Medication order communication using fax and document

Medication-Use technology Medication order communication
m e d i c at i o n - u s e t e c h n o l o g y
Medication order communication using fax
and document-imaging technologies
Armen I. Simonian
harp HealthCare is an integrated
regional health care delivery
system based in San Diego, California. Sharp’s Institutional Care
Division includes four acute care
hospitals and three specialty hospitals with a total of 1851 licensed beds.
Sharp recently began the implementation of a new electronic medical
record (EMR) system, which includes
computerized prescriber-order-entry
(CPOE), and expects to complete this
initiative at the seven affiliated hospitals by the end of 2009. Until CPOE
is fully implemented, clinicians
must continue with current procedures to transfer paper-chart orders
from nursing stations to centralized
and decentralized pharmacy orderprocessing locations. Traditionally, these procedures have entailed a
combination of pharmacy “runners”
rounding periodically to retrieve
orders and nursing personnel handcarrying orders to the pharmacy,
sending orders via pneumatic tube
systems, or faxing orders that print
out in the pharmacy. Problems with
these procedures include delays in
hand delivery, lost tubes, incorrectly
addressed tubes, unavailability of
tubes, unsuccessful faxes, fax printer
Purpose. The implementation of fax and
document-imaging technology to electronically communicate medication orders
from nursing stations to the pharmacy is
Methods. The evaluation of a commercially available pharmacy order imaging system to improve order communication and
to make document retrieval more efficient
led to the selection and customization of a
system already licensed and used in seven
affiliated hospitals. The system consisted
of existing fax machines and documentimaging software that would capture images of written orders and send them from
nursing stations to a central database
server. Pharmacists would then retrieve
the images and enter the orders in an
electronic medical record system. The
pharmacy representatives from all seven
hospitals agreed on the configuration and
functionality of the custom application.
Results. A 30-day trial of the order imaging system was successfully conducted
jams, and poor-quality or illegible
faxes. A review of the literature revealed two articles describing similar
issues with paper-order handling;
both institutions reported the use of
scanning technology to address these
Armen I. Simonian, Pharm.D., is Pharmacy Information Specialist,
Sharp HealthCare, 8965 Spectrum Center Boulevard, San Diego, CA
Melissa E. Lopez, Senior Systems Analyst, and Cathy Fuhrman,
Manager, Document Imaging Group, Sharp Information Systems
Department, are acknowledged for their original development of the
Am J Health-Syst Pharm—Vol 65 Mar 15, 2008
at one of the larger institutions. The new
system was then implemented at the
remaining six hospitals over a period of
60 days. The transition from a paper-order
system to electronic communication via
a standardized pharmacy document
management application tailored to the
specific needs of this health system was
Conclusion. A health system with seven affiliated hospitals successfully implemented
electronic communication and the management of inpatient paper-chart orders
by using faxes and document-imaging
technology. This standardized application
eliminated the problems associated with
the hand delivery of paper orders, the use
of the pneumatic tube system, and the
printing of traditional faxes.
Index terms: Computers; Medication
orders; Pharmacy, institutional, hospital;
Am J Health-Syst Pharm. 2008; 65:570-3
Development of electronic
communication for medication
To improve order communication, we investigated electronic order
communication methods to replace
the traditional written orders. Sharp
concept and their significant work on the programming and documentation of the software.
Copyright © 2008, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/08/0302-0570$06.00.
DOI 10.2146/ajhp070461
Medication-Use technology Medication order communication
HealthCare uses automated dispensing cabinets supplied by Pyxis
(Cardinal Health, Dublin, OH), and
therefore we decided to evaluate
the company’s companion product,
Pyxis Connect. This product captures images of written orders via
dedicated scanning devices placed
at nursing stations. The images are
sent to a central database server.
