hospital pharmacy supplement march 172015

Hosp Pharm 2013;48(3 Suppl 2):S1–S52013 � Thomas Land Publishers, Inc.www.thomasland.comdoi: 10.1310/hpj4803-S1

A Sociotechnical Model for Pharmacy

David C. Classen, MD, MSp; and Jeff Brown MEd†

The landmark Institute of Medicine (IOM) reportTo Err Is Human, published in 2000, describedthe magnitude of medical errors and breaches in

patient safety in the US health care system, together witha blueprint for building safety systems in health careorganizations.1 Yet, reports from the IOM issued 12years later suggest that little progress has been made inimproving safety in inpatient or ambulatory settings.2,3

Initial optimism that improving patient safetycould be quickly addressed has faded, and a growingappreciation of the tremendous difficulty in makinghealth care error free has developed. At the time that ToErr Is Human was published by the IOM, there wasmuch enthusiasm that technology was the universalantidote to safety problems. Indeed, there was almostmagical thinking that technology in the form of elec-tronic health records (EHRs) would erase medicationsafety issues entirely, if only they were widely adopted.By 2013, there has been wide adoption of EHRs inhospitals and ambulatory health care centers as well asbroad use of medication safety interventions such ascomputerized prescriber order entry.4 This has beendue largely to the HITECH Act mandates and criteriafor ‘‘meaningful use’’ of electronic data – the level ofuse that providers must attain to qualify for incentivepayments under the HITECH Act.5

MEANINGFUL USE INCENTIVE PROGRAMIn 2009, the HITECH Act (part of the American

Recovery and Reinvestment Act) authorized expen-ditures of about $20 billion (with estimates rangingfrom $9 billion to $27 billion) over 5 years to promotethe adoption and use of EHR technologies that wouldbe connected through a national health informationnetwork. As its centerpiece, the HITECH Act createdincentives for all hospitals and eligible physicians – notonly those associated with large systems – to adoptand use electronic information.6

The legislation set forth a plan for the ‘‘meaningfuluse’’ of health information technology (HIT) to im-

prove the quality of care and enable changes in deliverysystems essential to health care reform. Additionallyunder the HITECH Act, hospitals and physicians whomake ‘‘meaningful use’’ of interoperable EHRs canqualify for extra payments through Medicare andMedicaid. Physicians who adopt electronic records by2014 can qualify for Medicare bonus payments of upto $44,000. Beginning in 2016, those who have notadopted EHRs will be penalized in the form of reducedMedicare reimbursements. Similarly, Medicaid pro-viders can receive up to $63,750 over 5 years. Thesepayments and penalties depend on the provider meetingthe requirements for meaningful use.

The broad goal is to gradually acclimate providersto work-flow changes and practice improvement op-portunities that, ideally, will accompany the adoptionof technology. Thus, the meaningful use criteria havebeen structured into 3 stages, each progressively morerigorous:

� Stage 1 criteria, which took effect in 2011, requiresthat providers be able to electronically transmit med-ication orders, record patient information and prob-lem lists, demonstrate use of decision support tools,test systems to exchange health information withother providers, and submit a small number of clin-ical quality measures.� Stage 2 criteria, to take effect in 2014, will require

more robust exchange of information and otherhigh-value uses of EHRs.� Stage 3 criteria, to take effect in 2015, will require

providers to demonstrate greater use of decisionsupport tools, higher levels of information ex-change, and actual improvement in care coordina-tion and patient outcomes.

Despite the broad adoption of technology to im-prove medication safety, reports of adverse drugevents in hospital inpatients continue to occur at a highrate.2 A recent report cites poor technology design

*The University of Utah School of Medicine, Salt Lake City, Utah and Pascal Metrics Washington DC; †Applied ResearchAssociates, Fairborn, Ohio. Corresponding author: David C. Classen, MD, MS, University of Utah School of Medicine, 561East Northmont Way, Salt Lake City, UT 84103; phone: 385-226-1557; e-mail: [email protected]

Hospital Pharmacy S1

and poor integration into the clinical environment asreasons for technology’s lack of impact on medicationsafety.7 Both of these reports suggest that the de-velopment of a sociotechnical model is a key factor insuccessfully improving safety.2,7 This paper outlineshow such a sociotechnical model might be applied inthe hospital pharmacy setting.

PATIENT SAFETY AND THE PHARMACYThe safety of medications has been an issue since

ancient times; as has been observed by many, there are nounsafe medications just unsafe doses. Most developedcountries have regulatory systems that require the ex-tensive evaluation of the safety of new medications thatare brought to market. However, the safe use of medi-cations that are already on the market is an entirely dif-ferent matter; there is little regulatory oversight, andaccountability for medication safety falls primarily uponhealthcareproviderssuchasphysicians,pharmacists,andnurses.2 Pharmacists often play the major role in medi-cation safety, especially in the ambulatory setting of care.

HEALTH INFORMATION TECHNOLOGY INTHE PHARMACY

Pharmacy was one of the first areas in health care toadopt HIT to improve medication safety. The movementbegan in hospital pharmacies and spread to ambulatorypharmacies. Although the initial focus of HIT was onbilling, the development of pharmacist order entry pro-grams allowed for various forms of safety interventions,such as checking for allergies or drug-drug interactions,and calculating dosage adjustments. These practices be-came standard care in both inpatient and outpatientsettings. However, many studies have shown that com-pliance with these safety practices is less than optimal andoften puts patients at risk for adverse drug events.2

MEDICATION USE MODELBecause of persistent medication safety issues in the

inpatient setting, hospitals began to adopt a broaderrange of technologies in the pharmacy to reduce errors.These included robots for medication dispensing,computerized prescriber order entry for medicationordering, and barcoding for medication administration.The goal was the virtual elimination of medication safetyhazards through technological interventions. A sche-matic of these various technologies and their applicationin the medication use process is shown in Figure 1.

RESULT OF AUTOMATION IN THE PHARMACYThe US Veterans Administration (VA) hospitals

took the lead in implementing pharmacy technologies in

their inpatient facilities across the country. Automationof the medication use process was a major step forwardin improving medication safety and served as a modelfor adoption by other organizations. As such, therewas great interest in the impact of technology on ac-tual medication safety. A group of researchers at a VAhospital undertook a large study of the occurrence ofadverse drug events across all stages of the computer-ized medication use process.8 They found a high in-cidence of medication safety problems, with 483clinically significant inpatient adverse drug eventsamong 937 hospital admissions in a 20-week period. Itwas concluded that the major reason for these adverseevents was a failure to optimize the technology for thesociotechnical environment in which it was used and afailure to optimize the technology after implementation(eg, development and implementation of effectiveclinical decision support within the EHR system).

