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Closing the Medication Loop
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.
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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.
The medical center uses a core hospital information system, including the pharmacy module, from Medical Information Technology Inc., Westwood, Mass. It uses thermal printers and software from Zebra Technologies Corp., Vernon Hill, Ill., to create bar codes to affix to medications and patient wristbands. Nurses use wireless, Bluetooth-based scanners to capture and transmit data to their cart-based laptop or Tablet PC. That data then goes over the hospital's wireless network to the pharmacy and registration systems to verify medications ordered and patient identification.
Thicker Walls Pose Problem
Connectivity in some older parts of the hospital, however, can be a problem. The thicker walls absorb wireless signals.
Consequently, Southwestern Vermont is adding "presentation software" from Fort Lauderdale, Fla.-based Citrix Systems that saves data when connectivity is lost and automatically negotiates a new connection with the wireless network. That means nurses won't have to rescan codes if they lose a connection.
Having reliable connectivity is just one step toward acceptance. Ensuring that batteries are charged is equally critical in fostering nurse acceptance of bedside bar coding, Still says. The laptops and Tablet PCs have a battery status icon on the screen. In addition, the wireless network is programmed to check every five minutes to make sure the computers are connected to the network. If a computer is offline for 10 minutes, appropriate staff members are alerted.
"Your clinical staff is expecting 7x24 uptime," Still cautions. "They expect the computer to be fully charged. They expect the scanner to be fully charged. They expect the application to be up. And 99.9% uptime is not good enough."
Making sure its mobile computers that scan bar codes and document care were charged and always ready was a high priority when Underwood-Memorial Hospital in Woodbury, N.J., went live with bedside medication administration in July 2007. The hospital uses Dolphin 9500 Mobile Computers from Morristown, N.J.-based-based Honeywell.
The medications, scanners and a spare battery in a charger were to be on carts in the hallway that were nearly always plugged in. "Our rooms are not that large, and after chairs and patient equipment, fitting carts in the rooms could be challenging," says Connie Smith, R.N., information services coordinator. Nurses at the 305-bed hospital place their cart in a convenient place in the hallway easily assessable to their assigned rooms, carrying in the medication and scanner. Before go-live, additional wall outlets were installed where needed.
Making sure nurses didn't have to lug around carts and had enough battery power in the scanners would enhance their acceptance of the technology, Smith believed. "We wanted to make sure nurses were not impeded by the devices," she recalls. "They already were affected by a drastic change to their workflow processes because all of their paper tools were gone."
If the hospital didn't make using scanners convenient for nurses, "they would not use them," adds Tina Miskofsky, R.N., mobile solutions analyst at Underwood-Memorial. So before go-live, the hospital audited its wireless network to ensure it could handle the extra traffic.
But once bedside medication administration went live, it quickly became apparent that the wireless network audit had been sub par. The hospital experienced "massive wireless issues," Smith says. "We hit a snag in the road and immediately had to back off."
The network could not handle the additional traffic, and many areas of the hospital had poor network connectivity. "We also saw issues with the code-level of the software itself and some settings within the device that were associated with connectivity," she adds.
It took two or three months to work out all of the issues. By the end of October, nurses were gaining comfort using the devices for bedside wireless bar coding and documentation. "In the beginning, we lost a lot of credibility so we had to prove ourselves again," Smith says.
By early 2008, most nurses were using the bar code system when they administered medications. The reliable network was only one factor. The chief nursing officer stated that automated reports about how nurses used the system would become part of staff evaluations. These reports track how often clinicians use the scanner in comparison to just choosing the medication and administering it without scanning.
Such sticks aside, there also was growing appreciation among nurses that the tools were improving the quality of care. "It's real-time information you couldn't get before," Miskofsky says. "That word-of-mouth helped seal the deal."
By early 2008, reported medication errors were down 15%. The lesson, Miskofsky adds, is to do real-life load testing of the network before go-live. "You need to do almost an exact test replica of what you are about to be doing."
Still, there are some places within a hospital where bedside medication scanning is not appropriate. For instance, the drip rate of certain intravenous solutions has to be frequently monitored by nurses and changed to maintain appropriate blood pressure levels. Consequently, a bar code scan that is verifying a strict drip rate won't work with these IV solutions. The hospital now is considering using smart pumps to address this issue.
Automating Reconciliation
Another task toward closing the loop is medication reconciliation, a process to identify all the medications a patient is taking, not just those prescribed at the hospital.
When Beth Israel Deaconess Medical Center in Boston had a paper-based medication reconciliation process in the emergency department, less than half of reconciliations were considered complete.
