Pharmacy Technology Report September 2015

2015 • Vol. 1 No. 1

Supplement to Pharmacy Practice News

Automated Dispensing Cabinets:

Strategies For Boosting Safety Page 4

CPOE adoption rates at all-time high Page 10

Tech tools for 340B compliance Page 16

Bar coding helps handle drug waste Page 20

Getting smart pumps and EHRs to talk Page 24

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PHARMACY TECHNOLOGY REPORT • 2015

A supplement to Pharmacy Practice News

The Human Touch

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n 1999, the Institute of Medicine (IOM) released its seminal report, To Err is Human: Building a Safer Health System.

The report’s assertion that preventable medical errors in the nation’s hospitals may cause nearly 100,000 deaths annually ushered in a new era of patient safety, with several layers of oversight added to patient care soon after its release.

Fast-forward to 2015, and it is clear that technology has played a huge role in that safety improvement process, especially as it relates to medication dispensing and administration. Whether it’s computerized prescriber order entry, automated dispensing cabinets (ADCs) or “smart” programmable infusion pumps, technology has emerged as a powerful tool for preventing patient harm.

But as you read through this inaugural issue of Pharmacy Technology Report, you’ll hear echoes of that IOM report—namely, that technology isn’t a fool-proof method of error prevention.

In the case of ADCs, for example, “the units are only as good as the people who use them,” Matthew Grissinger, RPh, FASCP, the director of error reporting programs at the Institute for Safe Medication Practices, notes in our story on ADC implementation (page 4). The importance of a skillful human touch, such as having a pharmacist review

all new drug orders prior to dispensing, is evident in many of his recommendations.

In our coverage of other pharmacy technologies, including automated sterile drug compounding (p. 18), electronic health records (p. 25) and mobile health apps (p. 26), you’ll see this dynamic playing out.

You’ll also see that besides boosting patient safety, a well-executed tech rollout can yield a financial windfall as well. Thanks to a new smart IV pump system, one hospital we profiled is poised to recover $4 million annually in infusion charges that had been lost due to IV starts and stops not being accurately documented (p. 24).

If your hospital or health system has a similarly successful tale to tell, contact us so we can share your tech lessons learned with PTR readers.

David Bronstein Editorial Director davidb@mcmahonmed.com

Editorial Board Informatics

Jerry L. Fahrni, PharmD

Automation

Karl F. Gumpper, RPh, BCPS, CPHIMS, FASHP

Pharmacy and Informatics Consultant Fresno, Calif.

Mark Sullivan, PharmD, MBA, BCPS

Pharmacy Informatics Manager Boston Children’s Hospital Boston, Mass.

Beth Prier, PharmD

Ellen F. Secaras, RPh Pharmacy Clinical Systems Integration Manager Barnabas Health West Orange, N.J.

Associate Director, Pharmacy Informatics The Ohio State University Columbus, Ohio

Director of Pharmacy Operations Vanderbilt University Hospital Nashville, Tenn.

Pharmacy/Point-of-Care

Kevin A. Clauson, PharmD

Mark Neuenschwander

Associate Professor, Pharmacy Practice Lipscomb University College of Pharmacy Nashville, Tenn.

President The Neuenschwander Company Bellevue, Wash.

EDITORIAL STAFF David Bronstein, Editorial Director davidb@mcmahonmed.com

Marie Rosenthal, Senior Editor mrosenthal@mcmahonmed.com

SALES David Kaplan, Group Publication Director

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Best Practices for Safe Use of ADCs IT leadership, seamless integration among keys to success

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lthough few studies directly link automated dispensing cabinets (ADCs) to increased patient safety, more than 80% of hospitals use them today. If it seems ADCs got a hall pass without scrutiny in the literature these past three decades, there are two reasons for this, according to Matt Grissinger, RPh, FISMP, FASCP, the director of error reporting programs at the Institute for Safe Medication Practices (ISMP), in Horsham, Pa. First, newer, adopted technologies such as computerized physician order entry (CPOE) systems, smart pumps and barcoding can directly affect patient safety and therefore draw more attention. Second, he noted, ADCs address storage, which is only one facet of an expansive medication-use process that requires multiple steps to ensure patient safety: order entry, pharmacist review, nurse administration and barcoding technology.

Rather than debate the pros and cons surrounding the use of ADCs, experts express confidence in the current technology’s built-in safety features and the next wave of advances to come (sidebar, page 6), even as they worry about nurse workarounds and varied processes in different settings, such as emergency departments (EDs), that could compromise safety.

Therefore, Mr. Grissinger’s wish list isn’t about ADCs, but how hospitals use the cabinets.

“The ADC units are only as good as the way people use them,” he told Pharmacy Technology Report. Processes differ among hospitals, and those steps can vary even within the same facility among different units, such as medical-surgical and EDs, he noted.

Overrides and Other Variables One important aspect of ADC use is the issue of overrides. In STAT areas of care such as EDs, nurses are frequently given override privileges so they can be timely and pull medications without pharmacist review, even if a pharmacist is on hand. But there are steps that can be taken to ensure overrides aren’t posing a safety risk, according to Nilesh Desai, RPh, MBA, the director of pharmacy and clinical services at Hackensack University Medical Center (UMC), in Hackensack, N.J. “Pharmacists can review override medication pulls retrospectively to prevent potential patient issues such as allergy or interactions with the second dose,” Dr. Desai said. The only drugs available on override at Hackensack UMC are for “emergent or urgent use to treat pain, nausea or vomiting. They are usually injectables—fewer than 25 in

med-surg and 50 in the ED,” out of about 300 drugs in a typical cabinet, he said.

Mr. Desai regards his processes around cabinets as “more advanced than most hospitals, due largely to our IT leadership.” All 180 Omnicell G4 cabinets in use at 770-bed Hackensack UMC integrate with its Epic electronic health records (EHR) system, which includes pharmacy systems. “We have a complete, bidirectional interface. Every transaction that goes from our EHR to a cabinet has a corresponding confirmation from the cabinet to the EHR,” he stated.

This interoperability enables pharmacists to profile patients—to screen orders for safety before nurses can remove drugs from cabinets. Mr. Grissinger cited this as a best practice in his 2012 Pharmacy and Therapeutics article, “Safeguards for Using and Designing Automated Dispensing Cabinets” (2012;37[9]:490-530).

ISMP also detailed other best practices to follow and pitfalls to avoid in two publications, “Guidance on the Interdisciplinary Safe Use of Automated Dispensing Cabinets” (http://goo.gl/IqkSW2) and “ISMP Medication Safety Self Assessment for Automated Dispensing Cabinets” (http:// goo.gl/4lAAGn), both of which were issued after a 2007 summit. The reports are about to be reviewed again, but Mr. Grissinger expects no substantial changes. Noting that these documents “still represent the latest thinking on ADCs and patient safety,” he wondered, “who has really looked at these processes, and how recently have they revisited them?”

For example, Mr. Grissinger said pharmacists and technicians with ADC experience in one hospital setting might think they know safe practices, but then “face conflict and confusion when they take a different job elsewhere.” He suggested shadowing as a good way to learn the processes, cabinet brands, locations and drawer configurations that work best in their new workplaces.

