One unplanned event that I have to mention was the pleasure of eating breakfast next to Johnathan Paul, a senior engineer in enterprise R & D at Siemens. He casually sat down next to me this morning and asked me what sessions I was planning on attending. I promptly gave him my spiel about attending the various pharmacy sessions, but in addition I lamented the fact that I was going to miss the presentation on “Virtualization, Cloud Computing, SOA, Elasticity, De-Duplication…What Do These Technical Terms Really Mean and How Do We Apply Them?” because it was at the same time as the pharmacy update. I didn’t know at the time, but he was the presenter for that session. After I got past my initial embarrassment we had a great conversation about many of the topics he planned to cover. I came away with some great information and knowledge that Siemens is doing things behind the scenes that makes me downright giddy.

Session Attended

Medication Safety Track
Siemens Pharmacy / Medication Administration Check Solutions Update [Medication Administration Check, a.k.a. MAK, is Siemens BCMA system]

This is one of my favorite sessions to attend at Innovations because I like to see what I can expect out of Siemens Pharmacy in the near future. As I’ve mentioned previously our facility uses both Siemens Pharmacy and MAK and we’ve made it priority to always be up to date with the latest version of the software. Even though I was already aware of most of the information that was presented it was still good to get an official listing of enhancements coming down the pike.

Some of the new features presented include:

• Lot number, expiration and manufacturer tracking for vaccines in both the pharmacy system and MAK. In addition, the service pack due out later this year will also allow transmission of that information to the California vaccine registry. This is huge for our facility as it’s been a real point of contention over the past several months.
• The ability to attach a “reminder” to a medication in pharmacy at the formulary level or manually by the nurse. We currently use fake medication orders in the pharmacy system like “remove patch” to remind the nurses to do something. It’s not a good solution, but it works. With the upgrade these reminders can be built into the drug definition and will not require a separate entry by the pharmacists. This solves some issues and is a big positive in my opinion.
• The option to add a barcode to a medication at the order level. This is the one I’ve been waiting for. This will allow us to place patient/drug specific barcodes on items like pediatric syringes and compounded medications that were previously problematic.
• A completely redesigned pharmacy monitor. The pharmacy monitor is where incoming CPOE orders arrive in pharmacy. We don’t use the pharmacy monitor yet, but will as soon as we go live with CPOE later next year. The current pharmacy monitor has limited functionality and was in desperate need of an overhaul. The version shown today is a big improvement with expanded display, significantly more options for customization and better segregation of orders coming from various locations throughout the hospital. I think it sill needs some work and it won’t replace our current order management system, but it is a big improvement nonetheless.
• And a couple little things like customized options for user maintenance, improved reporting for ARRA and an improved area for “pharmacy instructions”, i.e. comments not seen by everyone.

I’ve been fairly critical of Siemens Pharmacy in the past and still think they have a lot of work to do, but I am excited to see some of the changes taking place. They appear to have the right people in place and the right attitude toward advancing their system to make it better in the future. I will reserve further comment until I see Siemens Pharmacy v24.2 in action at my facility. We’re scheduled to be upgraded sometime in October of this year.

Technology Solutions Track
Use of Desktop Virtualization with Soarian Clinicals

This session presented the experience of Alegent Health in Omaha, NE as they implemented thin-client technology in several of their patient care areas. Most of the information was generic, but several great questions from the audience and a general discussion following the presentation added to the overall value of the session. I came away with a better understanding of several components of the virtualized desktop. I’m especially interested in their “smooth-roam” feature, their smart card technology for logging in and out of systems, and their use of Wallaroo Medical Stations in patient access areas.

One thing I thought was odd was the presenters opinion of various non-thin client solutions. He bashed the use tablet PCs based on reasons that I did not agree with. It gave me the impression that the presenters motives were a little skewed toward his opinion rather than presenting the facts. It could have been presented a little more objectively, but overall it was great information.

Medication Safety Track
Implementation of a Closed Loop Medication Solution

This presentation basically covered several projects at HealthAlliance Hospital designed to close the medication loop between the physician order and administration of medication at the bedside. I’ve seen presentations like this before. In fact, one of the best closed loop medication presentation I’ve ever seen was at ASHP Midyear in December 2009.

