Medication Administration, Delivery and Reconciliation Systems · –QR code (Quick Response code),...

Medication Administration, Delivery and Reconciliation Systems

Foundational Curricula: Cluster 5: EHR Systems

Module 9: EHR Modules – Medications, Allergies, Clinical Decision Support and Order Entry

Unit 1: Medication Administration, Delivery and Reconciliation SystemsFC-C5M9U1

This work is produced by the EU*US eHealth Work Project. This project has received funding from the European Union’s Horizon 2020 research and

innovation programme under Grant Agreement No. 727552 EUUSEHEALTHWORK

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Curriculum Developers: Angelique Blake, Rachelle Blake, Pauliina Hulkkonen, Sonja Huotari, Milla Jauhiainen, Johanna Tolonen, and

Alpo Vӓrri

Unit Objectives

• Identify technologies related to patient identification within the medicines administration process, including Radio-Frequency Identification (RFID) and bar-coding

• Describe the basic mechanisms of electronic prescribing (e-prescribe), electronic medication administration, bar-coding and RFID, and medication reconciliation

• Describe how electronic systems can support the medication supply, delivery and administration processes in hospitals and other clinical settings

• Examine how technology affects the medication prescribing, delivery and administration process

• Define the health IT/eHealth principles of electronic prescriptions and bar-code administration



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Patient Identification

• Patient identification involves making sure the person who is receiving health care is formally recognized and differentiated from others

• The matching of a patient to an intended treatment is an activity that is performed routinely in all care settings. Risks to patient safety occur when there is a mismatch between a given patient and components of his or her care, whether these components are related to diagnosis, therapy or support

• The primary importance of patient identification is for the safety of the patient, but is also for the benefit of healthcare providers, insurance companies and government entities, and continuity of care



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Patient Identification (cont’d)

• Patient identification is made simpler with electronic devices such as bar codes, EHRs, and other system supports

• The most common treatment error associated with misidentification is that of a patient receiving a medication intended for another patient. However, this is only one of many potential errors that can be caused by misidentification, including:– incompatible blood transfusion reactions– incorrect diagnostic tests being given– being unaware of medication or food allergies– failure to treat a serious illness or disease– medical treatment for erroneous diagnostic lab

results– procedures being performed on the wrong site or

wrong patient



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Mechanisms Used in Identification Systems

• There are several types of mechanisms used in identification systems. Some of these identification systems are used to identify patients, while the same or other systems can also be used to identify products, such as computer devices, medical supplies or equipment, other hospital inventory, or medications

• Commonly used healthcare identification systems include:– barcode scanning systems

– radio frequency identification systems

– biometric systems



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Barcode Scanning Systems

• A barcode is an optical, machine-readable, representation of data; the output usually describes something about the object that carries the barcode

• A barcode reader (or barcode scanner) is an electronic device that can read and print out barcodes to a computer. The scanner consists of a light source, a lens and a light sensor translating optical impulses into electrical ones– Unlike the RFID, which we will explain later,

the barcode needs a visual connection between the code and the scanner



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Barcode Scanning Systems (cont’d)• Barcodes can be linear (one-dimensional, 1D)

or matrix (two-dimensional, 2D) (with pixels rather than lines)

• Types of linear barcodes include:– basic alphanumeric code, used for supplies and

equipment– one-track pharmacode, used for medications– two-track pharmacode, used for medications– International Society of Blood Transfusion (ISBT)

code 128

• Types of matrix barcodes include:– Aztec code, named after the resemblance of the

central finder pattern to an Aztec pyramid, is used in medication administration

– QR code (Quick Response code), popular for mobile tagging applications, is used in marketing

– Data matrix code, which encodes text or raw data in a pattern of black and white square modules, is used by the pharmaceutical industry for unit dose and product marking (product labeling)



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alphanumeric

QR code

Aztec code Data matrix code

one-track pharmacode

two-track pharmacode

ISBT code 128

Barcode Scanning Systems (cont’d)

• Barcodes are frequently used in patient identification, medication identification, blood transfusions, and the medication administration process

• Barcodes can be read with optical scanners, smart phones and other devices– With a linear barcode, this is done by

reading the varying widths and spacing of parallel lines on a medicine container or patient wrist band

– With a matrix barcode, which is used for encoding a large amount of data characters, often necessary for very small containers, this is done by reading the pixels or matrixed components of the barcode



