NURSING INFORMATICS PROJECT 1

Nursing Informatics Project

Joshua Rutledge

DTCC

02/16/2020
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Introduction

The year is 2020, society is the most advanced it has ever been. We are in the prime age of

technology and still correctional medicine lags far behind the standards of care set in the public

healthcare sector. One of the biggest hurdles in the correctional system is having adequate

medical staffing and outdated healthcare recording systems. This leads to medical errors, gaps of

care, and increased liability for healthcare and DOC staff. Not to mention it goes against the core

values of nursing which is providing optimal safe patient care. An article titled “After Four

Inmate Deaths, Judge Finds Medical Care at Virginia Prison Unconstitutional” dives into the

correctional healthcare sector and identifies such barriers holding back correctional medicine.

“there are still few too nurses, who often fail to follow through on required work” (Weiner,

2019), workloads are high, and staffing is low.  Medical staffing in a prison setting will always

be an issue based on the pure ethical dilemma of the desire for employment in such a hazardous

work environment. It has become an apparent precedent in correctional healthcare that the

workload is far too great for the staffing and that corners are being cut. With staffing being a

non-working issue. What can be done to improve the quality of care in this private healthcare

sector? My answer for this question is technology, tech is continually advancing and improving,

the decreasing of workload for healthcare staff through means of technological innovation can

prove instrumental to improvement in quality of care. The implementation of Clinical Decision

Support systems in the EHR to help manage medication reorders could aid in cutting down this

workload and aid in providing a better-quality healthcare in correctional systems. 

Current Problematic Workflow 

Currently I work as a staff nurse at James T Vaughn Correctional Center working mainly

in the infirmary. One major issue I have noticed in the year I have spent working in correctional
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healthcare is the falling off or expiration for prescribed medications. In the public healthcare

sector medications have prescriptions that can be filled by your Primary Care Physician for

multiple months requiring new prescriptions when they run out of medication. In the correctional

healthcare system, we use this same system, medications get prescriptions for 3 months for

example and the inmate is given a 30 day supply and must submit a sick call requesting refill 10

days prior to needing a refill of medication. In corrections security comes before healthcare. To

prevent large quantities of medications being readily accessible for inmates to trade they only

allow 30-day supplies for select medications. This process is called the “KOP” medication

process also known as Keep On Person medications. 

KOP Medication Gaps 

The KOP process has its problems but works within securities standards for healthcare

which were initiated by the Bureau of Correctional Healthcare Services (BCHS) and Department

of Corrections. The issue with this KOP process is that inmates are only given 30-day supplies

and do not know how many refills this medication might have. This in turn creates the current

issues I noticed personally in the correctional healthcare setting is that inmates will get

medication for their 3-month prescription and then the order will drop off. The inmate will

submit request after request until the request reaches the provider. The medical provider whether

it is a physician, a physician's assistant, or a nurse practitioner then has to go into the MAR

manually and re-order the prescription. This gap in the system causes gaps in medications and

for medications to go missed with no reporting because they are Keep On Person medications

and do not get recorded in the patient’s MAR. This gap in medications has not only occurred

with KOP medications but also with what we refer to in correctional healthcare as Nurse

administered medications. Normally the pharmacy nurses are in charge of notifying providers for
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prescription refills but due to the vast number of inmates administered medications by the

pharmacy sometimes these medications might not be noticed to be re-ordered right away.

Furthermore, this comes to another issue with this flawed process, when medications are finally

reordered it may take 1-2 days depending on the time of day they’re ordered to ship in from the

pharmacy distributing facility in Pennsylvania. In some situations, patients would be switched

over to a bridge for a stock held medication we keep on site, due to limitations in stock

medications we keep in house not always are patients able to be switched to a bridge medication.

This is an issue that would not be tolerated in the public healthcare sector so morally and

ethically why is it tolerated in the correctional healthcare sector?  

Process Innovation

It is clear that the current KOP medication and just the whole medication ordering

process is flawed in the correctional healthcare system. These issues are old age issues, issues

that would be prevalent in the 90’s and early 2000’s. With this new world of technology and

informatics there is no excuses for these gaps in healthcare to be ignored. People can argue that

money is an issue and for the most part they are correct money is a commonality for flawed

healthcare systems and processes. As I mentioned earlier in this text, this issue would not be

tolerated in the public healthcare sector so morally and ethically why is it ignored in the

correctional healthcare sector? Informatics the study of the communication, processing and

storage of data between networking systems provides new world answers for these old-world

problems. Looking at this flawed KOP system from an informatics perspective led to the

pinpoint of the major flaw in the current system which is causative for the large gaps in

healthcare. Fixing this flaw is not a simple answer with workloads already being high in the

correctional healthcare system due to insufficient staffing, this problem needs to be addressed
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while preventing an increase in staff workload. My idea to resolve this issue while minimizing

increase of staff workload is to employ the use of Clinical Decision Support alerting systems.