CHALLENGES WITH PHARMACY AUTOMATIONMany hospitals have emulated what the VA has

done by automating the entire medication use process.However, these projects are complex, expensive, andtime consuming; additionally, they are highly de-pendent on the implementation and integration with anEHR. In many hospitals, these projects have beentechnology focused and often not conducted withinor even in consideration of their existing sociotechnicalenvironment.9 Consequently, the potential safety ben-efits of such technologies have not been fully realized.2

SOCIOTECHNICAL MODELThe concept of sociotechnical systems arose from

studies of work organization, work systems, andmechanization in the British coal mining industry be-ginning in the late 1940s.10 These studies were spurredby the realization that increased mechanization hadgenerally not yielded increased coal production, as hadbeen anticipated. However, productivity had risenin some mechanized mines, and research in thesehelped to identify organizational and work-designprinciples to optimize the fit of people and technologyas interrelated and complementary components ofwork systems.10 Instead of designing technology anddropping it abruptly in the workplace – withoutconsidering its affect on human work performanceand vice versa – it became apparent that technologydesigners needed to take an integrative perspective onhuman and technical system roles and tasks.

Over the next 6 decades, safety investigation inhigh-risk sociotechnical domains, such as aerospaceand air transportation, identified organizational and

S2 Volume 48, Suppl 2, 2013

Sociotechnical Model for Pharmacy

work-design principles that support not only pro-ductivity, but also risk mitigation and safety.11-15 In late2011, the IOM introduced health professionals tothese principles, presenting a contemporary model ofsociotechnical systems in its report Health IT andPatient Safety.2 This report highlighted that accidentalpatient injury or death typically occurs as a result ofthe unanticipated effects of the interactions amongsociotechnical system components – namely, people,technology, processes, organization, and environment.

For example, successful medication administra-tion using a smart intravenous pump infusion system(smart pump) is not simply the product of a nurse’sinteraction with the pump’s computer interface at thebedside. Delivery of medication to a patient via thesmart pump is the end stage of a more extensiveprocess, which includes the physician order and ful-fillment process, and has many points of potential

interactive missteps. Following are some examples ofpotential interactive misadventures that were identi-fied after an organization-wide smart pump imple-mentation (Brown, field notes).

� Physicians’ handwritten prescriptions were sometimesmisinterpreted, resulting in processing of incorrectmedication and dosage at the onset of the medicationpreparation and administration process. These errorswere usually caught by pharmacy or at the bedside,but sometimes they were not noticed before the incor-rect medication/dose was administered to the patient.� The nurses’ operation and management of the pump

occurred in a clinical environment characterized byhigh levels of noise, which made alarm detectiondifficult outside of the patient’s room.� The pump’s alarm had the same tone for all condi-

tions, preventing auditory discrimination of criticality.

Figure 1. Technologies to reduce errors in the medication management process.



� False ‘‘upstream occlusion’’ alarms were numerous,lending to ‘‘alarm fatigue’’ and distrust of alarmsignificance.

� In a dimly lit clinical setting, a small and non-illu-minated operator screen was difficult to read andoperate. ‘‘Fat fingering’’ – hitting incorrect keys –often resulted in mis-sets and re-sets.

� If the drug to be administered was not in thepump’s drug library, the nurse needed to operatethe pump in basic mode, overriding its safety fea-tures. This occurred frequently.

� Nurses were often unfamiliar with the names ofgeneric drug substitutions, which made it challeng-ing to cross-check that they had the correct medi-cation for their patient. Google searches wereheavily relied upon.

� The therapeutic dosing rate for small adult andpediatric patients was sometimes lower than thepump could achieve. Nurses tried to compensatefor this constraint by periodically interrupting theinfusion in an effort to limit the dose.

� Nurses were frequently confronted with the need tocalculate unit conversions, when the pharmacy’sunits of measure differed from those used in thephysician’s order. Sometimes, the difference in unitswas not identified, leading to incorrect dosing.

� Work organization for nurses provided little or notimely opportunity for mutual support and cross-checking of unit conversion calculations and otherproblem solving.

� Reach-back by bedside nurses to pharmacy, fortimely guidance regarding a medication, was notsupported by pharmacy organization, staffing, andwork processes.

� Competing demands on nurses’ attention regularlyinterrupted pump set-up, resulting in prospectivememory challenges; failing to come back to theappropriate point in the interrupted procedureupon returning to the task.

The challenges that were observed with the clinicaluse of smart pumps arose from interactions amongpeople, technology, processes, organization, andenvironment – not simply from a nurse interacting witha smart pump. Although some of the challenges mightseem innocuous, they nonetheless harbored risk topatients. All were implicated in instances of patientsreceiving incorrect medications and/or incorrect dosages.There were no instances of lasting patient harm in thecases identified during this study, but the opportunity fordeath or serious injury due to the administration of anincorrect medication and/or dosage was clearly present.

The most common organizational response tothe potential misadventures was to retrain pharmacyand nursing personnel on policy and procedure and,in the case of nursing personnel, the operation of thesmart pump. This focus on the people closest to themisadventure – those who were attempting to safelyfulfill their tasks and patient care responsibilitiesdespite awkward technology, turbulent processes,disruptive work environments, and unsupportivework organization – left conditions for failure es-sentially untouched.

