Automating the Pharmacy Automating the Pharmacy Medication Cycle in Medication Cycle in Acute Care Settings Acute Care Settings

Enterprise Information Systems Steering Committee Nursing Informatics Committee and

Pharmacy Task Force

January 2010

Costs, Benefits and Potential Costs, Benefits and Potential Unintended Consequences Unintended Consequences

Goals

• Rationale and strategies for automating inpatient medication movement and related asset tracking

• Costs, benefits, unintended consequences • Potential business case for pharmacy­related automation in acute care settings

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Pharmacy­related Automation Technologies

• Auto­ID • Inventory Management • Unit Dose Packaging • Barcoding/Labeling • IV Compounding, Bag/Syringe Filling, Infusion Robots

• Pharmacy Robotic Dispensing Systems

• Decentralized Automated Dispensing Cabinets

• Barcode Medication Administration

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Inpatient Medication Management

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Automating Medication Movement in Acute Care Settings

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Beginning with the End in Mind…

• “Five rights” of medication administration – right patient – right drug – right dose – right time – right route

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Auto­ID: Identifying People and Things

• Barcode scanning – mature, cost effective, in common use

• Radiofrequency identification (RFID) – emerging technology, beyond line­of­sight – identifies every tagged item in range – read/write, real­time location – Proximity card authentication, access

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Auto­ID: Identifying People and Things

• Wi­Fi, infrared, ultrasound – Triangulation, room level location

• Magnetic strip cards – “What you have” authentication

• Biometric – “Who you are” authentication

• Fingerprint readers • Voice recognition

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Benefits of Auto­ID

• Documentation accuracy, completeness – Manufacturer, lot number, expiration date, formulation, date/time, etc.

• Workflow efficiency – System sign on/off time – Identify, authenticate items, persons – Location, flow of patients, equipment, supplies

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Potential Adverse Consequences of Auto­ID

• Bad tag – Wrong data entered originally – Data not readable (smudged, faded, wet)

• Bad placement – Wrong item, place, patient

• Bad reader – Malfunction, misplacement, interference

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Auto­ID: Costs and Business Case

• Cost varies widely (scope, technology) – Can be in the millions for large, multipurpose deployments

• Business case strongest for barcodes, magnetic strip badges, fingerprint readers, proximity cards – RFID costs still high

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Automated Pharmacy Inventory Management (PIM)

• Continuous drug quantity monitoring • Electronic ordering based on “MAXimum” and “MINimum” levels

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Benefits of PIM

• Right wholesaler orders, right time • Tighter inventory dollar control • Adequate drug supplies at all times • Better inventory turns, fewer expired meds • Improved staff efficiency • More accurate drug expense reports

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Potential Adverse Consequences of PIM

• System information accuracy – Monthly cycle counts needed – Back­ups in case of data corruption

• Interface challenges – Data feeds to/from other med cycle solutions

• “Picking” ­ repackagers, carousels, robots • Medication administration records (eMAR)

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Automated PIM: Costs and Business Case

• Cost depends on scope and degree of integration with other solutions – Can exceed $100,000 – Annual costs run 15%­20% of initial cost

• Business case (case study examples) – First­year savings >$300,000* – $600,000 reduction in inventory**

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* http://www.mckesson.com/static_files/McKesson.com/MPT/Documents/MAIFiles/CaseStudy_Shore_Memorial_Hospital.pdf ** www.talyst.com/resources/casestudies/parkview

Drug Unit Dose Packaging

• Re­package bulk meds à single doses • Available for tablets, capsules or liquids • USP­compliant unit dose packages • Facility­compatible barcodes • Pharmacy IS interface capability • “Robot­ready”

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Benefits of Drug Unit Dose Packaging

• Staff efficiency – Solid packaging labor reduced by 65% – Reduce ADC fill time by 70%

• Inventory control – When used with inventory carousels

• Wholesale drug costs – Bulk medications vs. single unit doses

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Potential Adverse Consequences of Drug Unit Dose Packaging

• Package integrity and printing quality – Frequent cleaning, calibration – Adequate training: loading packaging, ink – Proper inspection prior to dispensing

• Medication mix­ups – Human error

• Second verifier, pharmacist integrity check

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Drug Unit Dose Packaging: Costs and Business Case

• Costs – Oral solid repackagers

• ~$200,000 initial • ~$30,000 annual maintenance • ~$0.02 to $0.04 per dose

– Liquid repackagers • ~$20,000 initial cost • ~$0.05 to $0.08 per dose

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Drug Unit Dose Packaging: Costs and Business Case

• Business case (case study example)* – 75% staff technician time reduction in selecting refill medications

– Converted to packaging technician who streamlines packaging, does barcoding QA

– Net decrease in technician time needed for the pharmacy operation support of bedside barcode medication scanning

20 *http://www.mckesson.com/static_files/McKesson.com/MPT/Documents/MAIFiles/PACMED_Article_Pharmacy_Purchasing_and _Products_by_Michele_Weizer_(Sep2006).pdf

Pharmacy Barcoding/Labeling

• Dominant, well established form of auto­ID

• Machine­readable information about object or person

• Format determines amount of encoded information

• Enabling technology for every major step of medication handling

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Benefits of Barcoding/Labeling

• Help fulfill the “five rights” – Right patient, medication, dose

• Reduce typing, populate EHR, perform cross­checks

• Reduce dispensing errors • Improves tracking and accuracy, faster medication inventory updates

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Potential Adverse Consequences of Barcoding/Labeling

• Assuming barcode is always correct • Lack of manufacturer barcode standards

– hospital­specific barcode may be needed – specialized printers, label printing trays