Correctional healthcare contractors could integrate Clinical Decision Support alerting systems

into the Electronic Health Record (EHR) and the Medication Administration Record (MAR) to

alert physicians when medications are due to be reordered. 

Legal Barriers for CDS

One of the major issues with CDS systems is HIPAA compliance and protecting the

medical data housed in the electronic health record that CDS systems would have to be

integrated into. HIPAA is the Health Insurance Portability and Accountability Act. HIPAA was

enacted in 1996 to protect all individually identifiable health information that is held by or

transmitted by a HIPAA covered entity or business associate. This federally protects all patient

information from use or distribution to unprivileged entities. With the introduction of CDS

alerting systems that would mean contracted companies have to be privileged to private

patient healthcare information. According to current federal HIPAA law, “covered entities must

have contracts in place with their business associates, ensuring that they use and disclose your

health information properly and safeguard it appropriately” (HHS, 2017). Basically, if the

company responsible for healthcare has clauses in their contract protecting patient rights then

HIPAA would not be infringed if an outside contractor integrated CDS systems into the EHR.

Additionally, contractors would have to agree to terms of service for bids to integrate these

systems, and any responsible company could require these contractors to accept legal bindings

preventing the misuse of HIPAA protected patient information 

 
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Adapting Current Process

Clinical Decision Support systems are technological tools that basically aid physicians in

in computer-based tasks such as ordering treatments or medications.  Drug interaction alert pop-

ups are a widely used example of CDS that is currently integrated in the medication ordering

systems of healthcare facilities nationwide. Pill counters are a widely used CDS that monitors the

amount of medication being given out over the length of a prescription and are also widely used

in healthcare systems nationwide. Currently the EHR and MAR at my facility use both of these

CDS systems. Thinking about how these two systems work currently inspired the idea for the

combining of these two CDS systems. This combination of the two current systems would work

by using the pop-up alerting system already in place to prevent medication interactions and

basically using that program to have attendable pop up alerts to alert physicians when

prescriptions are nearing due dates for renewal and reordering. One issue I contemplated about

this solution is, what if different physicians that have no idea on the current care plan for this

patient just go in and start reordering medications? What if the care plan changes? This CDS

solution could be adapted to be physician specific to pop up alert for the physician that originally

ordered the medication who would be aware of the current patient care plan and prevent the issue

of continuing incorrect treatments/medications. Another issue I contemplated was how would the

EHR and MAR be able to accurately track when the medication in question is nearing the due

date for prescription renewal? The solution to this problem would be to integrate the pill counter

currently being used in the MAR to count down the prescribed amount of medication. The CDS

could use the pill counter to down the prescribed amount for example, a 90-day supply would

count down from 90 pills starting after initial dose is given to a set number of remaining pills,

and then pop up alerting the original ordering physician. The pop up would alert the physician
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this medication is nearing due for prescription renewal and reordering from the pharmaceutical

distributor. Through this pop up display, it would take the physician to the patient’s chart where

there could be a separate portal for medication cancellation/ reordering/ and even editing the

current prescription to fit any changes in plan of care. 

Benefits

Implementing this idea for a CDS alerting system would largely benefit correctional

healthcare systems nationwide. Physicians are currently tasked with the reordering of

medications when alerted by the sick call system. This would cut down the amount of sick calls

requiring triaging by the sick call nurses. The workload for physicians would remain the same

but would improve the process by making the task of reordering medications and prescribing

medications physician specific, improving patient safety. Due to the fact medications would be

reordered prior to running out of medication it would allow time for medications to be shipped

from the distributor and scanned into inventory which would minimize the number of medication

gaps associated with the old process. Reducing the amount of liability associated with the old

process and number of medications associated lawsuits against Department Of Corrections and

the healthcare contractor.  By automating this system of reordering this would prevent staff

nurses from manually having to reorder medications which is the current process in places where

sick call is unavailable such as the infirmary and reduce the workload of infirmary staff nurses.

Furthermore, this would allow security and the healthcare team to get a more accurate count of

medications being distributed in the facility because the amount would be automatically recorded

per patient per prescription in the MAR and EHR. According to a 2000 study cited by “A Better

Prescription for Reducing Medication Error and Maximizing the Value of Clinical Decision
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Support” its projected savings of nearly $900 million for affiliated companies after the

introduction of CDS systems (Kluwer, 2017).  This improved process uses current CDS systems

and would require minimal intervention for integration into the already existing EHR and MAR

and would benefit all currently involved healthcare team members and even benefit security. 

