Marrying Epic Ambulatory and Inpatient: a Pharmacist’s Perspective

Ambulatory and Inpatient care have historically been two different worlds with two very different mindsets. At times, they might as well be speaking two different languages. Bringing the two together during an Epic implementation is an absolute must for improving overall efficiency as well as patient safety. Both sides have legitimate concerns and needs.

With the right ingredients integrating Epic Ambulatory with Inpatient doesn't have to be a hard pill to swallow.

The Problem

With Epic in place, Ambulatory and Inpatient now share System Definition (global settings) and ERX Master File. Inpatient typically owns about 80% of this master file, but as Epic continues to expand, more and more fields from the Master File are shared. In order to implement Ambulatory Medications (Discrete Sig and Discrete Dispense), a pharmacist familiar with both inpatient and retail pharmacy practices is needed. Adding to the complexity are modules and ancillaries such as OpTime, Anesthesia, Beacon Oncology med build, and Willow Ambulatory. Conflicts appear when the common practices and requirements for each side are analyzed:

Inpatient:

• Have a set medication formulary.
• Physicians rarely need or want access to the database. Rather, they work from the set formulary of the hospital.
• Three clinical professionals (physician, pharmacist, nurse) are required to order, dispense and administer medications. They can easily communicate the medical terminologies and understand each other’ language.
• Inpatient pharmacists are not usually required to deal with third party insurances, days of supply, or dispense units.

Ambulatory:

• Physicians must have access to the database.
• Only two clinical professionals order and dispense (physician, pharmacist) medications. Patients generally self-administer medications, and therefore language must be less clinical and more patient-friendly.
• Retail pharmacists and clinics constantly deal with ever changing insurance policies, days of supply, and dispense units.
• Ambulatory will be using Facility Administered Medication (FAM) and Medication Administration Record (MAR); fields normally used only for inpatient functions.

Other Concerns:

Hospitals are acquiring more clinics through Community Connect. Different specialties will have particular medication requirements. So, keeping the new physicians happy with the changes is an ongoing challenge. Many physicians for example, order liquid medications by the teaspoon. For liability, it is safer to order in milliliters. Determining whether inpatient or the clinic will accept a change is no easy task.

The Solution

Accommodating the simultaneous needs of retail and inpatient pharmacies sharing a master file undoubtedly requires a little finesse. Some things you should consider:

• Find a pharmacist experienced with implementing Epic in both ambulatory and inpatient areas. This will allow for a competent liaison between the two departments.
• Create Preference Lists that will designate only key ambulatory physicians for database use. This will require some regular grooming, but having a well maintained list will prevent physicians from having to access the database directly.
• Interviewing physicians at the clinics to gather information for defaults is a must.
• Place a high emphasis on training and communication. No matter how great a build is, if communication between departments fails, embracing change will become difficult.

Wrapping Up

Combining Epic Ambulatory with Inpatient doesn’t have to be the nightmare that it at first appears. It does, however, take a good deal of planning and preparation to make sure things go well. Having someone with Epic clinical implementation experience can keep the lines of communication open between hospitals and clinics and is the key to smoothing transitions and ensuring everyone’s needs are addressed; all the while improving operational efficiency and patient safety.