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Whitepaper 4 20-fn%5_b2%5d Whitepaper 4 20-fn%5_b2%5d Document Transcript

  • The Business Case for Bar-Code Readiness Aligning Acute Care Hospital Goalswith Pharmacy Objectives to Ensure Patient Safety, Operational Efficiency and Cost Containment By Janet Silvester, R.Ph, MBA, FASHP and Chris Jones, R.Ph
  • About the Authors Janet A. Silvester, R.Ph, MBA, FASHP Director of Pharmacy and Emergency Services Martha Jefferson Hospital Charlottesville, VAA past president of both the American Society of Health-System Pharmacists (ASHP) and the VirginiaSociety of Health-System Pharmacists (VSHP), Janet A. Silvester has more than 30 years experienceadvancing pharmacy practice in a hospital setting. She currently serves as Chair of the ASHPExecutive Vice President Search Committee and Chair of the Virginia Pharmacy Congress. She hasreceived numerous honors, including VSHP’s Pharmacist of the Year award. Janet is a participant in theASHP Pharmacy Practice Model Initiative. Chris Jones, R.Ph Senior Executive Pharmacist Consultant Six Sigma Advanced Green Belt McKesson Automation Inc.An Executive Pharmacist Consultant with McKesson for the past 10 years, Chris Jones has workedwith hundreds of hospital pharmacies across the country to improve medication safety andoperational efficiency. Chris has over 22 years of hospital pharmacy experience, includingleadership roles as a former Director of Pharmacy and former Clinical Coordinator. He is activelyinvolved at the local, state, and national level of various pharmacy organizations, including past serviceon the Board of Directors for the North Carolina Association of Pharmacists and as an ASHP delegate.Chris is a two-time winner of the North Carolina Innovative Pharmacy Practice award and a recipient ofthe McKesson Automation President’s Award of Excellence. 2
  • Table of ContentsExecutive Summary ....................................................... 4Drivers for Change ......................................................... 6The Evolving Pharmacist Practice Model .......................... 9Building Your Business Case ......................................... 15Conclusions ................................................................ 17Appendices ................................................................ 17Appendix A: Advantages of Patient-Focused DispensingAppendix B: Examples of the Impact of Bar-Code-Based AutomationAppendix C: Business Realization MeasurementsAppendix D: Things to Keep in Mind 3
  • Executive SummaryWhile electronic health records (EHR) have garnered a significant amount of attention from U.S. hospitaladministrators, bar-code-based medication systems have quietly gone about doing their job of protectingpatients, improving efficiency, and containing costs.The implementation of bar-code-based systems in the hospital is both good medical practice and goodbusiness. Several studies have shown that bar-code technology can reduce errors in medicationdispensing, and this message has obviously hit home with hospital administrators and Directors ofPharmacy. In one survey, a significant 41% of hospitals responding were using bar-code medicationadministration in 2010.1Bar-code readiness is defined as having implemented the systems that serve as the foundation leadingto full, enterprise-wide bar-code medication administration (BCMA) and bar-code, electronic medicationadministration record (MAR) systems. By this definition, hospitals vary widely in terms of their bar-codereadiness. We believe this will change, as more hospitals implement the appropriate systems. This willbe largely driven by three important developments:1) Requirements of the Patient Protection and Affordable Care Act (H.R. 3590). Beginningin 2013, this legislation will begin to penalize hospitals that do not meet performance measuresestablished by the Centers for Medicare and Medicaid Services (CMS). Sixty-five percent of thosemeasures are related to medication use and safety; further implementation of bar-code-basedtechnology will make it easier for hospitals to maintain full reimbursement.2) Greater clinical involvement by hospital pharmacists. Pharmacist involvement in patient carehas been widely accepted as a way to improve patient outcomes. In fact, 97.3% of hospitals respondingto the 2009 American Society of Health-System Pharmacists (ASHP) national survey of hospitalpharmacy practice have pharmacists regularly monitoring medication therapy in some capacity.2According to an analysis of 298 studies published in the October 2010 issue of the journal MedicalCare,3 pharmacist participation in patient care was associated with a nearly 50% decrease in adversedrug reactions, along with fewer medication errors, improved patient compliance with drug regimens,higher overall quality of life scores, and improved outcomes, including better diabetes control, lowerblood pressure, and lower cholesterol. Bar-code-based pharmacy automation is largely responsible forfreeing pharmacist time and allowing them to assume expanding clinical responsibilities. This continuingtrend points to further adoption of bar-code systems moving forward.1 State of Pharmacy Automation. (2010, April). Pharmacy Purchasing & Products. 8(4).2 Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education—2009. Am J Health-Syst Pharm. 2010; 67:542-58.3 Chisholm-Burns MA, Kim Lee J, Spivey CA, Slack M, Herrier RN, Hall-Lipsy E, Graff Zivin J, Abraham I, Palmer J, Martin JR, Kramer SS, Wunz T. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Medical Care. 2010; 48(10):923-33. 4
