Section 1.5: Overview of the Medication-Use Process and Technology Touchpoints

1.5.1 The “Why”: A Unified Field Theory for Pharmacy Informatics

In the preceding sections, we have defined informatics, explored the DIKW pyramid, examined professional roles, and surveyed the regulatory landscape. We have assembled the individual components of your new professional world. Now, we must assemble them into a single, coherent, and practical framework. We need a “unified field theory” that connects every system, every technology, and every user action to a single, overarching process. That framework is the Medication-Use Process (MUP).

The MUP is a conceptual model, generally attributed to the work of the ASHP and ISMP, that breaks down the entire lifecycle of a medication within a health system into five distinct stages: Prescribing, Transcribing/Verification, Dispensing, Administering, and Monitoring. For an informatics pharmacist, this five-stage model is not just a useful concept; it is the fundamental schematic upon which your entire career will be built. It is the most critical mental model you will use to analyze a problem, design a workflow, or implement a new technology.

Why is it so important? Because medication errors do not occur in a vacuum. They are almost always the result of a breakdown at one or more stages of this process. A well-designed health IT ecosystem uses technology as a series of safety nets and efficiency-enhancers at each of these five stages. Your job as an informatics pharmacist is to be the expert architect of these technology-enabled stages. You must understand the unique risks, workflows, and goals of each phase and know which technological tools are best suited to support them. This section will provide a deep, exhaustive dive into each stage of the MUP, creating a detailed map that connects specific technologies to their precise place in the medication lifecycle.

1.5.2 A Visual Schematic of the MUP

Before we begin our deep dive into each stage, it is useful to have a high-level visual map of the process. The diagram below illustrates the five stages of the Medication-Use Process in a cyclical fashion, highlighting the key technologies that are dominant in each phase. Notice that the process does not truly end; the “Monitoring” stage provides critical feedback that informs the next “Prescribing” decision, creating a continuous loop of care.

1 Prescribing: The Genesis of the Medication Order

The prescribing stage is the genesis of the entire medication-use process. It encompasses the clinician’s decision to use a medication, the selection of the specific drug, dose, route, and frequency, and the formal documentation of that decision as a medical order. Historically, this was the stage most fraught with error, due to illegible handwriting, ambiguous abbreviations, and a lack of readily available information at the point of decision-making. Modern health IT has transformed this stage from the weakest link to one of the most technologically fortified.

Technology Touchpoints in Prescribing:

• Computerized Provider Order Entry (CPOE): This is the foundational technology of the prescribing stage. CPOE is the process of providers entering and sending treatment orders—including medications, labs, and imaging—electronically rather than on paper. This single innovation eliminates handwriting-related errors and provides the platform for all other advanced safety features.
• Clinical Decision Support (CDS): As we discussed in Section 1.2, CDS is the “brain” that works on top of CPOE. As a provider enters an order, the CDS engine is working in real-time to provide checks for allergies, drug interactions, appropriate dose ranges, therapeutic duplications, and other patient-specific guidance.
• e-Prescribing: The technology that enables the secure electronic transmission of a prescription from the CPOE system directly to a patient’s outpatient pharmacy. This eliminates the need for paper prescriptions, faxes, or phone calls, dramatically improving efficiency and safety.
• Formulary and Payer Integration: The EHR can be configured to display the patient’s insurance formulary status for a selected drug directly to the prescriber, helping them choose a preferred, lower-cost agent from the outset.
• Prescription Drug Monitoring Program (PDMP) Integration: Many EHRs now have the ability to connect directly to the state’s PDMP database, allowing a prescriber to see a patient’s full controlled substance history with a single click before issuing a new prescription.

The Pharmacist Informaticist’s Role:

Your role in the prescribing stage is to be the architect of a safe and efficient ordering experience. You will be responsible for building and maintaining the very tools that prescribers interact with every day. This includes building the medication records in the CPOE system, designing and tuning the CDS alerts, and constructing the evidence-based order sets that guide care. You are the pharmacist who ensures that when a physician orders “Lisinopril,” they are guided to the correct dose, warned about the potential for hyperkalemia, and informed if it’s not on the patient’s insurance formulary.

Masterclass Table: Common Prescribing Errors and Informatics Solutions

2 Transcribing & Verifying: The Pharmacist’s Clinical Review

The second stage of the MUP is the critical checkpoint where a pharmacist applies their clinical expertise to evaluate the appropriateness of a prescribed order. In the pre-CPOE era, this stage involved “transcribing”—the manual act of reading a paper order and entering it into the pharmacy computer system. While CPOE has largely eliminated the manual transcription step, the cognitive work of verification is more important than ever. This is the pharmacist’s opportunity to review the order in the context of the patient’s full clinical picture and to serve as the ultimate clinical safety net before the medication is dispensed.

