Interoperability Preparedness: What Hospitals Can Do to Be Ready for Smart Pump-EMR Interoperability

Evaluate practice

Prescribing

There must be a prescriber’s order for every infusion to pre-populate the pump. Today, it is not unusual for a nurse to take fluids from the central storage area and hang flush bags without an order. For keep-vein-open maintenance bags and flush bags, there must be standardized orders already signed by physicians that nurses can execute.

Prescribers need to use CPOE every time correctly and completely. Necessary elements include dose rate unit of measure, drug amount and unit of measure, diluent volume, dosing method (non-weight-based, weight-based, body surface area [BSA]), and whether scheduled medications have a standardized rate or infuse over time. Prescribers need to use current CPOE orders, not old retired order sets saved on a preference list. Physician “favorites” have to be checked to ensure they work for interoperability. The infusion rate has to be in the “Rate” field, not in the “Comments” section. CPOE orders that are no longer active need to be removed from physician preference lists. Improvements such as these do not need to wait until implementation; a hospital can enact them far in advance of device connectivity.

Pharmacy

Pharmacy order verification and dispensing also need to be standardized to support pre-population and to help ensure timely verification. In the emergency department, all automatically verified orders need to be checked to ensure they support interoperability. Smaller critical access facilities without 24-hour pharmacy services will need to consider how to ensure timely order verification.

Pharmacists have to maintain the same practice as prescribers. Ordered concentrations must be in the drug library. The infusion rate has to be in the “Rate” field, not in the “Comments” section. All fluids and scheduled medications must have a rate in the order, while continuous drips require dose units, such as units/hr or units/kg/hr for insulin.

Any manipulation of a total volume field by pharmacy may cause an order to fail if the resulting concentration is not included in the smart pump library. For example, an order for epinephrine 16 mg in 266 mL will not align to a library entry of epinephrine 16 mg/250 mL. All units of measure in the order and in the smart pump library need to align. If a physician can order vancomycin in milligram or gram dose units, then the smart pump library must include both milligram and gram dose units. If an oncologist enters an order using the BSA dosing method, then the drug library must support BSA dosing. Aligning the EMR formulary and the smart pump library is time-consuming but critical to the success of interoperability.

Practices must also be consistent in how pharmacy dispenses and labels drugs. For example, pharmacy could dispense a compounded IV admixture labeled with the total volume (260 mL) that includes the 10 mL volume of the added medication. Nursing, on the other hand, may infuse IV medications based on the total volume of the original medication bag (e.g., 250 mL). The infusion rate for a scheduled medication is determined by the total volume dispensed, so differences in infusion rates can affect nursing workflow in an outpatient infusion center differently than in other patient care areas.