Closing the Medication Loop

Joseph Goedert, News Editor
Health Data Management Magazine, December 1, 2008

Jefferson Community Health Center in Fairbury, Neb., in January went live with wireless, bar code enabled medication administration management software.

The system from San Diego-based IntelliDOT Corp. integrates with the hospital's pharmacy information system from San Francisco-based McKesson Corp., and hospital information system from Nashville, Tenn.-based Healthcare Management Systems.

Nurses use a hand-held device to scan bar codes on their badge, the patient's wristband and the medication to verify that the right clinician is giving the right medication to the right patient. Nurses also scan bar codes on I.V. bags before administering the solution. The bar code system even tracks I.V. tubing to make sure they are changed at specific intervals.

Moreover, the hospital has plans to interface its "smart" infusion pumps with its information systems and wireless network. This will enable clinicians to remotely check the status of infusions, such as the amount of solution left and whether it still is dispensing at the set rate.

Like a growing number of hospitals, Jefferson Community Health Center is working toward the goal of a "closed loop" medication administration process. The hospital is using information technology to monitor and verify the multiple steps of a complex process. But Jefferson Community isn't like most early adopters. It's a 25-bed critical care access hospital that could never have afforded McKesson's bar code package.

But after IntelliDOT gave the hospital a considerable break, it bought the technology for one-fifth the price of McKesson's comparable system, says Gary Mitchell, director of pharmacy. In return, the hospital is a reference site for the vendor.

A growing number of hospitals are adopting bedside bar coding of medications. They are capitalizing on the Food and Drug Administration's rule that requires the coding of medications, including unit-dose packages (see story, this page). Still other facilities are finding electronic tools can help improve the safety of medication administration. These tools include medication reconciliation software that meets new Joint Commission requirements, and a new dispensing cabinet that stores medications for specific patients (see story, page 38).

But Jefferson Community and other early adopters have found workflow changes to be a major challenge when automating medication administration processes. Some also have found that achieving good wireless connectivity is tough. One hospital, for instance, lost credibility with nurses following a rocky go-live and spent months working to get it back.

Patient Benefits

But striving to close the loop on medication administration brings clear benefits to an institution and its patients, says Charles Still, senior systems analyst at Southwestern Vermont Health Care, anchored by a 99-bed medical center in Bennington.

Electronic data, he notes, can be mined to identify errors that previously went unnoticed. "The issue with manual reporting systems is that risk management professionals say they only report 1% of all incidents. So, we did have an idea of the types of errors, but bedside scanning really highlights all of them."

Success in closing the medication administration loop, however, is not possible unless clinicians believe the technology will benefit them and their patients. Significant management support is key.

That's what Abha Agrawal, M.D., chief medical information officer of Central Brooklyn Family Health Network, wants other provider organizations to know.

"These are extensive, time-consuming projects," she cautions. "You need the strongest possible support of top executives and department managers. The support of our CEO, Jean Leon, set the tone for others."

The biggest problem that tiny Jefferson Community Health Center faced when bringing medication administration management technology to the bedside is one that any hospital of any size will have to tackle, says Mitchell, the pharmacy director.

"It's going to make some pretty substantial changes across the pharmacy and nursing departments," he advises. "Don't be overly optimistic of the implementation timetable. Give yourself time to work out problems-and there will be problems."

Vendors may market their bedside medication administration technology as a nursing system, but that's an incomplete description, Mitchell contends. "It really is a combination of a pharmacy and nursing system."

At Jefferson, the automated system upended tried and true workflows. For instance, pharmacy staff, rather than nurses, at the hospital now enter medication orders to populate the bar code system. They also have to enter the appropriate time a medication should be given, rather than typing "1QD" for "once daily." And because the bar code system also tracks oxygen orders and daily dressing changes-alerting nurses via the hand-held device to complete and document the orders-pharmacy staff also enter those orders. "That was a huge change for us," Mitchell recalls.

The transition proved rocky. Pharmacy staffers were frustrated with the large number of changes in workflow, compounded by frequent order changes requested by nurses. "We had frequent meetings with nurses," Mitchell says. "In the beginning, they were quite lively, I can assure you, in terms of who does what." Asked if pharmacy staff rebelled against the changes, Mitchell adds, "I would describe the pharmacy response as frustration to try to get the system to work the best it could."

Overall, it took about six months from the go-live in late January for all involved at Jefferson Community to be comfortable with the new processes.

The payback, Mitchell contends, is a higher level of care quality, an improvement that is readily apparent-and measurable. Utilization reports enable managers to identify nurses or other clinicians not regularly using the bar code system or not properly documenting completion of an order, such as hanging an I.V. bag.

Another report shows pending orders, such as medications to be administered or dressings to be changed. The pharmacy used to issue about a half-dozen action notices, or reminders, a day when an order was pending. "Our use of action notices has dropped tremendously," Mitchell says. "It really helped us close the loop."

Tricky Stuff

Putting all the parts together to close the loop, however, can be tricky. "The difficulty is the stack-up of all the technology you're using," says Charles Still, the senior systems analyst at Southwestern Vermont Health Care.

Since 2007, the delivery system's 99-bed medical center has been using wireless bar code technology at the bedside to verify the proper medication is being given to the right patient.

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