institutions, including coverage dur-
ing pharmacist shortages (e.g., ill-
ness, maternity leave), spontaneous
surges in order volume, and after-
hours coverage. With respect to ma-
jor obstacles during implementation,
only 4 of the 12 hospitals responded.
All 4 stated that the major complica-
tion was gaining system access from
home through the Internet. Of these
same 12 hospitals, only 2 indicated
they were currently having complica-
tions, specifically regarding legal un-
certainties and the proper employee
payment methods.
Analysis and resolution
The main purpose for establishing
a home-based order-entry program
at our institution was to provide ex-
tra pharmacist coverage during the
event of a spontaneous order surge
in an effort to maintain excellent
patient care. The following provides
an overview of the implementation
process of home-based order entry at
Parkview Hospital.
Utilization of technology. The
creation of a secure virtual private
network (VPN) is necessary in
home-based order entry. In situa-
tions where a company or individual
has a legal obligation to keep infor-
mation confidential, secure access
to that information is necessary. To
ensure security, a VPN incorporates
cryptographic tunneling protocols
to provide confidentiality (blocking
snooping), sender authentication
(blocking identity spoofing), and
message integrity (blocking message
alteration) to achieve privacy.10,11
At Parkview Hospital, the Cen-
tricity Enterprise (GE Healthcare,
Chalfont St. Giles, United Kingdom)
order-entry program is used in
conjunction with the electronic
medication-order-management pro-
gram Pyxis Connect (Cardinal
Health, San Diego, CA). A VPN
was created in conjunction with the
Parkview information technology
department. The servers used are lo-
cated within the pharmacy depart-
ment. To establish a VPN connection
for accessing the pharmacy depart-
ment program, authentication is
required. The delivery network used
to access these programs is a highly
secured system that uses multiple
authentication programs. Once the
VPN is established, all processing of
health care information is performed
within the systems located in the
pharmacy department and cannot be
retained by the off-site computer.
Determining pharmacist par-
ticipation. Pharmacists were asked to
indicate interest in voluntarily par-
ticipating in the home-based order-
entry program via e-mail. Individuals
considered for the program had to be
a Parkview Hospital employee, have
access to a computer with Internet
access and a telephone in their home
(both supplied by the pharmacist),
have a computer that was capable of
running pharmacy-order-entry da-
tabases adequately, be a licensed In-
diana pharmacist, and be established
as an individual who could perform
order entry (not in training). Phar-
macists who met these criteria were
trained in and tested on the home-
based order-entry process.
When determining how to pro-
vide home-based order-entry ser-
vices, three methods were assessed:
creating a list of on-call pharmacists,
creating scheduled home-based

order-entry shifts, and developing an
ongoing list of willing participants.
On-call pharmacists and scheduled
shifts would ensure the availability of
participants at the time of program
initiation. The major disadvantages
of this method are the financial obli-
gation of paying for on-call time and
time and a half for “called in” time
and the complexity of developing
and creating scheduled shifts. An on-
going list of home-based order-entry
pharmacists does not interfere with
schedule development and has less
financial obligation than does the use
of on-call pharmacists. Some disad-
vantages to an entirely volunteer list
may include lower pharmacist avail-
ability and possible bias in pharma-
cist selection. After evaluating these
methods, we determined that a vol-
untary list of pharmacists was pre-
ferred. Twenty five of 46 pharmacists
agree to participate in this program.
Home-based order-entry ini-
tiation and discontinuation. For
the purpose of this project, the terms
“on-trigger points” and “off-trigger
points” are used to describe the cri-
teria for the initiation and discon-
tinuation of home-based order entry,
respectively.
To determine the on-trigger and
off-trigger points, two separate inter-
nal studies were performed. Hourly
snapshots of the medication order
volume at Parkview Hospital were
collected over three to five days.
Based on the interpretation of the
data, including order volumes and
the pharmacy’s capacity to man-
age orders during the studied time
frames, an initial set of criteria was
established. On-trigger points were
defined as having at least 120 orders
and either greater than 50 orders that
had been idle for at least 60 minutes or
over 30 orders that had been idle for
at least 90 minutes in the queue. Off-
trigger points were defined as having
no orders greater than one hour old
and fewer than 30 orders in the queue
for over 45 minutes or fewer than 75
total orders in the queue.
case studies  Home-based medication order entry
In the event that the on-trigger
points are met, the lead pharmacist
utilizes the list of home-based order-
entry volunteer participants and
contacts them by telephone to deter-
mine their availability. A maximum
of three participants can be utilized
at a time due to the limited number
of VPNs set up for the department.