Pharmacists retrieve the order images on dedicated computer screens
in the pharmacy and perform order
entry in the EMR. Orders are linked
to the patient’s file by capturing key
data fields such as patient name and
medical record number. Completed
orders are stored in the central database and can be retrieved for review
and analysis as needed.
In May 2005, the Sharp information systems (IS) department evaluated Connect. The IS technical review committee (TRC) worked with
the pharmacy department and the
vendor to gather Connect business
case and technical data. The TRC recommended not moving forward with
Connect, mainly because the vendor
required the use of scanning equipment that did not conform to Sharp’s
hardware standard; in addition, the
product’s operating system did not
meet Sharp’s software standard.
During this review process, an IS
analyst reported that Sharp already
held licenses for software that could
perform the same functions. Sharp’s
accounts payable department had
implemented a paperless system
for tracking payment invoices and
checks: RightFax (Captaris, Tuscon,
AZ) fax server software and OnBase
(Hyland Corporation, Cleveland,
OH) image management software.
RightFax captures and stores faxed
images. OnBase accepts RightFax
transmissions, converts them to digital images, and adds further value to
the images with the addition of data
fields that can be searched and reported. For medication orders, since
the original documents would be initially transmitted as faxes, we could
continue to use our existing fax machines without the need to allocate
document scanners. The IS analyst
suggested that we consider customizing and using RightFax and OnBase
for electronic order communication,
retrieval, reporting, and storage.
Since using RightFax alone did
not involve any special customization or programming, one hospital
initiated a trial using RightFax to
communicate written orders. The
staff reported success with the process of receiving and viewing orders
via fax images, but the following
problems were identified with the
1. The pharmacist had to manually index
the order image by typing patients’ account numbers and usernames into
the two available comment fields.
2. The order status (routine or stat) and
sending nursing station had to be
overwritten by the account number
and username and were subsequently
lost because only two data (comment)
fields were available to store order
3. The software performed an automatic, periodic refresh, which slowed
order processing.
4. The archive process for completed
orders was cumbersome and slow.
Shortly after the TRC’s review of
Connect was completed, we decided
to move ahead with the IS’ recommendation of using RightFax and
OnBase for our medication order
communication. During a systemwide, interdisciplinary, informatics
working-group meeting, nursing and
pharmacy representatives agreed that
a single, reliable method centered on
OnBase would provide more efficient
order communication. Pharmacy
and IS convened a systemwide task
force consisting of pharmacy operations managers, pharmacy database
managers, and IS analysts to discuss
the workflow for processing order
images and identifying the design
specifications for Sharp’s customized
version of OnBase. Software development started in September 2005 and
the product was ready for testing in
October. The final product consisted
of two custom OnBase screens—
one for document processing, called
Workflow, and the other for queries
and retrievals, called Document Retrieval. Over the next two months,
dual screens were added to all pharmacy terminals, software revisions
and final testing were accomplished,
a user’s manual was created, staff
training sessions were held for the
first hospital slated to convert to
OnBase, and a “go-live” target date
was set.
Each pharmacy staff member attended a two-hour training course
that covered the contents of the user
manual and allowed time for practicing with the Workflow and Document
Retrieval screens. The topics covered
included definitions, descriptions,
and the functionality of all standard
and custom icons; workflow; queries;
retrieval; and troubleshooting.
After consulting with the systemwide nursing education specialists,
pharmacy managers agreed to be
mainly responsible for educating the
nursing staff by means of posters,
e-mails, and visits to all nursing stations on the conversion day. Nursing
managers also helped educate their
staff by discussing the change during
the preconversion period and nursing staff meetings.
The OnBase system went live at
the first hospital in early December
2005 and the software was tested
there for 30 days. Starting the first
week of January in 2006, we began a
60-day rollout of the software to the
remaining hospitals. By early March,
all sites were using OnBase to process
paper-order images.
