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Secure Locations, Secure Medications
Advanced information technology provides prescription for rising healthcare costs
By Sean C. Mitchem and H. Dwaine Smith
Consumers notice the effects of rising healthcare expenses when the co-pay costs for medications go up and when only a limited set of medications are available on a health plan's formulary. Healthcare organizations, in turn, try to keep costs down by optimizing medication options using a formulary of lower-cost medications based on best-accepted practices and by monitoring treatment outcomes and patient compliance to the doctor's prescription instructions.
Many healthcare organizations have set up their own pharmacy operations or have contracted with large prescription processing companies to help consumers save money on medications. By processing large numbers of prescriptions, these pharmacy operations can reduce costs. However, they also are pressured to assume some of the burden of rising medication costs by further increasing prescription processing efficiency as well as monitoring and managing drug regimens, laying much of the responsibility on pharmacists to rein in ever-increasing drug costs. These increased burdens on pharmacists have driven a demand for better pharmacy tools in the form of electronic information and packaging systems.
The state of Texas is responsible for providing medical services to its incarcerated population. In 2002, this population totaled 145,696 inmates, all of whom must be properly and promptly cared for while under the state's custody. The Texas Department of Criminal Justice (TDCJ) has contracted the University of Texas Medical Branch (UTMB), Galveston, to provide health services for the majority of this population at a variety of incarceration facilities including traditional prisons, private prisons, and mental health, medical and substance abuse facilities. UTMB places healthcare professionals on site within prisons and other medical facilities throughout the state to provide clinical (both hospital and ambulatory visits), dental, mental, vision and pharmaceutical services. While UTMB provides these services to 80 percent of the incarcerated population, they provide 100 percent of the pharmaceuticals required for all TDCJ facilities through a centralized processing facility located in Huntsville, Texas. Clinical pharmacy services include pharmacist's interventions to correct or clarify prescriber's medication orders, medication requests for items not on the TDCJ formulary, and formulary management.
Two systems were being used to record prescription actions for patients. One, maintained by TDCJ, is a legacy mainframe system that is hard-wired into each prison unit and the UTMB pharmacy. It is used to order prescriptions, process them and record compliance with prescription orders by patients. The other, maintained by UTMB Correctional Managed Care (CMC) utilizes a third-party electronic medical record system that contains extensive medical information about patients. The system includes a relational database and a client interface that allows providers to record patient demographic information, admissions and discharges, facility information, prescriptions, adverse drug reactions and laboratory results. The TDCJ mainframe system has no ability to interface with the electronic medical record, resulting in duplicate input being required to record prescription actions. Desiring a fully integrated system with the ability to maintain a longitudinal medical record, UTMB contracted Southwest Research Institute (SwRI) to develop a Pharmacy Replacement System (PRS) to replace legacy mainframe pharmacy applications with functionality that utilizes current technology and is tightly integrated with the existing electronic medical record.
Integration of the new components with the electronic medical record was accomplished using web technology. Services were defined for various pharmaceutical transactions with the electronic medical record, such as entering a prescription, retrieving a current medication profile, checking for possible drug reactions or duplicate therapies, entering medication administrations and other transactions related to ordering, approving and administering medications. The web services provided the "public" interface to the distributed PRS components, utilizing eXtensible Markup Language (XML) to represent the data within the transactions. The Simple Object Access Protocol (SOAP) is used as the messaging protocol between components. The use of web services pulls database transactions from system components, providing a set of reusable interfaces using a standardized protocol that enables code to be reused and integrated with other software components.
The electronic medical record uses a client-server architecture, where the client application (the user interface) communicates directly with the database using a standard database connection. While this technology performs adequately for actions such as reviewing or updating information, it is not suited to handle large transaction loads or a large number of concurrent users in a timely manner. To integrate the new pharmacy functionality into the electronic medical record in a manner that provides the fastest access to data, researchers developed a transitory, "extension" database that acts as an interface between the electronic medical record and the PRS. Prescriptions are placed in the extension database using "push" technology, where data is moved as it is processed. This allows for the placement of prescription information at the proper destination as quickly as possible, providing local access to data without the overhead expenses associated with searching large database tables.