  • 3) The effect on the bottom line. Bar-code-drivenAccording to an analysis of automation helps reduce the incidence of adverse drug298 studies...pharmacist events (ADEs) and avoid their associated costs; can increase revenue through better medication chargeparticipation in patient care capture; and also can result in reduced medication inventory, labor efficiency, and other savings. Fewwas associated with a nearly hospitals are in a position to ignore this collective50% decrease in adverse positive impact on their balance sheet,4 making it highly probable that bar-code readiness will gaindrug reactions. increasing attention in hospital board rooms and executive offices.Economics and patient centricity, then, make a strong case for bar-code readiness as the essentialrequisite step toward bar-code-driven dispensing technology and BCMA. Given the length of timeneeded for planning and implementing bar-code-enabled systems, there is some urgency to doing so inadvance of H.R. 3590 taking effect. It is also worth noting that bar-code readiness meets the definitionof “meaningful use” described in H.R. 1, the American Recovery and Reinvestment Act of 2009,making some or all of a bar-code readiness initiative eligible for federal funding. Hospitals shouldunderstand, however, that the stimulus package does not fund the introduction of new systems, onlysystems already under consideration. For this reason, now is the time for Directors of Pharmacy toengage with C-level administrators to formally acknowledge bar-code readiness and BCMA projects andinitiate project planning stages.Achieving bar-code readiness with bar-code-assisted distribution systems in the pharmacy freespharmacists from other tasks and can significantly increase the time they have available for clinicalduties that improve patient care. At the same time, these technologies also increase patient safetythrough greater accuracy in the medication distribution process within the hospital. Percentage of Hospitals Using BCMA, 2002-20095In this white paper, you will learn:• how to overcome common cost and 30% 27.9% technology obstacles to achieving 25.1% bar-code readiness; 20% 19.6%• how to align bar-code processes with 13.2% administration’s outcomes-based goals; and 10% 9.4%• quantifiable benefits of bar-code readiness at 3.2% 4.4% 1.5% hospitals that have successfully established 0% the essential bar-code medication 2002 2003 2004 2005 2006 2007 2008 2009 foundation.4 Kiselev M. Hospitals in Distress: How the Economy has Affected Financing of Health Care. Illinois Business Law Journal. March 16 2010, 15:34.5 Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education—2009. Am J Health-Syst Pharm. 2010; 67:542-58. 5
  • Drivers for ChangeThe Patient Protection and Affordable Care Act (H.R. 3590) is a significant driver for change faced byhospitals, and should serve as a major impetus for technology investments related to bar-code readiness.The bill establishes value-based purchasing of hospital services, emphasizing quality of care over quantityof care. This will have financial repercussions for hospitals. Beginning in 2013, for example, Medicareand Medicaid reimbursements will begin to be awarded – or withheld – based on a hospital’s scoreaccording to performance measures determined by the government. Fully 70% of the measures involvedare Centers for Medicare and Medicaid Services (CMS) Performance Measures; the remaining 30% willbe based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveyof patient priorities. The percentage of reimbursement at risk begins at 1% in FY13, rising to 1.25% inFY14, 1.50% in FY15, and so on. In a mid-sized hospital, 1% of reimbursement can total millions ofdollars in a single year, so meeting or exceeding performance standards will be critical.Centers for Medicare and Medicaid This aspect of the bill is, in itself, a convincing caseServices (CMS) Performance Measures for investment in pharmacy automation and bar-code readiness. Analysis of the CMS measures shows that two-thirds of care indicators (27 of 40) are related to medication use. This comprises more than half of the OTHER 13 total performance score on which reimbursement will be based. In addition, 15 of 26 indicators of the Joint CARE INDICATORS 27 Commission Center for Transforming Healthcare’s RELATED TO MEDICATION USE quality measures are also medication-related.Centers for Medicare and Medicaid Services (CMS) Performance Measures: Medication-Related Indicators Medication-Related IndicatorsPneumonia 5 of 7Heart Failure 2 of 4Acute MI 6 of 9Surgical Care Improvement Project 6 of 10Hospital Outpatient Measures 5 of 7Children’s Asthma Care 2 of 3Pregnancy and Related Conditions 0 of 3Process of Care Measures 27 of 40Hospital Consumer Assessment of Healthcare Providers and 1 of 10Systems (HCAHPS) 6
