The ZiuZ Inspector:

• Verifies the contents of each unit dose bag by analyzing the size, shape and color of each item
• Takes a photo of each side of the package and saves it for future reference. The images can be viewed with the ZiuZ Viewer pictured below.
• Can handle up to 3600 unit dose bags per hour

Just think, you don’t even have to be at the packaging site to verify the contents of each bag. All you would have to do is use some type of telepharmacy setup. Tech-check-tech anyone?

That’s pretty simple. Sure beats the heck out of counting the tablets by hand. 5…10…15…20….

More information on the Eyecon Pill Counter can be found here.

Pharmacy IV rooms are no longer overlooked when implementing innovative technologies. As pharmacy operations continue to evolve it is becoming clear that IV rooms are starting to receive their due respect. A certain percentage of healthcare systems already utilize some form of technology in the IV room, however the numbers are small. A 2007 ASHP national survey on informatics found that, depending on number of beds, between 9% and 27% of facilities were utilizing some form of device in sterile product preparation¹ (small-volume and large-volume parenterals). It is unknown what technologies these facilities were utilizing at the time of the survey.

Based on information from the 2011 Pharmacy Purchasing & Products survey on the State of Pharmacy Automation, adoption of automation and technology in the IV room remains low. Only 4% of those pharmacies surveyed were using a robotic IV device.² Of those 4% most implementations were in large hospitals. Furthermore, the survey shows that the overall use of robotics in acute care pharmacies is declining. However, that same survey showed increased interest in IV room automation, specifically “workflow management” systems. Approximately 20% of all survey respondents indicated interest in implementing one of these systems, 10% within the next two years.

This was the focus of another recent Pharmacy Purchasing & Products article.³ The article discusses the implementation of IV workflow management tools at two sites within Indiana University Health: Riley Hospital for Children and Bloomington Hospital. According to the article “Prior to adopting IV management tools, [they] employed [a] rather unsophisticated method for processing IV orders common in many hospitals. Labels were printed for individual IV doses or batches three or four times a day and a pharmacist would hand off the labels at the cleanroom pass-through window for a technician to sort by time.” This is common practice in many acute care pharmacy operations.

Indiana University Health determined that their system was outdated and basically unsafe, which led them to search for a viable alternative. Their review resulted in the selection of an IV workflow management system because “such technology could provide the solution [they] needed to bridge the gap between [their] overall bar code scanning protocol and [their]IV dose preparation process.”

Implementation provided Indiana University Health with several advantages over their previously utilized system for IV preparation. Items specifically mentioned in the article include:

• Improved safety through the use of bar code scanning
• Reduced waste
• Expiration tracking for compounded medications
• Standardized method of training and preparation
• ncreased accountability
• Improved data and reporting for medications compounded in the IV room

Overall the technology has been well received and successful at Indiana University Health. The article concludes with “this type of scanning should become the standard of care for all facilities with compounding processes in place.” I agree.

References:
1. Am J Health-Syst Pharm. 2008; 65:2244-64
2. State of Pharmacy Automation, Pharm Purch Prod. 2011
3. Pharm Purch Prod. Nov. 2011, Vol. 8, No. 11

Afterthought: DoseEdge is dominating the workflow management category inside the IV room at the moment. I’ve talked with a lot of pharmacy directors over the past 6 months and they’re either using DoseEdge or evaluating it as an option. I wrote about DoseEdge nearly two years ago here.

Baxa Corporation webinar on “DoseEdge®: Changing Pharmacy Practice Through Workflow Management.” Presented by Dennis Tribble, PharmD, FASHP. Original air date: March 25, 2010

From HealthOneMed’s website (the interactive display of the DAP’s capabilities is cool):

Dispense-a-Pill
HealthOneMed’s Dispense-A-Pill (DAP) Personal Medication Manager addresses the issue of medication non-compliance by integrating the disparate approaches of pill boxes, reminders, pill dispensers and medication alert devices into a single comprehensive device enabled by new technology developed and patented by HealthOneMed.

Click here to download the DAP brochure.

Safety & Security
DAP is unparalleled in its safety capabilities, including its “No-touch” pill organizing, loading and dispensing, advanced medication on demand capability (e.g. for “take as needed” medications), password protection (e.g. caregiver medication instructions not overridden by individual), childproof setting and battery back-up in case of power loss.

