Update: Looks like they got it working within 5 minutes of me posting this. It’s a nice format. Check it out for yourself here.

Abstract
Medication adherence tends to affect the recovery of patients. Patients having poor medication adherence show a worsening of their condition and/or increased complications. Unfortunately, between 20% and 50% of chronic patients are unable to manage their medications. This study proposes a model to improve the patients’ medication compliance by reducing medication frequency.

Published studies have shown that, based on the patients’ lifestyle, simplification of the medication frequency and remodeling of the medication schedule is able to help improve medication adherence. Therefore, this study tried to simplify medication frequency by combining therapies. Moreover, by adjusting according to lifestyle, the study also tries to remodel medication timing in relation to mealtimes to create personal medication schedules.

In this study, we used 19,393,452 outpatient prescriptions from the National Health Insurance Research Database to verify our system (algorithm optimized). At the same time, we examined the differences between the frequency summarized by general public and experts’ advice medication behavior. Compared with the experts’ advice method, this system has reduced the medication frequency in about 49% of prescriptions.

Using combined medication to simplify medication frequency is able to reduce the medication frequency significantly and improve medication adherence. Furthermore, this should also improve patient recovery, reduce drug hazards and result in less drug wastage.

During one conversation a pharmacist mentioned the concept of “witnessless waste”. Intrigued by the idea he and I started talking about ways to create a system that would allow nurses to waste controlled substances on the floor without the need for a second nurse to witness the process. The need to grab another healthcare professional to witness waste is a problem for any healthcare professional in a busy environment be it nurse, pharmacist or physician.

Anyway, I remember blogging about a system way back in 2010 that could potentially be the foundation for a witnessless waste product. The ValiMed system uses Photoemission Spectroscopy to quickly validate medication admixtures, including controlled substances. Depending on the solution being tested the ValiMed system can perform a comparison in anywhere from 1 second to 1 minute with as little as 0.15mL of fluid. It would be interesting to see a system such as this as a standalone witnessless waste system.

Imagine taking a system like this, developing additional functionality to measure the volume injected, record the nurses information, identify the waste and generate a permanent log of the transaction. These devices could be placed strategically throughout the nursing units for easy waste capture of controlled substances.

Another ideal place for a device like this would be in operating room s (ORs) where anesthesiologists are anything but meticulous with their record keeping when it comes to controlled substance waste. Below is an image taken from a actual OR where drugs were carelessly tossed in a box with no accountability. Can you imagine sorting through a mess like this? I can because I’ve had to do it at various times throughout my career. It’s no fun, and it lends itself to diversion.

A device that could analyze, measure and record waste in real time could go a long way in improving such a haphazard system. Of course this would only work for liquids. Now if I could only figure out how to liquefy tablets on the way into the machine….hmm. 

I had planned on blogging daily during the Summer Meeting, but obviously that didn’t happen. Perhaps it was the big dinner I had yesterday evening followed by the insanely good gelato that put me into a food comma, or then again maybe it was just laziness. Regardless, I skipped a day.

The Summer Meeting continues to roll on with some great sessions and lots of interesting conversation. All-in-all between yesterday and today I’ve attended the following:

• Opening session and keynote – The opening speech was what I expected; a lot of chest thumping and self promotion. Not to say that that’s a bad thing. It is what it is. The keynote, however, was nothing short of spectacular. Dr. Jay Kaplan was engaging and effective in delivering his message on change. I rarely sit through these things, but found myself staying nearly until the very end.
• Putting a face on medication errors: the patient perspective and how humans factor into safety – Medication safety is a big theme this year at the Summer Meeting, and why not. The testimonial given by Robert Weber, Pharm.D. was eye opening. As a pharmacist he experienced some fairly significant errors during his treatment for cancer. It’s hard to believe these type of mistakes still happen day in and day out in healthcare. The presentation on human factor engineering by Terry Fairbanks, MD was great. Healthcare should be making better use of human factor engineering. It may be time for me to go back to school.
• Management Case Studies C: Informatics – Meh.
• Redefining, reconstructing, reinventing: levering technology to impact and achieve the future pharmacy practice model – This was the crown jewel of the informatics sessions at the Summer Meeting. Fortier, Adamson, Churchill and Paoletti did an incredible job of presenting information on the use of technology in pharmacy practice. If you missed this session, you missed out. The session was recorded and I highly recommend you go to http://ce/ashp.org and grab the audio-synched slide presentation as soon as it’s available. I know I’ll be sitting through it at least one more time.
• Taking IT to the next level: optimizing automation and technology beyond the vendor – Another great session. Both Schlesselman and Cavanagh were credible in explaining how to approach optimization of systems to not only save money, but improve efficiency and create a better work environment as well. This is another session you should watch and listen to when available at http://ce/ashp.org.
• Informatics credentialing: is the time right? – Not what I expected. This session was really more about the credentialing process and what’s available than it was about providing evidence for or against pharmacy informatics credentialing. I have a rather interesting opinion about the topic if anyone would like to hear it. I won’t blog about it as it would come out more as a rant than a well thought out position.

The informatics sessions made good use of technology. The room was set up with two large screens; one for the presentation slides and the other for displaying the informatics Twitter stream for Brent Fox’s (@Brent_Fox) ASHP SM 2011 Informatics list. I love the idea, but I did experience some lag between the time I sent my Tweets and when they appeared on the screen, which created a minor problem as described below. 

The informatics sessions also used a new hi-tech polling system. Questions were displayed on the screen and answers could be submitted in real-time using a mobile phone via SMS, via the web at poll4.com or by Tweeting @poll YOUR ANSWER. I tried Tweeting my responses, but the lag mentioned above was problematic. SMS, i.e. texting worked great. I didn’t use the poll4.com at all. I would encourage ASHP to continue using this system as the interaction with the speaker and instant feedback was terrific.

I have to give ASHP credit for making this one of the most social media rich events they’ve ever hosted. ASHP promoted their new ASHP Connect platform, promoted the online version of InterSections, had signs encouraging attendees to blog about their experiences, encouraged the use of Twitter, etc. Which is why I find it inexcusable that there was no Wi-Fi offered in the conference rooms. I can’t quite wrap my head around the idea of promoting the use of the web at every turn and then not offering ubiquitous access to it for it’s members. I am dumbfounded. I asked about it at the meeting information booth and I was told that ASHP elected not to purchase it. Bummer. I’d pay an extra $5-10 per day for registration to have continuous Wi-Fi access. How about you?

Overall, the last two days have been exceptional. I would encourage everyone to consider attending the Summer Meeting next year if given the opportunity. Waiting an entire year between meetings, i.e. one Midyear to the next, is simply too long to wait when there’s so much happening in our profession.

“If you were given the opportunity to present to your DOP, VP and CFO a project that you deem would have the greatest impact on the pharmacy department as well as the health-system in general from any point of view, clinical, financial, operational, without regards to costs, what would it be?”"

John’s response was to “Study under what circumstances pharmacist order review (perfection) could be taken over by automated clinical decision support while increasing quality and safety” in addition to including a nice list of references related to ‘perfection’ (listed at the bottom of this post). I highly recommend looking at the references John provides because they’re informative and enlightening. You can also read more about the ‘perfection’ idea at one of John’s older posts here. It’s amazing that this discussion has been going on for well over a year and to the best of my knowledge has yet to make much headway.

Anyway, there hasn’t been much activity on the question from the listserv, but it was only posted eight hours ago. I’m not really sure the question can be answered in the way the author wants. I always have some things in the back of my mind that I think would have a significant impact on pharmacy practice, and healthcare in general. Unfortunately, In my opinion I don’t think there’s a single item out there that’s worth implementing in a vacuum. Rarely is a single piece of automation or technology going to make a drastic, wide-sweeping change in how pharmacists do their job. Most of the time we see incremental improvements that slowly evolve over time to drive us in a new direction.