  • Joint Commission Center for Transforming Healthcare: Medication-Related Indicators Medication-Related IndicatorsPerinatal Care (PC) 1 of 5Hospital Based Inpatient Psychiatric Services (HBIPS) 2 of 7Stroke National Hospital Inpatient Quality Measures (STK) 7 of 8Venous Thromboembolism Measures (VTE) 5 of 6Process of Care Measures 15 of 26H.R. 3590 and the CMS measures align the interests of hospital administrators with those of the pharmacy.Medications are used in nearly every area in the hospital, all of which would benefit from safe systemsthat employ bar-code technology. Bar-coded medication administration, partially enabled and stronglysupported by pharmacy automation, addresses enterprise-wide medication issues that can dramaticallyaffect performance scores – more so, for example, than computerized physician order entry (CPOE).The drug administration step is the last in the medication-use system where a medication error can bedetected and a potential adverse drug event (ADE) prevented. Indeed, a 2005 study showed that theuse of bar-code technology reduced the rate of potential ADEs due to dispensing errors by 63%.6 BCMAthereby provides a wider-ranging safety net in the medication-use process and greater potential safetygains, with a greater potential positive impact on performance scores. At a hospital dispensing The decrease in ADEs has a significant financial aspect, as well. Each ADE equals $2,2007 in millions of medication doses additional hospital costs; each preventable ADE, every year, bar-code $8,750.8 At a hospital dispensing millions of technology can prevent medication doses every year, bar-code technology can prevent thousands of ADEs. The savings can thousands of ADEs. The run into millions of dollars annually.9 savings can run into millions of dollars annually.6 Poon E, Cina J, Churchill W, Mitton P, et al. Effect of Bar-code Technology on the Incidence of Medication Dispensing Errors and Potential Adverse Drug Events in a Hospital Pharmacy. AMIA Annual Symposium Proceedings. 2005.7 Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA. 1997; 277:301-306.8 Aspden P, Wolcott J, Palugod R, Bastien T. Preventing Medication Errors. Institute Of Medicine. 2006; 115-117.9 Poon E, Cina J, Churchill W, Mitton P, et al. Cost-Benefit Analysis of a Hospital Pharmacy Bar Code Solution. Archives of Internal Medicine. April 23 2007. 7
  • In addition to the potential for safety gains realized by bar-code-driven pharmacy automation equipment,pharmacy automation and bar-code readiness are also critical to achieving meaningful use under theAmerican Recovery and Reinvestment Act of 2009 (H.R. 1). Meeting the meaningful use requirement isnecessary to receiving government funding for hospital technology projects. Bar-code infrastructure andeffective closed-loop medication management solutions are considered “meaningful” since theyare necessary for successful deployment of clinical systems that directly relate to the Federalgovernment’s overall healthcare goals.The significant importance of medication issues to the enterprise also argues for pharmacy involvementin technology decisions currently made at the executive level, even when those decisions reach beyondthe pharmacy. Certainly, for any technology that may in any way touch the administration of medication,it is only logical. Additionally, in most hospitals, the pharmacy has consistently been an early adopter inthe implementation of technological advances, often developing a project management skill set that cancontribute to the overall planning of the system and is useful as additional technologies are implemented.The value of the pharmacy in examining these solutions should not be undervalued.Also driving change is ASHP, an early and consistent leader in recognizing the game-changing aspects ofa bar-code-based medication system. ASHP’s official position on bar-code readiness and BCMA states,“The American Society of Health-System Pharmacists encourageshospital and health-system pharmacies to incorporate bar-codescanning into inventory management, dose preparation andpackaging, and dispensing of medications. The purpose of suchscanning is to ensure that drug products distributed, deployed tointermediate storage areas, or used in the preparation of patientdoses are the correct products, are in-date, and have not beenrecalled.”1010 ASHP Statement on Bar-code Verification During Inventory, Preparation, and Dispensing of Medications. June 2010. 8
  • The Evolving Pharmacist Practice ModelAs the use of bar-code-based pharmacy automation systems has spread, the role of the hospitalpharmacist has been changing. The hospital pharmacist’s role is becoming more an integrated positionwith increased clinical responsibilities,11 as automation allows the delegation of many tasks that do notrequire clinical judgment to well-trained technicians, freeing pharmacist time. Indeed, the ASHP’sPharmacy Practice Model Initiative sees pharmacists providing ever higher levels of patient care –including medication prescribing as part of a collaborative team – as certified pharmacy techniciansassume virtually every distributive function that does not require clinical judgment.Pharmacist Involvement in Therapeutic Drug Monitoring for Inpatients11 100% 90% 87.8 92.3 80% 75.6 75.5 80.1 73.2 64.6 79.2 70% 63.1 69.1 60% 63.3 58.6 50% 47.3 40% 36.5 35.5 37.9 30% 20% 10% 0% 2000 2003 2006 2009— Inpatient Pharmacists Routinely Monitor Medication Levels— Pharmacists Have Authority to Order Initial Serum Medication Level— Pharmacists Have Authority to Adjust Dosage for Routinely Monitored Medication— Pharmacists Are Notified When Medication Levels Fall Outside of Therapeutic Range11 Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education—2009. Am J Health-Syst Pharm. 2010; 67:542-58. 9
