Electronic Medication & Treatment (eMAR/TAR) Software in the Long Term Care Environment

Nancy Karen Culp RN
March 15, 2013 — 1,629 views  
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Nursing plays a vital role in this process since they will have the largest number of users and the software functionality and even hardware selection must be synchronized to their workloads rather than visa versa.  What actually should happen is that the software functionality be designed to "overlay" onto nursing processes in an effort to not only improve but streamline workflow as well.  That is a key factor of what Nursing Informatics is all about.  In other words, knowledge of nursing workflows and shift routines is vital in order to understand how the software will be used and if customization is needed to meet Long Term Care (LTC) needs. Or an organization may decide that altering a basic workflow needs to be done for their benefit and results in better resource utilization but that decision needs to be carefully evaluated. 

The advantages of using an eMAR/TAR software program are significant however the challenges are equally significant!  I will cover both ends of the spectrum for both. 

Authors Mia Copa: Please realize that this feedback is from my personal perspective and experiences.  Perhaps there are workarounds or vendors that have addressed these problems with solutions I am not aware of.  If so, please feel free to contact me with your feedback via avenues provided on ArticlesBase.com or e-mail address specified in my bio. Thank-you…


We are still struggling with finding and implementing an eMAR/TAR that meets the needs of the LTC nurse. In an attempt to find the right fit we have previously participated in two beta implementations and are on the doorstep of yet another.

In the LTC arena, medication/treatment workflows are unique.  The nurse usually starts at one end of the unit with their med cart and works their way to the other end. This process is repeated a few times during the shift based on scheduled administration times. By regulation, medication administration must be done within a one hour time frame before and one hour following the scheduled administration time which gives the nurse a 2 hour leeway to remain in compliance with the physician order. Treatments are usually scheduled for anytime during the shift but even that is limited by resident availability and certified nurse aide workflows.  For example, a treatment to the sacrum needs to be done with the resident is in bed and incontinence care has been done if applicable.  This requires a great deal of coordination and to see a unit team of nurses and C.N.A.'s work together to coordinate many variables is deserving of sincere recognition for all involved!

Advantages of an eMAR/TAR may include the following:

  • No more end of the month change over!!!  This is a biggie in terms of return on investment in terms of nursing time and elimination of potential discrepancies. Despite double or even triple checking the sheets you always want your best full time nurses working on the first day of the month to pick up anything that may have slipped thru the cracks…
  • Electronic resident identification assures that medication is being given to the right resident.
  • I just checked on-line to find a list of the 5 rights and discovered that we are up to 8 rights now!  eMAR's are designed to address all of these:
    • Right patient
    • Right medication
    • Right dose
    • Right route
    • Right time
    • Right documentation
    • Right reason
    • Right response
  • Nurses have to sign their initials literally hundreds of times during their shift so it's inevitable if their documentation habits are not solid, there will be missing initials (I can hear nurse managers groaning across the country lol)… the computer software should give the nurse a report that lists what is left to be done for their shift.  Interesting glitch we ran into here was that a 7-3 nurse checks to see what needs to be done and the software was designed to list meds/treatments 1 hour before their scheduled time so after 2 pm, the nurse was getting the 3-11 shift treatments on her list which muddied the report.  Interesting the little details that need to be addressed along the way.  This should be fair warning that you have software modifications writing into the contract with your software vendor.  Take my word for it, here is always something!
  • A software program that is designed to cue the nurse to complete follow-up documentation like effectiveness of pain medication is worth its weight in gold since this documentation is often overlooked.
  • Most software programs offer medication re-ordering at the click of a button!  This is a very valuable advantage.  It helps of the software also alerts the nurse that a re-order has already been placed.  And BEWARE of software systems that offer automatic re-ordering.  At least in our experience this feature has not been a positive one. It takes just one nurse that forgets to scan the new blister pack in or (heaven forbid) a medication is borrowed (I didn't say that…) and your count is off.  After having done many re-counts to reconcile the amounts which may involve hundreds of medications, this feature is not a favorite of mine.
  • Reports.  I love the reports!  Using the report data for investigative and quality improvement purposes was interesting and valuable indeed.  Once we compared medication time administration between nurses and found that one particular nurse only took half the time for a med pass as all the other nurses.  Gee, do you think she was actually administering all the meds as ordered?  Or the PRN med report showing that a particular nurse gives many more control pain meds than any other, hmmm, you know what that means. 