Solutions implemented at HealthAlliance Hospital included CPOE, pharmacy barcoding and unit-dose distribution, BCMA and eMAR. The presentation was a little dry, but made some important points. Several slides were presented showing changes in prescribing habits and recorded medication errors following each system implementation. No mention was given as to how the data was collected however, which lessons the impact of the information just a little bit.

Overall, the first day was a success. Tomorrows focus will be on CPOE in the morning, followed by my presentation at 11:00 am and a small group demonstration of Siemens newest version of Soarian Clinicals. I’ll let you know how it goes.

Here’s an HL7 feed from a ketorolac order. Note the red lettering:

PID|||0000194291^9^M10^KDHCD^PN~3017197^^^KDHCD^MR|3017197|ZZZTESTINGDRAEGRXXXX, ZZZTESTING||19740525|F|||361 N ABC AVE^^VISALIA^CA^93291|||||S|UNK|00001942919|||
PV1||I|3N^29^A||||TEST, A DOCTOR|||OP|||||||TEST, A DOCTOR |||||||||||||||||||||||||||200810231335||||||
ORC|NW|1|||||^Q6H&0600,1200,1800,2400&^^201004292400^201004302400^^^11111110||201004281226||JFT|TEST, A DOCTOR|||201004290000||
RXE||543^KETOROLAC TROMETHAMINE^2502190|30||MG|VIAL|THIS IS ONLY A TEST…..|||1|||AM1405427|JFT|||||||||||
NTE|||EVERY 6 HOURS|RXR|IV||||

Pyxis doesn’t recognize 2400 as a “real” time, and rightfully so. For those of you that don’t know, 2400 hours doesn’t exist in military time. Midnight is 0000 hours. Why would Siemens use 2400 hours to represent midnight? I have no idea, but Pyxis didn’t like it so it refused to deal with the order and simply discontinued it. The fix was a programmatic change by Siemens.

The idea of standardization isn’t new or limited, yet its use continues to elude healthcare. The concept is applicable to not only data, but processes as well. Unfortunately not everyone buys into the idea. I’ve even heard some argue that standardization removes clinical decision making from healthcare. What? That doesn’t even make sense. Standardized processes can actual create clinical decision making time by simplifying a repetitive task and creating consistency designed to prevent errors.

I spent several wonderful years working in a compounding pharmacy in the Bay Area; 3 years as an intern and about 2 years as a pharmacist. Many extemporaneous compounding formulas are complex so the owner of the pharmacy, whom I had tremendous respect for, had a rule that ingredients were placed to the left of a compound prior to use and to the right after use. If you’ve ever worked in a busy pharmacy then you understand interruptions and how easy it is to forget something in a hectic environment. The rule was a simple one, but saved my bacon on more than one occasion. And it certainly didn’t impair my clinical judgment. Similar standardized systems are used in hospital cleanrooms where attention to ingredient detail is paramount.

Other standardized processes that I’ve found beneficial over the years include:

• Standardized doses for pediatrics. I spent a few years working in a pediatric ICU. The facility I worked for had a robust set of policies that allowed the pharmacist to round doses ordered in mg/kg to the nearest “standardized dose”. For example let’s say a physician orders metoclopramide 0.15 mg/kg in a 1.85kg child. The resulting dose is approximately 0.28mg. As a pharmacist I was allowed to round that dose to 0.3mg, which was an available standardized dose. The advantages were obvious: fewer dosage sizes meant less waste, less labor for preparation and fewer opportunities for error, i.e. grabbing the wrong dose. In addition, many of the dosing increments requested were too small to be accurately measured by a syringe and would have been an estimate anyway.
• Standardized drip concentrations. Many hospitals use standard drip concentrations for pressors and other vasoactive medications, i.e. dopamine, norepinephrine, dobutamine, etc. This makes order entry easier and faster, reduces waste, reduces the risk of programming errors on pumps and creates a less complex process for drug dictionary maintenance on smart pumps.
• Standardized administration times. I love the use of standardized administration times. What’s a standardized administration time? I’m glad you asked. That’s when a hospital defines the times a drug will be administered based on the latin sig used, i.e. Q6H may be represented by 0000, 0600, 1200, 1800 or TID may be 0700, 1300, 1800. There are many possibilities. The use of standardized administration times has many advantages including easier and quicker order entry, consistency among nursing staff and less variability for the patient. Those that argue that this is a bad idea because it is difficult to get on a standardized schedule, just give me a call. There is absolutely no pharmacokinetic or pharmacodynamic reason why medications cannot be administered on a standardized schedule while in an acute care setting. You can try to argue that you can’t wait an extra 12 hours to give a multi-vitamin or that you can’t give cefazolin 2 hours early, but you won’t win based on any science that I’ve studied.