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Barcodes used in Healthcare

Barcodes are used in:• Hospital wristbands

– For patient identification, electronic health record integration

• Medication identification and management– Labeling of medications, containers and dispensing

devices– Labeling of unit dosing

• Specimen collection and blood infusion– Easier and safer method for labeling samples

• Supplies and medical equipment• Surgical instruments and medical device

sterilization– Barcodes are less expensive than RFID– Ideal for stationary humans and moving objects, e.g.

blood sample collection and analysis



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Radio-Frequency Identification (RFID)

• Radio-Frequency Identification (RFID) is a method that uses electromagnetic fields and radio frequencies to identify, track and scan nearby tags specified for this purpose– Passive tags collect energy from nearby RFID

reader’s radio waves– Active tags have their own local power source,

thus they can be read from further distance than passive tags

– RFID does not require straight visibility between reader and the device• thus the tags (and readers) can be hidden inside

devices or clothing (or skin, which, for example, is used to identify pets)



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Radio-Frequency Identification Uses in Healthcare

• Some organizations utilize RFID integrated into identification cards or bracelets to identify patients

• RFID is more commonly used to identify equipment, devices and other valuable articles used in the healthcare setting

• RFID tags can store information regarding the patient information or conditions, such as whether the patient has been in contact with infectious diseases– This can aid in achieving infection

control and other processes



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• RFID tags are also used in hospital equipment and medication– RFID tags are located in radiation

protection vests to locate them faster during an inspection

– RFID tags can be used to keep track of supplies• New orders are placed only when the

information systems report the supply is running out

• RFID can also be used to reduce supply overstock



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Radio-Frequency Identification Uses in Healthcare (Cont’d)

RFID

Biometric Systems• Biometrics refers to metrics related to human

characteristics. Biometrics can be grouped into physiological and behavioral characteristics– Physiological characteristics include attributes of a

person’s body and its parts. Behavioral characteristics are related to the pattern of a person’s behavior

• Biometrics authentication is used in eHealth as a form of patient identification, system user identification, and device or electronic record access control

• Biometric identifiers are the distinctive, measurable characteristics used to label and describe individuals. Common biometric identifiers used in eHealth include:– fingerprint– face recognition– DNA– palm print– hand geometry



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− iris recognition− retina recognition− signature− voice recognition

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Biometric System Modes• There are two basic modes of any biometric

system: verification and identification– In verification (or authentication) mode, the

system performs a one-to-one comparison of a captured biometric identifier with a specific template stored in a biometric database. This is done to verify the individual is the person they claim to be

– Three steps are involved in verification:• generating reference models for all users, and storing

them in the model database• matching the samples with reference models to

generate the genuine and impostor scores and calculate the threshold

• performing testing against the stored template; secondary identifiers such as a smart card, username or ID number may also be used for comparison



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Biometric System Modes (cont’d)– In identification mode, system performs a one-to-

many comparison against a biometric database in an attempt to establish the identity of an unknown individual

– The system will succeed in identifying the individual if the comparison of the biometric sample to a template in the database falls within a previously set threshold

– Identification mode can be used for two types of recognition:• Positive recognition, where the user does not have to

provide any information about the template to be used• Negative recognition, where the system establishes that

the person is who he or she (implicitly or explicitly) denies being

– Negative recognition can only be achieved through biometrics, since other methods of personal recognition such as passwords, PINs or keys are ineffective



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BCM, RFID, Biometrics and Medication Administration

• The medication preparation, dispensing and administration process can be enhanced with RFID, barcode scanning, and biometrics– Single and multiple dose medications can

be prepared or packaged with RFID and barcodes. This is frequently used for IV preparations, unit dose medications, chemotherapeutic drugs, and other pharmaceuticals

– Medication dispensing devices such as Pyxis machines can also utilize biometrics for user access, such as for nurses and nursing assistants

– Inpatient and outpatient prescription drugs can be tracked and traced with barcodes via charge capture



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Electronic Prescribing (e-prescribing)

• Electronic prescriptions (ePrescribing, or eRx) is the computer-based electronic generation, transmission and filling of a medical prescriptions

• ePrescribing replaces paper and faxed prescriptions once electronic health records have been implemented