NEED FOR HUMAN FACTORS RESEARCH AND PRACTICEIN HEALTH CARE

Approaches to the improvement of patient safetyhave thus far had transient and limited benefit.16 Asa result, there is a widespread call for increased ap-plication of ‘‘human factors’’ principles and methodsto improve the design and functionality of healthcare systems, especially in areas where technology isapplied.2,17,18

The overarching goal of human factors pro-fessionals is to aid in designing tools, processes,technologies, organizations, and environments thatsupport safe and effective human performance. Toooften, designs for health care technologies are basedon flawed assumptions about the domain and envi-ronment of use or on requirements derived frompreference surveys, focus groups, and market research –approaches that typically do not yield designs thatmatch the operators’ needs in the context of use.7

Despite recognition of the need, no ‘‘human factorstoolkit’’ is available from health care oversight entitiesor technology vendors to achieve these purposes. It isimperative that health care organizations depart fromthe notion of safety management as something thatcan be achieved through a succession of narrowlydefined ’’safety projects’’ that address surface mani-festations of adverse component interactions – thatis, the phenotype rather than the genotype, the com-ponent rather than its interactive context. This is es-pecially important in areas of health care wheretechnology has been aggressively adopted, such asmedication safety. While there is need for research todeepen understanding of safety management in com-plex sociotechnical systems, human factors principlesand methods that can help already exist, yet are rarelyapplied to safety management in health care.19-21

Cognitive system engineering (CSE) is a branch ofhuman factors science and practice that has arisenspecifically to study and support risk mitigation andsafety improvement in sociotechnical systems.22 CSE



specialists develop technology design requirements byfirst researching the context for which a new tech-nology is contemplated. They consider the interactiveeffects of system components in developing design re-quirements and support implementation efforts thatare sensitive to unanticipated risks. They also conductadvanced safety investigations, seeking an under-standing of adverse events through a sociotechnicallens. Benefits of CSE applied to development of designrequirements include technologies that best match theneeds of clinicians in the context of use, proactivesurveillance for emergent risk and the developmentof corrective strategies, and more effective adverseevent investigation leading to more effective safety in-terventions. Had this approach been used for auto-mation of the medication use process, more safetybenefits might have been achieved.2

Improving patient safety remains a major chal-lenge for the US health care system. Early results suggestthat the broad adoption of technology to improve safetyhas not achieved the intended result, especially in thearea of medication safety – an area that has seen per-haps the most technology adoption.2 The IOM hascalled for a new approach to patient safety: the socio-technical model, which offers the potential for a leapahead in system-based safety management for healthcare. To truly effect improvement in patient safety,safety management must become autonomic. It is es-sential to the safety-health of the organization, un-derlying and guiding all activity.

REFERENCES1. Institute of Medicine. To Err Is Human: Building a SaferHealth System. Washington, DC: National Academy Press; 2000.

2. Institute of Medicine. Health IT and Patient Safety: BuildingSafer Systems for Better Care. 2011. http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx. Accessed January 22, 2013.

3. Wynia MK, Classen DC. Improving ambulatory patientsafety: learning from the last decade, moving ahead in the next.JAMA. 2011;306:2504-2505.

4. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP na-tional survey of pharmacy practice in hospital settings:dispensing and administration—2011. Am J Health SystPharm. 2012;69:768-785.

5. Blumenthal D. Implementation of the Federal Health In-formation Technology Initiative. N Engl J Med. 2011;365:2426-2431.

6. President’s Council of Advisors on Science and Technol-ogy. Report to the President. Realizing the Full Potential ofHealth Information Technology to Improve Healthcare forAmericans: The Path Forward. Office of Science and Tech-nology Policy. December 2010. http://www.whitehouse.gov/

sites/default/files/microsites/ostp/pcast-nitrd-report-2010.pdf.Accessed January 23, 2013.

7. Brown J, Tonkel J, Classen D. Using technology to enhancesafety. In: The Essential Guide for Patient Safety Officers. 2nded. Oakbrook, IL: The Joint Commission; 2013.

8. Nebeker J, Hoffman J, Weir C, et al. High rates of adversedrug events in highly computerized hospital. Arch Intern Med.2005;165:1111-1116.

9. Troiano D, Morrison J, Federico F, Classen D. Safely au-tomating the medication use process. Not as easy as it looks.J Healthc Inf Manag. 2009;23(4):17-23.

10. Trist E. The evolution of socio-technical systems: a con-ceptual framework and an action research program. In: Van deVen A, Joyce W, eds. Perspectives on Organizational Designand Behavior. NY: Wiley Interscience; 1981.

11. Rasmussen J. Human errors. A taxonomy for describinghuman malfunction in industrial installations. J Occup Acci-dent. 1982;4:311-333.

12. Rasmussen J, Duncan K, Leplat J, eds. New Technology andHuman Error. Vol. 4. New York: John Wiley & Sons; 1987.

13. Hollnagel E, Nemeth CP, Dekker S, eds. ResilienceEngineering Perspectives. Volume 1: Remaining Sensitive tothe Possibility of Failure. Farnham, UK: Ashgate PublishingCompany; 2008.

14. Weick KE, Sutcliffe KM. Managing the Unexpected: Re-silient Performance in an Age of Uncertainty. 2nd ed. NewYork: Jossey-Bass; 2007.

15. Patankar MS, Brown JP, Treadwell MD. Safety Ethics: Casesfrom Aviation, Healthcare, and Occupational and EnvironmentalHealth. Farnham, UK: Ashgate Publishing Limited; 2005.

16. Classen DC, Resar R, Griffin F, et al. ‘‘Global trigger tool’’shows that adverse events in hospitals may be ten times greaterthan previously measured. Health Aff (Millwood). 2011;30:581-589.

17. Gurses AP, Ozok AA, Pronovost PJ. Time to accelerateintegration of human factors and ergonomics in patient safety.BMJ Qual Saf. 2012;21:347-351.

18. Brown JP. Achieving high reliability: other industriescan help health care’s safety transformation. J Healthc RiskManag. 2004;24(2):15-25.

19. Nemeth CP, Wears RL, Woods DD, et al. Minding thegaps: creating resilience in healthcare. In: Henriksen K, Battles JP,Keyes MA, Grady ML, eds. Advances in Patient Safety: NewDirections and Alternative Approaches. Vol. 3. Performanceand Tools. Rockville, MD: AHRQ. Publication No. 08-0034-3.

20. Dekker S. Drift into Failure: From Hunting BrokenComponents to Understanding Complex Systems. Farnham,UK: Ashgate; 2011.

21. Woods DD, Hollnagel E. Joint Cognitive Systems: Patterns inCognitive Systems Engineering. Boca Raton, FL: CRC Press; 2006.

22. Hollnagel E, Woods DD. Joint Cognitive Systems: Foun-dations of Cognitive Systems Engineering. Boca Raton, FL:CRC Press; 2005. g




Technology and Automation in Hospital Pharmacies:Current and Future States

Mark H. Siska, BS Pharm, MBAp

The use of automation and information systemsin hospital pharmacy practice surfaced in the1960s, primarily to manage the growing op-

erational demands with limited resources. The pro-fessional practice model transitioned from a focus ondistribution, preparation, and dispensing in the 1970sto patient-centered pharmaceutical care in the early1990s and then to medication therapy management atthe turn of the millennium. As a result, the use ofautomation and technology to augment and advancehospital pharmacy practice became critical.

