Adoption of iv room technology

On March 14 I posted a piece called Recommendations for technology-assisted CSP preparation.

The piece received a fair amount of traffic and some good feedback, including a comment left at my site – something that rarely happens. The comment’s author had some interesting, and valid, points. One item in particular caught my attention:

I have specific concerns with your recommendations: 1. “Must be simple to install, use. and maintain”: Even the best and more well-designed CSP production process is not a “simple” process. I’ve observed innumerable different hospitals’ CSP production processes — and there is ONE absolute truth: they are ALL different; and one nearly absolute truth: each technician makes a specific product “his or her way”. Absent a clear commitment to process standardization by a pharmacy, adding technology cannot ever be “simple”. And process change is rarely or ever “simple”.

Two thoughts on the above:

1) “Simple” is a relative and comparative term. It’s not black and white. “Simple to install” can mean many different things. Once, when I was much younger, the starter went out on my Chevy pickup. I called my grandpa for advice. He gave me instructions and told me it was a piece of cake and shouldn’t take long. Two hours later and more frustration than I care to admit, I was still crawling around under my truck with a quivering arm, busted knuckles, and no starter. Again, I called my grandpa. He showed up a while later, crawled under my truck, and with the starter in one hand, and a socket wrench in the other, proceeded to install the starter in a matter of minutes. To him is was simple. Something he’d done dozens of times. For me, having never changed a starter, it was complex and difficult. It’s all relative.

A specific iv room system may be quite difficult to install, but may be much simpler than its nearest competitor. Again, it’s relative. If I were a pharmacy director, or a pharmacy operations manager, I’d pick the easier route given similar functionality. In fact, being simple to install, use and maintain are at the top of my criteria for choosing pharmacy technology. If you can’t meet those criteria, then you had better have one heck of a system, otherwise you’ll end up on my cutting room floor. Pharmacy is a mess, adding unnecessary complexity is bad mojo.

2) I believe this is an old-school mentality. That is to say “this is how I built it, now deal with it”.* If there’s one thing the consumer industry has taught us is that people will chose the product that is simple to use, even at the loss of functionality. Vendors should always strive to make things simple to install, use, and maintain. Always. One of the biggest mistakes I see in pharmacies is failure to standardize, simplify, and minimize. People talk about “LEAN” and other similar processes but then turn right around and do the opposite.

Don’t take my word for it. Do a little research. According to a systemic review by Greenhalgh, et al. (1) technologies are more readily adopted when they (emphasis is mine):

  • Have a clear, unambiguous advantage in either effectiveness or cost-effectiveness
  • Are compatible with the adopter’s values, norms, and perceived needs
  • Are perceived as simple to use
  • Offer trialability, i.e. users can experiment on a limited basis
  • Observable benefits
  • When the technology can be refined and modified by the adopter to meet their specific needs
  • It is relevant to the user’s work and improves task performance
  • Knowledge to use the innovation can be codified and transferred easily
  • Carries a low degree of uncertainty, i.e. they are perceived as having little risk.
  • The technology is offered as an “augmented product” (e.g. with customization, training, and a help desk).

On the flipside, innovations are less likely to be adopted when the items above are put into a negative light, i.e. items are ambiguous, are incompatible, difficult to use, offer little to no benefit, and so on.

Do the same drivers of adoption outlined by Greenhalgh apply to pharmacy? It’s difficult to say for sure as there has been no pharmacy-specific data to suggest they do or don’t. However, I think they do. There are items in the list that will seem like common sense to some, while others will view them as nonsensical. For example, trialability is something that is rarely available to end users prior to selecting pharmacy technology. One may have the option to see the product in a live environment, which I highly recommend, but seldom does one have the ability to spend any appreciable time for a trial period. In contrast, compatibility, once seen as low priority, now tops many lists when evaluating technology purchases. I believe this is a byproduct of the increased adoption of electronic health records (EHRs), which are seen as integrated and compatible with many systems. Whether or not EHRs actually provide such integration, interoperability, and compatibility is an entirely different matter.

Usability – i.e. being simple to install, use, and maintain – has only recently landed on the radar of pharmacies interested in purchasing technology. We can thank the consumer market for that. Today’s consumer gadgets focus more on usability than true functionality. This has begun to spill over into other industries, most notably healthcare. I can recall my experience with pharmacy information systems (PhIS) during the early years of my career. They were terrible. The systems were often functionally rich and usably poor. It wasn’t until quite recently that PhIS’ become more usable. One has only to look at the introduction of EHRs, and subsequent outrage by physicians, to see why. Physicians wield a disproportionate amount of power within healthcare systems, so when they were forced to begin using EHRs with poorly designed user interfaces, the vendors heard about it. The result of all that complaining has led to significant improvements in usability. Because the PhIS is an integral part of many EHRs, pharmacists have benefited greatly. I dare say that we are nowhere near the experience seen in consumer products, but the improvements are nonetheless welcome.