One thing to remember when creating a standardized process is to keep it simple. We often forget that complicated processes are fraught with opportunity for error. Everything we do should be broken down into the fewest possible steps and still remain safe and effective. Personal experience tells me that we’ve done a poor job of simplification in healthcare. We tend to complicate a process more often than simplify it; double and triple checks with multiple initials, paper trails, sign-off sheets, pharmacokinetic tracking forms, SBAR forms, manual lot number tracking, etc. If you’re using a paper form in this age of technology, you’re doing something wrong.

Don’t feel bad, we’re not the only ones responsible for creating a bloated and oftentimes overly complex system. Every time something goes wrong in healthcare the federal, state and local governments enact new regulatory processes that requires a barrage of paperwork and complex procedures. It’s an all-out assault on simplification, standardization and common sense.

Have you ever wondered why it takes so long to train a pharmacist after they’ve been hired? Every pharmacist has a similar core skillset that can be applied to most situations, right? Right. Their lengthy on the job training has nothing to do with their drug knowledge or decision making skills, but everything to do with learning all the idiosyncrasies associated with practicing pharmacy in an acute care setting. They have to spend time learning the rules, then the exceptions to the rules, then the exceptions to the exceptions and so on down the line. I’ve worked in six different hospitals during my benign career, so believe me when I tell you that it’s true. Some of the systems I’ve been exposed to were so old and complex that no one could remember when they were implemented, but everyone was afraid to change them.

It has been a busy month, so I won’t make any promises, but over the next couple of weeks I hope to present a couple of additional examples of where standardization is needed in pharmacy and why it’s necessary. Stay tuned.

We had a minor pharmacy system upgrade yesterday. The system was down for about 45 minutes. Although minor, the upgrade required the removal of the previous version of the pharmacy software prior to installing the new version. Overall the process went smoothly. However, within a few minutes of giving the pharmacists the all clear I began receiving phone call after phone call because the upgrade “didn’t work” and they couldn’t “get into Siemens”. The problem: the install client failed to put the shortcut icon for the pharmacy system on their desktop. Seriously, that’s the problem? Wow!

The “problem” brought the pharmacy to a standstill. So, the next time you talk about carousel technology, automated packaging, or clinical decision support software, remember that many pharmacists still struggle with using a computer; a device that is common in nearly every household in America.

I bet Steve Jobs doesn’t have these problems. ;-)

As I wrap up my time here at Innovations ’09 a few thoughts come to mind:

I should have stayed an extra day or two. There are two hospitals near here that I would love to visit: Pinnacle Health in Harrisburg and Main Line Health. When I grow up, I want to be like them.

Overall Innovations was a good experience, but I am looking forward to the ASHP Midyear in December of this year. I hope to see you all there.

Where did My Mumps Job Scheduler (MJS) Go? – This was a pretty basic “how-to” session covering the new job scheduler, Cache, used in the latest version of the pharmacy system. Boring, but helpful.

Integrating Siemens Pharmacy to Maximize the Pharmacist Role – This was the most interesting presentation of the day, by far. Yakima Valley Memorial hospital is located in Yakima, Washington. Their pharmacy department is clinically solid and technologically advanced. They make extensive use of various custom pharmacy system reports to monitor antibiotic therapy, follow patients with poor glycemic control, and follow-up on patients with questionable orders. In addition, