When it comes to using information technology to support medication administration, there’s no tried-and-true recipe for success. Many hospital executives agree that a handful of technologies can play key roles in improving medication safety. But creating a “closed loop” process to automate all the steps from the ordering to the distribution of medications is a remarkably complex undertaking.
There’s no consensus on what comes first, second or third in automating all the steps involved. And technology won’t solve anything unless it’s paired with changes in doctors’ and nurses’ workflows.
Computerized physician order entry certainly can play a critical role in improving medication administration. But only about 8 percent of hospitals have the costly technology in place so far (see January 2009 issue, page 18). That could change, however, as a result of looming extra payments from Medicare and Medicaid to hospitals under the federal economic stimulus package. Hospitals that use qualifying electronic health records systems that enable physicians to place orders electronically stand to gain extra payments.
Other technologies that can help improve medication safety include electronic medication administration records, which often, but not always, are subsets of broader electronic health records; automated medication dispensing cabinets; pharmacy information systems; and bar codes on medications and patient wristbands. In addition, some hospitals are devising ways to automate the medication reconciliation process, keeping more accurate records of all the drugs patients take before, during and after a hospital stay (see sidebar, page 28.)
Pioneering organizations and analysts alike say that it’s difficult to measure the success of medication administration automation efforts because it’s tough to pinpoint errors that are avoided and near-misses. And many hospitals lack meaningful data on error rates.
No ‘Best Practice’
When it comes to using I.T. for medication administration, “there is no best practice,” notes Susan Newbold, Ph.D., R.N., associate professor of nursing informatics at Vanderbilt School of Nursing, Nashville, Tenn. Nevertheless, she adds, “Medication administration is becoming more of a priority because of the perceived link to patient safety.”
There is, no doubt, a multitude of possible error points in administering medications — poorly written prescriptions, contra-indicated drugs, look-alike pills, and harried nurses administering doses to patients on the fly. Newbold suggests that one good starting point to plug these potential safety gaps, however, is to create an electronic medication administration record that all clinicians can use as a reference. Once a hospital has added CPOE with clinical decision support, it then can add bar coding as an important way to close the loop, she suggests.
But bar coding can raise some serious challenges, Newbold says, because it generally requires the use of unit-dose packaging. This packaging is more costly. Hospitals must either pay extra fees to manufacturers, or take on the extra expense of acquiring their own packaging equipment.
The key to any medication administration automation project is to analyze workflows to make sure they’re efficient before installing new I.T., says Brian Harvey, a pharmacist and senior consultant at Beacon Partners, Weymouth, Mass.
“Many of the current workflows at hospitals are based, unfortunately, on the legacy software that they are using,” he says. “These workflows are developed to compensate for the flaws in older software. Unfortunately, a lot of organizations want to continue to do things the way they’ve always done things.”
A cross-section of clinicians should develop workflow changes “to maximize the safety features that are built into new software, rather than try to make it look and feel like the old system,” Harvey adds.
In many cases, hospitals should start the effort to automate medication administration by updating their pharmacy systems, he argues. Once CPOE is implemented, a hospital can move on to adding more decision support as well as bar coding, he suggests.
Relatively few hospitals, regardless of size, have automated all the steps to “close the loop” of medication administration. But 74-bed Citizens Hospital, long a trailblazer in electronic medical records, has managed to automate virtually every step.
Meanwhile, other hospitals are taking widely varying approaches to automating bits and pieces of medication administration. Many have started the journey with an electronic medication administration record. Hiawatha Community Hospital, however, has focused its initial efforts on bar coding paired with drug dispensing cabinets (see sidebar, page 24).
And Children’s National Medical Center discovered a missing link in the medication administration chain. So it created its own sophisticated, custom-made calculator that nurses use to help ensure medication safety (see sidebar, above).
A rural, public facility, Citizens Hospital in Bolivar, Mo., has used tax-exempt bonds and grants to fund an ambitious clinical automation effort that streamlines all aspects of medication administration.
Its Project InfoCare initially involved implementing core clinical and financial information systems throughout the hospital as well as its related outpatient facilities, explains Denni McColm, CIO. “We wanted to promote to the community that we provide seamless care across the continuum,” she says.
When executives pitched the idea of investing in I.T. to the hospital’s board, “we did not sugarcoat it,” McColm recalls. “We told them it would be expensive. And they said ‘we thought you should have automated a long time ago.’”
In 2002, the hospital installed core systems from Meditech Inc., Westwood, Mass. All nurses and doctors now document treatment using electronic health records.
Highly Advanced
The hospital is one of the smallest to earn the highly advanced Stage 6 designation from HIMSS Analytics in recognition of its clinical automation efforts. One of the many criteria for achieving the recognition is implementing a “closed loop” medication administration system. HIMSS Analytics is a research unit of the Healthcare Information and Management Systems Society, Chicago.
Citizens eventually added an electronic medication administration record, or EMAR, to its clinical system. It also expanded its use of Pyxis drug dispensing cabinets from Cardinal Health, Dublin, Ohio, to offer nurses access to unit doses of all medications on patient floors. (Cardinal plans to spin off Pyxis to a new public company, CareFusion, later this year). And it added CPOE and bar coding from Meditech. Today, it gets about 80% of its drugs from manufacturers delivered in bar-coded single-dose packages.
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