• ePrescribing allows a medical provider (physician, pharmacist, nurse practitioner, or physician assistant) to electronically transmit a new prescription or renewal authorization to an outpatient, community or mail-order pharmacy

• ePrescriptions contain the same information as would be placed in paper prescriptions, except electronically. They are transmitted from the doctor to the pharmacy system faster than the patient could transport the paper prescription – Patient identification processes for picking up the

medications may vary by location, and may be a combination of some form of self-identification, such as passport, driver’s license, two-factor identification, or other ID depending on the country policy



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Benefits of e-Prescriptions

• ePrescribing enables providers to send error-free, accurate, and understandable prescriptions electronically from their offices or clinics directly to the pharmacy

• The process can reduce many of the risks associated with traditional prescription writing, including:– Avoiding the need to interpret a provider’s handwriting and instructions– Reducing prescribing and dispensing errors– Decreasing the work needed to create and fill a prescription– Speeding the receipt of prescribed drugs to patients– Preventing adverse drug interactions and reactions– Providing more availability to substitute less expensive drug alternatives by

checking the formulary of the insurance provider in the doctor's office– Improving medication compliance (having the patient take the prescribed

medications on time) by reducing lost and unfilled prescriptions and minimizing patient costs

– Reducing the incidence of drug diversion (drug abuse) by alerting providers and pharmacists of counterfeit prescriptions or duplicative prescriptions for controlled substances



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Electronic Medication Administration Record (eMAR)

• The electronic medication administration record (eMAR) is the electronic report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional

• The MAR is used in hospitals worldwide, and is replaced by the eMAR in hospitals that have electronic health records



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eMAR Content

The actual eMAR content varies from hospital to hospital and country to country. However the record typically contains this format:• Administrative/Demographics

– Patient Name (often Surname, First name, Middle Initial) and other identifying data

– Date of Birth / Age– Treating team details– Allergies– Other, variables: weight, special diet, oxygen therapy,

application time of topical local anaesthetics, e.g., Eutectic Mixture of Local Anesthetics (EMLA)



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eMAR Content (Cont’d)

• Prescription/Medication Details– Drug name – Medication type / classification– Dosage strength– Route– Frequency– Medication indication / Diagnosis– Tracking capabilities– Prescribing provider details

• The eMAR relays drug dosage data to the pharmacy, which is then connected to hospital nursing stations



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Benefits of the eMARBenefits of the eMAR include:• The provider is able to order, re-order, refill and add medications directly

in the eMAR. In addition, an eMAR:• Improves quality of care and safety• Requires less manual data-entry• Eliminates the need for paper orders and prescriptions in the hospital• Provides drug interaction and allergy flags and alerts• Provides audit tracking tools and enhanced security with user

authentication• Reduces or eliminates physician and pharmacy error rates• Documents the patient’s real-time medication history and refill history• Provides access to all historical administration information on demand• Promotes real time information exchange among users• Increases efficiency by processing medication orders in real time• Enhances the integrity of the EHR• Helps organizations on their journey to a paperless system



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The Five Rights of Medication Administration

• The EMAR can help the bedside nurse ensure the “five rights of medication administration” are met:



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1. Right patient 2. Right drug 3. Right dosage

4. Right route 5. Right time

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The Five Rights of Medication Administration (Cont’d)

• Procedures for ensuring each of the Five Rights must take into account human factor and systems design issues (such as workload, ambient distractions, poor lighting, problems with wristbands, ineffective double check protocols, etc.) that can threaten or undermine even the most conscientious efforts to comply with the Five Rights

• In the end, the Five Rights remain an important goal for safe medication practice, but one that may give the illusion of safety if not supported by strong policies and procedures, a system organized around modern principles of patient safety, and a robust safety culture



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Medication Reconciliation

• Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking

• It includes reconciling medications across all encounters of care, including acute care episodes (hospital admissions), outpatient care, and other care episodes

• There are three steps to medication reconciliation:

1. Verify by collecting the list of medications, vitamins, nutritional supplements, over-the-counter drugs, and vaccines

2. Clarify that the medications and dosages are appropriate

3. Reconcile and document any changes



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Medication Reconciliation (cont’d)