After the hospital automated the process in January 2008, that rate rose to above 90% almost immediately, says Shelley Calder, R.N., an ED clinical nurse specialist.
Clinicians and I.T. specialists at the hospital and Harvard Medical Faculty Physicians set the stage for medication reconciliation when they developed an emergency department information system (later commercialized and marketed by Waltham-Mass.-based Forerun Inc.). In 2007, they built the medication reconciliation module. Nurses use Tablet PCs at the bedside to enter patient medications. That information is placed in the electronic records system under an ED Visit tab and includes any hospital-prescribed and patient self-reported medications.
Rolling out the electronic reconciliation was an easy transition, Calder says, because the paper process was replaced with a similar process using Tablet PCs. "The application and training were provided to staff two weeks prior to full implementation," Calder explains. "This allowed a transitional period, easing the use of the electronic application and Tablet PC into daily workflow."
An additional feature added to the software after implementation required staff to complete the medication reconciliation before a patient left the emergency department. Until reconciliation was done, the software would not proceed to other discharge functions. "Clinicians would disregard the electronic process as they had with paper," Calder says. "This ensured that reconciliation would be completed prior to discharge."
When a patient is discharged from the ED, the electronic version of medication reconciliation is transmitted to the patient's primary care physician if the physician is part of Beth Israel. Patients also get two printouts-one for themselves and one for the next provider. Beth Israel plans to more tightly integrate the reconciliation application with the hospital's EHR system to support hospital-wide medication reconciliation.
Kings County Hospital Center in Brooklyn in recent years has taken a number of steps to close the loop in medication administration processes from prescribing to administration.
The 630-bed facility implemented robotic dispensing systems in the pharmacy and dispensing cabinets on the floors, and mandated computerized physician order entry.
The final step was bedside bar coding, using technology from Reston, Va.-based QuadraMed Corp., which went live in November 2007, says Agrawal, the chief medical information officer for Central Brooklyn Family Health Network, which includes the hospital.
Widely Used Technology
Bedside bar coding covers 30 inpatient units. Some 700 nurses and respiratory therapists are using the technology. "This is the most important step for patient safety," Agrawal notes. "We have closed the loop on the inpatient side. There's no paper involved."
Nurses quickly learned and adopted the bar code system, so that was the easy part of the transition, Agrawal recalls. "But they started finding workarounds for workflow and we continue to work on that."
Here's an example: To prevent errors with bar coding, nurses need to take the cart inside the room and scan the patient wristband and medication. But some nurses would print an extra wristband for one or more patients at the station, then leave the cart outside the room and scan the flat printed wristbands. Wristbands unattached to the patient's wrist are easier to capture than those worn by patientys.
The workaround carries safety risks. Visual safety alerts that may come up are not seen because those alerts are displayed on the laptop - on the cart - out in the hall. "We have to constantly reinforce good practices with them," Agrawal says. "The training of users after go-live is more important than before go-live."
She believes the prime reason for their leaving carts outside the room is that some nurses view the carts as bulky and tough to move around a room, rather than too many inappropriate alerts being issued. So continued training is needed for this and other issues that arise, such as overriding alerts.
QuadraMed's bar code system generates reports that show the number of alerts issued and who got them, and how often the alerts are overridden. "We can target a particular alert and provide additional training," Agrawal says.
Another big challenge with bedside bar coding has been the wireless technology, she advises. "Be mindful that you'll have to hire a staff to constantly maintain the carts, scanners, wireless cards and wireless network to keep uptime."
One problem that can easily be avoided, she and other bar code users note, is to select two-dimensional bar codes rather than linear. The 2-D codes affixed to wristbands and medication packages are much easier to read.
Other tips: Units with heavy use of I.V. medications will need more training time. And, psychiatric units were not as problematic as envisioned, because patients did not adversely react to scanner beeps.
Brooklyn Family Health Network is planning to adopt electronic prescribing in its community clinics as electronic medication administration moves to the ambulatory side. The clinics have adopted computerized physician order entry, but still issue paper scripts.
This is the last story in an in-depth, three-part series on point-of-care technologies in Health Data Management during 2008. Health Data Management also ran three other series this year on CIO issues, revenue cycle management and EMRs, EHRs and PHRs. We will offer seven series in 2009 covering patient safety, executive management, revenue cycle management, EHR achievement, information exchange, I.T. security and hardware. These series are designed to provide insightful, concise and timely information to our readers on the technology and business issues that shape their strategic initiatives.
-Gary Baldwin, Editorial Director
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