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David Morrison
Project One for
Nursing Informatics 7/24/09
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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.
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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 2007.
Yahoo Finance (Yahoo’s investor page) states that it has a market
capitalization of 54.17 million $. Yahoo also lists its ‘target stock price’ to
go from 6.53 to 11.00 in one year.
The Washington Post stated (contradictively) that it had 763 employees in
2007, and placed it on its “Top 200 D.C Area Businesses” in 2009. The
Post also states it has revenues of 137 M$ 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.
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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.
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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.
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McGonigle & Mastrian (2009, p. 185-189) 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 email it, using web-based email (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.
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Staff are ultimately responsible for securing patient information.
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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.
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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).
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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 email 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.
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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).
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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.
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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.
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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.
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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.
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Fetter, M.S. (2009). Improving Information Technology Competencies: Implications for
Psychiatric Mental Health Nursing. Issues in Mental Health Nursing, 30:3–13, 2009.
Healthcare Informatics ‘HCI 100 List’ (2009). Healthcare Informatics, 26(6):20-56, 2009.
Retrieved July 20, 2009 from http://www.healthcareinformatics.com/ME2/dirsect.asp?sid=C6AF5F270EBF4809A9E6881632AEA97F&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:
http://projects.washingtonpost.com/post200/2008/QD/
Quadramed’s Homepage (n.d.). Retrieved July 18, 2009 from
http://www.quadramed.com/
Yahoo Finance’s Quadramed Corp. (QDHC) page (2009). Retrieved July 24, 2009 from:
http://finance.yahoo.com/q?s=QDHC