  • Studies involving care programs with expanded clinical involvement by pharmacists, such as TheAsheville Project,12-15 are showing significant improvement in clinical outcomes and may be encouraginghospitals to accelerate the trend. In the Asheville study involving hypertension and dyslipidemia, forexample, the period of pharmacist clinical involvement showed a 53% decrease in risk of a cardiovascularevent (CV) and greater than 50% decrease in risk of a CV-related emergency department or otherhospital visit.12In the 2009 ASHP survey, the trend toward pharmacist clinical involvement is clear:• 64.7% of hospitals used clinical generalists in an integrated pharmacy practice model.• 97.3% used pharmacists to regularly monitor medication therapy, with nearly 50% of those pharmacists monitoring 75% or more of patients.• In more than 92% of those surveyed, pharmacists monitor serum medication concentrations or surrogate markers; in 80.1%, pharmacists can order initial serum concentrations, and in 79.2%, adjust serum dosages.• In 27.9% of hospitals, pharmacists provided medication education to patients.16Activities Implemented to Improve Patient OutcomesAs the value of the pharmacist’s clinical involvement has become clearer, hospitals have turned to variousmethods to stimulate pharmacist clinical practices. For instance, during the past several years, commonmethods included promoting the value of clinical pharmacy services, increasing access to patient-specificdata, and expanding pharmacy technician responsibilities. Not surprisingly, considering the role of automatedsystems in freeing pharmacists to assume more clinical duties, 29.9% of hospitals have implementedautomated dispensing systems. In addition, 35.4% expanded pharmacy technician responsibilities, and23.5% redeployed pharmacists to patient care units. This latter number is especially significant since,according to an analysis of 298 studies published in the October 2010 issue of the journal Medical Care,17pharmacist participation in patient care was associated with a nearly 50% decrease in adverse drugreactions, along with fewer medication errors, improved patient compliance with drug regimens, higheroverall quality of life scores, and improved outcomes including better diabetes control, lower blood pressure,and lower cholesterol.12 The Asheville Project: Clinical and Economic Outcomes of a Community-Based Long-Term Medication Therapy Management Program for Hypertension and Dyslipidemia. Journal of the American Pharmacists Association. January/February 2008.13 The Asheville Project: Long-Term Clinical, Humanistic, and Economic Outcomes of a Community-Based Medication Therapy Management Program for Asthma. Journal of the American Pharmacists Association. March/April 2006.14 The Asheville Project: Long-Term Clinical and Economic Outcomes of Community Pharmacy Diabetes Care Program. Journal of the American Pharmacists Association. March/April 2003.15 The Asheville Project: Participants’ Perceptions of Factors Contributing to the Success of a Patient Self-Management Diabetes Program. Journal of the American Pharmacists Association. March/April 2003.16 Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education—2009. Am J Health-Syst Pharm. 2010; 67:542-58.17 Chisholm-Burns MA, Kim Lee J, Spivey CA, Slack M, Herrier RN, Hall-Lipsy E, Graff Zivin J, Abraham I, Palmer J, Martin JR, Kramer SS, Wunz T. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Medical Care. 2010; 48(10):923-33. 10
  • The argument can be made for a correlation between the use of automated dispensing technology and theever-greater share of dispensing responsibilities assumed by technicians over the past several years.Bar-code-based automation greatly reduces the chances of error and requires significantly less experthuman supervision. This would allow moving the dispensing process into the purview of non-pharmacistpersonnel and enabling pharmacists to evolve into more integrated roles. The cumulative growth of bothdispensing automation and technician responsibilities since 1997 may well have laid the groundwork for theaccelerated expansion in the number of hospitals employing an integrated pharmacy practice model – and thebroadening of pharmacist practice area involvement and influence – seen in the most recent ASHP studies.Comparative Growth of BCMA and Integrated Pharmacist Practice Model18 25.1 27.9 9.87 19.6 7.94 6.71 9.4 13.2 5.51 5.1 2005 2006 2007 2008 2009— Percentage of hospitals using BCMA— Mean number of integrated pharmacist positions per 100 occupied bedsFreeing