The challenges and considerations of an eMAR/TAR are as follows:

  • The LTC nurse has a medication cart full of meds and treatment supplies.  This makes the use of a computer on wheels (COW) impractical for the larger med passes. The nurse would have to move both the med cart and the COW up and down the hall which is impractical and may be ergonomically incorrect.  In light of this, computers (laptops or pads) need to be placed or attached to the top of the medication cart.  An arm that holds the computer up off the top of the med cart is most desirable so as to preserve the vital space on the top of cart needed for preparation and supply space used by the nurse. Another consideration if both sides of the cart are used (drawers on both sides) the computer holder/arm needs to swing 180 degrees for accessibility! 
  • Wireless connectivity is a must and to have the ability to continue medication administration and documentation if connectivity is lost or the server is down is critical due to the static time frame for dispensing meds.  This may require a software program that can synchronize at a later time.  One time when we were live with an eMAR, the off site server went down in the middle of the 9 am med pass.  It was a Saturday and I drove over 30 miles from my home (almost in my pajamas) at a neck breaking speed to get to the facility to assist staff in printing out the MAR/TARS so dispensing of medications could continue within a reasonable time.  Remember without paper systems, we had no record of what had already been given, all that was on the server.  We thought we had all bases covered by placing a back up server on site in the facility that synched up with the main server every few minutes and printing the hardcopies was all that needed to happen (a brilliant back-up system created by the software vendor and our programmers).  What we discovered was that it took over 20 minutes for all the sheets to print and they were in alphabetical order instead of room order which further delayed getting the sheets to the nurse!  Ugh…
  • Extended battery life.  If medications and treatment time frames exceed battery life this will change the well established workflow.  I have seen this happen and the nurse is forced to keep the cart stationary to stay plugged in at one location and needs to walk back and forth from the cart to the residents rather than taking the cart to the resident. This results adding valuable time onto the med pass for a nurse that already works on a tight schedule.  A 7-3 nurse may spend as many as 4-5 hours of their shift administering meds and doing treatments…

One more very important reminder.  While eMAR's are designed to do everything including stand on their head, it does not replace the nurses careful oversight and judgment calls as needed. The computer doesn't tell the nurse that the resident has changed and further assessment needs to be done or that the physician needs called for direction because their labs are off or vital signs warrants holding the medication.  To make this point unforgettable, when I covered this point in my training sessions I would rubber band a blister pack of meds to my forehead.  Yes, I looked silly but using the training technique of shock and awe I attempted to create a memorable vision the nurses would not forget!  And they didn't.  To this day nurses that have been thru my training session look at me with a grin of remembrance!  Well, no matter the point was made and that's the important thing...

Well, that's it in a nutshell… realizing that memories of events and opinions are in the eye of the beholder!  I work for a premier care LTC provider and innovative company The McGuire Group based out of Buffalo NY.  We have had much success with our e-documentation systems.  Our first experience with eMAR/TAR & CPOE implementation was first attempted in 2007, the second was a few years ago and like I said we are on the door step of another.  I will no doubt report our findings at a later date… here's to hoping the third time is a charm and we will have much success based on all the lessons learned along the way and hoping that software vendors have stepped up to the plate closing the loopholes based on their own implementation experiences!


Nancy Karen Culp RN

iNancy Nancy Karen Culp RN is an educator, writer and dynamic professional speaker with extensive experience in the Long Term Care sector of our health care continuum. Experienced in the areas of nursing administration, education and training, quality improvement and nursing informatics. Various roles over the years include Director of Nursing Services; Program Director for Nurse Aide Training; Clinical Information Systems Coordinator for Electronic Medical Record development and implementation and HIPAA Privacy Officer". [email protected]