Hackensack UMC Revamps With New ADCs Hackensack brought in Omnicell ADCs in April 2012 as part of a multidisciplinary revamp of its medication-use policies and processes that involved nurses, radiologists, anesthesiologists, pharmacists and IT. “Nurse feedback is key because nurses perform 80% of cabinet transactions, and are as large a stakeholder as pharmacy in the safe use of ADCs,” Mr. Desai said. see ADC SAFETY, Y page 6

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ADC SAFETY continued from page 4

ADCs stock 85% to 90% of what nurses need for profiled patients with pharmacist-verified orders at the hospital. Their mix is “customized to the needs of each unit, for example, bariatric, heart failure and oncology,” he added. “The dynamic management of ADCs is very important. Customization improves access and timely availability. Efficient distribution gives pharmacists more time to focus on patient counseling.”

The remaining 10% to 15% of medications are patient-specific, filled by the pharmacy and delivered to the right ADC because “our cabinet can manage them systematically and still maintain safeties with scanning,” Mr. Desai explained.

Hackensack UMC also requires technicians to scan barcodes when filling and replenishing cabinets to ensure the right medications go in the right bins. Ideally, when nurses scan barcodes at the patient’s bedside, end-toend technology ensures they have the right medication to administer to the right patient. Also, certain high-alert medications, such as insulin, require nurses to scan their removal from the cabinet, print a label that they affix to the syringe and scan again when administering.

Hackensack UMC’s new processes around ADCs led to a 30% overall reduction in missing medications in the pharmacy, and lower error rates when administering medications such as insulin, compared with previous systems, noted Mr. Desai, who did not provide further details on the extent of the error reductions.

Maximizing Safety Investment To maximize a hospital’s safety investments in cabinets, Mr. Grissinger, Mr. Desai and industry sources also

suggest these steps: Have an ample number of well-located cabinets (one main unit plus auxiliary cabinets for every seven to 10 patients), and timely order verifications of CPOE by pharmacy 24 hours per day, to speed delivery of first doses and minimize line queuing. Otherwise, impatient nurses might remove see ADCs C , page 8

The Next Wave: True Interoperability

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nce health care providers integrate automated dispensing cabinets (ADCs) with electronic health records (EHR) (as Hackensack University Medical Center [UMC] has done), they will have “a single source of truth for patient information. This will allow them to spend less time switching between programs or on administrative tasks,” said Kristin Russel, MBA, MPA, a senior director of North American marketing at Omnicell.

“True interoperability enhances safety through the availability of real-time information such as lab results, and increased efficiency.”

Examples of cabinet vendors that have built interoperability with leading EHR vendors include the Omnicell G4 with Epic, and the Pyxis MedStation with Cerner Millennium.

ADCs such as the MedStation Enterprise (ES) System further enhance patient safety and medication management by allowing “standardized pharmacy policies and

procedures to be implemented across an entire health system of hospitals, clinics and ambulatory facilities,” noted David Swenson, RPh, a vice president of clinical strategy, Medical Systems, CareFusion. Once hospitals implement the ES System, for example, he sees the technology helping to ensure optimized medication management across the health system; their advanced analytics will also optimize medication inventory management and help prevent narcotics diversion.

At Hackensack UMC, Nilesh Desai, BS, RPh, MBA, the director of pharmacy and clinical services, seeks an app for every technician’s iPhone that would guide tasks when filling, replenishing or transferring medications, or removing discontinued medications from cabinets.

—A.H. Sources reported no financial relationships other than their employment by named companies.

►

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ADC SAFETY

Customize alerts to ADCs. This can be done for patient allergies, same patient names or sound-alike continued from page 6 drugs, to alleviate “alarm fatigue” and prevent duplicate doses around nursing shift changes, said Kristin Russel, multiple doses in advance and hold them in their pockMBA, MPA, a senior director of North American marketets, which would compromise accuracy. “In today’s IT environment, there’s no reason a ing, at Omnicell. pending physician electronic medPrint patient-specific labels at the ADC for IV solutions and drawnication order cannot be verified … within minutes or even seconds … up syringes to ensure right patient to allow nurses access to a veriand shorter time to first dose, and fied order in the ADC,” said David for other medications that may not Swenson, RPh, a vice president of be administered immediately.

Not sure if your hospital Other tips include using bioclinical strategy, Medical Systems, is doing all it can to minimize mishaps related to ADCs? CareFusion. metric log-ins to enhance security, Use other time-saving technoloADC experts noted. It’s also imporTake the Institute for Safe gies. Time savers include the Pyxis tant to balance needs and costs Medication Practices’ Medication ES Link Queue and Waste Module, of storage capacity versus highSafety Self-Assessment for which allows nurses to presecontrol drawers. Also, don’t sacriAutomated Dispensing Cabinets. lect medications prior to going fice single-item access control, as provided by the Pyxis MedStation to the ADC. Also, Omnicell softThe tool can be accessed ware allows nurses to save trips CUBIE or the Omnicell FlexBin, for at https://www.ismp.org/ example, to store more medication by checking electronically from selfassessments/ADC/Login.asp. their workstations if pharmacy has line items, because open-matrix drawers can provide high capacreplenished a cabinet’s medications, and Anywhere RN enables ity but potentially lead to incorremote order input. rect drug selection if barcoding is absent. (Single-dose dispensing Take advantage of analytics. Platforms such as CareFusion’s SmartWorks and for controlled substances discourages diversion.)

Omnicell’s Pandora drive analytics engines can be —Al Heller another useful enhancement. The technology identifies medication discrepancies and potential diversion, and Sources reported no financial relationships other than their employment tracks nurse overrides. by named companies.

ISMP’s Checklist for Keeping Drug Cabinets Safe ✔ Link the ADC to the pharmacy computer so a pharmacist can review each new drug order and screen it for unsafe doses and other errors.

✔ Prevent overrides and other workarounds that enable operators to access medications without adequate pharmacist review.

✔ Eliminate look-alike drug names from alphabetical lists of drugs on ADC screens; wrong drugs can easily be chosen and endanger patients.

✔ Limit drug stocks in the ADC; units that have excessive vials make it far more likely for an excessive dose of a medication to be accessed and dispensed.

Source: Matthew Grissinger, RPh, FASCP. P&T 2012;37(9):490-491, 530.

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Leapfrog study:

CPOE Gains Traction, Boosts Outcomes

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omputerized physician electrronic health records (EHRs). Many order entry (CPOE) sysstaffe ers at Crawford County Memorial tems have been around for Hosp pital, a 25-bed critical-access hosa while, but only in the past pital in Denison, Iowa, don’t have to go back that far to remember few years have hospitals and their health systems begun to pains with CPOE. The hostruly see the benefits. Since pital first implemented a CPOE the enactment of the Health system about a decade ago Information Technology for and, according to Kelly Meeks, Economic and Clinical Health PharmD, the director of phar(HITECH) Act’s meaningfulmacy, it didn’t go well. “The first time we did it, we tried to do a use program, which incentivfull-house [implementation] all at ized providers and hospitals to use the technology, CPOE once. That is a lot of change manadoption rates have not only agement for any organization, even a small one such as ours. It jumped significantly, but the systems also have been more just didn’t work,” Ms. Meeks said, effectively implemented. adding that people weren’t ready.

The Leapfrog Group, a For the second CPOE impleRichard Schreiber, MD, CMIO at Holy Spirit Hospital, in Washington, D.C.-based nonmentation, which began a few Camp Hill, Pa., is part of a team that has reduced hospiprofit group of employers and tal length of stay by improving CPOE adoption rates. years back, Crawford County purchasers, tracks CPOE adopMemorial shifted its strategy. tion among hospitals every year. In 2014, it found that an The hospital brought providers on board a few at a time and created a group of super users from different all-time high of 1,339 hospitals reported using CPOE in one inpatient unit, compared with 384 in 2010 (the year departments, such as pharmacy and nursing, to aid in HITECH was passed). Moreover, 2014 also saw a record the process. The latter was especially pertinent when 59% of hospitals meet Leapfrog’s standard of entering 75% bringing the CPOE to the emergency department, the of inpatient medication orders, while passing the group’s final part of their second rollout. evaluation test for effective alerting.

Adding Telepharmacy To The Mix Other studies published in the past few years prove CPOE’s merits in improving care and reducing costs.

“For a while, we had our IT nurse print the weekend One such effort was conducted by Richard Schreiber, schedule and highlight the list of super users and leave it MD, the chief medical informatics officer at Holy Spirit in the ER. That way, [physicians working those weekends] Hospital, a community hospital in Camp Hill, Pa., that is didn’t feel they were on their own and had to work their way part of the Danville, Pa.-based Geisinger Health System. through it,” Dr. Meeks said. Furthermore, Crawford County Memorial contracted with a clinical telepharmacy Lowering Hospital Length of Stay company, San Francisco-based PipelineRx, to help proDr. Schreiber, whose hospital implemented CPOE in cess medication orders remotely during off-hours for the 2008, led a team of researchers to study whether emergency department staff. increased rates of CPOE adoption would correlate with Overall, the new CPOE has reaped both tangible and soft benefits, Dr. Meeks said. The hospital attested to stage 1 reductions in hospital length of stay (LOS). Using data from 2008 to 2012, his team found that once adoption of meaningful use and received the incentive dollars. It also created a cooperative mentality among IT employrates exceeded 60% in a hospital, there was a 20% reduction in LOS. Moreover, Dr. Schreiber’s team used more ees, physicians, nurses, pharmacy staff and others workrecent data to show that the converse was true. “In the ing should-to-shoulder, she said, which has led to a more last two years of data, we found several specialties where efficient environment.

CPOE rate went down and [LOS] went up,” he said.

It’s not just small hospitals that have pressed the restart button on CPOE. The Ohio State University’s Conclusions drawn from this kind of extensive data were harder to prove with the first iterations of CPOE in Wexner Medical Center, an academic medical center the 1980s, when studies were limited to CPOE adoption with more than 900 beds, in Columbus, implemented at university facilities that used predominantly home-built see CPOE TRACTION, page 12

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Barriers to CPOE Adoption

CPOE TRACTION continued from page 10

CPOE around 1999 and then once again, more than a decade later, in 2011. The change came when the hospital moved to an Epic (Epic Systems) EHR. “We had many disparate systems that were interfaced but not integrated. We wanted an integrated application. We went away from niche applications and wanted everything to be on a single system,” explained Beth Prier, PharmD, the associate director of pharmacy informatics at OSU’s Wexner Medical Center. Having that integrated system means the pharmacist verification of an order is done more efficiently and reduces transcription errors, Dr. Prier said.

Spreading Out the Work Luke VanderWeide, PharmD, a pharmacy practice resident at OSU’s Wexner Medical Center, added that before Epic was installed, physicians would send the medication order to the pharmacists, who would then enter and process it in their own specific system. Furthermore, the integrated CPOE allows for rounding pharmacists to verify orders on rounds, as soon as the physician enters a medication request. “That way, you’re not only expediting care, you’re also spreading out some of that verification work, so we’re able to allocate time for our pharmacists to work on other activities for patient care,” Dr. Prier said.

Even the second time around, these hospitals are finding that the CPOE process has room for improvement.

Dr. Prier said prescribers would like clinical alerts within the CPOE to be configured in a way that’s more meaningful. The majority are overridden, she said. Dr. Meeks noted that Crawford County Memorial is hoping to better streamline evidence-based medicine practices into the CPOE system. Both pointed to The Leapfrog Group’s Evaluation Scoring Tool as a valuable

10% | Efficacy concerns 13% | Training 23% | Process change Source: J Med Syst. 2015;39(2):15.

information source for process improvement.

Despite these shortcomings, overall, the direction seems to be positive across health care providers. For those who are still struggling to reap the benefits of CPOE, specifically those in the pharmacy department, Dr. Prier said, there needs to be a paradigm shift. “Historically, when we managed pharmacy systems, it was figuring out what our pharmacy needs to function. What do we need to do to dispense drugs properly? It was all about pharmacy,” she noted. “Under the integrated model, with CPOE, the physician knows the drug and the dose they want. They don’t want to be bothered with the details [on dispensing].

You have to shift your focus to think about how that ordering process will be viewed by your physicians.”

Dr. Schreiber, who said a successful CPOE implementation comes from the top down, agreed that the focus has to go to the ordering medical staff. He said leadership must provide direction so the majority of potential ordering physicians get on board and the hospital can reach that 60% goal for adoption.

He also noted that this type of e-prescribing initiative isn’t simply an IT project, where the technology is used to launch CPOE and the developers neglect fine-tuning with clinicians—a point echoed by Dr. Meeks. “The technology isn’t the [end goal]; just because you implement CPOE doesn’t mean you won’t have problems processing orders,” she said. “Change management takes weeks and months.

You have to be patient and create a team environment.”

—Gabriel Perna None of the sources reported any relevant financial conflicts of interest.

An Affordable Solution for Halting Drug Diversion

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rug diversion in the nation’s hospitals remains a frustratingly stubborn operational challenge. Fortunately, automated dispensing cabinets (ADCs) include a variety of features designed to thwart the problem.

But not all hospitals can make the investment in full-featured ADCs. For such facilities, Capsa Solutions says it has an alternative—its FirstDose 2.0 Medication Dispensing System, which audits drug inventories in real time to spot discrepancies. FirstDose also indicates users who access the unit, the time they access it, and the medications they remove for specific patients. The drug cart can control narcotic medications further by limiting access to only those staffers who are assigned to administer medications, or via one-time access codes provided by the pharmacy. Moreover, the system is configurable for standard oral solids, IVs and narcotics.

“Real-time accountability is a big step toward stopping diversion within a facility. FirstDose does at a fraction of

the cost essentially what other ADCs do—it is well-suited for LTC [long-term care] providers or specialty acute care facilities,” said Todd Ross, the vice president of marketing, Capsa Solutions, Portland, Ore. The cabinet also features CartWatch Remote Management System software, which provides medication or mobile computing cart fleet security from a single remote PC location within the health care facility. The pharmacy can issue custom reports and review activity by carts, users, groups of carts or users, and events—and update with a single central command authorizations at all carts, for instance, when a staff nurse leaves or a contract nurse starts. “Nurse turnover or changes in nursing access to the medications is always a big issue,” Mr. Ross said. “The pharmacy gains much tighter regulation over medications stored in carts by having this real-time access control across an entire health care facility.”