Program description
Fax machines at nursing stations
are programmed with two speed-dial
buttons—one for stat orders and one
for routine orders. When a nurse
faxes an order to the pharmacy, the
Am J Health-Syst Pharm—Vol 65 Mar 15, 2008
Medication-Use technology Medication order communication
order is converted to a digital image and stored in the corresponding
OnBase Workflow queues rather than
printing on the pharmacy’s fax machine. Nurses have been instructed
to send each patient’s order(s) in a
separate fax event to minimize the
need for the pharmacy to split document pages. Nurses are also provided
with rubber stamps and have been
instructed to stamp “faxed to pharmacy” just below the end of the faxed
written order. The rubber stamp
process is used to bookmark the end
of the last order segment used on the
page faxed to the pharmacy.
Pharmacy computer terminals
are set up with dual screens. The
normal procedure is to open the
EMR on one screen and the Workflow on the other screen. The pharmacist or technician opens the desired Workflow queue corresponding
to a pharmacy location with its
associated nursing stations and then
opens a document to be processed
within that queue. Attention is paid
to the thumbnails in cases where the
fax contains multiple pages that may
need to be separated.
Next, the appropriate patient file
is activated within the EMR and the
pharmacist or technician enters the
medication order(s) in the EMR.
During the order entry process, the
pharmacist or technician can use
standard computer functionality to
zoom in, zoom out, and rotate the
order image. Annotations may also
be added to the document using
these features:
1. Virtual highlighter: Calls out sections
of the document.
2. Arrow: Points to particular orders or
text sections.
3. Addendum to text: Draws a box in
which a note can be inserted.
4. Ellipse: Draws a circle around an order or text.
5. Sticky note: Allows the pharmacist
or technician to type a message and
minimize it, indicated by a sticky note
icon displayed on the document.
When order entry in the EMR
has been accomplished, the document is linked to the patient’s profile
and electronically filed. The linking
process is accomplished by simply
double-clicking (left mouse key) on
the patient’s demographic banner at
the top of the EMR screen. The folder
structure and icons, custom built into
the software by IS, represent various
filing actions that can be achieved by
clicking on an icon:
1. Complete icon: The Complete dialogue box opens and the pharmacist
double-clicks on the EMR patient demographic banner. Patient information keyword fields are automatically
populated in the Workflow dialogue
box, and the pharmacist then clicks
the Index button to file the document
in the Complete folder.
2. Incomplete icon: The Incomplete
dialogue box asks the reason for the
incomplete designation. Linking
the document to a patient file is optional, since the incomplete reason
may be an illegible fax. Incomplete
reason codes are MD Clarification,
Allergy Pending, Drug on Order, Drug
Unavailable, Order Illegible, Pending
Lab (laboratory test result), Second
Signature, and Other. When Other
is chosen as a reason, a text note
window opens for the pharmacist
or technician to provide the reason
for the incomplete order. The document is then routed to the Incomplete
folder or to the Second Signature
folder. Completed documents can
be reworked by marking the document as incomplete. The document
is opened in the Complete folder and
the pharmacist clicks the Incomplete
icon. Again, the reason for an incomplete designation must be selected
before filing the document.
3. Change Status icon: If the incorrect
status button was pressed during the
fax transmission, the pharmacist can
reverse the status—stat to routine or
vice versa.
4. Trash icon: Documents are trashed
as needed in cases of duplicates or
Am J Health-Syst Pharm—Vol 65 Mar 15, 2008
junk faxes. Trashed documents can
be returned to the nursing care area
processing queue by using the Return
to Queue icon with the Trash folder
open. Only pharmacy managers can
permanently clear trashed documents
by clicking the Empty Trash icon.
5. Preprocess icon: Pharmacy technicians
use OnBase to view orders and to
enter those orders in the EMR. Technician order entry creates unverified
orders in the EMR. The pharmacist
verifies the order in the EMR and
then completes the document in the
Workflow dialogue box.