• Workflow workarounds • Significant maintenance costs • Complex, interacting systems

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Barcoding/Labeling: Costs and Business Case

• Cost varies widely (scope, technology) – Can >$1M for large system implementations

• Especially if linked to robotic systems – Annual maintenance of 15%­30%

• Business case – Safety and quality – Averted cost of ADEs – Time efficiencies

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IV Compounding Systems & Infusion Robots; Bag & Syringe Fillers

• IV compounding systems and infusion robots – Prepare complex, calculation­intensive IV solutions (e.g., TPN)

– Clinical alerts for safety issues (osmolarity, electrolytes, lipids, precipitation)

• Automated bag & syringe fillers – Load, de­cap, fill, recap, label, weigh, deliver sterile syringes

– Reconstitutes vials, prepares pediatric dilutions

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IV Compounding Systems & Infusion Robots; Bag & Syringe Fillers

• Benefits: – Quick, consistent, accurate, aseptic delivery of product into a final container

– Improved safety when calculations and clinical screening software is included

– Less exposure to toxic chemicals – Higher efficiency, fewer repetitive task injuries

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IV Compounding Systems & Infusion Robots; Bag & Syringe Fillers

• Risks – Incorrect use of software, compounder – Misinterpretation of warnings, clinical flags – Contamination – Manual task­related errors

• Loading of stock solutions • Addition of small volume ingredients • Labeling of the final containers

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IV Compounding Systems & Infusion Robots; Bag & Syringe Fillers

• Cost – At least $250K ­ $350K for initial cost

• Business case – Quality, safety, efficiency, worker exposure – Paucity of data on financial return on investment (ROI)

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Central Pharmacy Robotic Dispensing Systems

• Automates storage, dispensing, returning, restocking, crediting of barcoded unit­dose meds

• Dispenses meds – into labeled envelope or bin – on a fastened, labeled ring

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Benefits of Central Pharmacy Robotic Dispensing Systems

• Free pharmacists, technicians from error­ prone repetitive manual tasks

• Decrease drug handling mistakes • Information tracking (lot numbers, expiration dates, unique dose identifiers)

• Improve charge capture, billing accuracy

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Central Pharmacy Robotic Dispensing Systems: Risks

• Mislabeled medications à errors • Limited capacity robots à “manual picks”

– Match to desired formulary size • Inadequate resource allocation à inefficient, inaccurate robot performance

• Flawed processes à workarounds

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Central Pharmacy Robotic Dispensing Systems: Costs, Savings

• Cost: can be in the millions of dollars • Savings: inventory costs, expired meds costs, pharmacist check time, ADEs

• Revenue benefits: charge capture • Vendor estimates of payback periods as short as 1.8 years (no peer review data)*

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* http://www.mckesson.com/static_files/McKesson.com/MPT/Documents/MAIFiles/Hybrid_Distribution_System_Business_Case_Analysis.pdf http://www.mckesson.com/static_files/McKesson.com/MPT/Documents/MAIFiles/CaseStudy_CookevilleRegional.pdf

Decentralized Automated Dispensing Cabinets (ADCs)

• Secure med distribution, storage • Auto­ID or password access • Nurse selects from list of pharmacist­approved patient medication orders

• Drawers open one at a time prompting nurse to remove meds

• All user transactions are logged

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Benefits of Automated Dispensing Cabinets

• Fewer adverse drug events (ADE) • Lower medication costs • Improved charge capture • Higher pharmacy and nurse productivity • Compliance with Joint Commission standards, National Patient Safety Goals

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Automated Dispensing Cabinets: Risks

• Workflow change associated risks • Cabinet footprint, drug capacity, location impact on nurse workflow efficiency

• Over­reliance on ADC technology to eliminate medication errors

• ADC “override” function permitting dispensing prior to pharmacist review

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Automated Dispensing Cabinets: Costs and Business Case

• Cost – Typical ADC cabinet costs $50K­$60K

• Business case – Very limited research on ROI of ADC technology alone

– Most documented pharmacy automation savings reported include ADC technology

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Barcode Medication Administration and eMAR (BCMA­eMAR)

• Facilitates, electronically records bedside med administration

• Scan caregiver’s name badge, patient wrist band, medication

• Supports accurate assessment of the “five rights” just prior to administration

• Links to EHR decision support tools 37

BCMA­eMAR Benefits

• Patient safety • Intelligent warning systems

– duplicate therapies, drug­drug, drug­lab, drug­food, or drug­diagnosis risks

• Documentation for quality and performance improvement initiatives

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Potential Adverse Consequences: BCMA­eMAR

• Workarounds to avoid efficiency losses – Unreadable medication barcodes – Malfunctioning scanners – Unreadable or missing patient wristbands – Non­barcoded medications – Unreliable wireless connectivity – Patient care emergencies

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BCMA­eMAR: Costs and Business Case

• Cost – Varies but typically exceeds $1M initial and ~30% of initial cost per year for maintenance

• Business case – Solid peer­review literature supporting positive ROI after first year of full operation*

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* Maviglia S. et al. Arch Internal Med 2007;167:788­94 Mekhjian H. et al. JAMIA 2002;9:529­39

Conclusions

• Medication movement in acute care settings is complex and error­prone

• Pharmacy­related IT can help – Ensure the 5 rights of medication management

– Increase efficiency and reduce ADEs • Interfaces can increase advantages

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Conclusions

• Business case – ROI analyses are difficult, data are sparse – Financial ROI strongest for barcode technology, BCMA­eMAR

– Potential ROI for inventory management, unit dose packaging systems

– “Soft” ROI considerations matter • Quality and safety

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Questions and Comments

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