—Al Heller

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Clinical Decision Support—The Next Level

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linical decision support (CDS) tools are about to become a lot more sophisticated, according to medical informatics expert Craig Rusin, PhD, an assistant professor in the Department of Pediatrics-Cardiology at Baylor College of Medicine who is affiliated with Texas Children’s Hospital, both in Houston. Dr. Rusin and his colleagues at Texas Children’s Hospital have developed software that can predict clinical events, such as cardiac arrest, as far as six hours in advance.

“We collect tremendous amounts of data on our patients, but we haven’t seen any big changes in what’s done with the information that we gather through monitoring equipment,” Dr. Rusin said during a session at the American Society of Health-System Pharmacists 2015 Summer Meetings in Denver. “Physiologic data have the potential to be used much more effectively than they currently are.”

He and his team illustrated this potential when they set out to reduce the incidence of cardiac arrest in pediatric stage I palliation patients awaiting their second palliative surgery. First, they identified and ranked the 10 most relevant signs of a cardiac arrest, ranging from the obvious (need for cardiopulmonary resuscitation) to the subclinical (hypotension), and from the intermittently monitored

cardiorespiratory arrest one hour before the event with a high level of sensitivity and specificity. In some cases, the algorithm was able to detect events more than five hours in advance, Dr. Rusin said. He further noted that the algorithm can continuously calculate the real-time relative risk of cardiac arrest, displaying a score directly

‘Gathering data is a challenge when there is poor interoperability between devices.’

—Craig Rusin, PhD

on the patient’s monitoring device and alerting clinicians of patients at risk for imminent cardiac arrest.

Despite the immediate promise of sophisticated CDS tools, Dr. Russin said several hurdles need to be overcome before algorithms like this one can be rolled out.

“Gathering d data is a challenge when there is poor interoperability between devices,” he said, adding that the algorithm is not commercially available yet and needs to undergo further “real-world” evaluation, “and approximately 30% of collected data are unusable because there is too much ‘noise.’”

Additionally, the same monitor does not ecessarily n accompany patients when they are e transferred between beds, leaving breaks in the e data-gathering process. “And simply knowing the probability of an imminent event does not address the e actual problem—the algorithm needs be used as partt of an effective clinical intervention protocol,” Dr. Rusin said.

More Focu Focus Is Good

(rise in lactate of >2 up to 24 hours) to the continuously observed (oxygen saturation ratio >50%-60%).

The researchers then programmed a “supercomputer” to sift through more than 54,000 hours of data collected from 25 of the hospital’s stage I palliation patients.

Among these patients were 20 instances of spontaneous cardiac arrest, including four related deaths.

On the basis of data from the 10 risk variables previously identified, the team developed a predictive algorithm that, in a retrospective analysis, predicted episodes of

Jerry Fahrrni, PharmD, a phar macy practice and informatics co onsultant who is based in Fresno, Calif., commented that “anything that can help focus the CDS alert system, and thus provide fewer but more valuable alerts a al ler erts ts a ts and nd n d rreduce ed ed fatigue, would be important.”

“We are still in the infancy of the Big Data movement, and although we understand we need data [to] find trends that provide clinical value, it’s not clear what that model looks like,” Dr. Fahrni said. “Work like that done

by Dr. Rusin and his team will be important for pharmacy practice moving forward.”

—David Wild Dr. Rusin is the co-founder of Medical Informatics Corporation.

Dr. Fahrni reported no relevant conflicts of interest.

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Tools for Ensuring a Clean 340B Audit T

he University of Kansas Hospital (KU), in Kansas City, did all of the usual things to prepare for a Health Resources and Services Administration (HRSA) audit of its 340B drug discount program in January. But with 340B-optimized software, planning was easier and the hospital came through the process without any citations.

After receiving notice from HRSA, a pharmacy audit and compliance team got to work, meeting weekly for at least two months to review prescriptions from each of its five pharmacies to look over reports like an auditor would, according to Randy Lutz, RPh, operations manager for

Trouble on the Audit Trail Here are some violations and sanctions incurred during 2015 HRSA audits: Div Diversion: 340B drugs dispensed at contract pharmacies for prescripc tions written at ineligible sites, not supported by responsibility for care.

Duplicate D discounts: Incorrect or in ncomplete information in the Medicaid Exclusion File.

Lack of oversight: Entity d did not provide contract pharmacy oversight.

Flawed purchasing: Coverred outpatient drugs were obtained through a group purchasing organization.

Poor documentation: Covered entity had inaccurate information on the Medicaid Exclusion File; also, incorrect 340B database record (incorrect entries for addresses for offsite outpatient facilities).

Sanctions for these violations included repayment of drug discounts to manufacturers, 340B contracts selfterminated, and in some cases, outright removal from the 340B program.

Source: www.hrsa.gov/opa/programintegrity/auditresults/ fy15auditresults.html.

KU’s outpatient pharmacies. The team reviewed all 340B policies and procedures to ensure they were up to speed, and conducted 340B training sessions with front-line staff.

Their outpatient pharmacies, which process about 13,000 prescriptions per month, handle mainly 340B prescriptions, with a few specialty drug orders for employees. The hospital also had a relatively new agreement with a contract pharmacy and had recently opened a new wholesale acquisition cost (WAC) account with a wholesaler.

The main hospital pharmacy uses software by ScriptPro’s pharmacy management system, which includes real-time 340B processing that manages lists of qualified providers and patient encounters, and ensures that dispensing occurs from either its 340B or WAC inventory as appropriate. The system also automatically orders replenishment against

the 340B or WAC accounts. The other pharmacies, taken over as part of KU’s purchase of a local network of cancer centers, use software from Sentry Data Systems and QS/1 Data Systems that qualify and process 340B prescriptions after they have been dispensed by the pharmacy.

The auditors requested a spreadsheet listing all 340B prescriptions filled between June and November 2014, including the prescription number, drug name, National Drug Code number and other key data, Mr. Lutz said. They also wanted third-party payor information and drug acquisition price. “ScriptPro was able to provide that for me relatively quickly,” he said, adding that the company also produced reports during the planning phase. Sentry sent a representative to the audit, and a ScriptPro representative was available on call, he noted.

Bernie Knutsen, a systems development project manager for ScriptPro, based in Mission, Kan., stressed that “340B audits are very scary ... because the fallout from a failed audit can be very serious” (box). To prevent such an occurrence, the company has embedded 340B functionality within its pharmacy management software, which can be customized to determine prescription eligibility and meet other 340B regulations, Mr. Knutsen noted. The system also tracks 340B virtual inventory and sends electronic transmissions of orders to suppliers. ScriptPro also can work with pharmacies to establish 340B pricing models and generate reports for in-house or audit purposes.