Pharmacists to Be PharmacistsTechnology is increasingly available to support the safe use of medication. Its use continues to improvethe medication-use system and is at the heart of a classic “virtuous circle”: as the pharmacy automates,pharmacists are freed for clinical work, improving patient care, thereby helping to support furtherautomation, and so on.The use of automated dispensing cabinets has become widespread, and while BCMA and CPOEtechnologies are being utilized in less than half of U.S hospitals, their use is decidedly growing, withBCMA adoption outpacing CPOE in 2009. CPOE systems with clinical decision support systems were inplace in 15.4% of hospitals in the 2010 ASHP survey, BCMA systems in 27.9%, smart infusion pumps in56.2%, and complete EMR systems in 8.8%.1818 Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education—2009. Am J Health-Syst Pharm. 2010; 67:542-58. 11
  • Technology Use, Inpatient Dispensing19 ROBOTICS 42% 47% 54% CAROUSEL 77% 72% 69% AUTOMATED DISPENSING CABINETS n/a n/a 90% BAR-CODE PACKAGING 66% 64% 71% 2008 2009 2010Bar-code readiness and BCMA initiatives add an additional safety check to the final step in themedication-use system, and this no doubt explains to a large degree the speed with which they havebeen and are being adopted:• 27.9% of U.S. hospitals live on BMCA systems in 2009, compared to just 1.5% in 2002*• 233% growth in central pharmacy automation systems, 1999-200620• 500% growth in “machine-readable coding”* used to verify doses before dispensing, 2002-200821• 61% growth in hospitals outsourcing unit-dose bar-code packaging, 2002-200821• 86% of the 500 most frequently prescribed oral solid medications are available in manufacturer unit-dose, bar-coded packaging22* Robots, carousel systems, and sometimes manual unit dose pick stations use machine-readable coding for safety and inventory verification purposes.Technology Use, Prescribing and Drug Administration23 BAR-CODE DRUG ADMINISTRATION 29% 33% 41% CPOE 28% 31% 35% 2008 2009 201019 Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education—2009. Am J Health-Syst Pharm. 2010; 67:542-58.20 Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education—2006. Am J Health-Syst Pharm. 2007; 64:507-20.21 Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration—2008. Am J Health-Syst Pharm. 2009; 66:926-46.22 McKesson Health Systems data report 2010. Oral solids sales data.23 State of Pharmacy Automation. (2010, April). Pharmacy Purchasing & Products. 8(4). 12
  • Pressure for 24/7 Pharmacy Service CoverageAnother argument for bar-code readiness can be inferred from the rise in 24/7 pharmacy servicecoverage. According to the 2010 ASHP survey, 41.2% of hospitals provided 24-hour inpatient pharmacyservices, up dramatically from 30.2% in 2005. The average number of hours per week pharmacydepartments were open and available to provide services has also increased, from 101 hours in 2005,to 103.8 hours in 2007, to 106.2 hours in 2008, to 112 hours in 2009.24-28From strictly a patient care point of view, around-the-clock on-site pharmacy services are preferable tomore limited hours of operation, even with the inevitable drop off of demand during nighttime hours.The primary barrier to extended or 24/7 coverage has traditionally been financial, since more hourssignificantly increase pharmacy labor costs without necessarily generating commensurate medicationservices income. Over the past five years, perhaps the largest single change in many hospitals is theincreased use of pharmacy automation. That increase and the growth in 24-hour inpatient pharmacyservices have been simultaneous, suggesting that the efficiency, staffing, and cost-reduction benefits ofautomation have been notable enablers of longer pharmacy hours.This seems more than plausible when comparing the variation in extended hours growth amonghospitals of different sizes. As might be expected, large hospitals with 600 or more staffed beds hadthe highest incidence of 24-hour pharmacy services, at 98.4%, while only 8.8% of the smallest hospitals(fewer than 50 staffed beds) operated around-the-clock pharmacies. Certainly, need plays a significantpart in such a wide discrepancy, but it must also be noted that larger hospitals are far more likely toemploy pharmacy automation than the smallest institutions.Supporting the Drivers for ChangeIn terms of pharmacist duties, bar-code automation technology is enabling change that is being drivenby the need for increased patient safety (H.R. 3590) and also for process efficiency as a response tocost constraints.The effects of central pharmacy automation solutions are allowing patient monitoring to increasingly beperformed by integrated pharmacists performing both distributive and clinical roles. The use ofdistributive pharmacists to monitor medication therapy has declined and the use of other pharmacists tomonitor medication therapy has steadily increased over the past nine years. In 2000, 49.2% of hospitalshad distributive pharmacists monitor medication therapy, 40.6% used clinical pharmacists, 51.3% usedintegrated pharmacists, 9.4% used pharmacy residents, and 24.5% used student pharmacists.2824 Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration—2008. Am J Health-Syst Pharm. 2009; 66:926-46.25 Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Prescribing and transcribing—2007. Am J Health-Syst Pharm. 2008; 65:827-43.26 Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education—2006. Am J Health-Syst Pharm. 2007; 64:507-20.27 Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration—2005. Am J Health-Syst Pharm. 2006; 63:327-45.28 Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education—2009. Am J Health-Syst Pharm. 2010; 67:542-58. 13
