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Below is a really good discussion on the use of technology for pharmacist "auto-verifing" with CPOE.  Since this is taken from a list serv that is open to subscribers and this blog is open to all, I have taken the names out to protect the innocent.   I am doing this so this issue is brought to a larger audience.   Perfection, btw, is the term that has been proposed for the order checking and transformation that is done with pharmacist review in CPOE.

These articles are a good back drop for this discussion.

A. J. Flynn
Opportunity cost of pharmacists’ nearly universal prospective order review  
http://www.ajhp.org/cgi/content/full/66/7/668
(go to the online version NOT the paper AJHP b/c there are some good eLetters)

J. Poikonen
An informatics perspective on nearly universal prospective order review
Am. J. Health Syst. Pharm., April 15, 2009; 66(8): 704 - 705.
http://www.ajhp.org/cgi/content/full/66/8/704

D. A. Tribble
Automating order review is delegation, not abdication
Am. J. Health Syst. Pharm., June 15, 2009; 66(12): 1078 - 1079.
http://www.ajhp.org/cgi/content/full/66/12/1078

P. G. Pierpaoli
Creatively using our intellectual capital
Am. J. Health Syst. Pharm., June 15, 2009; 66(12): 1087 - 1087.
http://www.ajhp.org/cgi/content/full/66/12/1087

The List Serv discussion (various authors):

At our recent monthly Pharmacy Directors meeting the following question was raised by one of the Directors:
 

Here is the latest in the ongoing discussion of eliminating near universaly prospective order review (NUPOR) from the pharmacists daily work load.

Dennis Tribble elaborates and articulates the issue in a thoughtful way.

Automating order review is delegation, not abdication

Dennis A. Tribble

Am J Health Syst Pharm 2009;66 1078-1079
http://www.ajhp.org/cgi/content/full/66/12/1078

The two other articles are now free to all.

Pharmacy Practice News published a well balance story on NUPOR.  You need a register for the complete story, fyi.

http://www.pharmacypracticenews.com/index.asp?section_id=239&show=dept&issue_id=504&article_id=12995

It turns out Michael Maddux of Am College of Clinical Pharmacy supports the idea and puts forth some excellent points.

POSTED: APRIL 13, 2009  Should the ‘Sacred Cow’ of Near Universal Drug Order Review be Gored? Sarah Tilyou

This response to Allen Flynn's first commentary on NUPOR hit the presses last night. This might only be available to subscribers of Am J Health Syst Pharm. If you would like a copy, drop me an email.  

An informatics perspective on nearly universal prospective order review

John Poikonen Am J Health Syst Pharm 2009 66: 704-705. [Full Text] [PDF] 

Along with this commentary from Bill Zellmer will give you an idea of the future of pharmacy

Seeking "better ways" in hospital pharmacy

William A. Zellmer Am J Health Syst Pharm 2009 66: 713. [Full Text] [PDF] 

John Poikonen john@poikonen.net http://twitter.com/poikonen http://pharmacyinformatics.wordpress.com http://www.evernote.com/pub/poikonen/PublicPharmacoinformatics

Posted via email from RxDoc.Org

The ongoing series on No More NUPOR can be seen by clicking the link to the left.  It is part of a new and improved RxInformatics.com site.

The following statement was put forth at the Am Soc Health System Pharmacist's (ASHP) House of Delegates in Seattle in June of 2008.

Use of Clinical Decision Support to Limit Need for Near-Universal Pharmacist Order Review  -- ASHP should advocate study of the potential use of clinical decision support in the place of the current practice of near-universal pharmacist order review.  

It was turf’ed to the ASHP’s Council of Pharmacy Management for guidance.  Their report has recently become available (page 8).

My ‘glass is half full’ interpretation of the Council’s report is that they fully and unequivocally support this recommendation.  This is fantastic and hope that research interest and dollars follow.

Now the rest of the story…..   Here is the write up with my comments inserted, followed by comments of the current and future Chairperson of the ASHP Section on Pharmacy Informatics and Technology.

Use of Clinical Decision Support to Limit Near-Universal Pharmacist Order Review.

The first article on NUPOR is out in the April 1st, Am J Health System Pharmacy.  It is brilliant and will change the face of pharmacy as we know it (IMHO of course).

Opportunity cost of pharmacists’ nearly universal prospective order review

Allen J. Flynn

Am J Health Syst Pharm 2009;66 668-670 http://www.ajhp.org/cgi/content/full/66/7/668

The original ‘No More NUPOR’ post is here. To remind you - NUPOR is Near Universal Pharmacist Order Review, the current state of practice for medication orders. There is a group of informatics professionals that are questioning this scared cow. Here is the latest in what will be a series of commentaries on the subject.

The following is a series of email conversations with some very high placed influential pharmacy leaders. Their names are not revealed as the points are more important than who said them.

First this was noticed in the March 2009 Journal of Health System Pharmacy.

Executive Summary on the Global Conference for Hospital Pharmacy Practice (August 2008): “Optimally, all medicine orders should be reviewed by a pharmacist, but many countries do not have adequate resources to support this practice. Hospital pharmacists should assess which patients or patient care areas are in the greatest need of this service and then focus their order-review efforts on those patients or patient-care areas.”

This position more or less endorses the concept of NUPOR that is clearly not universally accepted, yet a standard of practice in the US.

The next suggestion was that this statement 

“is essentially the "endorsed" preamble to (no more) NUPOR....”

Which was then noted that

“This is essentially the internationally "endorsed" preamble to (no more) NUPOR....”

It occurred to me that some may take pot shots that the US is far better than most countries, to which I shot back (with out thinking beyond that)

From the Executive Summary on the Global Conference for Hospital Pharmacy Practice (August 2008):

“Optimally, all medicine orders should be reviewed by a pharmacist , but many countries do not have adequate resources to support this practice. Hospital pharmacists should assess which patients or patient care areas are in the greatest need of this service and then focus their order-review efforts on those patients or patient-care areas.”

The concept of studing the possibility to eliminate NUPOR with better computerized clinical decision support originated with Allen Flynn, pharmacist informatics guru at Univ of Michigan Medical Center.  He will have a brilliant commentary in the Am Journal of Health System Pharmacy in the April 1, 2009 issue.  I will have a follow up in the April 15th issue and Dennis Tribble, CTO/CPO, ForHealth Technologies will have a subsequent letter on the subject in the May or June time frame.

The basic premise is that we need to study the impact of mandating near universal pharmacist order review on patient care and the profession.  If computerized clinical decision support can do some part or segment of order review as good or better than pharmacists, then that will free pharmacists to do more beneficial services for patients.  The AJHP commentaries will explore this in some depth.   I encourage all to read and comment on this revolutionary topic.  Please comment directly in the new AJHP response system on the AJHP.org site that is below the articles.  Of course I welcome comments to this blog, but that will have wider exposure (for now, at least).

At a speech by Robert Wachter of the great blog Wacher’s World he indicated that when you gore sacred cows, expect a lot of Mooing.  NUPOR is a pharmacy sacred cow.  From time to time I will be posting the various Mooing and Musings on this topic.  I welcome your comments as this plays out, which I suspect might be a number of years.

John Poikonen, PharmD

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