Awareness of usability in pharmacy system will only continue to grow. The next generation of pharmacists and technicians have grown up with technology in their hands and it’s going to spill over into the products they chose for the pharmacy. So companies better take note. It’s time to simplify the installation and maintenance processes, standardize the user experience across your product line, and minimize complexity.

———————–

* Akin to “Hey you kids, get off my lawn!”

(1) Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., and Kyriakidou, O. (2004). Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. The Milbank Quarterly, 82(4), 581–629.

2 thoughts on “Adoption of iv room technology”

  1. Hi Jerry,

    Can’t resist: Why does everyone in healthcare assume that “what we do is different and needs its own special answer”?

    There is NO NEW TECHNOLOGY here. ALL of the techniques and technologies being “discovered” in this area are, from the viewpoint of every other industry’s manufacturing process, genuinely ancient.

    Want to see barcoding in use to track inventory and enable billing? Go to a supermarket. Want to see barcoding in use to manage complex assembly processes for electronics? Go to ANY manufacturing line. What you will ALSO see is carefully crafted and optimized workflow and the elimination of process variation. Want to see that in action without barcodes? Visit Burger King or McDonalds and “have it your way”. You can be absolutely certain that every BK or McD’s will make your custom sandwich using the exact same workflow. I’ve watched this in Israel, London, and the US — and even through the menu varies, the workflow is the same.

    Compounding CSPs is JUST an example of low volume/high mix manual manufacturing – and by no means in any way unique enough to make the learnings in every other industry inapplicable. Virtually every potential iota of an issue encountered with this type of manufacturing process has been exhaustively and thoroughly explored, solved, and proven out by literally tens of thousands of manufacturing process optimizations.

    In our case, every ingredient (yes, the same barcode is on every vial of one manufacturer’s Cefazolin vial) and tool (parenteral syringe, repeater pump, scale, etc.) is known and understood.

    The lessons of thousands of person-years on the topic include:
    a. Process variation by the “operator” is a clear path to increasing quality issues.
    b. Workflow STANDARDIZATION and OPTIMIZATION are the keys to quality results.
    c. “Inspecting quality into a process” is the least viable approach to quality improvement (never succeeds/costs more than it’s worth).

    There is no new technology adoption curve to drag pharmacy IV rooms through as “pioneers”. Compounding CSPs is not an art form – it’s a manual manufacturing process.

    At issue is ONLY the willingness to accept the notion that “the way we do it” is the issue — and not the tools we scatter around our IV rooms and hoods.

    The hundreds of hospital pharmacies who have succeeded in re-engineering their PROCESS of making IV doses and thereby making them safer, more consistent, better tracked/managed, reducing waste, improving turnaround, etc. – are pioneers in that they accepted that “the way we do it” doesn’t cut it.

    The few places where these efforts failed / were rejected have not been 100% the fault of the tools — there’s a giant portion of the root cause in “we didn’t commit to changing our process”

    SAP (the largest enterprise management SW product) bases its effectiveness on NOT doing things the way their customers were doing it before SAP. Experience proves that you either adopt “the SAP way” to run your processes or your ERP project fails. This is not SAP’s arrogance – it’s hundreds of projects of process learning at work.

    Those who have been through an EPIC conversion may well have seen the same approach.

    Please let’s not turn this into something philosophical about simplicity or the tools available. It’s about “changing US” — which is NEVER “simple”.

    Best

    Dennis

  2. Dennis-

    Appreciate your thoughts. I don’t disagree with anything you said. If you’ve read my site over the years, you can probably find similar thoughts throughout. However, I don’t think EPIC is a great example as regulation and government incentives have driven that process. I’ve come across several healthcare systems that are suffering from buyers remorse. Of note, I’ve used EPIC. While it has several great features, it’s a usability nightmare. Also, the “they didn’t know what they wanted until we built it” argument is old and tired. It’s worked a few times, and those are the stories everyone points to. How about the thousands of failures based on the same principle. I believe it’s a combination of strategies – a bit of what they need plus a bit of what they don’t know they need.

    I have great respect for your knowledge and consider you part of the elite number of individuals that recognized the problem and began working on a solution long before anyone else. I don’t feel that my thoughts are any more philosophical than yours. We must discuss simplicity and available tools. As you pointed out, nothing in this space is new, innovative, or exciting. So why are things such a mess? Because we don’t talk about simplicity and standardization nearly enough. Perhaps we’re looking at the problem in the wrong order. Perhaps we should work on simplification and standardization first, then provide tools that make sense within the defined workflow. Then again, maybe not. Pharmacy remains the wild west of workflows, which is why technology designed for the IV room is all over the board.

    Again, appreciate your thoughts.

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