• Medication reconciliation involves:– creating the most accurate list possible of all

medications a patient is taking– comparing the list against the most recent medication

list, pharmacy records, or physician’s orders– ensuring all ongoing outpatient medications are

known on admission to a hospital or emergency room– ensuring all discharge medications are communicated

to the patient’s primary care provider

• Some transition points that require special attention include:– Admission to a hospital– Transfer from the emergency department to other

care areas– Transfer from the intensive care unit to the nursing

ward– Discharge from the hospital to home, aged care home

or another care facility



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Contents of Medication Reconciliation

• A medication reconciliation list should include:– All information from any eMAR – Outpatient medications:

• Name of the drug• Dosage• Frequency• Route

• A comprehensive list of medications should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions (hereafter referred to collectively as medications)

• Over-the-counter drugs and dietary supplements are not currently considered by many clinicians to be medications, and thus are often not included in the medication record. However, as interactions can occur between prescribed medication, over-the-counter medications, or dietary supplements, all medications and supplements should be part of a patient’s medication history and included in the reconciliation process



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Benefits of Medication Reconciliation

• More than 40 percent of medication errors are believed to result from inadequate reconciliation in handoffs during admission, transfer, and discharge of patients

• Of these errors, about 20 percent are believed to result in harm to the patient

• Many of these errors could be averted if medication reconciliation processes were in place

• Medication reconciliation can reduce or prevent:– errors of omission– duplication of medications– incorrect doses or timing– adverse drug-drug or drug-disease interactions

• Medication reconciliation provides the ability to import and export medication lists from and into EHR/EMRs



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EHR Support of Care Processes in Clinical Settings

• In this unit we have identified several technologies for patient identification and other healthcare processes that are aided with identification systems, such as prescribing and medication administration

• Patient, device and product identification technologies have many benefits in healthcare. They help provide:– Quality of care improvements– Verification and validation of patients and users– Accuracy of information, with no interpretation or transcribing needed– Safety and security, with reduction of errors– Enhanced integrity of electronic information – Electronic processes are faster and more efficient than paper and

manual processes– Universality, interoperability and standardization of information



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Unit Review Checklist

Identified technologies related to patient identification within the medicines administration process, including Radio-Frequency Identification (RFID) and bar-coding (SB02)

Described the basic mechanisms of electronic prescribing (e-prescribe), electronic medication administration, bar-coding and RFID, and medication reconciliation (MB04)

Described how electronic systems can support the medication supply, delivery and administration processes in hospitals and other clinical settings (MB02)

Examined how technology affects the medication prescribing, delivery and administration process (MB03)

Defined the health IT/eHealth principles of electronic prescriptions and bar-code administration (ML02)

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This work is produced by the EU*US eHealth Work Project. This project has received funding from the European Union’s Horizon 2020

research and innovation programme under Grant Agreement No. 727552 EUUSEHEALTHWORK

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Unit Review Exercise/Activity

Select the correct barcode on the right with the following questions:1. What type of barcode would

typically be used with blood to be transfused?

2. What type of barcode would likely be used for hospital marketing purposes?

3. Which two linear barcodes might be used for medication labeling?

4. Which two matrix barcodes might be used with medication administration?



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alphanumeric

QR code

Aztec code Data matrix code

one-track pharmacode

two-track pharmacode

ISBT code 128

Unit Exam (cont’d)

3. Which of the following statements is true about barcodes?

a. A linear barcode is one-dimensional and made of linesb. A matrix barcode is one-dimensional and made of pixelsc. An Aztec barcode is an example of a linear barcoded. A two-track pharmacode is made of pixels

4. Which of the following processes does not require straight visibility between reader and the device?

a. barcode readingb. biometric identificationc. RFID readingd. one-track pharmacode reading



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5. eMAR stands fora. Effective Medical Administration Rulesb. Electrical Maintenance in Acute care Roomsc. Electronic Medication Administration Recordd. Electronic Medication Automation Record

6. Medication reconciliation meansa. Listing all medications, vaccines, vitamins and other

drugs that the patient from encounter to encounterb. Listing the prescription refill history of the patientc. Creating a list of drugs that the patient is allergic tod. Calculating the optimal dosage of a drug for maximal

effect and minimal adverse effects



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7. The five rights for medication administration include all of the following, except:

a. right patientb. right dosagec. right routed. right side

8. Which of the following is not a step involved in biometric verification?

a. generating reference models for all usersb. matching the samples with reference models c. performing testing against the stored templated. negative recognition



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