The publication of consecutive Institute of Med-icine (IOM) reports – To Err is Human: Building aSafer Health System (1999) and Crossing the QualityChasm (2001) – significantly changed the landscapeof medication management technology.1,2 Althoughoperational efficiency remained an important driver,the IOM reports placed technology and automationin the forefront for improving the quality and safetyof medication use. The 1999 report made it clear that,to advance medication safety, health-system phar-macies must ‘‘implement proven medication safetypractices’’ to reduce reliance on memory; to stan-dardize terminology; to use constraints and forcingfunctions, protocols, and checklists; and to minimizedata handoffs.1 The report also referenced severalemerging technologies and called for automation ofpatient-specific clinical information within the contextof an electronic health record (EHR) integrated withcomputerized prescriber order entry (CPOE), drugdistribution, and medication administration systems.These systems ideally work together within andacross organizational boundaries; share real-time,patient-specific clinical information; provide timely,relevant clinical-decision support at the point of care;and create data-mining capabilities.1,2

In this article, I examine the current state ofhospital pharmacy technology, level of integration,and security and privacy considerations. In addition,

I discuss the future state of technology in hospitalpharmacy practice and the role pharmacy informaticswill play to support next generation systems.

CURRENT STATE OF HIT: BUILDING THE COREDespite increased levels of awareness and the

development of a conceptual framework for an idealtechnology-enabled medication use process, adoptionwas slow until the passage of the American Recoveryand Reinvestment Act and ‘‘meaningful use’’ measuresin 2009 and 2010.3,4 This legislation provided thestimulus in the form of financial incentives and even-tual penalties to aid health systems with implementingcore medication management supporting technologies.More important, these measures demonstrated a com-mitment by health care and government leaders toleverage health information technology (HIT) to im-prove the quality and safety of the medication useprocess. Prior to the meaningful use ruling in 2010,hospitals exhibited limited adoption of CPOE;however, rates nearly tripled – from 19% in 2010 to54% in 2012 – following its publication.5 Similar in-creases were observed with the implementation ofother core systems, including barcode-enabled medi-cation administration, medication reconciliation sys-tems, and electronic medical records (Figure 1).6 Thepublication of the meaningful use timelines and cor-responding financial incentives have kept health sys-tems busy building and implementing applicationsthat support core medication management.

INTEGRATIONA fully integrated, technology-enabled closed-loop

medication management system is designed to feedoutcomes from medication processes back into thesystem to facilitate the development and use of im-proved practices and to effectively monitor patientcare across the continuum. A closed-loop systemconsists of a succession of applications that are

*Assistant Director, Informatics & Technology, Pharmacy Services, Mayo Clinic, 201 W. Center Street, Rochester, MN 55902;e-mail: [email protected]


interconnected and can share data fully and in realtime. The transition between each process is seamless;information is computer readable and usable acrossall systems that support the medication use process.Closed-loop medication management effectively re-duces many steps in the complex process, significantlyreducing opportunities for error.7

Despite a well-designed plan to build an ideal,technology-enabled medication management infra-structure, achievement of a fully integrated state hasbeen difficult. Obstacles include the absence of well-defined processes, a lack of uniform technical andsemantic standards, as well as the desire to expedi-tiously address the safety and quality concerns iden-tified by the IOM. Instead, a focus on single functionalareas and ‘‘quick wins’’ has produced a number ofsingle-threaded and ineffectively integrated solutions.The first-generation EHR medication managementapplications have offered good integration withintheir proprietary suite of tools. However, the lack ofboth incentives for vendors to connect and an overallintegration strategy within the medication manage-ment domain has made integration a significantchallenge, with many remaining opportunities forimprovement.

FUTURE STATEAny conversations involving the future state of

automation and technology for medication manage-ment must center on connectivity and interoperability,patient-centered care, remote and mobile capabilities,

technology-enabled technician distribution, automa-tion, and analytics.8

The future practice model positions pharmacists inthe role of medication therapy managers. Thus, itis clear that the supporting technologies will requireaccess to large amounts of patient-centered, real-timedata and information that are effectively filtered andprioritized across the continuum of care. Integratedinformation systems must allow for continuous moni-toring and detection of medication-related problemsand prospectively alert the pharmacist of the need forintervention. In addition, the information must be ac-cessible remotely, when and where the user needs it andindependent of the computer or mobile device beingused.9

The operational systems must be built around theclinical systems and created in a way that permitsproduct selection, dispensing, distribution, and prep-aration oversight. To support a technology-enabledtechnician distribution model, it will be necessary forthe technologies to provide additional assurances thattechnicians have performed distribution tasks cor-rectly and in an auditable fashion.10

Despite offering a number of significant benefits,currently available pharmacy operational systems willrequire dramatic re-engineering in the emerging era ofintegration and closed-loop medication management.These systems must evolve and progress to pharmacypatient care systems for the provision of medicationtherapy management (Table 1). Additionally, theymust incorporate functionality to support pharmacistdocumentation; notification of colleagues and otherdisciplines of the need to intervene; surveillance, re-view, and analysis of clinical data for monitoring; andeducation of patients and providers.11

ROLE OF PHARMACY INFORMATICSThe future state of technology to support medi-

cation management will depend on pharmacy in-formatics reform. This pharmacy subspecialty willbe called upon to develop systems that supportclinical practice, with drug distribution and prepara-tion as end products of managing medication ther-apy and improving medication-related outcomes.10,11

Pharmacy informatics will play a significant role inmedication-related data quality management, secu-rity and privacy, monitoring, and ongoing mea-surement and evaluation of the effectiveness oftechnology-related solutions. Informaticists will par-ticipate in development efforts and in maintainingcurrent technology and knowledge assets that includethe following12:

Figure 1. Percentage of US hospitals implementing coremedication use process systems – 2009-2012.5,6 EMR 5

electronic medical record; CPOE-CDS 5 computerizedprescriber order entry and clinical decision support;BCMA 5 barcode medication administration; Med Rec 5

medication reconciliation system.


Technology and Automation in Hospital Pharmacies

� Corrective maintenance – steps to correct produc-tion-related problems with the network, interface,hardware, software, or utilization of informationsystems.