  • In 2009, of the 97.3% of facilities where pharmacists regularly monitored medication therapy for patients,44.6% had distributive pharmacists regularly perform this function, 44.6% used clinical pharmacists, 65.2%used integrated clinical–distributive pharmacists, 13.5% used pharmacy residents, and 38.3% used studentpharmacists.29Pharmacist involvement in medication safety initiatives, including technology adoption, continues to bestrong, interconnected to others and focused on the medication-use system. Interdisciplinary committeesreviewed ADEs in 89.3% of hospitals. Prospective analysis such as failure modes and effects analysis wasconducted in 66.2% of hospitals and retrospective analysis such as root cause analysis was conducted in73.6%. Safety culture had been assessed by 62.9% of hospitals. ADEs were reported to external groups by60.7% of hospitals.29Looking AheadThe 2010 ASHP National Survey reveals pharmacy directors’ future plans for the pharmacy practice modelin their hospitals. Directors from all sizes of hospitals expected a transition toward a more patient-centered,integrated model and away from a centralized drug distribution-centered model. Some pharmacy directorsat smaller hospitals envisioned moderate growth in the use of a clinical specialist-centered model, whilesome pharmacy directors at larger hospitals envisioned a moderate decline in the use of a clinicalspecialist-centered model.To keep pace with the needs of patients, the desires of personnel, and technological changes, 46.7% ofhospital pharmacy departments were working to change their practice models or had already done so inthe past three years. The most common barriers were a lack of pharmacist staff resources, a lack ofpharmacy staff with needed training, and resistance to change from current staff. Other barriers included alack of automation to support change, a lack of hospital leadership support, and a lack of qualifiedtechnician staff. Only 9.7% of hospitals had not experienced barriers to their practice model changes. Staffissues represented significant challenges to envisioned practice models of hospital pharmacy directors.29Current and Expected Future Structure of Pharmacy Practice29 DRUG DISTRIBUTION- CENTERED 24.4 4.1 PATIENT-CENTERED, INTEGRATED 64.7 83.6 CLINICAL SPECIALIST- 10.9 12.3 CENTERED 2009 Future29 Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education—2009. Am J Health-Syst Pharm. 2010; 67:542-58. 14
  • Building Your Business CaseThe ASHP organizes the medication-use process into six areas: prescribing, transcribing, dispensing,administration, monitoring, and patient education. Examining the dispensing function in detail illustrateshow bar-coding across these multiple steps and hand-offs can ensure accuracy, resulting inimprovements in safety, operational efficiency, and inventory management. This makes bar-codereadiness and bar-code-based systems vital to any patient-focused dispensing initiative or patient-centricbusiness model.Bar-code scanning has been shown to increase safety and reduce errors at all of these dispensing points:• Receipt from the distribution center• Stocking into automation systems or manual pick stations• Dispensing in pharmacy for patient-specific purposes• Dispensing in pharmacy for cabinet restocking purposes• Quality assurance checking by pharmacists or technicians (tech-check-tech)• Restocking at automated medication cabinet• Dispensing at automated medication cabinet• Delivery to nurse server, inpatient medication cabinet, or workstation on wheels near patient roomOver the five years of the The Correlation Between Safety and Savingsstudy, bar-code system While it’s widely accepted that pharmacy bar-codecosts totaled $2.24 million. systems reduce the incidence of dispensing errors,The net benefit after five there are some who question the financialyears was $3.49 million. implications of this increased safety. In 2006, a five-Break-even was reached year study was completed at a “large, academic, nonprofit tertiary care hospital pharmacy”30 in orderwithin one year. to assess the actual costs and benefits of a pharmacy bar-code system implementation.The results were impressive. Over the five years of the study, costs for implementing and maintainingthe pharmacy bar-code system totaled $2.24 million. The dispensing error rate after systemimplementation was reduced by 31%. Even more striking, the potential ADE rate dropped by 63%.30 Asnoted earlier in this paper, additional hospital costs per ADE are $2,200 and $8,750 per preventable ADE.In terms of avoided ADEs alone, the hospital realized annual savings of $2.20 million over the courseof the study. The net benefit after five years was $3.49 million. Break-even was reached within oneyear of the system becoming fully operational.3030 Poon E, Cina J, Churchill W, Mitton P, et al. Cost-Benefit Analysis of a Hospital Pharmacy Bar Code Solution. Archives of Internal Medicine. April 23 2007. 15
