Ensure effective use of technology in improving medication management
Workflow changes dramatically
As hospital systems add new technology to improve and change pharmacy department workflow, medication management also evolves and changes. This requires pharmacy leaders to anticipate new safety concerns and develop new practice models.
Continuum Health Partners of New York, NY, has been involved in this evolution for the past six years, starting first with the implementation of automated dispensing machines (ADM), and more recently the health system installed a new computerized provider order entry (CPOE) system which is interfaced with the ADMs.
"We completely changed our workflow," says Deborah A. Wible, PharmD, chief pharmacy officer for Continuum Health Partners, which is comprised of Beth Israel Medical Center in New York, NY; St. Luke's Roosevelt Hospital Center in New York, NY, and Long Island College Hospital in Brooklyn, NY.
"We used to have a physician order system which made its way to pharmacy, and we had to have someone double-enter it into the pharmacy system," Wible explains. "We had to process the order and get the medication back up to the unit, and then the nurse would administer it, and record it on the medication administration record (MAR)."
The new system has the provider entering the order into the CPOE system. The information immediately populates the MAR and the pharmacy verification queue, Wible says.
"So there is not anybody double-handling information," she adds.
Also, now the hospital bills only for the medication that's administered, and there are no credits for returned medications.
Here are some of the other ways the new technology has improved and changed pharmacy workflow and processes:
• Safety enhancements: "When providers put in orders they can get alerts as to whether the patient has allergies or contraindications," Wible says. "You can make this as robust as possible in terms of decision support."
The system also provides notices when a medication decision requires lab results or approval from another department, such as infectious diseases, she adds.
Since all order entries are electronic there are no more errors due to handwriting interpretation, prohibited abbreviations, or transcription, Wible says.
"We don't have in place barcode bedside verification, which will be a further enhancement," she says.
However, the new system directs nurses to the correct drawer where medication can be removed.
• Regulatory compliance: Electronic systems eliminate abbreviations and handwriting issues, thus meeting compliance standards set by the Joint Commission of Oakbrook Terrace, IL.
Hospital staff are not permitted to access medications until after the pharmacist has reviewed the order, and this helps to prevent regulatory noncompliance issues.
"You can have some exceptions with an override process," Wible notes. "But you can obtain all kinds of useful information out of these systems, and these help you monitor the process and look for medication diversions."
The electronic system also has the ability to set up order sets or treatment protocols that would help a health system comply with the Joint Commission's national patient safety goals for anticoagulants, she adds.
• Financial improvements: Electronic medication management makes it possible to charge for medications based on administration, thus eliminating the drug crediting process.
"When you first set up the machines you might have an increase in inventory," Wible says. "But over time you lower your inventory because you do not have to do returns, you're only putting in the stock you're using, and you can adjust your par levels based on usage."
The electronic dispensing and CPOE system give pharmacists a better idea about medication usage and prescription patterns, she says.
"We have used the system to improve usage," Wible says.
"There is the potential to put up messages associated with prescribing," she adds. "It can have a message that's tied to a particular drug, providing restrictions or warnings."
Also, providers who view the electronic information could see a drug tip of the day on the computer screen when the computer goes into its sleep mode. These items might pertain to the Joint Commission's standards, infection control, and hand-washing, she says.
Another area of financial improvement involves changing a hospital's staff mix: "There's a possibility you could massage your professional and technical staffing mix," Wible says.
"When you have the dispensing cabinets you have the ability to more fully utilize technicians for the drug distribution process, assuring adequate oversight by pharmacists," she explains. "You don't have to have a pharmacist spend hours reviewing carts and instead move them to verification and review."
Since pharmacists no longer need to be stationed in a central pharmacy, they can review orders and interact with medical teams at the various hospital units, she adds.
"So maybe they're not doing the traditional rounding, but they are unit-based," Wible says. "So I think that's another kind of interesting practice model, and because of the computerization, you have the ability to utilize that kind of staffing model."
• Implementation process: Implementation of new technology impacts workflow during the process, as well as after the system is fully integrated into the hospital.
Continuum Health Partners implemented new technology for five hospitals with each hospital going up one at a time, Wible says.
"We did the big bang approach, and there was a lot to manage," she adds. "We had a multidisciplinary team spend time planning for the change."
Also, hospital leaders assessed the implementation process and post-implementation period.
"Twice a day we would have calls to troubleshoot what would come up and how people were monitoring the system," Wible says.
"We had people on the units that were knowledgeable of the system's functionality to help field questions," she says. "These people were not clinicians, but they knew how to get in touch with clinicians when necessary."
It helped that the organization's administration gave full support to the project, Wible notes.
"We also had all the senior administrative and physician leadership support the concept that this was the way we were going to move forward, and that this would be our new practice model," she adds. "We did not allow exceptions: Everyone had to use the provider order entry system."