“Once the organization sets the rules for prescription eligibility, the program takes care of the rest,” Mr. Knutsen explained. “The computer will direct pharmacy staff to select the correct inventory item and send the third-party claim with the correct indicators to prevent duplicate rebates under the applicable Medicaid and Managed Medicaid carve-in/carve-out rules.” The program adjusts for subsequent coverage changes and corrections, he noted.

Going it Alone Not Advisable With the intricacies of the 340B program, “you need to have software that interfaces with your hospital information system that will help determine whether patients are qualified,” said Ernest R. Anderson Jr., MS, RPh, a consultant in Brockton, Mass. “Having a company that can do all of this for you [is advantageous]. It’s impossible to keep track of it by yourself.” There are several categories of 340B support vendors, he noted, including independent firms such as Macro Helix, Sentry and Talyst, that can do split billing for pharmacies and handle the contract pharmacy piece. Some drug wholesalers also offer 340B consulting and management services, he pointed out.

—Karen Blum Mr. Lutz and Mr. Anderson reported no relevant financial conflicts of interest.

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PHARMACY TECHNOLOGY REPO RT • 2015

A supplement to Pharmacy Practice News

COMMENTARY

Manual compounding ‘fraught with human error’

Is Automation the Safety Fix CSP Needs?

By Niels Erik Hansen, PhD

S

everal recent events point to glaring problems in ensuring the safety of compounded sterile preparations (CSPs)—problems that technology might be able to solve.

The Department of Health and Human Services’ Office of Inspector General (OIG) issued a 2015 report about hospitals’ use of stand-alone compounding pharmacies for CSPs. The study was spurred by concerns about the quality of CSPs after the 2012 meningitis outbreak and deaths caused by contaminated injections from the New England Compounding Center (NECC), an independent compounding pharmacy.

According to the OIG, most acute care hospitals use CSPs and get at least some of them from stand-alone compounding pharmacies. For hospitals that participate in Medicare, the Centers for Medicare & Medicaid Services (CMS) and other agencies are responsible for overseeing the safety of CSPs as part of the hospital certification process.

However, the OIG found, most CMS oversight agencies do not consistently review hospitals’ preparation and use of CSPs, nor their contracts with the pharmacies that supply them.

Although the report did not speculate whether such inconsistencies could put patients at risk, the OIG recommended that CMS inspectors receive more training on safe compounding standards and regularly review hospital contracts with compounding pharmacies.

Clearly, the NECC meningitis outbreak continues to resonate among health care providers and policymakers. The Drug Quality and Security Act (DQSA), passed

by Congress in 2013 in response to the NECC tragedy, provides enhanced rules for preparing and tracking compounded medications. The law allows compounding pharmacies to voluntarily register with FDA as outsourcing facilities (hospitals that participate in Medicare are required to purchase CSPs only from registered outsourcing facilities) and undergo enhanced inspections.

Although DQSA was a step in the right direction, it still does not resolve several critical issues. Chain of custody documentation and inspections that are more stringent are improvements, but neither measure addresses the biggest risk to the safety of CSPs: manual compounding.

The fact is manual compounding is fraught with risks from human error and contamination. Instituting extra process steps, including checks and rechecks, may be reasonable, but each extra step adds another opportunity for errors to be made. Putting aside the mold-covered equipment that inspectors found at NECC, just misreading the label on an admixture vial could be hazardous.

In 2007, actor Dennis Quaid’s twin infants received adult doses of a blood thinner—1,000 times stronger than a pediatric dose—because a pharmacy technician drew medication from a vial whose label was similar to the vial that should have been used (both infants survived). Last December, a woman in Oregon died after receiving an IV containing the wrong medication during an emergency department visit, although the label on the bag listed the medication that was ordered by her physician. Inspections that are more frequent may not have prevented either of these errors, but automated compounding could have done so.

Hospitals and outsourcers are being held to a higher sterile compounding standard following the NECC tragedy, which was linked to site contamination with several bacteria, including Penicillium, Aspergillus, and Cladosporium species.

From a regulatory standpoint, automated compounding provides many advantages. Some systems already have features that would allow compliance with DQSA; for example, an electronic audit trail documenting the details of every dose dispensed, including every vial used, an aseptic compounding chamber with ISO Class 5 air and much more. Some systems are also fully compliant with USP Chapter <797> compounding standards, also required by DQSA. As the population ages and more people rely both on hospitals and compounded medications provided by their doctors (such as in the NECC case), ensuring the safety of CSPs is going to be even more important. If Congress and the FDA really want to ensure the safety of compounded drugs, as well as assure that compounding pharmacies comply with regulations, then they must provide incentives for outsourcing pharmacies (and, for that matter, hospital pharmacies) to implement automated compounding.

Dr. Hansen is president and CEO of ARxIUM, an automation and pharmacy solutions provider created by the merger of Intelligent Hospital Systems and AutoMed Technologies, with headquarters in Winnipeg and Buffalo Grove, Ill.

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PHARMACY TECHNOLOGY REPO RT • 2015

A supplement to Pharmacy Practice News

Barcode systems can help ensure proper disposal

The Scoop on Pharmaceutical Waste

I

n December 2008, Ryan Forrey, PharmD, MS, the associate director of pharmacy and infusion services at The Ohio State University Comprehensive Cancer Center–James Cancer Hospital in Columbus, said in an interview that hospitals need far greater clarity from the Environmental Protection Agency (EPA) about the safe disposal of hazardous pharmaceutical waste.

The EPA, he noted, was still regulating unused and outof-date hazardous medicines as if they were no different from other potentially harmful industrial waste—just as it had been doing for more than two decades since the passage of the Resource Conservation and Recovery Act (RCRA) of 1976.

In a follow-up interview, Dr. Forrey said the situation hadn’t changed much. “The environment is just as complex and difficult as it was then,” he said.

However, after nearly seven years and several false starts, the EPA finally appears to be close to publishing a proposed new rule for the safe management and disposal of hazardous pharmaceutical waste generated by health care facilities. The proposal, expected this summer, may provide some relief for hospitals and health care systems, which have long struggled to comply with the RCRA hazardous waste regulations, along with myriad other federal and waste laws that relate to drug waste.

‘I’ve spent the last 20 years working in this area [managing pharmaceutical waste] exclusively. I have enough trouble keeping up.’

—Charlotte Smith, RPh, MS Hospitals also have to contend with periodic surveys by the Joint Commission, covering hazardous pharmaceutical waste disposal from the perspective of both medication management and environment of care standards. Hospital pharmacies are also facing more stringent hazardous drug management rules under United States Pharmacopeia (USP) Chapter <800>, which was published in March 2015 for a period of public comment that ended May 31. (USP is reviewing the comments but has not set a date for finalizing the chapter.) As for the EPA rule, if the timing goes as expected, the proposal will be followed by a public comment period and then by an agency review, in which comments will be evaluated and revisions made before the final rule is released—probably well into 2016, or even later. An EPA representative told Pharmacy Technology Reportt that

“we just don’t know” when the proposed rule will appear in the Federal Register. “We never know when it’s going to get back from OMB [Office of Management and Budget],” whose clearance is required for any proposed federal rule before it can be published.