  • Granted, the hospital in question is a large facility, dispensing more than six million medication doses annually. However, the research found that implementation of a similar bar-code system at a smaller hospital would show a significant return on investment (ROI), as well. Even with changes in details of system implementation and use, such as leasing, purchasing, or repackaging costs, any hospital with a minimum of 1.75 million annual doses could expect to realize a positive ROI within a five-to-ten-year period.31 Cost and Benefits of Pharmacy Bar Coding31 $600,000 $400,000Cost/Benefit $200,000 $0 -$200,000 -$400,000 1 2 3 4 5 Years — Benefits — Recurring costs — 1-time costs 31 Poon E, Cina J, Churchill W, Mitton P, et al. Cost-Benefit Analysis of a Hospital Pharmacy Bar Code Solution. Archives of Internal Medicine. April 23 2007. 16
  • ConclusionsThe question no longer is if hospitals will become bar-code ready but, simply, when. The economicand professional drivers, along with real-world bar-code readiness and BCMA results, are making itan inevitability. The performance demands of H.R. 3590 and the demonstrated patient care benefitsof increased clinical involvement by pharmacists are creating a perfect storm that aligns the goals ofadministrators and the pharmacy. Increased pharmacy automation and increased pharmacyinvolvement in enterprise technology decisions are the logical outgrowth.Pharmacy automation and bar-code readiness are also critical drivers in achieving meaningful useunder H.R. 1. However, hospitals should bear in mind that the stimulus package does not fund theintroduction of new systems, but rather is meant to accelerate the adoption and implementation ofsystems already under consideration. For this reason, now is the time for Directors of Pharmacy toengage with C-level administrators to formally acknowledge bar-code readiness and BCMA projectsand initiate project planning stages, if they have not done so already.We are in the midst of an important and exhilarating period for health-system pharmacists and theinstitutions and patients they serve. Bar-code readiness is central to the trends already in progress, andwill become only more important to the entire enterprise in the years directly ahead.AppendicesAppendix A: Advantages of Patient-Focused DispensingAutomated patient-centric dispensing:• Assures proper patient-centered pharmacotherapy• Establishes effective drug use and control• Establishes bar-code foundation necessary for BCMA• Improves safety by scanning every medication before leaving pharmacy• Reduces pharmacist dispensing labor, freeing pharmacists for patient-specific roles• Reduces nursing labor by reducing med-prep time and multiple trips to patient rooms• Brings meds closest to patient (WOWs, nurse servers, etc.)• Significantly reduces cabinet overrides (including overrides of medications that cannot be scanned which reach patient bedside without pharmacist oversight)• Reduces nursing complexity, interruptions, and workarounds (associated with cabinets)• Positions hospitals for “just in time” delivery to coincide with medication administration• Introduces standardization and scalability (census increases, fill for multiple sites, etc.)• Increases pharmacy technician labor efficiency• Minimizes duplicative medication inventory on nursing units and waste associated with expired medications• Provides capital cost certainty (no cabinet scope creep)• Eliminates variability in medication processes• Delivers fast time to value and strong ROI 17
  • Appendix B: Examples of the Impact of Bar-Code-Based AutomationEvergreen Hospital Medical CenterKirkland, Washington250-bed community-based facility• Improved medication dispensing accuracy to 99.9%• Conducted nearly 24,000 clinical interventions annually, saving approximately $1.9 million• Cut first dose fill labor by 78%• Reduced cart fill labor by 72%• Decreased crediting labor by 50%• Strengthened narcotics managementShore Memorial HospitalSomers Point, New Jersey300-plus bed, not-for-profit acute care facility• Established bar-code foundation to support patient safety, productivity, and inventory management initiatives• Projected 28% ROI in less than five years, and a project net present value of more than $700,000• Projected 3% annual revenue increase over ten years (totaling $220,000) as a result of accurate charge capture of floor stock and controlled substance medications• 220% increase in documented clinical interventions by pharmacists, resulting in additional yearly savings of $416,000 through reduced ADEs• 90% reduction in pharmacist checking labor• 42% increase in medication inventory turns, effectively cutting inventory costs by 30%, and saving $166,000• 80% reduction in the number of medication stockouts on nursing units• 93% reduction in time required for narcotics reconciliationComanche County Memorial HospitalLawton, Oklahoma283-bed