6. Split icon: When the nursing staff has
faxed multiple patients’ orders in one
fax event, the pharmacist or technician highlights the entire multipage
document and then saves each patient’s orders in a separate, new document. The newly created documents
retain the original document’s status,
location, and date–time data.
Completed documents remain
in the Complete folder for 24 hours,
after which they are filed in the archives. Pharmacy staff can retrieve
documents from the archives as
needed via the Document Retrieval
screen. Document searches can be
screened by a date and time range
and by any of the keyword data fields
such as patient name, visit number,
medical record number, nursing station, and pharmacist.
Experience with the program
The implementation of RightFax
and OnBase went according to the
project plan without any delays. The
only technical issue encountered was
a problem with the indexing of the
patient’s profile to the document in
certain situations; this problem was
corrected within the first few weeks
of our “go-live” date. Reference documents, including a user’s manual
and frequently asked questions, were
posted on Sharp’s intranet and
have been updated as needed. We
did not conduct any formal surveys,
but the system seems to have been
Medication-Use technology Medication order communication
well accepted by pharmacy and
nursing departments based on both
solicited and unsolicited responses
provided by the staff to management
Even though the new technology introduced two new issues
(a change in a document’s stat or
routine status and the need for
document splitting), an overall
improvement was realized with the
move to a standard, more reliable
method of communicating orders.
With the move to electronically
transmitted document images, we
were able to discontinue the handdelivery method and the use of
the pneumatic tube system and
printed faxes, thereby eliminating
the problems associated with these
After the successful completion
of this project, we began to consider
other ways to use these new tools to
further reduce the amount of paper
handling and to gain more usefulness
from the data through better reporting. Three major enhancements were
added during the year after the system’s implementation.
First, to provide managers and
other personnel snapshot views of
order turnaround time (TAT) and
workload (WL), two intranet-based
reports were created on the pharmacy website. The reports, which ac-
cess the OnBase archives and use an
identical interface, can be searched
by date, time, and queue. Results
from either report can be exported
to a spreadsheet by clicking on an
Export button. The TAT report shows
the time elapsed from the point at
which the document is received into
the Workflow queue to the time the
document is completed. Separate
TAT numbers are calculated for stat
and routine documents. In the detailed view of the TAT report, stat
and routine TATs are shown for each
queue (for each real or virtual pharmacy location) and for each nursing
station associated with a given queue.
The WL report shows the number
of documents received per hour, per
queue, and per nursing station (on
the detailed view).
The second enhancement added
was the electronic storage of active
medication profiles for use during
EMR downtime. At 0700 and 2300
every day, an active medication
profile is automatically created and
electronically transferred from the
EMR to OnBase. The previous day’s
profiles are automatically deleted 24
hours after their creation. During
EMR downtimes, pharmacy staff can
use the Document Retrieval screen to
access and search the latest backup
copy of a patient’s active medication
The use of OnBase to receive faxed
statements from our drug wholesaler
was the third enhancement. Buyers
use the Document Retrieval screen
to display the most recent statement. After comparing and verifying
daily delivery invoices against the
semimonthly statement, the buyer
marks the document as approved. An
authorized pharmacy manager issues
the final approval, and the approved
statement is transferred to the OnBase
queue used by the accounts payable
department for final processing.
A health system with seven affiliated hospitals successfully implemented electronic communication
and the management of inpatient
paper-chart orders by using faxes and
document-imaging technology. This
standardized application eliminated
the problems associated with the
hand delivery of paper orders, the use
of the pneumatic tube system, and
the printing of traditional faxes.
1. Cronk JD. Digital scanning and consolidated entry of medication orders in a multihospital health system. Am J Health-Syst
Pharm. 2002; 59:731-3.
2. Carswell JL, DiPiro CV, Gomez TA et
al. Evaluation of turnaround time for
medication order processing with use of a
novel scanning system. Hosp Pharm. 2006;
Am J Health-Syst Pharm—Vol 65 Mar 15, 2008