Pharmacy chief outlines changes needed to implement new technology

Staff input is crucial to process

Making major technological changes in hospitals is both expensive and very labor-intensive. Hospitals should plan for pilot tests of the new equipment, educating and marketing the change to staff, and receiving feedback that will result in process changes.

The preparation work in advance of rolling out new technology systemwide is necessary to prevent long-term workflow problems and glitches.

"When you go through this trial period you really begin to see how processes actually are working in comparison to what we think they are doing," says William W. Churchill, RPh, MS, executive director of pharmacy services at Brigham and Women's Hospital in Boston, MA.

Brigham and Women's Hospital spent five years implementing a new barcode verification technology within an electronic medication-administration system (eMAR).

"We found that we had to make several changes in our order entry system, several changes in pharmacy processes, and changes in nursing processes," Churchill says. "It was not a surprise to most of us that we had to make changes, but it was a surprise that we had to do it in all three areas, and this was a fairly large undertaking."

Here are some examples of changes they made during the implementation process and how they solved problems:

• Moving from paper to electronic orders: "We were half in the paper world and half out of it," Churchill says. "We had electronic order entry, but manual eMAR."

Before eMAR, doctors would write orders with detailed instructions for the nurse. Then the nurse would record these on the eMAR. This process proved problematic.

For instance, a doctor would write an order for a medication and say that if the patient's heart rate is less than a certain value, the patient should be given this other medication dosage, Churchill explains.

This type of instruction was not a medication order, but a type of "if-then" decision tree that could not be translated in an electronic order. And physicians commonly wrote these types of instructions, which left hundreds of potential orders that could not be easily translated to the eMAR.

"There was no way to populate it on the eMAR because the only way it would populate on eMAR was if you had an official order that would appear on the pharmacy order and nursing order," Churchill says.

"So we had to get all these instructions and make them eMAR friendly," he adds. "We had to make them appropriately list instructions for nurses, and we had to make sure none of the instructions contained what was tantamount to a medication order."

Pharmacists educated nurses on what to do if clinicians wrote a medication order within a medication order in their instructions. Since these were not valid in the eMAR world, nurses would have to call physicians when the patient's specified condition changes occurred and ask them at that point whether they wished to change the medication order. Then these changes could be reviewed by a pharmacist for clinical efficacy and safety.

"I think there were a lot more calls to physicians about getting orders written the right way," Churchill says. "This was very early on in the process when we were working our way through the early stages of barcode and eMAR verification."

• Learning more about bedside administration of medication: "We in pharmacy didn't know nearly as much as we would have hoped about medication scheduling," Churchill says.

Pharmacists needed to learn more about how intravenous antibiotics and other medications were scheduled, he adds.

The solution is to have pharmacists spend time with nurses to hear about the workflow issues nurses face daily in scheduling medication, he says.

"We took for granted that pharmacists would know how to do this, and we did have pharmacists meet with nurses, but that wasn't enough," Churchill says.

Having nurses educate pharmacists on their workflow demands in scheduling medications would be a more ideal approach.

• Avoiding barcode problems: The pharmacy had the responsibility of making certain every drug had a barcode on it and that each barcode worked.

"These were things we spent some time going through and testing in the pharmacy before it moved to nurses," Churchill says. "We weeded out the bad barcodes and repackaged medications that didn't have barcodes on them."

The hospital developed its own repackaging center with a machine designed for putting on barcode labels on injectable vials and syringes.

"We repackaged oral solids, oral tablets, and handled unique dosage formats like suppositories," Churchill says. "We hired repackaging technicians."

This work began in 2003 with the staff doing barcodes for 2-2.5 million doses a year up until about five years ago when the FDA required that all medication be barcoded. After this the amount of product that arrived without barcodes dropped off dramatically, Churchill says.