� Customized maintenance – steps to modify alreadyexisting functionality to improve the user interfaceor address new regulations or safety and qualityinitiatives.

� Enhancement maintenance – steps to improve thesystem beyond already-existing capabilities, includ-ing hardware and software.

� Preventive maintenance – steps to reduce the risk ofsystem problems, replace servers or hardware, andupgrade security patches.

Pharmacy informatics requires the continuous studyof the human impact of information systems anddevelopment of technologies and automation to optimizesafety and quality. New skills will be required, including13:

� A firm grasp of the fundamental principles of phar-macy practice and the medication use process,

� Comprehensive knowledge about the safe and ef-fective use of medications,

� Expertise to effectively translate and seamlesslycommunicate medication information across themedication use process continuum of care,

� Ability to interpret and implement requirements toensure the safe and comprehensive use of medica-tions across all disciplines and processes,

� Exploratory analysis coupled with deep knowledgeof clinical processes,� Outcomes data — analytical skills, and� Understanding of process–outcome relationships.

SECURITY AND PRIVACY CONSIDERATIONSAs primary administrators of medication-related

data, those who practice pharmacy informatics mustmaintain a firm grasp of their organizations’ securityand privacy strategies, policies, and procedures. Fur-thermore, they must understand the potential threatsand sources of security and privacy breaches and en-sure that all needed administrative, physical, andtechnical controls are in place to reduce privacy andsecurity risks.14

SUMMARYAn environmental scan of the current and future

state of medication management technologies revealsthat most health systems have moved beyond goodintentions to implementing the core applications andmaking progress toward a technology-enabled closed-loop medication system. The initiation of the mean-ingful use objectives and associated financial incentivesand penalties has prompted health systems to takemore determined steps to improve adoption. Currentpharmacy information management systems mustchange from a focus on distribution and fulfillment tothat which supports patient-centric pharmaceuticalcare across the medication use continuum.

REFERENCES

1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err IsHuman: Building a Safer Health System. Washington, DC:National Academy Press; 1999.

2. Committee on Quality of Health Care in America. Cross-ing the Quality Chasm: A New Health System for the 21stCentury. Washington, DC: National Academy Press; 2001.

3. 111th Congress of the United States of America. AmericanRecovery and Reinvestment Act of 2009—Title XIII: HealthInformation Technology. http://www.gpo.gov/fdsys/pkg/BILLS-111hr1enr/pdf/BILLS-111hr1enr.pdf.bin/getdoc.cgidbname5111cong_bills&docid5fih1enr.pdf. Accessed January 15, 2013.

4. Centers for Medicare and Medicaid Services. Final rule onmeaningful use. Fed Regist. 2010;75:44314–44588.

5. Pedersen CA, Schneider PJ, Scheckelhoff DJ. 2012 ASHPnational survey results: implications and trends for today’spractice. Session presented at the 2012 ASHP Midyear ClinicalMeeting; December 5, 2012; Las Vegas, NV.

6. The 7th annual state of pharmacy automation. PharmPurch Prod. 2012;9(8):1-96. http://www.pppmag.com/article/

Table 1. Pharmacy patient care system functionalrequirements11

System domain Examples

Documentation � Medication histories� Home medication lists� Allergies and intolerances� Pharmaceutical care plans

Responsibility-sharing � RPh-patient assignments� RPh work calendars� Facilitate RPh consults� Messaging between RPhs

Review and analysis � Holistic med profile review� Prioritization of care activity� Pharmacokinetic analyses� Pharmacodynamic analyses

Education management � Patient education content� Track education provided� Patient learning assessment� Provider education content

Note: RPh 5 Registered pharmacist.



pppv9n8s0/State_of_Pharmacy_Automation_2012. AccessedJanuary 15, 2013.

7. Bowles M. Closed loop electronic medication manage-ment. White paper. http://www.marcbowles.com/Publications/CLEMM%20Whitepaper_Final_Extract.pdf. Accessed Janu-ary 15, 2013.

8. Fortier CR. Safe, effective, and efficient medication distri-bution: challenging paradigms and bedrocks. Am J Health SystPharm. 2011;68:1127.

9. Buchholz D, Dunlop J, Jimison E, Maxson G. Enablingdevice-independent mobility with dynamic virtual clients. Whitepaper; Intel Corporation: November 2009. http://www.intel.com/content/dam/doc/white-paper/intel-it-mobile-computing-independent-mobility-dynamic-virtual-clients-paper.pdf. Ac-cessed January 15, 2013.

10. Technology-enabled practice: a vision statement by theASHP Section of Pharmacy Informatics. Am J Health SystPharm. 2009; 66:1573–1577.

11. Flynn A. Technology innovation priorities to support arelational, patient-side pharmacy practice. Presented at: Uni-versity Hospital Pharmacy Executive Group. Considerations inAdvancing the Practice of Pharmacy in Academic MedicalCenters. University of Michigan, Ann Arbor; March 2-3, 2012.

12. Health Information Technology Toolkit. Ongoing SystemMaintenance, Administration, and Data Quality Management.Bloomington, MN: Stratis Health; 2009. www.stratishealth.org/documents/HITToolkitNH/2.Utilize/2.1Implement/2.1.21Ongoing_System_Maintenance.doc. Accessed January 24, 2013.

13. American Society of Health-System Pharmacists. ASHPstatement on the pharmacist’s role in informatics. Am J HealthSyst Pharm. 2007;64:200–203.