Although the EPA has lagged in updating its pharmaceutical waste regulations, it has not been entirely inactive, said Charlotte Smith, RPh, MS, the senior regulatory advisor of PharmEcology Services, a business unit of WM Sustainability Services, in Houston. “Over the years,” she said, “EPA has responded gradually to concerns and has changed some of the applications of the law for pharmaceuticals.

“Given the EPA’s current resources, they’ve done the best they can do,” she added. “I’m hoping that they now have addressed this area more completely because the universal waste rules, as they were proposed in 2008, really would not have helped us a lot in some of these other areas.”

One thing that won’t change, Ms. Smith noted, is the list of RCRA hazardous pharmaceuticals. “The proposed rulemaking that hopefully is coming this summer has to do with changing the rules regarding pharmaceutical waste management in health care,” she said, “but nothing to do with changing the P and U list.” That list stratifies drugs by degree of hazard, with those rated as P being the most harmful for the environment and people’s health. Any additions to those lists will come much later, she said. see DRUG WASTE, E page 21

A supplement to Pharmacy Practice News

New chemotherapy compounds and other hazardous drugs continue to be approved every year. “None of those are regulated,” Ms. Smith said. “That is what is so frustrating.”

Whatever the rule’s final form, the end goal will be to protect the environment and, ultimately, people’s health by keeping toxic and bioactive compounds out of the nation’s water supplies and unregulated landfill sites.

How many hospitals are currently fulfilling that environmental obligation is unknown. Ms. Smith believes that only about 50% of health care organizations have implemented programs that fully meet federal and state standards.

“There is still a tremendous room for improvement,” she added.

PHARMACY TECHNOLOGY REPORT • 2015

For hospital pharmacies, nursing and other departments, the biggest challenge is staying on top of the changing regulatory landscape while meeting the demand for safer and more cost-effective patient care. “I’ve spent the last 20 years working in this area exclusively,” Ms. Smith said, “and I have enough trouble keeping up.”

The need to stay current is especially acute in large and expanding integrated health care delivery networks, where the medical and pharmaceutical waste streams from multiple hospitals and outpatient treatment facilities can seem like a mighty river.

In Chicago, for example, the 894-bed Northwestern Memorial Hospital is the largest of four hospitals that see DRUG WASTE, E page 22

Why Geisinger Decided Against a DIY Approach

H

ospital pharmacy directors may look at pending federal rules for hazardous drug waste management as timely reasons to improve their own disposal practices in 2015 and 2016.

To avoid institutional fines that could reach six figures and a potential criminal stigma will be motivation enough for some facilities. Others will act in order to become better environmental stewards, and strive to comply with drug disposal requirements from a long list of regulatory groups (state agencies, the Joint Commission, Drug Enforcement Administration [DEA], etc.).

The question is, what’s the best strategy for meeting these rigorous new standards—going it alone or seeking ouside help?

“Regulations are so complicated, and they’re changing.

I don’t recommend anyone try to do it by themselves,” said Claude Parnell, the operations director of Enterprise Pharmacy for the 1,742-bed Geisinger Health System, in Danville, Pa. Mr. Parnell launched the Geisinger initiative six years ago as one of the first in Pennsylvania, “with no other hospitals doing this to bounce ideas off of.”

The isolation he faced as a pioneer wouldn’t be the case today. Yet, Mr. Parnell feels just as strongly now as then that “an outside vendor is essential. Regulations often require clarifications at the state level, so we can know if what we propose to do would meet their standards. Having someone already involved in waste stream management of pharmaceuticals, who can help us speak with regulators, can be a huge benefit [in such cases].”

In fact, “there were times when I reached out to DEA or state [regulators] myself, and those contacts typically wound up [contacting] our vendor because they knew how to engage in those tech-to-tech conversations,” he added.

Geisinger went live with its drug disposal initiative in 2008 with a top-down feeling that “it was the right thing to do,” Mr Parnell recalled. The health system, using the expertise of Stericycle, in Lake Forest, Ill., has since diverted 112,425 pounds of drug waste from the environment. Also, a take-back initiative that began in 2012 has collected 3,022 pounds of medications brought in from people’s homes.

“We’re covered now system-wide in inpatient and outpatient areas, with no issues ever with Joint Commission or Department of Health visits.”

When choosing a vendor, he said to consider more than one, validate their track records, get feedback from their clients and clarify cost figures. In addition, assess their familiarity with all relevant regulatory bodies and the latest pharmaceuticals, particularly hazardous and toxic ones such as oncology medications. Ask vendors how they train clients—most commonly, he noted, they will train decision-makers, and rollout becomes the health system’s responsibility.

To build a case internally for this type of initiative, literature documentation will help earn senior executive support, especially since this is an added cost with no tradeoffs in labor savings, Mr. Parnell pointed out.

“You may already have the right culture to activate,” he added. “Don’t underestimate the interest [that] staff members, especially nurses, may have in improving.

Geisinger nurses used to query me before the 2008 rules took hold. They weren’t comfortable disposing of controlled or other substances down the drain. It wasn’t hard to gain acceptance for a better way.”

—Al Heller Read more about Geisinger Health in Pharmacy Practice News (September 2015, page 1).

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DRUG WASTE continued from page 21

comprise the Northwestern Medicine Health System. It has more than 100 clinics and employs about 2,000 attending physicians. Despina C. Kotis, PharmD, Northwestern Memorial’s director of pharmacy, told Pharmacy Te c h n o l o g y R e p o r t t h a t health systems of this size “need a strong partnership” with a vendor to sustain the effort needed to manage all of the waste streams and keep abreast of federal and state regulatory changes.

Another key to sustainability, she said, is enlisting the people “who are really at the sharp end of the stick at the patients’ bedsides” to be the champions of environmentally safe waste disposal management.

Ongoing staff education is also a must, say pharmacy directors. Dr. Forrey, who just became the director of pharmacy at Emory University Hospital Midtown in Atlanta, said the challenge that most institutions face is “making sure that clinical staff members, who aren’t experts in this area, are educated and have the resources available at the time they are making decisions” on waste disposal. The Ohio State University, he said, uses a computer-based learning module that staff members are required to review every year to keep them abreast of current best practices.

It is not just clinical staff who require education on hazardous drugs, he said. Many patients leaving the hospital also need strong guidance, particularly those on oral chemotherapy. “We’re seeing more and more of these hazardous drugs out in the general patient population,” Dr. Forrey said. Before discharge, he noted, “our pharmacists educate patients not only on the appropriate use of chemotherapy—the dosing schedule and potential side effects—but also on the risks of handling” these drugs and how to dispose of them safely.

At Northwestern Memorial Hospital, Dr. Kotis said a new specialty pharmacy offers comprehensive pre- and postdischarge nursing and pharmacist services to patients on specialty medications, many of them potentially hazardous and requiring Risk Evaluation and Mitigation Strategies.

How to dispose of these drugs, she said, is one of the matters that pharmacists discuss with patients before discharge and afterward in follow-up phone calls.