Personalization & Connectivity
HealthOneMed is unique in its approach to integrating personalization into the DAP.  Enabling the DAP to record personalized medication reminders (e.g. a granddaughter recording a reminder message, “Grandpa, time to take your medicine”) helps an individual adhere to his medication protocol. FunMinderstm are personalized reminders that can be set for life’s other important activities, errands or appointments. In addition, caregivers can view medication compliance history and be alerted if an individual misses his medication.

Capacity
The DAP is unique as it can manage up to 16 pill and non-pill medications.  The DAP can store and dispense 90+ days of up to 8 different pill medications as well as manage up to 8 additional pill and non-pill medications, including topical creams, liquids, eye drops, inhalers or insulin injections.

Click here to view an interactive display of the DAP’s capabilities.

Click here to view the DAP’s FAQs.

MedVantx, Inc., has announced the deployment of its patent pending Patient Profile™ patient medication and adherence reporting engine across its network of 3,600 high prescribing primary care providers participating in the Company’s integrated program of initial free medication therapy, adherence management and home delivery program. This new program utilizes the Company’s proprietary automated ATM like sample management system (“MedStart™“) and an integrated secure web reporting portal to provide physicians visibility to their patients’ adherence to chronic medication therapy…

The MedStart™ system automates the traditional sampling process for the physician; captures physician sampling data for inclusion in the patients’ claims history medical record and provides consumers access to highly relevant drug and disease state educational materials. Since patients don’t always get prescriptions filled, physicians can enhance adherence by providing their patients with initial therapy and better informational tools to manage their conditions right from the office…

 

Now with the availability of the MedVantx Patient Profile™, physicians are able to view data about how patients, on an individual basis, are complying with their prescribed medication treatments.  By showing exactly when a patient fills prescriptions, physicians can detect late refills, gaps in medication fulfillment, discontinued treatments and more to accurately access and improve patient compliance.

Interesting concept. I often wonder if simply getting rid of chain and grocery store pharmacies, and going back to neighborhood community practices would be the best way to improve patient medication compliance. I’ve worked in chain, grocery store and community pharmacies and have always felt that the small community practice knows their patients best and provides the best patient care when it comes to medication management. Something to think about anyway.

More on the system mentioned above can be found at the MedVantx website.

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.

Pharmacies can use PharmASSIST OPTIx in stand-alone mode or integrated with Innovation’s PharmASSIST Symphony® workflow systems, which enables end-to-end prescription tracking, problem management, and reporting. In addition to processing a pharmacy’s countable medications, PharmASSIST OPTIx handles all non-countable products (e.g., ointments/creams, liquids, syringes, inhalers, etc.) for prescription filling and remote verification. The system can also assist pharmacies with physical inventory control.”

It reminds me of a non-cleanroom version of DoseEdge.

Additional automation is needed for it to be a real game changer, but it’s still pretty cool technology. It would be slick if the person filling the prescription never had to touch the product and the end result could be remotely verified.

Product website here.

OPTIx brochure (PDF).

I avoided the more traditional sessions on therapeutics, choosing instead to focus on the informatics and medication safety sessions. Based on the information presented it was obvious to me that these two disciplines are intimately linked. After all, the idea behind much of the technology we use in healthcare today is to improve patient safety.

In 1999, the Institute of Medicine (IOM) published the now infamous To Err Is Human: Building a Safer Health System. The information presented in that report sent shockwaves through the healthcare industry. More than a decade later we haven’t seen much improvement in the number of mistakes made in hospitals, but To Err Is Human effectively changed the foundation of healthcare forever. While healthcare remains squarely focused on caring for patients, the approach to how we provide that care has changed dramatically. The interest on patient safety has generated an immense body of literature aimed at using automation and technology to improve patient care.

Before diving too deep, it’s important to understand where the errors within the healthcare system occur. Leape’s landmark paper in 1995(1) analyzing ADEs in hospitalized patients found that adverse events occurred as follows: ordering 38%, transcription 12%, dispensing 11%, and administration 39%. Bates found similar results in a study also published in 1995 in the same issue of JAMA (2). Bates found that of ADEs that were considered preventable, 49% occurred during the ordering stage, 11% occurred during the transcription stage, 14% occurred during the dispensing stage and 26% occurred during the administration stage.

