I’VE BEEN THINKING ABOUT BALLPOINT PENS, FAX machines, moms, and MOMS, as in medication order management systems. It is interesting to observe how technology can both aid and inhibit the process of medication orders making their way—intact—from the physician to the pharmacy.

For their first 200 years, physicians in America’s hospitals wrote orders with styluses and fountain ink. Back then, penmanship was a core subject in our schools and a doctor’s orders were easy to read. The doctor my mom worked for when I was a kid used a Schaeffer fountain pen, while upstarts wrote orders with Parker TBall Jotters. Over the years, technology has advanced, and somewhere along the line, penmanship took a hike. Now, it seems that possessing indecipherable handwriting is a prerequisite for becoming a physician.

I imagine some people figured the typewriter could bring an end to illegibility, but understandably, doctors continued to prefer the portability of pen and paper. And even when ward clerks transcribed doctors’ orders via an Underwood or IBM Selectric, for an order to be filled, a piece of paper still had to be physically transported from the ward on the third floor to the pharmacy in the basement. Not all of them made it.

Along the way, the telephone offered hope: Just call the order in! However, Michael Cohen summarizes the professional wisdom on the matter in Medication Errors (the bible on the subject). He begins the section entitled Verbal Orders with, “Verbal (spoken) orders should be avoided whenever possible.” Suppose a doctor or nurse says “every four to eight hours” when calling in an order, but the person on the other end of the line hears and writes “every 48 hours.”
When the pneumatic tube system came along, handwritten orders were delivered to the pharmacy after flying through a labyrinth of pipe. As useful as these systems are, they have a way of doing with medication orders what dryers do with socks: Too many orders get lost or take detours.

Then came the fax machine. Faxes were so effectively sent from the ward to the pharmacy that, today, there is hardly a hospital in the country that does not utilize this technology. However, this approach has not been without its problems. As Michael Cohen writes, “Ideally, no faxed order to the pharmacy should be filled until the original copy has been received.” Why? Because noise on the transmission line and dust in the machines have a way of making those all-important decimals mysteriously disappear or, in other instances, appear in inappropriate places.

Another highly touted solution is the tablet PC, a device that uses handwriting, which makes doctors feel comfortable. Yet, for all of a tablet PC’s initial appeal, a doctor can get frustrated when the computer is unsure which handwritten word was meant, and subsequently offers several possibilities to choose from. After all, paper never argued with doctors’ pens.

There may be a bit of poetic justice in all this, however. When using a tablet PC, doctors would have to learn to write clearly enough that a human could read it. Hmm...

Today, many say the ultimate solution is computerized physician order entry (CPOE). However, CPOE has its own issues, not the least of which are the expense of implementing the systems and the difficulty of motivating doctors to use them. Doctors insist that the computerized entry process take no more time than it takes to scratch an order on a paper chart. “When I can speak my orders into a handheld,” my neighbor (a doctor) tells me, “I’ll be willing to make the switch.” That would be nice, but what about safety experts’ warnings against verbal orders? Will the computer do any better than humans in distinguishing “48” from “four to eight”?

Eventually, the barriers to CPOE will be overcome and the day will arrive when most physicians will enter orders directly into computers. However, for most hospitals, that day is probably five or more years away.

In the meantime, while paper rules, I encourage my clients to adopt another technology: medication order management systems, or MOMS. These systems solve a number of problems associated with getting handwritten orders from the physician’s hands to the pharmacy, intact, and I might add, they deliver a relatively quick ROI (18 months on average). In one example of the cost savings MOMS can provide, consider that scanners require only single sheets of paper. With MOMS, those expensive, fourpage NCR forms become a thing of the past.

How do MOMS work?
Each patient ward is outfitted with a scanner. Handwritten orders are fed into the scanning device, are converted into electronic images, such as PDFs, and are sent electronically by the MOMS to a system “inbox.” Pharmacists can access the system from any computer in the hospital, open and read the orders, and arrange them in a queue for filling, with STAT orders first. At any time, nurses can go online and see the status of an order to determine if it has been received and opened, where it is in the queue, and if it has been approved and filled.

High-resolution scanners eliminate most of the noise and dust problems plaguing fax machines, and pharmacists can enlarge PDFs for clarification and apply time-stamped notes to the documents. In addition to the ability to send illegible orders back to the prescribing source for clarification, pharmacy can archive and easily retrieve those orders for quality improvement purposes. All in all, MOMS promote greater and more efficient communication between clinicians and caregivers.
MOMS save everyone time and limit the number of phone calls, voice mails, and pages between pharmacists and nurses. Pharmacies are quieter and wards are calmer. Because each transaction is time-stamped and progress can be viewed by anyone at any point, the system helps resolve discrepancies over “lost” orders and “foot-dragging.” Everyone is held accountable, while argument and blame are reduced.

Pharmacists also no longer have to make the trek to the fax machine and rummage through a stack of papers. They can access order information and review orders from any computer in the hospital. If the system is browser-based, they can even do this from home or from a hospital across town, and because the system archives the order, papers don’t have to be filed.

The benefits are significant and immediate. I have yet to meet a MOMS user on the ward or in the basement who didn’t feel this type of system was a winner. Suppose I were a director of pharmacy, and the only piece of medication-use automation my hospital had was a pharmacy information system. What would be the next component I would add? A MOMS. This even makes sense to my long-retired, technology-averse mother.

Mark Neuenschwander is president of the Neuenschwander Company and a recognized expert in medication-use automation. He can be reached at mark@hospitalrx.com.