Technology Touchpoints in Verification:

• Pharmacist Verification Queue: This is the pharmacist’s primary worklist in the EHR. It is a real-time, prioritized list of all new medication orders that require review. The system can be configured to route different types of orders to different queues (e.g., chemotherapy to the oncology queue, pediatric orders to the peds queue).
• Integrated Clinical Data Views: A well-designed EHR presents the pharmacist with all the necessary information to make a clinical judgment on a single screen. This includes the medication order itself, the patient’s allergies, height, weight, lab results (especially renal and hepatic function), problem list, and other active medications.
• Pharmacist-Facing CDS: While many alerts fire for the prescriber, another layer of CDS can be designed specifically for the pharmacist. These might be “informational” alerts that the prescriber doesn’t need to see but are relevant to the pharmacist’s review (e.g., “Patient is due for a vancomycin trough level”).
• Intervention Documentation Tools: When a pharmacist identifies an issue and makes a recommendation that changes the order, it is critical to document this clinical intervention. Informatics teams build structured documentation tools that allow pharmacists to capture this data in a reportable format, which is essential for demonstrating the value of pharmacy services.

The Pharmacist Informaticist’s Role:

Your role in this stage is to design an efficient, safe, and information-rich verification experience for your staff pharmacist colleagues. You want to minimize clicks and screen jumps while maximizing the visibility of relevant clinical data. You will work on configuring the verification queues, designing the layout of the clinical data views, and building the structured tools for intervention documentation. Your goal is to create a digital environment that allows the verifying pharmacist to perform their cognitive work with the least possible friction.

3 Dispensing: Preparing and Distributing the Medication

Once an order has been verified by a pharmacist, the dispensing stage begins. This phase involves the physical preparation and distribution of the medication from the pharmacy to the patient care area. This is a process that is heavily reliant on logistics, inventory management, and, increasingly, sophisticated automation and robotics. The primary goals of technology in this stage are to improve accuracy (ensuring the right drug is selected) and efficiency (reducing the manual labor required for picking, packaging, and delivering medications).

Technology Touchpoints in Dispensing:

• Automated Dispensing Cabinets (ADCs): These are the secure drug storage devices located on nursing units (e.g., Pyxis, Omnicell). Verified orders are electronically “profiled” to the ADC, allowing a nurse to select the patient and see only the medications that are due for them. This is the single most important technology for decentralized dispensing.
• Central Pharmacy Robotics: For high-volume oral solid medications, many hospitals use robots that can receive an electronic order, pick the correct medication, package it into a unit-dose packet, label it with a barcode, and dispense it, all with no human touch.
• Medication Carousels: These are rotating shelves that spin to present the correct medication bin to a technician, who then picks the item. The process is barcode-verified to ensure accuracy.
• IV Workflow Management Systems: These systems provide a digital workflow for the sterile compounding process. The technician is guided by on-screen instructions and must scan the barcode on each ingredient (e.g., the drug vial, the diluent bag) to ensure the correct components are used. Many systems also use gravimetrics (weighing the final product) or digital photography to further validate the preparation.

The Pharmacist Informaticist’s Role:

As we discussed in Section 1.3, the Automation & Technology Specialist is the archetype who owns this stage. Your job is to be the master of the interface between the EHR and the various dispensing technologies. You are responsible for managing the drug databases in these systems, ensuring they are synchronized with the EHR formulary, optimizing their configuration (e.g., PAR levels in ADCs), and troubleshooting the complex hardware and software issues that can arise. You are the engineer who keeps the logistical engine of the pharmacy running smoothly and accurately.

4 Administering: The Final Check at the Bedside

The administration stage is the final and most critical checkpoint in the MUP. This is where the medication actually reaches the patient. The historical “Five Rights” of medication administration (Right Patient, Right Drug, Right Dose, Right Route, Right Time) are all validated at this stage. This phase, traditionally performed by nurses, was once a major source of error. The introduction of bedside technology has revolutionized this process, creating a powerful, closed-loop system that verifies each of the five rights electronically.

