Nationwide Children's Hospital
Columbus, OH
Parenteral nutrition (PN) is a high-risk medication according to the Institute for Safe Medication Practices (ISMP). Although most inpatient PN is now prescribed within the electronic health record (EHR), home parenteral nutrition (HPN) still depends on spreadsheets, paper prescriptions, and fax, a gap named in a 2018 national call to action and judged "not feasible" by a 2021 international summit on PN quality and safety. The primary safety risk for HPN is transcription, with rate described as high at 15.6 per 100 prescriptions. The purpose of this initiative was to build a single PN prescribing system, housed entirely within the EHR, that serves both inpatient and ambulatory settings without manual transcription.
At this freestanding children's hospital, where about 40 children receive HPN at any time, a pharmacist previously re-entered each order into a spreadsheet at every transition of care. The ordering process was significantly different between inpatient and ambulatory settings requiring converting weight-based ion doses to salts per liter, double checks of dosage changes, compounding instructions, and different amino acid formulations before the prescription was printed and faxed to the home-infusion pharmacy. A multidisciplinary team of an intestinal rehabilitation and informatics physician, clinical and informatics pharmacists, and an intestinal rehabilitation nurse began design in 2019. The team implemented EHR-based HPN prescribing for the hospital-owned home-infusion pharmacy in November 2024 using a printed, signed, and faxed prescription. State regulation prevented converting that prescription to an electronic fax, so the team advocated directly with the State of Ohio Board of Pharmacy, which approved a resolution in November 2025 permitting computer-generated fax of PN prescriptions. The resulting unified order shares the same appearance, dosing logic, and safety features in both settings, adds context-aware preparation and dispensing instructions for the home-infusion pharmacy, embeds prescriber-facing dose warnings, routes each order through pharmacist verification, and transmits by electronic fax from within the EHR.
In April 2026, all HPN prescriptions were converted to the unified order across every home-infusion pharmacy and service line. As of September 30, 2026, 37 patients had been transitioned, 13 prescribers across four service lines were using the order, and 105 prescriptions had been sent through the closed EHR pathway to six internal and external home-infusion pharmacies. Manual transcription for a new order fell from 39 to 1. Replacing the spreadsheet with a single EHR record removed the in-house source of prescription discrepancy, made HPN orders and their components visible to the full care team, and created a traceable record of every change. Prescribers can now update orders in real time, and pharmacists apply clinical review and safety checks rather than transcribing, which enables higher level of practice by the pharmacists and maintains their critical safety assessments.
A fully electronic, transcription-free HPN prescribing workflow is achievable even in pediatrics, the most demanding population for HPN, and pairing pharmacist-led informatics design with regulatory advocacy offers a model other health systems can adopt.
Left to Right: Shawn Pierson, R. Zachary Thompson, Meighan Marlo, Michelle Gniadek, Ethan Mezoff