Since the publications by Leape and Bates much work has gone into making the medication use process safer. At the forefront of this work has been an advance in automation and technology. Among those technologies being explored include: 1) computerized provider order entry (CPOE) for ordering; 2) pharmacy information systems and clinical decision support for transcription; 3) automated carousels, barcoding and automated dispensing cabinets for dispensing; and 4) barcode medication administration (BCMA) and smart pumps for administration. This isn’t an all-inclusive list, but rather an example to demonstrate the extent to which healthcare has gone to improve patient safety through the use of automation and technology.

With that said, I find it interesting that one of the most error prone steps in the medication distribution phase is often overlooked. I’m speaking specifically about the process of returning/restocking medications in the pharmacy. I have observed the process many times and outside the use of robotics, the system is completely manual, open to selection bias, full of interruption and fraught with error.

Example return/restocking process:

1. A series of medication are returned to the pharmacy.
2. The medications are placed in a return bin regardless of medication type, dosage form, storage requirements, etc.
3. Tablets in the return bin are sorted for restocking.
4. Someone, most likely a pharmacy technician takes the sorted medications and places them back into pharmacy stock.
5. The medications are now ready for use.

Notice that step number three above is highlighted in red. This is the step in the process that is most open to error.

Let’s just say that during the sorting process the medications are not sorted properly and a hydrALAZINE tablet finds its way into a hydrOXYzine bin. I’ve seen this happen many, many times. The packaging and names are similar so the single hydrALAZINE tablet goes undetected in the wrong bin. So the next time hydrOXYzine is needed in bulk, i.e. for an ADC replenishment, the hydrALAZINE ends up in the pile of hydrOXYzine tablets. Since the tablets are loose, the pharmacist checking the bag full of hydrOXYzine fails to see the single hydrALAZINE tablet.

The hydrALAZINE is mistakenly sent to an ADC cabinet along with the hydrOXYzine where a nurse pulls the hydrALAZINE from the ADC thinking it is hydrOXYzine. Sometimes the nurse fails to recognize the error and the hydrALAZINE is administered to the patient in place of hydrOXYzine.

Hopefully the facility utilizes BCMA and the error is avoided. However, only about 35% of hospitals in the country were using BCMA as of 2010(3). However, if the facility is not utilizing technology like BCMA, the incorrect medication is administered to the patient where it could potentially cause harm.

Although the example above involves several failures during the medication use process, it all began with a breakdown during the restocking phase. I’ve seen this exact error many times during my career, as well as many others caused by sound-alike-look-alike medications.

It’s clear to me that the return/restocking phase of the medication distribution process is the weakest link, and is rarely acknowledged when thoughts of improving the process come to mind. So what’s the answer? Does the process need to be automated or is a better manual process the answer? I don’t know what the solution is, but I think it’s time we gave it some thought.

References

1. Leape L.L., D.W. Bates, D.J. Cullen, J.W. Cooper, H.J. Demonaco and T. Gallivan et al. 1995. “Systems Analysis of Adverse Drug Events.” ADE Prevention Study Group. JAMA 274: 35-43.
2. Bates D.W., D.J. Cullen, N. Laird, L.A. Petersen, S.D. Small and D. Servi et al. 1995. “Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention. ADE Prevention Study Group.”JAMA 274: 29-34.
3. Pedersen C.A., Schneider P.J., Scheckelhoff D.J. 2011. “ASHP National Survey of Pharmacy Practice in Hospital Setting: Prescribing and Transcribing – 2010” Am J Health-Syst Pharm 68: 669-88.

A similar study conducted by NEHI found that poor medication adherence results in illnesses and ensuing treatments that cost some $290 billion in unnecessary spending each year, $100 billion of that in avoidable hospitalizations alone.

Two members of Congress recently introduced bills to allow Medicare reimbursement for more patients to sit down with therapists one-on-one and equip patients with pill boxes or text message services that help patients become more adherent, the USA Today report said.

The Toronto University College of Pharmacy conducted a study that found medication therapy saved about $93.78 per patient annually in a study of 23,798 people, USA Today reports.”

