Pharmacy OneSource hosted a webinar “debate” today that had two excellent speakers presenting their cases for which technology should implement first; Computerized Physician Order Entry (CPOE) or Bar Code Medication Administration (BCMA). The webinar was well worth the time.
The case for CPOE was presented by John Poikonen, Pharm.D. John is the Clinical Informatics Director at UMass Memorial Health Care, an Academic Medical Center and health system in central Massachusetts. John is an interesting informaticist as he has repeatedly spoken out against the lack of evidence supporting BCMA. It was a good fit for him to argue for CPOE implementation ahead of BCMA. He brought up some great points and presented a fair amount of literature to back them up. You can read more of John’s musings at RxInformatics.com.
The case for BCMA was presented by Steve Rough, the Director of Pharmacy at the University of Wisconsin Hospital and Clinics, and Clinical Assistant Professor at the UW-Madison School of Pharmacy. Steve has done quite a bit of work with bar code medication scanning technology and presented an excellent case for BCMA.
Both presenters had valid reasons and good arguments for their positions. I for one am in favor of both CPOE and BCMA, but would personally push for BCMA ahead of CPOE for several reasons. CPOE requires a much larger investment in resources, both human and financial, when compared to BCMA. There is also a reasonable expectation that BCMA will stop errors at their most vulnerable point, the administration phase. I’ve mentioned this before and Steve brought up some of the very same points in his presentation. Finally, CPOE requires buy-in from physicians in order to be completely successful. And if there is one thing you can count on it’s that physicians will fight you tooth and nail when it comes to technology and change.
You can grab a copy of the presentation slides here.
I think we need to look beyond this debate of CPOE vs. BCMA to the implications of “meaningful use” of EHR. Although the definition of this term is still under development, it seems clear that both CPOE and BCMA will both contribute to help close the medication management loop and move hospitals toward the goal of “meaningful use”. Hospitals are being incented to adopt certified EHR systems that incorporate both CPOE and some form of “computer assisted administration”.
Jason Hess of KLAS touts CPOE adoption as key to achieving meaningful use. In fact, CPOE is a significant component in the Meaningful Use Matrix. By 2011, hospitals must use CPOE for at least 10% of orders, and Physicians practices must use CPOE for 100% of their orders.
Although there is much controversy about the efficacy of BCMA, I would argue that the shortcoming is not in barcoding per se, but in poor implementations of first generation BCMA products. RxInformatics talks about how the current generation of BCMA applications did not meet expectations due to “design and implementation faults and resulting staff workarounds that mitigate the efficacy of barcoding”. I would conclude that this doesn’t mean BCMA or barcoding should be abandoned, but that there is a huge opportunity for improvement. The first generation of systems clearly fell short of what was needed.
Prior to July, the Meaningful Use Matrix called for “medication administration using bar coding”. Unfortunately, the ONC has since revised the matrix to call for “closed loop medication management, including eMAR and computer assisted administration” without any reference to barcoding. In my opinion this is a step backwards. The ONC has been influenced by inconclusive studies done on first generation BCMA systems. RxInformatics states that these systems have major design flaws that affect their efficacy in improving patient safety. Meanwhile, they admit that barcoded medication systems reduce Pharmacy dispensing errors. If barcoding works in the Pharmacy, why not at the bedside? I would argue that there is a challenge ahead for BCMA vendors, but that barcoding at the bedside should not be abandoned. As a principle, in order to completely close the medication management loop it seems obvious that medications must be scanned upon administration as well as upon dispense.