All About eMARs
An Interview by ComputerTalk with Allcare Pharmacy’s Fred Harris
Allcare Pharmacy, headquartered in Arkadelphia, Ark., operates both eight retail locations as well as several closed-door pharmacies that specialize in long-term care, assisted living, and correctional facilities. In this interview, Fred Harris, vice president with responsibilities for everything from operations to business development, talks with ComputerTalk senior editor Will Lockwood about the eMAR (electronic medication administration record) the pharmacy developed and continues to use, describing the key aspects of this technology based on years of experience.
ComputerTalk (CT): It’s my understanding that Allcare has developed its own eMAR.
Harris: Yes, that’s right.
CT: How long ago did you do this?
Harris: We’ve been working on this for 15 or 16 years. We developed it first for correctional facilities. We learned pretty early on that that is a real tough sales cycle, with state government and state budgets. This goes far enough back that there really weren’t laptops readily available. So we did it with PCs and mainframes. When mini-PCs became available, we rewrote the program and adapted it for long-term care. Probably been doing that for 10 or 12 years. Then about six years ago we spun it off into a separate company, which focuses exclusively on the iMAR, as we call it.
CT: With all this experience, and your knowledge of the different requirements in the different markets, what are the fundamentals of an eMAR?
Harris: It needs to be designed so that you can document any scheduled task at the bedside, whether it’s a medication administered, a vital sign taken, a finger stick, or anything that goes along with interacting with the resident. Ours has a drug database right in the background which really is integral to knowing about drug interactions, allergies, side effects, and all this type of thing.
CT: Is this drug database an unusual feature?
Harris: Yes. Some other vendors have it and some don’t.
CT: So the eMAR is a tool used to create an electronic record of all the interactions with the resident. One thing that’s interesting is that this sounds like it goes beyond the traditional paper MAR, covering not just medications, but treatments as well.
Harris: Yes, that’s right. It goes beyond the traditional MAR to include treatment, tasks, diet, procedures, lab results, and more. All this can be documented on the same electronic record.
CT: I’d think there’d be an advantage in the paper world to keeping all these details in separate records; to make it easier to find what you need. In the digital world, putting them all together in a searchable format that also allows for cross referencing.
Harris: Right. In a digital version you can see trends, not only in a patient but in an entire population as well.
CT: How does making a record like this electronic change how you use it then?
Harris: It gives the practitioners, the physicians, real-time information so that they don’t have to go sifting through a chart to see if they’ve ever tried a patient on a specific medication, for instance. We keep a full record for every patient, covering as much time as we’ve been serving them. Our consultants use it to make recommendations based on all the details available. This makes their job a lot easier. It’s really designed for the benefit of the facility itself. A byproduct of it, especially with short-cycle just around the corner here, is that the transfer of information in real time is becoming more and more critical. With this you can have a true interface between the orders at the pharmacy and the delivery. The facility knows that an order has been processed and is on its way over while getting away from all the faxing of orders and calls. We know instantly when there are changes. Whether you are using an on-demand model or cycle fill, you need real-time information. You are going to serve new admissions better, and particularly benefit facilities that serve a lot of Medicare Part A patients.
CT: How can an eMAR play into a broader electronic care record for patients?
Harris: We are just about to enter a pilot project with a hospital to transmit information about patients to the acute care facility. We all know that a huge number of the mistakes made occur when a patient is moving between an acute care and a long-term care setting. If we can get that information to the hospital -- dispensing record, allergies, all of it -- then when the patient is discharged, and that same information can come back to the facility in real time, then you can eliminate duplication of therapies and other issues that create all the errors.
CT: What you’re describing would be a major step in improving the continuity of care patients receive.
Harris: That’s what we have to move to. We are HL7 compliant, so we can pretty much communicate with any other software package to share information.
CT: Is HL7 the primary exchange protocol you use to interface with a range of providers successfully, then?
Harris: Yes. We even take it a step further. Orders can originate bi-directionally, either from the pharmacy or from the facility. We attach a barcode to the order label so that when it gets to the facility, we can have a third verification step that tells staff administering the medication that they have, for example, the right patient and the right time. It’s pretty difficult to do bi-directionally, so we have a sophisticated interface with the pharmacy system that allows this.
CT: What makes this bi-directional order origination difficult?
Harris: The drug database is the thing that’s the key. To take a real life example, a 60 mg dose of furosemide is pretty common, but it comes in 20s and 40s. So you have to order one and a half 40s or three 20s, and if the facility does the former and the pharmacy decides it doesn’t want to split tablets and sends out three 20s, the eMAR system needs to know that this order for 40s was filled with 20s. If it is the same order, it will let you update it and put into inventory what the pharmacy actually sent. Now if the pharmacy sent you a totally different drug, you will see that this is not a match.
It goes back to the fact that on paper, you don’t take the time to rewrite the order. You get lulled into the notion that whatever the pharmacy sends is right. You give it, even though it doesn’t really match. That’s where errors can occur. We not only transmit orders in real time, but we clarify them as well. This way what the nurse records as administered always matches what the pharmacy sent. If it doesn’t, they have to do a clarification order right then.
CT: This keeps the records clean, then, and helps you keep a record of why changes were made, right? What else?
Harris: For patients that take over the counter medications, our system can recognize the UPC barcode to make sure you are administering the right OTC. For example, if the resident has an order for aspirin 325 and you scan a bottle of aspirin 81mg chewable, then you’ll find out that you’ve got the wrong medication.
CT: So you are bringing the same barcode-driven workflow with all of its safety checks out from the pharmacy and into the facility.
Harris: That’s right. We’ve been using barcode technology in the pharmacy for a number of years, so we just adopted that same safety feature for the nurses to use in the facility.
CT: One final question. You do things in-house, so you have a lot of control over what goes on. For the pharmacists out there who don’t have the ability to develop an eMAR in-house, what are some of the strategies for getting started with this technology?
Harris: They really need to evaluate the different products and look for limitations. Are they looking for something that they can grow into? Are they just looking for an inexpensive product that gets them into the technology, but doesn’t have the features they’ll need in the future? For example, you may look at a simple version that doesn’t have bi-directional order entry, so all orders have to originate at the pharmacy. What do you do then when it’s 2 am and there’s a new order that needs to go in? You want to look for a system that is multi-user, real-time, and that can produce whether the Internet is up or down. Web-based products sound good until you consider what happens when there’s no or slow connectivity. You want to consider whether the eMAR will be able to grow with you as you get more facilities. For the facility it’s all about the ability to make a single entry, about the interface. They aren’t going to have one system that does everything, but they don’t want to have to make repeat entries in each system they use. These are important considerations since I really believe that in the next three or four years eMARs will be more the rule than the exception.