As John mention’s at RxInformatics, automated order processing could have a big impact on the way we practice by significantly reducing the amount of time pharmacists spend entering trivial orders. Pharmacy automation in the form or robotics, automated IV preparation, automated packaging, etc also creates an environment where pharmacists have more freedom with their time. Clinical surveillance software can free up pharmacists by pinpointing patients that need pharmacists intervention without the necessity of having to rummage through hundreds of “normal” patients and worthless documentation to find them.

Another idea on the listserv proposed the use of RFID technology to provide real-time medication tracking with integrated CDS. Anyone that knows me understands that I’d love to see that one come to fruition as I’m a big fan of RFID technology. However, based on what I’ve learned in recent months RFID technology isn’t quite ready for prime time application in pharmacy. Not yet, anyway.

So, what project would I deem having the greatest impact on the pharmacy department as well as the health-system in general from any point of view? I can’t think of a single solution, but rather a complete overhaul with implementation of many complex pieces of automation, technology and strategic workflows.

There’s nothing on the market today – software, hardware, practice model – that’s advanced enough to “fix it all”. Just sayin’

References listed by John Poikonen at RxInformatics.com

1. A new term for transcribing Am. J. Health Syst. Pharm., Oct 2008; 65: 1801 – 1802. http://www.ajhp.org/cgi/content/full/65/19/1801
2. Flynn AJ. Opportunity cost of pharmacists’ nearly universal prospective order review. Am J Health-Syst Pharm. 2009; 66:668–70.
3. Poikonen J. An informatics perspective on nearly universal prospective order review. Am J Health-Syst Pharm. 2009; 66:704–5.
4. D. A. Tribble Automating order review is delegation, not abdication Am. J. Health Syst. Pharm., June 15, 2009; 66(12): 1078 – 1079.
5. P. G. Pierpaoli Creatively using our intellectual capital Am. J. Health Syst. Pharm., June 15, 2009; 66(12): 1087 – 1087
6. IBMs’ Watson 1; Human Jeopardy contestants 0 http://www.pcmag.com/article2/0,2817,2375791,00.asp

I spent the day tracking down pharmacy automation and technology. Did you really expect me to do anything else? I don’t ever recall being as excited as a clinician as I am being an informatics pharmacist. Anyway, here are some things I found interesting:

• The first session I attended today was Better Patient Care and Safer Staff with IV Compounding Automation presented by Eric Kastango, RPh and Tom Crampton, PharmD.
  • Kastango shared some great information on how automation can be used to not only assist pharmacies in meeting USP <797> standards, but provide increased patient safety as well. He presented some eye opening facts regarding the number and severity of mistakes created during the IV compounding process. While he didn’t speak specifically about a single automated compounding device (ACD), he did present the conceptual value of such devices. He referred to them as “idiot savants”, which I find strangely accurate. My favorite quote from his presentation comes from Bill Gates, “The first rule of any technology used in a business is that automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency.” This is a truism.
  • Tom Crampton spoke about his experiences with automation and technology in IV preparation as the director of pharmacy at Allegiance Health in Michigan. He laid out quite an extensive history of their journey from little automation to where they are today. In addition he presented some great data showing the value that automation has brought to his department as well as how it has had a positive impact on patient safety. One take-away from Crampton’s talk was that you shouldn’t forget about the human element while implementing automation and technology because as humans we always find a way to mess things up. I was impressed by his vision and implementation of pharmacy automation and technology. Allegiance Health would be a great place to visit.
  • I walked away from this presentation with a question burning in my mind; has the implementation of USP <797> been shown to reduce drug errors and decrease patient infection rates? Seriously, I don’t know. Presenters talk about USP <797> with absolute confidence, but I don’t recall ever seeing any solid evidence that it alone has made a significant difference in drug errors or patient safety. If anyone knows differently please don’t hesitate to educate me.
• Following the presentation on ACDs I took a field trip to the exhibit hall where I spent some time looking at all the different ACD vendors. The two devices that caught my attention were RIVA and i.v.STATION, and of those two I was more impressed with i.v.STATION. The i.v.STATION device had a much smaller footprint and moved smoothly and efficiently through the compounding process. I thought it was pretty cool. Here’s a video courtesy of McKesson and Health Robotics showing i.v.STATION in action.

• I spent the late morning and early afternoon meeting with some colleagues and talking specifically about pharmacy technology in the acute care setting before making my way to the poster sessions. There were quite a variety of posters on display, from your typically IV stability studies and impact of pharmacy services on various areas of care, to how pharmacists are using social media like Twitter and Facebook. If you get the opportunity I would highly recommend checking out the posters. There’s always a couple of gems in there, you just have to root them out.
• My afternoon concluded with a session titled “Clinical Rule Development and Sharing: The Power of Collaboration” presented by John Poikonen, PharmD and Allen Flynn, CPHIMS, CHS. This session focused on the development of clinical rules for use in various pharmacy systems and the struggles associated with developing these rules in a standardized, reusable format. During the presentation John and Allen spent about 20 minutes developing a theoretical clinical rule with the help of the audience. By the time various pieces of logic were built into the rule it became obvious why developing a set of these rules is so difficult. In addition to developing the templates for the clinical rules John touched on some collaborative efforts that are under way to develop an open source cloud based set of rules that could be leveraged against existing pharmacy information systems. What a great concept.
• And just to top it off I returned to my room to discover that a Podcast interview that John Poikonen and I did with Todd Eury for Pharmacy Technology Resources had been posted.

It really doesn’t get much better than that, but then again there’s always tomorrow.

As this is only my second ASHP Midyear in my career I’m excited to see if the experience matches that of last year. I’m sure it will as I continue to be impressed by the number and variety of sessions crammed into such a short period of time. Of course I’m particularly interested in the informatics sessions, but it’s ok if you find yourself sitting in on one of the talks updating you on what’s happening in the clinical world. I won’t hold it against you.

The week for me will kick off on Sunday morning with the Talyst Users Group meeting followed by a session on RFP’s and contracts put on by the ASHP Section of Pharmacy Informatics and Technology’s Advisory Group on Pharmacy Operations Automation. I’ll round out Sunday’s activities by attending the McKesson Safe Compounding Reception. And it will only get better from there as the week will be filled with sessions on clinical decision support, barcoding, telepharmacy, the application of social media to pharmacy, and so on and so forth.  My week will conclude with the session titled mHealth: There’s an App for That where I will be presenting information on the integration of the iPad into pharmacy services.

The information I’m presenting was pretty cutting edge at the time I submitted the slides, but is now clearly dated. That’s the downside of having to submit presentation slides so far in advance. Anyway, it should still be worth the time and effort. I’ve always found it educational for myself to present information to people as someone always has something interesting to add or a good question to stimulate the thought process.

I’m looking forward to the next five days. I’ll be Tweeting (@jfahrni) as much of the event as possible in addition to posting about the day’s activities whenever feasible. I hope to see you there. If you’d like to get together and talk a little pharmacy informatics/automation don’t hesitate to give me a Buzz, Tweet or email.

I am a fan of automation and technology in any setting, but especially in the acute care pharmacy. I believe that the continued use, development and advancement of pharmacy technology should be a key component of any plan to change the current pharmacy practice model. Unfortunately, the situation is problematic because current pharmacy technology is either poorly designed for the needs of the pharmacy or the pharmacy in which it is used has a poorly designed workflow that doesn’t take advantage of it. Why is that? Who’s to blame; someone, anyone, no one? Valid questions.

I had an incredible opportunity this week to spend time with some people who research, design and implement pharmacy automation and technology. It’s eye-opening and refreshing to speak with people who are passionate about the same things as me. We all sat around a table in an informal, conversational manner and threw around a lot of ideas, talked philosophically about healthcare and gained insight into a great many things. The entire session was very productive and educational. But one of the most important messages I walked away with was the understanding that the designers of pharmacy automation and technology are not the limiting factor in the advancement of pharmacy practice; we are. Their ideas and thought processes are clearly ahead of the current thinking in healthcare, specifically pharmacy. I’m not exactly sure why pharmacy is slow to consider the future, and even slower to adopt new technologies, but here are some things I think might contribute to the problem:

• There is a clear lack of pharmacist involvement in the development of pharmacy automation and technology – Sure there are some pharmacists that dabble in software development, or play around with new technologies, but overall there appears to be little interest within the profession. I see this at meetings where informatics sessions have very few attendees, while the clinical sessions are bursting at the seams with pharmacists trying to get a peek at the latest information for disease state management, clinical application, etc. The most interesting thing about this scenario is that the information presented in the “clinical sessions” is rarely cutting edge. The information is valuable to many, but most, if not all of it can easily be found in the literature. Pharmacy automation and technology information, on the other hand, is often times much harder to come by. Take a look at the recent blog by Dennis Tribble. He touches on the software side of things only, but the idea is applicable across all pharmacy automation and technology.
• Healthcare administration fails to see the big picture – Hospital administration often fails to see the advantages of automation and technology implementation in the pharmacy. If you’ve ever worked in an acute care pharmacy you know exactly what I mean. It is a rare hospital indeed that can see the benefits of spending time, energy and money on improving pharmacy operations. How do you improve pharmacy operations? You streamline the distribution process, and one way to do that is through judicious use of automation and technology. What does improved pharmacy operations get you? Efficiency, which translates to more pharmacist time for clinical activities. What does increased pharmacist clinical activity get you? Fewer drug misadventures, better and safer patient care, and a significant cost savings to the healthcare system. Simple, logical, reasonable thought, but rare in the healthcare environment.
• There is a lack of innovators in the field – Let’s face it; if pharmacists were innovative we wouldn’t still be using the same practice model that we’ve had for over two decades. Even the recent PPMI Summit put on by ASHP offered relatively little innovative thinking. I haven’t had the opportunity to go through all the PPMI presentations, but what I’ve seen to date are simply iterations on the same old theme. We continue to speak in terms of “current” practice instead of talking about “future” practice. I think it’s time to pick a goal that seems crazy on the surface, and then start designing the methods and strategy to make it work. Somewhere along the way a vision of the future will emerge. Smartpumps, automated dispensing cabinets, carousel technology, automated packaging, robotics, etc are all valuable technologies used in pharmacy today. Yes, today. While we should continue to develop, standardize and streamline today’s technology, we must begin to investigate the future; period.
• There is a clear lack of pharmacy leadership from the top down – I don’t know how else to say this, but there are few leaders in the pharmacy world that have the foresight and testicular fortitude to do what needs to be done. One of the themes of the PPMI Summit was to “be bold”. To do that pharmacy leadership from the top of the corporate ladder to the front lines of pharmacy practice are going to have to make changes, lots of changes. We cannot be afraid to fall flat on our collective faces. The detriment to innovation and development is being in a comfort zone, and being afraid to do something that might not work. Failure is a tool, one that the profession of pharmacy has failed to utilize.
• Pharmacy refuses to be empowered – Vendors give us the ability to help ourselves, but we refuse to accept it. We refuse to utilize key features and concepts of the technology we have at our disposal and we refuse to take ownership of making sure the hardware and software we use is used to its fullest potential. Several times during the scrum described above someone asked me why I simply didn’t use a particular feature of a product to do something I was lamenting over. My typical response was that I wasn’t aware of the feature they were speaking about. That’s disappointing as I should be familiar with the product’s capabilities; my fault not theirs. The vendors create a product, provide the end users with training, produce training manuals and videos, have listservs for us to bounce ideas off other users and give us “help desks” that we can access for additional information when we get ourselves in trouble. What else can they do? They can’t force an end user to use the technology correctly or to its fullest potential. I’m guilty of putting blame on the vendors because it’s easier than working harder to get the most out of their systems. I think it’s time I changed my approach.

That’s it. We’re our own worst enemy. It’s time to point the finger at ourselves and critically evaluate our endgame. Let’s be honest with ourselves and work toward the answers, whatever they may be.

I’m looking forward to ASHP Midyear in December as it will give me the opportunity to visit with other pharmacists from across the country. I’m interested in finding out what the real opinion is about our future and where pharmacy automation and technology fits in that plan. I often gain more knowledge and information by spending time with these pharmacists than I do any other way. I’m excited about it and hope to see you there.

The World Health Organization (WHO) defines PV as:

Pharmacovigilance is concerned with the detection, assessment and prevention of adverse reactions to drugs. Major aims of pharmacovigilance are:

1. Early detection of hitherto unknown adverse reactions and interactions

2. Detection of increases in frequency of (known) adverse reactions

3. Identification of risk factors and possible mechanisms underlying adverse reactions

4. Estimation of quantitative aspects of benefit/risk analysis and dissemination of information needed to improve drug prescribing and regulation.

The ultimate goals of pharmacovigilance are:

• the rational and safe use of medical drugs
• the assessment and communication of the risks and benefits of drugs on the market
• educating and informing of patients.

Almost every mention of PV I found referred back to the WHO definition, so I will consider it my working definition for now. Based on the WHO definition it appears that PV focuses on surveillance of problems after the fact with emphasis on finding ways to prevent them from occurring in the future.

HIMMS defines CDS as “a clinical system, application or process that helps health professionals make clinical decisions to enhance patient care. Clinical knowledge of interest could range from simple facts and relationships to best practices for managing patients with specific disease states, new medical knowledge from clinical research and other types of information.” The HIMMS definition of CDS is very broad and could be used to describe almost any piece of hardware or software used in the healthcare industry. So based on this definition I suppose PV would be considered a sub-category of CDS.

Personally I have always considered CDS to consist of systems designed to present clinicians with important patient related information during the decision making process, hence the ‘DS’ in ‘CDS’. This would include clinical alerts, drug-drug interactions, real-time laboratory notification, disease-drug incompatibilities, etc. While these systems can act as standalone applications, I’ve found them to be more beneficial when used in conjunction with existing clinical systems, such as a pharmacy information system (PhIS) or computerized provider order entry system (CPOE).

Some third party vendors that provide CDS software include:

• Clinical XPert Clinical Workflow Solutions by Thomson Reuters. This solution is designed to “give clinicians real-time access to patient data to support clinical surveillance, patient rounding, medication reconciliation, and clinical care coordination.”
• MedMined Data Mining Surveillance Service by CareFusion. Because MedMined is a “tool for discovering clinically meaningful patterns in complex data sets” I suppose this makes it specifically a PV system under the CDS heading. Right?
• Dynamic PharmacoVigilance Module (DPV) by Vigilanz. I suppose there is no arguing that this system clearly falls into the PV category.  DPV “automates the monitoring of drug therapy and its effect on patient physiology, as well as the changes of patient physiology and the resultant impact on drug therapy. It identifies preventable adverse drug events in real-time and provides the clinician with actionable data and guidance.”
• TheraDoc by Hospira. There are several products under the TheraDoc umbrella.
• Sentri7 by Pharmacy OneSource. “Sentri7 is a software as a service (SaaS) web-based platform that pulls information in real-time from your disparate hospital information systems, stores, and analyzes it to assist you in making decisions. You can use preconfigured clinical rules or set up your own that notify healthcare personnel about intervention opportunities.”

To be truly effective I believe that any type of CDS tool must be available on any device independent of platform. It shouldn’t matter whether the device is a smartphone, tablet, netbook, laptop or full blown desktop computer. In addition, CDS tools must also be well integrated into any and all hospital systems to be beneficial to the end user.

Consider CDS a centralized database hub with the brains and logic to find potential outliers in your system and intervene before something bad happens.

Anyway, the presentation is below. There is an embedded video near the end that didn’t pull into SlideShare. It’s about a 30 second look at how we use Citrix on the iPad to access various clinical applications. I attempted to upload in to YouTube, but kept getting an error. I’ll try again later. If you want to see the elongated version of the videos simply go to YouTube and type in “Kaweah Delata iPad“, or something similar, and several options will pop up.