14. Houlding D. Health information at risk: successful strate-gies for healthcare security and privacy. White paper. IntelCorporation; 2011. http://www.intel.com/content/dam/www/public/us/en/documents/white-papers/strategies-for-healthcare-security-and-privacy-paper.pdf. Accessed January 15, 2013. g




Implementation of a Clinical Decision Support System

Stacy Calloway, MS, PharmD, BCPSp

Today’s health care environment imposes manychallenges on health care organizations andproviders, including the increasing complexity

of patient care coupled with the dynamic nature ofmedical information, clinical practice guidelines,and mandatory reporting requirements. New federalrequirements have been put in place for electronicmedical records and clinical decision support, as wellas critical patient safety issues such as health care–associated infections (HAIs), antibiotic-resistant in-fectious diseases, and medication errors. A majorbarrier to addressing these challenges may be thefragmentation of medical information, with dataspread across various databases and systems within anorganization. This hinders hospital-based cliniciansfrom retrieving relevant and timely informationneeded to provide quality patient care. Emergingevidence suggests that clinical information technolo-gies, such as electronic medical records, computerizedphysician order entry, and electronic decision support,can improve the quality of care within a hospital.1-3

Medical institutions are increasingly using clinicaldecision support systems (CDSS) to assist cliniciansin maximizing the benefits of clinical surveillancethroughout their organizations.4,5 These systems in-tegrate patient data from a variety of hospital in-formation sources and offer tools for automated,real-time surveillance, as well as alerting, analysis,and reporting capabilities. A 2009 study found thathospitals with automated notes and records, orderentry, and clinical decision support had fewer com-plications, lower mortality rates, and lower costs.6

Hospitals that had higher scores in decision supportwere associated with a 16% decrease in adjusted oddsof complications, as well as a $538 lower cost for allhospital admissions.

Although CDSS is a highly promising approachfor identifying patients who would most benefit frominterventions by pharmacy clinicians, there are fewreported examples of the effect of implementing CDSSon clinical pharmacy measures. This article describes

the impact of this system on pharmacy clinical inter-ventions and the costs associated with those inter-ventions. In addition, the processes and lessons learnedfrom this initiative are discussed.

IMPLEMENTATION OF SOFTWAREGood Shepherd Medical Center is a 425-bed

acute-care community hospital in eastern Texas. Thepharmacy department uses a decentralized model, with14 staff pharmacists on site along with 3 remote order-verification pharmacists, 4 night-shift pharmacists, 3clinical pharmacists, and 29 pharmacy technicians. Thepharmacists are decentralized to serve the intensive careunit (ICU), neonatal ICU (NICU), telemetry units, med-ical/surgery units, central pharmacy, and the IV ad-mixture room. The clinical pharmacists specialize inoncology, critical care, and internal medicine; they ad-dress complex clinical questions and perform therapeuticdrug monitoring of dangerous/high-risk and high-costdrugs. These pharmacists also serve in staffing roles whenneeded, attend daily multidisciplinary rounds, and par-ticipate on hospital committees.

Good Shepherd implemented a CDSS in February2011 to document clinical interventions, follow drugconsults, and document adverse drug reactions. Thisdata-mining software facilitates clinical decisionmaking, medication safety, and infection preventionand management. The pharmacy department hastrained multiple departments in the hospital, includingcase management, social work, and physicians, on theuse of the software to optimize their workflow. Tofully optimize the new system within the department ofpharmacy, in-service training was provided to all thepharmacists; a computer-based learning module wasalso required to document competency on the newsystem. Pharmacists learned how to look up patients,follow pharmacokinetic consults, and document inter-ventions and adverse drug reactions. To manage dailywork flow, pharmacists learned how to run dailyalerts for intravenous to oral (IV to PO) conversionsand to adjust dosages for changes in renal function.

*Pharmacy Clinical Director, Good Shepherd Medical Center, 700 East Marshall Avenue, Longview, Texas 75601; e-mail:[email protected]


Department standards were revised to add clinicalintervention documentation. An average of 5 phar-macy interventions per shift was set as ‘‘standard,’’and an average of 8 documented interventions per shiftachieved ‘‘above standard.’’ Cost values for theinterventions were unchanged to maintain consistencyin reporting; however, new intervention categorieswere assigned cost values based on previously pub-lished pharmacy intervention literature.7-11

MULTIDISCIPLINARY ROUNDS:WORKFLOW REDUCTION

On a daily basis, the 3 clinical pharmacists meetwith a multidisciplinary care team (MDT) representingsocial work, case management, dietary, respiratory,nursing, and physical therapy on each unit. The MDTsdiscuss individual patients to optimize care and ex-pedite discharge.

Before the implementation of CDSS, pharmacistswho attended multidisciplinary rounds would performtime-consuming ‘‘pre-rounding’’ functions, requiringthem to print out patients’ medication profiles and listsof patients to follow. An entirely paper-based recordsystem was used to provide case summaries and todocument the MDT’s discussion and decisions.

With the new clinical surveillance system, phar-macists bring their tablet computers to rounds. Thisenables them to access patient profiles, identify and acton any drug-related problems, and document inter-ventions in real time. During rounds, the pharmacistsscreen patients for IV to PO conversions, renal dosing,antibiotic streamlining, and any drug-related prob-lems. In addition, they review any alerts (discussedbelow) that have fired for specific patients and de-termine whether to leave a note on the patient’s chartor call the physician.

TARGETED CLINICAL ALERTSThe CDSS software allows the pharmacy to set up

alerts to identify patients for priority clinical inter-ventions. The decentralized pharmacists can run alertson patients who may need renal dose adjustments orare candidates for IV to PO switch. The pharmacydepartment has a hospital-approved protocol forpharmacists to follow in performing these services, inaddition to pharmacokinetic dosing, without physi-cian approval. Other alerts were set up for situationsthat required follow-up by a clinical pharmacist, suchas those with more chart work and interaction with thepatient and physician.

To realize some of our major clinical initiatives,hospital administration identified antimicrobial

stewardship, adverse drug reactions, and core meas-ures as target areas for CDSS alerts and pharmacyinterventions.

Antimicrobial Stewardship AlertImproving antimicrobial use and preventing an-

timicrobial resistance are key priorities for hospitalsnationwide. Antimicrobial stewardship programsensure appropriate drug selection, dosing, and dura-tion. According to the Centers for Disease Controland Prevention, studies indicate that nearly 50% of anti-microbial use in hospitals is unnecessary or inappropriate.7

Furthermore, overuse of antibiotics contributes to thegrowing challenges posed by Clostridium difficile andother antibiotic-resistant bacteria.12

CDSS can enable pharmacists to compare andleverage patient data from different systems – forexample, pharmacy orders and microbiology results –in real time. It also offers tools for identifying potentialadverse drug events, IV to PO conversion opportu-nities, drug-bug mismatches, and discontinuation orde-escalation opportunities in a timely manner. An-other way the CDSS has aided antibiotic stewardshipis in its ability to compile an instant antibiogram.Before the new software was implemented, antibio-gram data were compiled and reported manually andthis usually took between 1 and 2 weeks. Antibio-grams are created by the CDSS data-mining capabilityto pull microbiology data directly from the labo-ratory’s data system. The pharmacist can decidewhich isolates and drugs to include in the antibiogramand can specify dates and units of the hospital toget the most accurate and up-to-date view of insti-tutional resistance patterns. Instead of generating ahospitalwide antibiogram every year, we are able togenerate instant snapshots and quarterly reports forthe units.

