Citizens Memorial Healthcare (CMH) is a rural healthcare network located in Southwest Missouri. The network includes a 74-bed rural hospital, five long-term care facilities, 16 physician clinics and a home care agency. All patient care services are connected into one electronic medical record (EMR). Network physicians enter their own orders for procedures and medications, eliminating paper medical records. The initiative, known as Project Infocare, serves 1,600 users.

The following lessons learned at UHN ring true for us as well.

If possible choose a single-system approach to on-line medication management; avoid the need for complex interfaces and systems integration. Fortunately, we were creating all new systems when we implemented computerized physician order entry and the electronic MAR at CMH. Because we chose an integrated strategy, we did not face the daunting task of interfacing systems as complex as those required by nurses, physicians and pharmacists to order, dispense and administer medications.

Small to mid-sized hospitals should consider analyzing all representative and key workflows up front so that a complete end-state system can be built from the start. We also experienced a need to "rebuild" the pharmacy and provider order entry tables so that the system was win-win for both the pharmacists (who tend to see medications as inventory items) and physicians (who tend to see medications in doses). Our system provides the capability to bridge the two viewpoints, but forethought, planning and communication are required to make it a reality.

Solicit input, review and approval from all three clinical disciplines when building custom medication orders sets; expect standards for medication orders and medication procedures to evolve over the course of the project. Like UHN, we built our own ordering conventions for medications. Building these "order strings," as we identified them, from the historical medication orders throughout our network proved useful. Vendors now have pre-set ordering conventions for purchase that will simplify this process for facilities in the future.

When implementing clinical decision support alerts, start with only the most important ones and then add more over time as clinician comfort level increases. We also implemented clinical alerts originally in an "overly safe" mode. We quickly realized that we were inducing "alert fatigue," as it is now called in the industry. Like UHN, we backed off the severe alerting status. In the future, I see clinical alerting becoming more sophisticated. For one thing, we will become better at identifying specific allergies. Currently, if our nurses enter an allergy to a combination drug that includes acetaminophen, the physician is flagged to the acetaminophen allergy - even though the allergy may have been to the other medication in the combination drug. Training in allergy specificity will help with this problem. Third-party vendors will also improve over time in their ability to alert appropriately.

Our congratulations to UHN on their successful implementation of a complex system across so many care units!

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