Workflow 1

Medication begins Patient submits

to run low sick call for
medication refill

Pharmacy nurse Sick call triaged to

realizes medication pharmacy for refill
card is empty

Need for new

prescription order
Pharmacy nurse re
from provider ? NO
orders medication
from distributor
Medication arrives at
YES midnight and is
scanned into inventory
Provider writes a new by pharmacist
Medication refill
prescription in EHR
request sent to
distributor by
provider Medication
distributed to
patient by nursing
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Workflow 2

Medication begins
to run low 7 days
left.

Pill counter CDS

sends alert
automatically at 7
days until empty

Need for new

prescription order
Medication
from provider? NO automatically
reordered by CDS
Medication arrives at
YES midnight and is
scanned into inventory
CDS system alerts by pharmacist
New prescription
provider via popup
sent to distributor
alert for prescription
by CDS
renewal provider Medication
renews prescription distributed to
patient by nursing

Department of Corrections

DEPARTMENT:  Pharmacy & POLICY DESCRIPTION: Medication Reordering

Therapeutics Policy and Procedure Development 
PAGE: 1 of 5 REPLACES POLICY DATED: 2/14/2020
EFFECTIVE DATE:  2/28/2020 REFERENCE NUMBER: 00001
APPROVED BY: Pharmacy and Therapeutics

SCOPE:  All Delaware Correctional Healthcare Medication Administration Records and Electronic
Health Records
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PURPOSE:  To establish revised policy and procedure in the areas for developing, managing,
updating, and administering the drug formulary system.
POLICY: 
1. Implementing the integration of Clinical Decision Support alert systems into the EHR

2. Implementing the integration of Medication Counters into the electronic Medication

Administration Records

3. Combination of Medication Counters and Clinical Decision Support alerting systems

to track medication quantity, monitor prescription lifespan, automate medication order
refilling, and populate alerts for medical providers to prescribe expired medication
prescriptions. 

4. Provide all medical staff involved with Pharmacy and Therapeutics with an efficient
automated reordering system to streamline prescription renewals and automate
medication renewals.  

PROCEDURE:

1. CDS/Medication Counter Medication reordering/renewal procedure.

1. Medications are quantitated for by prescription length, frequency, and dosage. 
2. Medications are prescribed with a set number of refills within FDA guidelines
and medication end dates up to the prescriber’s discretion.
3. Medications begin count down after being scanned into inventory and first dose
is administered in electronic Medication Administration Records. 
4. Once Medication Count reaches 10 doses left and are available for refills.
Medication refill request is automatically sent to the Pharmaceutical distributor for
refill. 
5. Medication is refilled and scanned into inventory for distribution to intended
recipients.

2. When the prescription order has expired and needs renewal by the medical provider.
1. Clinical Decision Support alerting system populates an attend-able encounter in
provider specific medication renewal portal of the Electronic Health Record.
Medication revision and prescription editing tasks are available via the medication
renewal portal.
2. Providers that previously wrote the prescription are responsible for renewal of
expired prescriptions.
3. Prescription is renewed and reordered automatically from the Pharmaceutical
distributor. 
4. Prescriptions requiring hard copy are flagged in EHR by Clinical Decision
Support system and alert physicians to mail hard copy prescriptions for select
medications.
5. Medication is refilled and scanned into inventory for distribution to intended
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recipients

Conclusion

We as a society, set standards of care for healthcare to provide optimal patient care and

safety for those in need of medical intervention, observation, and management. The correctional

healthcare has fallen behind and as technology advances and patient needs change through time,

policies and processes can become outdated and ineffective. The current process utilizes nurses

and the sick call process to alert physicians when prescriptions run out. This process leaves a

large room for human error which is where patients fall through the cracks and medication gaps

are the result. With the implementation of CDS alerting systems we can fill this gap of care,

reduce workload for all healthcare members, and promote a safer more efficient form of

correctional medicine. The barriers holding back correctional healthcare are major and crippling

but through the implementation of new technology and procedures to adapt to the changing

population and patient needs we can combat this injustice and promote equal, safe, and quality

healthcare for everyone. 

Resources:

HHS Office of the Secretary,Office for Civil Rights, & Ocr. (2017, February 1). Your Rights
Under HIPAA. Retrieved January 31, 2020, from https://www.hhs.gov/hipaa/for-
individuals/guidance-materials-for-consumers/index.html

Kluwer, W. (2017, January.). A Better Prescription for Reducing Medication Errors and
Maximizing the Value of Clinical Decision Support. Retrieved from
https://www.wolterskluwercdi.com/sites/default/files/documents/white-papers/cdi-cds-value-
whitepaper.pdf

Weiner, R. (2019, January 7). After four inmate deaths, judge finds medical care at Virginia
prison unconstitutional. Retrieved January 21, 2020, from
https://www.washingtonpost.com/local/legal-issues/after-four-inmate-deaths-judge-finds-
medical-care-at-virginia-prison-unconstitutional/2019/01/03/ecc7cad0-0f6f-11e9-84fc-
d58c33d6c8c7_story.html