community hospital• Established bar-code foundation to support patient safety, productivity, and inventory management initiatives• Projected 42% ROI in less than eight years, with 7% cost of capital and project net present value of more than $17 million• Projected eight-fold increase in time spent by pharmacists on clinical intervention activities, resulting in annual 10% reduction in ADEs and related costs• 90% reduction in pharmacist checking labor• 33% improvement in technician picking labor and 33% decrease in technician training time• 92% decrease in missing doses and 75% decrease in medication cabinet stockouts• $26,000 savings per year through bulk medication purchasing• $80,000 gain in additional annual revenue through automated medication charge capture during administration• 54% reduction in annual cost of medication write-offs due to expired medications 18
  • St. Dominic-Jackson Memorial HospitalJackson, Mississippi535-bed, not-for-profit, acute care hospital• Established closed-loop, bar-code-based system throughout medication-use process• Immediate BPOC 99.9% scan rate enabled by bar-code automation foundation• 801% increase in the number of pharmacist-patient interventions over five years• Improvement from 0% to 78% of pharmacist time spend on clinical activities• $1.8 million in annual cost avoidance through pharmacist-patient interventions• $204,000 reduction in cost of medication inventory over five yearsHybrid Distribution Case Study(Multiple-hospital analysis of pharmacy-to-bedside hybrid medication distribution system by Shack &Tulloch, Inc.)730-bed Spartanburg Regional Medical Center, Spartanburg, South Carolina649-bed Mississippi Baptist Medical Center, Jackson, Mississippi512-bed The Medical Center, Bowling Green, Kentucky (contains three hospitals)• 99% robot dispensing accuracy• 96% reduction in picking errors with automated carousel• 50% reduction in missing medications• 75% reduction in expedited medications• 10% reduction in ADEs• 60% increase in technician productivity• 39% increase in pharmacist time for clinical activities• 8% increase in nursing time with patients• 75% reduction in expired medication costs• 30% reduction in medication purchase costs• 15% improvement in medication inventory costs• 40% reduction in cabinet assets• 58% composite ROI (6-year project life, no terminal value) 19
  • Appendix C: Business Realization MeasurementsAn oft-repeated management mantra says, “You can’t manage what you don’t measure.” Here aresome common metrics pharmacies use for process improvement and for reporting to hospitaladministration. Tracking these and other relevant metrics can help reassure administrators thatpharmacy automation and bar-code readiness have been worthwhile investments.Medication Dispensing Stage Unit of MeasureLength of Patient Stay DaysPharmacist Labor $/hr.Tech Labor $/hr.Nurse Labor (Vending, Travel, Patient Care Time, Reduced Steps/ $/hr.Improved Workflow, Time, and Motion)Medication Inventory (Turns, Stockouts, etc.) $Medication Turnaround Time % or #/hr.Medication Availability for Administration % or #/hr.Technology ROI/TCO $/5 yearsTechnology Integration with Existing Systems $/interfacesUnit-Dose Readiness of Meds (Scan Readability) %Employee Satisfaction (Nurse, Pharmacy, Physicians) %Patient Satisfaction %Employee Turnover/Employment Stabilization % 20
  • Appendix D: Things to Keep in MindPharmacy automation supports Bar-Code Medication Administration• Positive bar-code identification of drug and patient at point of care• Supports IT strategic plan and provides safety net for nursing• Helps ensure the “five rights” – right medication, patient, time, dose, and routePositive BCMA results are only possible if the right infrastructure is in place• Bar-coded medications• Bar-coded patient ID bracelets• Bar-coded employee badges• Wireless network• Point-of-care hardwareSome common challenges/ barriers• Competing priorities between clinical/quality measure work and order entry requirements for pharmacists• Bar-code packaging burden• Changing NDC codes requiring database changes• Space – balance needs for technology, medication storage, and workflow• Hard to keep the vision over many yearsOperational tips for bar code use• Scan entire order prior to bringing in pharmacy • Identifies NDC changes to correct in database for scanning • Identifies product changes due to drug shortages that must be added to database• Scan test all drugs after packaging – assures “scanability” at bedside• Continually optimize robotics and ADC inventory, check SA/LA drugs in matrix drawers• Make one technician responsible for packaging to create equipment “expert”Lessons from the real world• Engage with the C-Suite early, educating them on the benefits and challenges of automation and bar-code readiness• Talk about the changes often – staff need time to get used to process change• Communicate the benefits – people buy in easier if it helps patients and supports a better practice model• Automation doesn’t equal faster, just safer• Go back to C-Suite and show them the positive outcomes – remind them they made a good decision• Share with the media 21
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