Technology Touchpoints in Administration:

• Barcode Medication Administration (BCMA): This is the cornerstone technology of administration safety. The nurse uses a handheld scanner to scan a barcode on their own ID badge, a barcode on the patient’s wristband, and a barcode on the unit-dose medication package. The BCMA system compares these three scans to the active medication order in the EHR. If any of the “Five Rights” do not match, the system generates a real-time error message, preventing the administration. This creates a “closed-loop” medication process.
• Electronic Medication Administration Record (eMAR): The eMAR is the nurse’s digital record of all medications administered to a patient. The moment a medication is successfully administered via BCMA, the eMAR is automatically and instantly updated with the exact time of administration. This eliminates manual charting and provides a real-time, accurate record of what the patient has received.
• Smart Infusion Pumps with Interoperability: Modern IV “smart” pumps can be wirelessly integrated with the EHR and BCMA system. When a nurse scans an IV medication, the validated order details (drug, concentration, rate) are sent directly from the EHR to the pump, pre-programming it. This eliminates the need for manual programming, a major source of dangerous infusion errors.

The Pharmacist Informaticist’s Role:

Your role in this stage is to ensure the integrity of the data that drives the BCMA and smart pump systems. You are responsible for making sure that every single medication record you build in the EHR has the correct barcode information associated with it. A single error in linking an NDC to a medication record can bring the entire BCMA process for that drug to a halt. You are also the primary owner of the smart pump drug library, building the dose error reduction software (DERS) with its upper and lower safety limits that provides the “smarts” for the pump.

5 Monitoring: Closing the Loop

The final stage of the MUP is monitoring. Once a medication has been administered, its effects—both therapeutic and adverse—must be assessed. This stage is about evaluating the outcome of the medication therapy and feeding that information back into the clinical decision-making process. Technology in this stage is focused on aggregating patient data to identify trends, detecting potential adverse events, and providing clinicians with the insights needed to make informed decisions about continuing, discontinuing, or adjusting therapy.

Technology Touchpoints in Monitoring:

• Clinical Surveillance and Analytics Platforms: These are powerful software tools (sometimes integrated into the EHR, sometimes third-party) that continuously scan vast amounts of patient data (labs, vitals, medications) in near real-time. They use sophisticated rules and algorithms to identify patients who may be at risk for a specific condition or an adverse drug event.
• Adverse Drug Reaction (ADR) Reporting Tools: These are structured documentation tools within the EHR that allow any clinician to report a suspected ADR. This captures the event as structured data, which can then be aggregated and analyzed by the pharmacy department or a P&T committee.
• Data Warehousing and Business Intelligence (BI) Tools: These systems extract massive amounts of data from the EHR and other systems and store it in a specialized database called a data warehouse. BI tools (like Tableau, Qlik, or Power BI) are then used to query this data and create dashboards and reports for monitoring long-term trends, such as adherence to clinical guidelines or antimicrobial usage patterns.

The Pharmacist Informaticist’s Role:

The Analytics Pharmacist is the key player in this stage. Your role is to be the expert at extracting, analyzing, and interpreting the data generated by the MUP. You will build the rules in the clinical surveillance platform to alert pharmacists to patients with acute kidney injury on nephrotoxic medications. You will design the dashboards that track anticoagulant use and associated bleeding events. You will write the reports that show which antibiotics are being overutilized. Your work in this stage is what turns the massive volume of data generated by the EHR into the actionable knowledge and wisdom that drives quality improvement and demonstrates the value of the pharmacy enterprise.

1.5.3 Conclusion: The MUP as Your Lifelong Mental Model

This deep dive into the five stages of the Medication-Use Process concludes our foundational module. The MUP is more than just a chapter in a textbook; it is the fundamental, enduring framework for your entire informatics practice. Every project you will ever work on, every problem you will ever be asked to solve, every system you will ever build or manage will fit somewhere into this five-part structure.

When a new medication safety issue arises, your first step will be to ask: “Where in the MUP is this failure occurring?” When you are asked to evaluate a new piece of technology, you will ask: “Which stage of the MUP is this designed to improve, and how does it integrate with the other stages?” When you are designing a new workflow, you will walk through all five stages to ensure there are no gaps or unintended consequences.

You have now been equipped with the essential vocabulary, the core conceptual models like DIKW and the MUP, an understanding of the professional roles, and the context of the regulatory environment. You have laid the foundation. In the modules that follow, we will begin to build upon this foundation, taking each of these concepts and exploring them in far greater, more practical detail. You have completed your orientation; it is now time to begin your specialized training as a Certified Pharmacy Informatics Analyst.