If available, these participants are
notified to log into the Internet,
access the VPN, and perform order
entry with the same vigilance, con-
fidentiality, and care as they would
onsite.
The lead pharmacist or parti-
cipant determines when the off-
trigger points are met and thereby
discontinues home-based order
entry. Discontinuation is confirmed
by telephone.
Determining pharmacist com-
pensation. There are two main meth-
ods for determining compensation
for pharmacists conducting home-
based order entry. The first method is
to pay for the time spent performing
order entry. An advantage of this
method is that proper compensa-
tion is easily calculated. Major
disadvantages include the potential
limitation in technology available to
the participant (e.g., slow computer-
processing time) and environmental
distractions, which may lead to a
less-productive order processing
than if conducted onsite.
The second type of payment
method is to pay per order processed.
This requires the creation and cat-
egorization of a library of orders in
which each order is categorized and
given a monetary value. With this
method, environmental distractions
and available technologies at a phar-
macist’s home are not major con-
cerns with respect to overpayment.
Some disadvantages include the
time spent calculating proper pay-
ment and possible biased selection
of orders to be processed (e.g., only
processing orders of high value).
For Parkview Hospital, we con-
cluded that paying per time spent
Am J Health-Syst Pharm—Vol 66 Nov 1, 2009
in performing home-based order
entry would be utilized. Each par-
ticipant must perform at least 15
minutes of entry to receive any pay-
ment. Once home-based order en-
try is discontinued, the pharmacist
completes an electronic timecard
that indicates the time spent enter-
ing orders. This form is submitted
to the pharmacy administration,
who evaluates it for agreement
with the home-based order-entry
initiation and discontinuation
documented by the onsite phar-
macist and incorporates it into the
employee’s biweekly paycheck.
Current complications. Han-
dling problem orders was a concern
during the implementation of the
program. Contacting providers from
a nonwork environment can be dif-
ficult due to the presence of family
members and friends or the com-
plications associated with paging a
physician to a number outside of the
hospital. Providing all participants
with a telephone or paying for the
minutes spent for contacting pro-
viders was not budgeted. The use of
an instant messaging program may
be a viable alternative when physi-
cians are employed by an institu-
tion and available round-the-clock.
Instant messaging is currently not
available in our community-based
facility. If problem orders require
attention, the pharmacists entering
the orders are instructed to notify
the onsite pharmacists using Pyxis
Connect and make a follow-up tele-
phone call.
Discussion
The Joint Commission standards
are constantly evolving in light of
best practices and new technology.
Remote order entry has been con-
sidered an acceptable alternative
for meeting the requirement for
pharmacist review for after-hours
services since 2004,12 given its influ-
ence on improving pharmacy’s ef-
ficiency during after hours. It could
also be used to maximize compliance
1941
 case studies  Home-based medication order entry
with the current Joint Commission
standards (e.g., MM 4.1, MM 8.1).13
Therefore, home-baased order entry
could be used in a similar manner.
Though established, the Parkview
Hospital pharmacy home-based
order-entry program is in its infancy.
At the time of writing, home-based
order entry was used several times
and onsite pharmacists reported that
it was easy to contact home-based
order-entry pharmacists, that there
were no problems with logging into
the VPNs, and that turnaround time
remained close to our target of 25
minutes. No formal evaluation of
the program’s effectiveness has been
conducted. Upon further utilization
with positive results, the program’s
application may expand by provid-
ing increasing pharmacist coverage
during predicted and unpredicted
pharmacist shortages (e.g., open
positions, sick calls, family medical
leave).
1942 Am J Health-Syst Pharm—Vol 66 Nov 1, 2009
Conclusion
A community-based hospital suc-
cessfully implemented a home-based
medication order-entry program.
The program alleviated the shortage
of pharmacists during spontaneous
surges of medication orders.
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