Once an institution’s resistance patterns have beenidentified, empiric therapy can be developed for var-ious disease states. Information derived from theantibiogram can also justify development of antibioticrestrictions and use of pharmacy-preferred antibiotics.In collaboration with the emergency department atGood Shepherd, physician guidelines were developedfor the treatment of urinary tract infections (UTIs) inthe inpatient and outpatient settings based on unit-specific data generated by CDSS. Although manyinstitutions typically use a fluoroquinolone for UTItherapy, by running a quick antibiogram we learnedthat E. coli susceptibilities to this class are relativelylow (74%), whereas susceptibilities to ceftriaxoneexceed 95%.



Antimicrobial stewardship efforts have been mul-tifaceted at Good Shepherd, with a more formalizedprogram taking shape in recent years. An initial effortwas the development of criteria for the use of van-comycin. Patients who have received vancomycin formore than 72 hours are screened via the CDSS alert.Upon the determination of vancomycin trough goals,the pharmacist assesses whether vancomycin is in-dicated and intervenes if the patient does not meetcriteria for use.

The CDSS antimicrobial monitoring alerts areuseful for identifying drug-bug mismatches and posi-tive cultures with no antibiotic orders on the patient’sprofile. Pharmacists keep track of culture results forthe patients on their units, in addition to days of an-tibiotic therapy, to determine when to intervene fordrug de-escalation and discontinuation. Dose opti-mization and IV to PO conversion also play a large rolein stewardship efforts. Making sure that patients areon the proper dose to optimally manage an infectionmay require an increase in dosage of antibiotics, in-cluding cefepime, piperacillin-tazobactam, and otherantibiotics that require high-dose regimens for sometypes of infections. A renal dosing protocol allowspharmacists to automatically adjust medications, in-cluding certain antibiotics, to avoid adverse effects inpatients who have fluctuations in renal function.

Adverse Drug Reactions: Trigger Tools AlertThe use of CDSS has become instrumental in the

identification and documentation of adverse drugevents (ADEs). The concept of ‘‘trigger tools’’ involvesidentification of abnormal lab values or the dispensingof antidote-type medications to ascertain a possibleADE. Lab values in the trigger tool alert function in-

clude neutropenia (white blood cell count , 3,000/mm3),thrombocytopenia (platelet count , 50,000/mm3),hypoglycemia (blood glucose level , 60 mg/dL), in-ternational normalized ratio (INR) . 3, activatedpartial thromboplastin time . 100 seconds, elevatedserum drug levels, and presence of C. difficile toxin. Areport can be generated daily to identify patients whohave these lab ‘‘triggers.’’ The pharmacist can reviewa complete list of medications dispensed to those pa-tients using the CDSS platform.

Antidote medications used to reverse unfavorablephysiological states include phytonadione for highINR, digoxin immune Fab for digoxin toxicity, glu-cagon or 50% dextrose in water for low glucose levels,or naloxone for oversedation. Patients receiving theseantidotes are screened for potential ADEs; this activ-ity is documented in the patient’s medical record as aclinical intervention. Documentation includes the typeof ADE and level of severity and whether treatmentwas required. These data are compiled monthly withother reported ADEs and presented to the hospital’sPharmacy and Therapeutics Subcommittee and thePatient Care Committee. The use of CDSS to identifythese triggers and efficiently compile data in a simple,straightforward fashion makes this program invalu-able to the pharmacist attempting to identify trends inproblems related to a certain class of drug or to aparticular unit of the hospital.

Core Measures AlertsAlerts were also created within the CDSS to

identify patients who may be failing core measuresbased on their disease state. For example, core mea-sures alerts were created for patients with stroke, in-cluding those admitted with a diagnosis of cerebrovascular

0500

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CDSS Implementa�on

Figure 1. Number of pharmacist clinical interventions accepted by physicians: before and during CDSS im-plementation. CDSS 5 clinical decision support system.



event, stroke, or transient ischemic attack, or thosewho had received alteplase therapy. Medication pro-files for stroke patients are reviewed for a statin orantithrombotic agent. Patients without the requiredmedications are forwarded to the hospital’s coremeasure specialists for follow-up. This type of alertwas also set up for patients admitted with congestiveheart failure or acute myocardial infarction.

RESULTSClinical interventions made by Good Shepherd

pharmacists using the CDSS were associated witha very high physician acceptance rate (.99%), and theaverage number of accepted interventions increasedremarkably – 116% per month – since implementationof the system (Figure 1). The majority of interventionshave been completed during patient rounds, but in-terventions have also occurred in a variety of othersettings, such as order clarifications, therapeutic in-terchanges, and medical record reconciliation.

Cost savings related to pharmacist interventionsincreased from an average of $118,068 per month to$184,945 per month (Figure 2), representing an esti-mated annual savings increase of $802,524 and totalsavings of $2,219,340.

DISCUSSIONThe results described here have been well received

by Good Shepherd’s administration. CDSS implemen-tation has helped the hospital to overcome an existingstruggle to obtain and document the data needed forclinical initiatives. The department of pharmacy nowuses a multifaceted approach to encourage pharmacists

to document interventions. These interventions areessentially the same activities the pharmacists werealready performing, but with training on the newsystem, they can add documentation to get credit fortheir work.

The ease of documentation on the mobile CDSSplatform was instrumental in the dramatic and sus-tained increase in pharmacist clinical interventions,which in turn demonstrated significant value to theinstitution. As a result, 2 additional full-time clinicalpharmacist positions have been approved, andfunds have been budgeted for tablet computers forpharmacists to use on daily multidisciplinary roundsto retrieve patient data and document interventionswith the CDSS.

Clinical information technologies can improve thequality of care within the hospital environment byintegrating patient data from a variety of hospitalinformation sources and offering tools for automated,real-time surveillance, alerts, analysis, and reporting.Additionally, these systems can enhance antimicrobialstewardship by ensuring appropriate drug selection,dosing, and duration. The CDSS was shown to posi-tively impact pharmacy clinical interventions, clinicaldocumentation, and institutional costs.