Technology Can Help Technology can also play an important role. Nebraska Methodist Hospital in Omaha uses its barcode system to help ensure proper pharmaceutical waste disposal, said Firouzan (Fred) Massoomi, PharmD, FASHP, the pharmacy operations manager. When nurses scan a drug label at

A supplement to Pharmacy Practice News

a patient’s bedside, the action triggers a computer droptrigge down box that specifies the app propriate receptacle for disposal, and the nurse is required to acknowledge it.

Methodist Hospital has tried posting colorful, graphic educational ssigns in clinical areas, bu ut found them less than eff e ctive. “They’re o nly as go ood as the person who wants to read them,” he said.

Disposal is also a factor in the hospital’s formulary decisions, he said. Discussions on candidate drugs focus not only on clinical trial data and costs, he said, but also “the back end—the time and cost associated with handling that product, how is it stored, the tools needed to compound it properly and safely, and the cost for disposing.”

Dr. Massoomi said he would like to see the complexity wrung out of the EPA’s regulations on hazardous drug waste. “The RCRA document wasn’t written for hospitals and the quantities we deal with; it was written for manufacturers who deal with 55-gallon drums of products.”

“Basically,” he added, “I’d like to have pharmaceuticals listed as just one type of waste, where we don’t have any sorting and it is all designated to be incinerated. The concentrations of the RCRA-listed [products] are so low that proper incineration is where we need to be. It would save everybody a lot of angst.”

Dr. Massoomi gives lectures to pharmacy interns from the University of Nebraska and Creighton University on a variety of topics, including waste management. “I try to articulate that we are the drug experts, and that means we take as much care up front in choosing the drugs for our patients as we do in how we want to properly dispose of them,” he said. “The last thing we want to do is allow these drugs to get into our environment or into the wrong hands, where we cause a negative impact on society.”

Dr. Massoomi also said hospitals need to begin planning for changes as soon as the proposed EPA rule is published. Pharmacists tend to wait until the final document is released, and “then we’re in this ‘hurry-up’ mode to try to become compliant,” he said. “We did that with USP Chapter <797>, and we’re doing it now with USP [Chapter] <800>.” A better approach would be “to read those documents now and plan for what’s coming,” he said. “That means budgeting, policies and procedures, and working with your administrative folks.”

—Bruce Buckley

None of the sources reported any relevant financial conflicts of interest other than their employment by named companies.

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PHARMACY TECHNOLOGY REPO RT • 2015

A supplement to Pharmacy Practice News

With a tight focus on systems integration ...

Smart Pumps and EHRs Can Play Nice

T

he interoperability function linking a Montana hospital’s “smart” programmable infusion pumps and electronic health record (EHR) system helped to improve patient safety and ramp up rev venue capture, according to a new study.

Researchers at SCL Health–S St. Vincent Healthcare, in Billings, said connecting the two health h information technology (IT) components cut infusion alerts and programming overrides by more than 20%, and reduced canceled infusions by 33%.

Moreover, the researchers, who presented an abstract in Denver at the American Society of Health-Sy ystem Pharmacists 2015 Summer Meetings (poster 44-M), believed the eig ght-hospital SCL Health System can ca apture as much as $4 million annually iin iinfusion f i charges that were being lost because infusion stops and starts were not accurately documented.

Outcomes such as these highlight the need for greater interoperability among health IT components, commented Todd Walroth, PharmD, the pharmacy manager of clinical services at Eskenazi Health in Indianapolis, who was not involved in the study.

“All of us are asking for this kind of interoperability, but vendors have not been incorporating this functionality into their systems,” Dr. Walroth said.

Indeed, when SCL Health–St. Vincent Healthcare—one of eight hospitals in the Denver-based SCL Health System— began the process of implementing the new functionality in September 2013, they were only the second institution with access to the interoperability function that linked CareFusion’s Alaris pumps and Epic’s EMR system.

Jennifer Biltoft, PharmD, the system manager of clinical effectiveness for SCL Health System, helped with implementation of the interoperability function. She said the primary impetus for undertaking the project was potentially enhanced patient safety, but “the revenue piece is really what convinced administrators to support implementation of the pump–EHR interoperability.

“Our analyses showed SCL Health was losing as much as $300,000 or more per month in infusion charges as a system, because infusion stops and starts were not being documented accurately in the EHR,” she explained.

With the administration’s blessing, Dr. Biltoft, along with Lonnye Finneman, PharmD, the director of pharmacy at St. Vincent Healthcare, and their colleagues formed an implementation committee consisting of pharmacists, nurses,

quality experts, clinical informatics staff, IT specialists, clinical engineers, project managers and educators. Dr. Biltoft said the bulk of the work they did before implementation was to create an Alaris drug library that matched the Epic EHR drug library and update u records in Epic to include all the required infussion data fields, such as rate of infusion and duration n.

“We also had to cross-reference our formulary and d make sure all the relevant information was in the library,” Dr. Biltoft said. Also, they needed to make workflow changes, such as reconfiguring rooms so that infusion pumps and EHR computers could be accessed at the same time for the most accurate infusion documentation.

In May 2014, eight months after embarking on its implementation journey, the St. Vincent team rolled out the interoperability function.

Although the team did not directly measure clinical outcomes, Dr. Biltoft reported several patient safety improvements. For example, her team found that during the ninemonth period after implementation, nurses more than doubled their use of patient barcode identification. The average number of total monthly pump alerts dropped by 22% (from 1,845 before the system was put in place to 1,447 afterward) and the average monthly number of override alerts decreased by 20.5%, from 1,560 before interoperability to 1,240 after implementation of this function. Moreover, there are now nearly 20% fewer instances of reprogrammed infusions and 33% fewer canceled infusions, suggesting a drop in programming errors, Dr. Biltoft reported. (The study was done independently, without any commercial funding.)

The function reduced lost infusion revenues by 16.8% soon after implementation, Dr. Biltoft noted, adding that “perfect documentation” can help the eight-system hospital capture the $4 million in infusion charges that had been falling through the documentation cracks every year before implementation of interoperability.

Dr. Walroth commented that although St. Vincent Healthcare required a significant eight-month investment to implement the functionality, the benefits in potential patient safety and the additional revenue “make a compelling case to administrators that this kind of project is worth investing in.”

—David Wild Drs. Biltoft and Walroth reported no relevant financial conflicts of interest.

A supplement to Pharmacy Practice News

PHARMACY TECHNOLOGY REPORT • 2015

A Team Approach to Optimizing EHRs W

hen it comes to optimizing the impact of your electronic health record (EHR) system, experts say it is not always what you use, but how you use it.

“You can have a great EHR system with lots of safety features, but some important ones might or might not be turned on,” said David Bates, MD, the chief of the Division of General Internal Medicine and Primary Care at Brigham and Women’s Hospital, and medical director of Clinical and Quality Analysis for Information Systems at Harvard Medical School, both in Boston.

David Bates, MD Dr. Bates speaks with authority: He is not only a leading expert on bioinformatics, but also Brigham and Women’s Hospital is currently transitioning to a commercial system, Epic (Epic Systems), after 20 years of building and refining its own EHR system.

Citing two reasons that his institution is making the switch, Dr. Bates said, “Vendors do a very good job of keeping products up to date with meaningful-use requirements and their systems integrate very well across an institution.”