Problems with medication adherence are nothing new. A recent study in the March 2011 issue of Academic Emergency Medicine ¹ looked at the impact of poor medication adherence on emergency department visits. According to the article “risk for medication nonadherence due to cost concerns was identified in a quarter of nonemergent urban ED patients in our sample and was more likely to be reported by patients experiencing other economic and psychosocial risks. These findings indicate a need to include discussions about medication affordability and referrals to social services as part of ED discharge planning.”

Several options exist to help curb the impact of the medication adherence problem here in the United States. The use of simple technologies like the GlowCap, the Pill Timer and MedReady can go a long way in improving compliance, as can the use short message services (SMS) (i.e. text messages delivered to mobile phones). While SMS has been shown to be beneficial in several disease states ^2-5, it doesn’t work for everyone.⁶

While technology certainly plays a role in improved medication compliance, it’s important that we don’t forget the human element involved in the process. Pharmacists are linchpins in the medication use system. They can play a significant role in improving the medication use process and reducing healthcare costs through medication therapy management (MTM). MTM has been shown to improve medication compliance and reduce overall healthcare cost.^7-8 While the concept of MTM isn’t new, the approach has received renewed interest in light of the PPMI and via pharmacy organizations like the American Pharmacists Association.

With over $200 billion at stake it shouldn’t be a question of which approach to use (i.e. technology or pharmacist intervention), but rather when do we start. Based on the size of the opportunity, the answer should be now.

References:

1. Mazer M, Bisgaier J, Dailey E, et al. Risk for Cost-related Medication Nonadherence Among Emergency Department Patients. Academic Emergency Medicine. 2011; 18: 267–272.
2. Lester, R., Ritvo., Mills, E., et al. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomized trial. The Lancet. 376:1838-1845.
3. Strandbygaard,U., Francis, ST., Backer, V. A daily SMS reminder increases adherence to asthma treatment: A three-month follow-up study. Respiratory Medicine. 2009; 104:166-171.
4. Hanauer DA, Wentzell K, Laffel N, Laffel LM. Computerized Automated Reminder Diabetes System (CARDS): e-mail and SMS cell phone text messaging reminders to support diabetes. Diabetes Technology & Therapeutics. 2009; 11:99-106.
5. Miloh T, Annuziato R, Arnon R, et al. Improved adherence and outcomes for pediatric liver transplant recipients by using text messaging. Pediatrics. 2009; 124:e844-e580. (free full text PDF)
6. Hou MY, Hurwitz S, Kavanagh E. Using daily text-message reminders to improve adherence with oral contraceptives: A randomized controlled trial. Obstetrics & Gynecology. 2010; 116:633-640.
7. Smith M, Giuliano MR, Starkowski MP. In Connecticut: Improving patient medication management in primary care. Health Affairs. 2011; 30:646-54.
8. Hirsch JD, Gonzales M, Rosenquist A, et al. Antiretroviral therapy adherence, medication use, and health care costs during 3 years of a community pharmacy medication therapy management program for medi-cal beneficiaries with HIV/AIDS. Journal of Managed Care Pharmacy. 2011; 17:213-23.

Smaller facilities typically have fewer pharmacists resulting in a more centralized approach to pharmacy services, while larger facilities typically have more pharmacists to shuffle around into a broad range of pharmacy services. Larger facilities typically have a more developed, more robust clinical services often including clinical specialists in fields such as cardiology, infectious disease, critical care medicine, pediatrics, and so on. Unfortunately, smaller facilities typically don’t have the luxury of a clinical specialist because they don’t have pharmacists to spare.

Beyond clinical services, I find smaller facilities tend to lack the amount of automation and technology that I see in larger facilities. It’s not for lack of desire, but rather a lack of funds. Budgets appear to be proportional to hospital size (i.e. the larger the hospital, the bigger the budget), which results in smaller facilities utilizing less technology and automation. This doesn’t mean that small hospitals aren’t progressive in their approach; it simply means that you won’t find many million dollar robots filling carts for 20 patients.

The American Society of Health-System Pharmacists recently published its national survey of pharmacy practice in hospital settings (1). The data was collected in 2010 and evaluates practices and technologies related to prescribing and transcribing. While that may sound like a relatively narrow focus, the data presented is actually quite extensive.