The CMC pharmacy processes 10,000 to 15,000 prescriptions each day. Every prescription must be reviewed by a pharmacist, processed for filling and shipped to the destination unit in a day. To ensure the most efficient processing, SwRI developed data caches to hold new prescriptions awaiting review. These caches enable multiple pharmacists to gain local access to prescription data and allow processing to continue during short-duration outages of the Internet. In addition, this process ensures that processed prescription transactions are completed before they are removed from the pharmacy server. Quick, careful prescription handling is the key at the pharmacy, so the server components were designed to provide pharmacists with immediate access to data to ensure patient safety.
Pill Window Dispensing
Inmates receive medications, one dose at a time, at a designated pill window within their prison unit. Pill windows are only open for a limited time each day because of security concerns. Within that short time frame, pharmacy technicians must be able to quickly provide the prescribed medications to each patient, then move on to the next patient. On-site data caches provide local access to prescription information, significantly speeding up the medication administration process. Prescriptions are pre-cached before the pill window opens, allowing faster transactions. Administration events are cached until the update transaction at the electronic record database is confirmed. The caches are refreshed automatically every night at a configurable time.
For those units not wired for broadband Internet access, SwRI developed a remote user access capability that allows technicians in those facilities to order prescriptions and to record medication administration events over the Internet, even if their connection is limited to a 26K phone line connection. These applications, hosted on a server at CMC headquarters, use encryption and digital certificates to ensure security and provide the minimum services necessary for providers to manage their patients. Units that previously faxed prescription orders and used paper charts to manually record medication administration events can now perform prescription-related actions securely over the web. This allows CMC to provide the new system to all its units now, while the infrastructure is being put in place for full PRS service.
CMC is installing the hardware and infrastructure to replace the mainframe technology used at the central pharmacy. The current implementation plan is to first connect the Federal Bureau of Prisons facilities in Beaumont, then conduct a phased deployment of the PRS throughout Texas prison units, after which it plans to connect the Texas Youth Commission units. Recently CMC has also tested the capability of running the PRS application from a wireless Internet-capable hand-held device with much success. Utilizing hand-held wireless devices will allow CMC to provide pharmacy services to rural county jails and to prisoners in transit between facilities.
Development of the PRS has provided CMC with a set of application tools that are both functional and cost-effective. Using the PRS, CMC will be able to eliminate duplication of effort. Pharmacists will be able to view prescription orders and medical record information as a single record, reducing review times. Medical administration records now are stored with medical records, giving medical providers a single source of medical information. Inventory transactions can be tracked while the prescription is in transit and reconciled at delivery time, reducing losses. Medication-related reports will now be generated from a single data source, allowing a richer set of reports that are easier to generate and faster to reproduce. Control of access to medical data is now simpler because there is only one source of the data that needs to be managed. The ability to enter prescription orders over the Internet has eliminated the practice of faxing orders, also eliminating the need for a specialized software application to process them and the manpower to enter the faxed orders into the system. In short, CMC providers, pharmacists and technicians are now better equipped to perform their primary mission, providing quality medical services to the incarcerated population of the state of Texas.
The authors wish to acknowledge the following people for their valuable contributions to the success of the Pharmacy Replacement System: Kelly Jackson, infrastructure lead and co-architect; Stephen Johns, graphical user interface lead; Augie Pedraza, Roel Almendarez, Lorraine Cantu, software developers; Victoria Zhou and Gail Beezley, database developers and Dr. Sandra Dykes, security services, all from the SwRI Automation and Data Systems Division. Additionally, the authors would like to thank Dr. Glenn Hammack, UTMB technical manager, for his energy and enthusiasm.
Published in the Spring 2004 issue of Technology Today®, published by Southwest Research Institute. For more information, contact Joe Fohn.