Like other institutions implementing a new EHR system, Dr. Bates’ team is familiarizing itself with the EHR’s features, which includes making sure built-in functions are operational. He said one way to ensure clinical decision support (CDS) features are enabled and working properly is to perform a “flight simulation” evaluation, part of the Leapfrog Group’s CPOE Evaluation Tool, which Dr. Bates helped develop (see leapfroghospitalsurvey.org/ cpoe-evaluation-tool).

When

EHRs Work...

The process involves creating hypothetical patient EHR records and scoring the system based on the comprehensiveness of warnings and alerts, Dr. Bates said.

“The cases in the test include actual orders that have caused death or serious harm to patients, including in studies we conducted,” he noted. “They are things that do come up, like ordering a drug at a dose five times higher than usual, or ordering too high a dose of a drug in a patient with kidney failure.”

Once CDS features have been set up, organizations need to track a system’s real-world patient-safety impact, said Karl Gumpper, RPh, the pharmacy informatics manager at Boston Children’s Hospital. “It’s important to pick metrics that you can evaluate to see whether the processes and functions are working as planned,” stressed Mr. Gumpper, who is also the former director of pharmacy informatics and technology at the American Society of Health-System Pharmacists.

Quality improvement tools such as Fishbone diagrams and Plan, Do, Study, Act (PDSA) cycles can help optimize EHR processes and features, as well as address any unintended consequences of EHR implementation, Mr. Gumpper said (see the Institute for Healthcare Improvement for resources on PDSA cycles: (http://goo.gl/D7Vm4c).

ONC Report Makes the Case for Safety

Health IT benefits follow: reductions at three large 48% | Mortality dialysis centers following EHR adoption. in overall patient-safety 27% | Decline events in Pennsylvania hospitals that implemented advanced EHR systems.

Source: U.S. Department of Health and Human Services’ Office of the National Coordinator (http://goo.gl/T1oaiS).

For hospitals still seeking motivation for implementing EHR systems, both experts pointed to the safety gains that can accrue from the technology, as detailed in a recent report by the federal Office of the National Coordinator (box). For more details on the report, as well as interviews with several hospitals that have documented impressive health IT safety gains, please visit Pharmacy Technology Report’s Web-only coverage at www.pharmacypracticenews.com/PTRONC. —David Wild Dr. Bates and Mr. Gumpper reported no relevant financial conflicts of interest.

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PHARMACY TECHNOLOGY REPO RT • 2015

A supplement to Pharmacy Practice News

Blister packs, mobile apps among tools used

Painless Ways To Boost Drug Compliance

T

o improve medication adherence, health systems with ambulatory care aspirations can learn some lessons from Bryan Coehrs, PharmD, RPh, and his colleagues at a Toledo, Ohio-based pharmacy chain.

To help their assisted-living patients cope with the complexities of taking multiple drug regimens, the community pharmacists started using blister packaging, placing all of a patient’s medications for the week into sections divided by time of day and day of the week. However, filling the cards by hand took about 20 to 30 minutes for every four cards, said Dr. Coehrs, the director of operations at The Pharmacy Counter, affiliated with the ProMedica Health System of northwest Ohio and southeast Michigan. As the desire for the service grew, they realized that they needed a more automated solution.

Four years ago, they purchased a robotic system and blister cards from Omnicell, and opened a self-contained adherence pharmacy where three pharmacists and three pharmacy technicians fill and dispense medications for about 800 patients.

“We had a relatively slow start because we were asking patients to give up the way that they had pills dispensed essentially since the 1950s, in small brown vials,” Dr. Coehrs said. “But it’s become a very large-scale program for our small chain, to the point where we’re getting new robotics to handle the capacity by the end of the year.”

Approximately 32 million Americans take five or more daily medications, noted Troy Hilsenroth, RPh, MHA, MBA, the vice president of Omnicell’s nonacute care division.

A 2006 study found that using the company’s packaging increased medication adherence among 200 seniors from 61% to nearly 97% in a six-month period (JAMA 2006;296[21]:2563-2571).

Other Compliance Tools At least a dozen companies produce some type of multi-pill packaging, according to Deborah Pasko, PharmD, MHA, the director of medication safety and quality for the American Society of Health-System Pharmacists. It’s one of a wide variety of potential solutions for medication nonadherence, from paper charts and simple pill boxes, to smartphone applications or phone reminders, to smart caps for medication vials that record each time a bottle is opened, Dr. Pasko noted. Taking it one step further, eTect and Proteus Digital Health are placing tiny, ingestible biosensors onto each tablet that activate when patients take their medications, transmitting data through a wearable patch or monitor to an app or medication adherence program.

“Part of the big challenge with medication adherence is there’s no one-size-fits-all solution,” said Kevin Clauson, PharmD, an associate professor at Lipscomb University

College of Pharmacy in Nashville, Tenn. There are many dimensions to nonadherence, he pointed out, including socioeconomics, patient conditions and therapies.

Care4Today Mobile App Dr. Clauson and his colleagues from The AIDS Institute and the University of Florida are launching a new study exploring the effects of a free suite of apps called the Care4Today mobile health manager on medication adherence; it also will track providers’ opinions about its effect on adherence and workflow. The study, funded by Janssen Healthcare Innovation, which produces the apps, will be done in HIV patients seen at a couple of Department of Health clinics in Florida. Through the program, patients receive cellphone reminders to take medications and can document taking medications. Results can be shared with health care providers or family members, and the company donates 25 cents to one of four charities for each day one of its registrants takes all prescribed medications.

“That creates another touch point by which you can look at external motivations” for medication adherence, Dr. Clauson said. “You’re not just helping yourself; you’re literally helping other people by taking your medications as intended.”

—Karen Blum The sources reported no relevant financial conflicts of interest other than their employment by named companies.

Web Only More than 600 apps are available for promoting healthy behaviors. To read about several of these apps, see www.pharmacypracticenews.com/ PTRHealthApps or scan the adjacent QR code.

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• 64 Bit Compatible • Enhanced Printing, Fonts and Date Calculations • 1-D and 2-D Multi-Part Bar Codes • Include Tall Man Lettering, Shapes and Images • Scan Bottles to Import from Included NDC Database • Security Options to Ensure Your Work Flow • Group and Sort Your Formulary • Searchable Electronic Log • Easy Database Networking • Supports All Medi-Dose® and LiquiDose® Laser and Thermal Labels

MILT 4 is the newest version of Medi-Dose's industry M leading labeling and bar coding software. Every feature oof this custom-written program was specifically ddesigned to accommodate the needs of healthcare pprofessionals. With our large variety of laser and direct tthermal labels, you can clearly identify and easily bar code all medications.

Download Demo at MediDose.com

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800.523.8966

Don’t let medication keep you in the pharmacy. Virtually perform medication management activities from anywhere with the Pyxis® ES system. Through a single source of truth for formulary information, our integration engine helps eliminate redundant tasks. And, pharmacists can be relieved of identity-management responsibilities with Active Directory integration. Because dictating where and how to spend your time isn’t acceptable behavior for medication. Never let good medicine go bad.

Learn more at carefusion.com/TheGoodMed-ES.

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