Does charge-on-chart hurt or help medication chain of custody?

By | April 4, 2017

Historically, hospital pharmacies have used a charge-on-dispense (COD) model for medications. The model charges the patient for a medication when it is dispensed from the pharmacy and credits the medication if it’s returned to the pharmacy unused. Simple, but labor-intensive. The model itself has been around for a long time.

The introduction of electronic health records (EHRs) and electronic medication administration records (eMARs) has pushed the COD model aside in favor of the charge-on-chart (COC) model; sometimes referred to as “charge on administration” (COA). In the COC model, the patient isn’t charged for a medication when it is dispensed from the pharmacy because the charge is captured when the medication is scanned by the nurse and administered to the patient. When the nurse scans the medication, the information is captured by the eMAR and charted, hence the name. There are several benefits to this model, including no need for the pharmacy to credit medications that go unused. Unused medications are simply returned to the pharmacy and folded back into the inventory.

Put simply, the COC model eliminates the need for pharmacies to charge and credit medications as they are dispensed and returned to the pharmacy. But here’s a little untoward side effect of the COC model, it eliminates much of the pharmacy audit trail for medication movement into and out of the pharmacy.

The old COD model wasn’t perfect, and there were plenty of discrepancies, but I wonder if the COC model has created even less transparency regarding inventory reconciliation and the movement of medications throughout the hospital.

Inventory management systems like AutoPharm from Talyst and Pyxis Pharmogistics from Carefusion should, in theory, give pharmacies real-time inventory numbers. But the promise of these systems has fallen short. Both utilize barcode scanning to track inventory, which unfortunately requires humans to be diligent when scanning items in and out of inventory. Human laziness usually prevails, and numbers are frequently inaccurate.

Medication tracking systems are available from a couple of companies, but also utilize barcode scanning, thus fall prey to the same weakness mentioned above. These systems also fall short when following medications throughout the medication distribution process as they typically stop as soon as the medication is delivered to the nursing unit, i.e. they don’t track the return of the medication.

Track and trace regulation, which will require serialized barcodes and tracking from manufacturer to patient, could potentially help with this issue. However, that process has the same weaknesses as those mentioned above, namely human intervention.

RFID technology would surely be better than barcode scanning, except that RFID tags are too costly for use on all medications and drug manufacturers are nowhere near ready to do anything like this.

Currently, the only medications that receive enough scrutiny in a pharmacy to determine location and quantity at any given moment are controlled substances, i.e. morphine, fentanyl, oxycodone, and so on. And this falls short on some level once the medication leaves direct oversight of the pharmacy.*

It’s interesting to think that as much time as we spend managing inventory in a hospital pharmacy, we still have a long way to go.

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*This includes leaving the pharmacy itself as well as storage devices like automated dispensing cabinets (ADC). When a medication leaves the ADC we assume it has been administered to the patient once it has been charted. We cannot confirm this, however. For all we know, the healthcare provider that removed the medication and documented the administration, simply put it in their pocket and walked out with it. You never know for certain.

One thought on “Does charge-on-chart hurt or help medication chain of custody?

  1. Warren Quillin

    As you know there is even more to COC (COA) than you described in you article. The setup is complicated and there is a rather intensive reconciliation process to get the charges corrected daily. Plus drugs that require a JW modifier are even more complicated. Then there are the areas that don’t scan routinely like surgery and the hospital’s OP clinics. So there is quite a lot of maintenance to keep up with this, plus somebody has to audit the charges regularly and fix the issues that come up. Humans will always be involved till someone invents some better AI type technology to do this better, but probably not till after I retire.

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