David Morrison Project One for Nursing Informatics 7/24/09

 Quadramed Corp’s POCMAR (Point of Care Medication Administration Record) is used for electronic recording of medication administration where I work, at Central State Hospital (CSH). There is no version number. It is typically used with Quadramed’s CPOE (computerized physician order entry) system. The physician (or ARNP) uses the CPOE to order medications, the nurse uses the system for information about medications and for recording their administration of those medications.

 Quadramed is a dedicated healthcare informatics company, providing information technology (IT) to hospitals.  It is number 30 on “Healthcare Informatics” list of top HCI companies (see bibliography at end), which states that it had 610 employees in  Yahoo Finance (Yahoo’s investor page) states that it has a market capitalization of million $. Yahoo also lists its ‘target stock price’ to go from 6.53 to in one year.  The Washington Post stated (contradictively) that it had 763 employees in 2007, and placed it on its “Top 200 D.C Area Businesses” in The Post also states it has revenues of 137 M$ and a net income of 63 M$ (meaning its profit margin is 38% - very high). The Post also lists its total assets at 172 M$, while its stockholder equity is 108 M$, suggesting that its stock are significantly undervalued.  While there is some contradiction in these data, the overall picture from analysts’ data and some of Quadramed’s recent acquired contracts - is one of a dedicated healthcare informatics company with a stable (and perhaps expanding) future.

 Hardware: POCMAR runs on standard desktop computers, requiring a LAN (local area network) for the computers to exchange information. There are no specific upgrade options available to the POCMAR, but Quadramed does offer an array of other healthcare software in care management, health information management and revenue management.

 User’s passwords expire periodically, the system locks out after a number of bad login attempts, and the POCMAR also locks out after being inactive – all of these settings are defined by system administrators. At CSH, RN’s, LPN’s, administrators and IT professionals are the only staff with passwords to the system.  POCMAR is not a web-based system, so it is only accessible by using the dedicated, on-site software – this eliminates many issues in securing network information discussed by McGonigle & Mastrian (2009, p.185).  CSH’s policies and procedures also stipulate appropriate use of the POCMAR system, including (in accordance with HIPAA guidelines) maintaining information on-site and limiting access to role-relevant functions.

 McGonigle & Mastrian (2009, p ) also mention other potential security threats, gaps and potential breaches that are relevant to the POCMAR – as they are with most EHR’s:  ‘Shoulder surfing’: the system is often used at the nursing station, which is specifically designed to be at a central location to promote ease of monitoring the unit and connection between patients and nursing staff.  The system does not incorporate ID badge scanners or biometrics devices, allowing potential for compromised user passwords.  Using the Window’s operating system, it is possible to copy any information on a computer screen using the ‘print screen’ feature and save that information either to a flash drive (their use is not blocked at CSH) or save it to a PDF file and it, using web-based (employees have internet access at CSH).  Since licensed staff can float to any unit, staff are able to review medication administration for patients on other units, using the ‘change unit’ feature. Staff are ultimately responsible for securing patient information.

 POCMAR system is intuitive and user-friendly. I was never formally trained to use the system. I have IT staff and HR staff available to help me, and could have used my initial preceptor at CSH for help, but have never needed to do so. There is also a help program, which is very straightforward (I never used this before preparing this presentation).  The system requires very basic computer literacy, such as using a mouse, and comfort with a keyboard.

 As mentioned previously, the system is designed to provide electronic information about what medications (routine and PRN) a patient has been prescribed, and to allow nurses to document their administration of medications.  The system is updated constantly, one example would be in the administration of NOW orders for management of the violent and escalating patient.  In this case, the nurse pages the OD (on-call doctor), informs them of the behavior, discusses previous patient-specific guidelines for management of violent behavior (GIV - Guidelines For Violence), receives the NOW order via the POCMAR, administers a PO or IM medication, and documents the intervention with both the POCMAR and paper charting. Including medication, route, site (for IM), and follow up (effectiveness).  As an experienced user of the system, I can say that the POCMAR does meet expectations both of myself and other users of the system (other nurses I have talked to about the system at CSH).