REFERENCES1. Amarasingham R, Diener-West M, Plantinga L, et al.Hospital characteristics associated with highly automated andusable clinical information systems in Texas, United States.BMC Med Inform Decis Mak. 2008;8:39-50.

2. Bates DW. The quality case for information technology inhealthcare. BMC Med Inform Decis Mak. 2002;2:7-10.

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000 CDSS Implementa�on

Figure 2. Accepted pharmacist clinical interventions translated into dollar savings: before and during CDSS im-plementation. CDSS 5 clinical decision support system.



3. Bates DW, Gawande AA. Improving safety with infor-mation technology. N Engl J Med. 2003;348(25):2526-2534.

4. Coiera E, ed. Guide to Health Informatics. 2nd ed. London:Arnold; 2003.

5. Kaushal R, Shojania K, Bates D. Effects of computerizedphysician order entry and clinical decision support system onmedication safety: a systemic review. Arch Intern Med. 2003;163:1409-1416.

6. Amarasingham R, Plantinga L, Diener-West M, et al.Clinical information technologies and inpatient outcomes.Arch Intern Med. 2009;169:108-114.

7. Lazarou J, Pomeranz BH, Corey PN. Incidence of adversedrug reactions in hospitalized patients: a meta-analysis ofprospective studies. JAMA. 1998;279:1200-1205.

8. Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP.Adverse drug events in hospitalized patients. Excess length of

stay, extra costs, and attributable mortality. JAMA. 1997;277:301-306.

9. Bates DW, Cullen DJ, Laird N, et al. Incidence of adversedrug events and potential adverse drug events. Implications forprevention. ADE Prevention Study Group. JAMA. 1995;274:29-34.

10. Bates DW, Spell N, Cullen DJ, et al. The costs of adversedrug events in hospitalized patients. Adverse Drug EventsPrevention Study Group. JAMA. 1997;277:307-311.

11. Suh DC, Woodall BS, Shin SK, Hermes-De Santis ER.Clinical and economic impact of adverse drug reactions inhospitalized patients. Ann Pharmacother. 2000;34:1373-1379.

12. Centers for Disease Control and Prevention. Get smartfor healthcare. 2011. http://www.cdc.gov/getsmart/healthcare/.Accessed January 16, 2013. g




Continuing Education Post-Test

1. The sociotechnical model is important becausehealth information technology (HIT) in its currentstage of implementation has not realized its truepotential to improve patient safety.

a. Trueb. False

2. Meaningful use incentives apply to the use of elec-tronic data by:

a. Large health care systems.b. Physicians.c. All hospitals.d. All of the above.

3. Technological interventions in the medication useprocess include all of the following, except:

a. Physician order entry.b. Smart infusion pumps.c. Medication order verification.d. Automated surveillance for adverse events.

4. The potential safety benefits of automating themedication use process have not been fully real-ized because:

a. Automation projects have not considered theexisting sociotechnical environment.

b. Technologies are not optimized after imple-mentation.

c. Clinical decision support is not providedwithin the electronic health record system.

d. All of the above.

5. Specialists in cognitive system engineering developtechnology design requirements by first conducting:

a. Proactive surveillance for emergent risk.b. Interviews with hospital administrators.c. Research on the context for new technology.d. On-site inspections of the health care facility.

6. Core technologies to support medication manage-ment include all of the following, except:

a. Electronic medical record.b. Smart pumps.c. Computerized prescriber order entry.d. Barcode medication administration.

7. The benefits of closed-loop medication manage-ment include all of the following, except:

a. Improved oversight of pharmacy compound-ing practices.

b. Deployment and development of improvedpractices.

c. Ability to effectively monitor patient careacross the continuum.

d. Ability to reduce the opportunity for error.

8. A major obstacle to achievement of an integrated,technology-enabled medication management in-frastructure is:

a. A focus on single functional areas.b. Uniform technical and semantic standards.c. Incentives for vendors to connect.d. An overall integration strategy.

9. The future state of automation and technology formedication management:

a. Centers on remote and mobile capabilities.b. Positions pharmacists in the role of medication

therapy managers.c. Requires real-time data that are filtered and

prioritized.d. All of the above.

10. Pharmacy informatics must play a significantrole in all of the following maintenance respon-sibilities, except:a. Customized maintenance.b. Enhancement maintenance.c. Operational maintenance.d. Preventive maintenance.

11. Data show that hospitals with automated notesand records, order entry, and clinical decisionsupport had:a. Fewer complications.b. Lower costs.c. Lower mortality rates.d. All of the above.

12. Clinical decision support systems (CDSS) assistwith pharmacy workflow by providing alerts thattarget patients who require clinical interventions.a. Trueb. False


13. According to the Centers of Disease Control andPrevention, what percentage of antimicrobial usein hospitals is considered unnecessary or inap-propriate?a. 15%b. 30%c. 50%d. 75%

14. What are some ways that a CDSS improves an-timicrobial stewardship efforts?a. Generation of an electronic antibiogramb. Alerts for patients on vancomycin .72 hoursc. Alerts for drug-bug mismatchesd. All of the above

15. Data-mining software facilitates all of the follow-ing, except:a. Medication safety.b. Clinical decision making.c. Reduced need for documentation.d. Infection prevention/management.

AccreditationThis CE activity is co-sponsored by

ProCE, Inc. and Hospital Pharmacy.ProCE, Inc. is accredited by the Ac-creditation Council for Pharmacy Edu-cation as a provider of continuingpharmacy education. ACPE UniversalActivity Number 0221-9999-13-016-H04-P has been assigned to thisknowledge-based, home-study activity(initial release date 03-05-13). This ac-

tivity is approved for 1.5 contact hours (0.15 CEU) instates that recognize ACPE providers. This CE activ-ity is provided at no cost to participants. Statementsof credit will be issued online upon completion of theevaluation and the post-test with a score of 70% orhigher. No partial credit will be given.

Release Date: March 5, 2013Expiration Date: March 5, 2016

How to Obtain CE CreditContinuing education for this activity is processed

through the ProCE online CE Center. To receive CEcredit, please go to:

� www.ProCE.com/HealthIT-HPJ� Enroll in the activity and complete the evaluation

and post-test.

With a passing grade of 70% or greater on thepost-test, you will be able to print your CE statementof credit online.

For questions related to registering for andobtaining CE credit, contact ProCE at 630-540-2848or [email protected].


Continuing Education Post-Test

hospital pharmacy supplement march 172015

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