Hospitals in the survey were broken down into seven categories based on bed size: < 50, 50-99, 100-199, 200-299, 300-399,400-599, and > 600.

Several items in the survey caught my attention and help distinguish larger facilities from smaller ones. These items include:

1. Approximately 20-30% of hospitals with 0-599 beds responded to the survey, while greater than 40% (41.4%) of the facilities with more than 600 staffed beds responded. Interesting.
2. Facilities with more than 600 staffed beds had the largest percentage of “restricted prescribing of certain categories of medications to certain specialties or only with consultation.” The percentage of hospitals using such a policy trends upward as the size of the facility increases (i.e. the smallest had the lowest percentage while the largest had the largest percentage). I wonder if that’s more a product of the evolution of the practice model or the simple fact that larger healthcare systems have more specialty practitioners.
3. The use of pharmacists to help with medication compliance and medical history is woefully low with only 31% of responding facilities indicating that pharmacists were involved. In my opinion, a pharmacist should be involved with medication compliance 100% of the time.
4. Drug information:
   1. Nearly 89% of pharmacy directors reported that electronic drug information sources were available on the hospital network, but “the availability of electronic drug information varies by hospital size (p < 0.05); for example, 100% of hospitals with 400 or more staffed beds have drug information available on the hospital network, compared with only 78% of hospitals with fewer than 50 staffed beds.”
   2. Only 25.5% of respondents provided electronic information on individual hand-held devices. This doesn’t mean that more clinicians weren’t using mobile drug information; it simply means that the facilities weren’t providing it. I think this will change over time as drug information providers will develop more robust licensing agreements with facilities to provide drug information across multiple electronic platforms.
   3. Only 19% of facilities utilized embedded electronic drug information in CPOE systems. Not surprising when you consider the large number of facilities across the country that have yet to implement a formal CPOE system.
5. “Regardless of the pharmacy department’s hours of service, 10.1% of hospitals have pharmacists process patient care orders from home through a telework-type arrangement.” This is a great use of telemedicine, and I hope to see the trend of using this technology continue to rise.
6. 34.5% of hospitals have BCMA and hospitals with 200-299 staffed beds are most likely to have BCMA systems. This is the one item in the survey that went against the trend of larger facilities being at the top. With that said, I was a little surprised at the low percentage of facilities with BCMA.
7. Only 19% of hospitals have CPOE systems with CDS, and larger hospitals are more likely to have CPOE systems in place. Expect this number to rise significantly in 2011-2012 secondary to ARRA and the HITECH Act.
8. 65% of hospitals are using smart infusion pumps, but again, it’s more common in larger facilities with over 90% of facilities who have more than 600 staffed beds using smart pump technology.
9. Just over 40% of hospitals surveyed used some form of an antibiotic stewardship program. More than 80% of hospitals with more than 600 staffed beds reporting its use.
10. Surprisingly, smaller hospitals administer significantly more doses both per 100 occupied beds and per patient day. I’m not sure how to take this, but suspect that there are fewer policies in place in smaller facilities to help curb unnecessary prescribing; pure speculation on my part.
11. Inpatient pharmacists outnumber pharmacy technicians per 100 occupied beds; 15.4 pharmacist FTEs per 100 occupied beds vs. 13.2 pharmacy technician FTEs per 100 occupied beds. Interesting.

Overall it appears that larger hospitals do have a slight edge over smaller hospitals. They’re more likely to have CPOE systems in place, utilize smart infusion pumps, have online drug information resources, and appear to be more likely to make use of advance clinical services like antibiotic stewardship programs. Does this mean that larger facilities provide better patient care? That’s a difficult question to answer.

Ultimately, I believe there are two ways to look at the data presented by ASHP. First, if you want to be on the cutting-edge of technology and pharmacy practice, then you should look to larger hospitals for gainful employment as a pharmacist. However, an alternate viewpoint might be that smaller hospitals provide more opportunity. For example, if you want to build a pharmacy practice model of your very own, you might want to consider looking into smaller facilities where services and technologies have yet to be fully implemented. The choice is yours.

(1)    Am J Health-Syst Pharm. 2011:68:669-88