 The POCMAR is a specific software application (it is not a web-based program or interface). Facilitating greater security (as mentioned); there is less potential for ‘hacking’ into the system and, unlike the web-based programs at CSH, most users cannot access the system at home.  It does need to work with Quadramed’s CPOE (computerized physician order-entry) system. As mentioned, prescriber’s enter medications using the (related) CPOE program and nurses obtain information and document, using the POCMAR.

 The system appears to be designed by and for nursing staff; the use of the system is an integral part of my duties as a CSH nurse.  It is not for use by other clinicians.  I do not know if nurses were integral to the design, but the ease of use implies that they were. I called QUADRAMED 3 times, and left messages, to ask follow-up information about how the system was designed, and never received a follow-up call. I had clearly identified myself as an NP student writing a research proposal.  Also, interestingly, when I attempted to use the ‘sales’ option via the directory I also got only a voice message prompt (that was also not returned).

 In describing clinical decision support (CDS) characteristics, McGonigle & Mastrian (2009, p.140) state: CDS are tools that "provide(s) clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care". They give the examples of alerts and reminders, clinical guidelines, information retrieval, and online access to organization policies and procedures.  CDS should have both standardized features (e.g. dosing time alerts) necessary for every patient, as well as providing a flexible platform for individualized care and comments. It should also link to sources for further drug information, and research tools.

Alerts and Reminders: - POCMAR has a ‘future scheduled doses’ tab, routinely used by nurses at the beginning of the shift, to avoid omitted doses. - POCMAR has a flag that comes up when I hit a dose that is not yet ready to be administered. Standard Features: -Congruent with the 6 rights of medication administration, POCMAR has a picture for every patient. - Allergy information on every patient. Flexible Platform: -POCMAR also has room for additional patient-specific information such as protocols for insulin administration, or for the administration of detox medications such as Ativan or Librium.

 One critique I do have of the system is that the medication information provided is not internet based to allow for frequent updates, and does not have pharmacologic class information.  Fetter (2009) has identified the need for improving IT competency among mental health nurses, in particular in the use of EHR’s, and in promoting evidence-based practice.  We recently had a patient who was sent to UL and diagnosed with ‘cholinergic storm’. It would have been nice to have had pharmacologic class information listed, and to have additional sources of information about medications available.  Web-based information could be non-patient specific, to maintain the additional security that an stand-alone application provides.  There is no specific alert for medications that are in a class contraindicated by the allergy information entered. There are no specific alerts for medication interactions, contraindicated with the other medications prescribed.

 At CSH, we do not currently use the POCMAR to have patient-specific information such as guidelines for violence (GIV) information – as to what medications we should give to a particular patient, if they begin to escalate aggressively. I believe the system is flexible enough to accommodate this, but I am referring here both to the specific program, and its use as part of an ‘information system’.  At CSH we are currently ‘double-charting’: entering medication administration information in both the POCMAR and in the patients (paper-based) charting. We could improve the system by moving to exclusively EHR’s, supplementing the POCMAR system with another more general system for documenting pertinent patient information, such as general progress behavioral responses to treatment.

Within its limitations as a system specific medication administration, the POCMAR system is an intuitive, flexible, easy to use program, made by a financially stable (if hard to reach on the phone) company, whose focus is specific to healthcare informatics.

 Fetter, M.S. (2009). Improving Information Technology Competencies: Implications for Psychiatric Mental Health Nursing. Issues in Mental Health Nursing, 30:3–13,  Healthcare Informatics ‘HCI 100 List’ (2009). Healthcare Informatics, 26(6):20-56, Retrieved July 20, 2009 from informatics.com/ME2/dirsect.asp?sid=C6AF5F270EBF4809A9E AEA97F&nm=T he+HCI+100http:// informatics.com/ME2/dirsect.asp?sid=C6AF5F270EBF4809A9E AEA97F&nm=T he+HCI+100  McGonigle, D., & K. Mastrian (2009). Nursing informatics and the foundation of knowledge. Sudbury, MA: Jones and Bartlett Publishers.  Post 200 top D.C. Area Businesses (2009). Retrieved July 20, 2009 from:  Quadramed’s Homepage (n.d.). Retrieved July 18, 2009 from  Yahoo Finance’s Quadramed Corp. (QDHC) page (2009). Retrieved July 24, 2009 from: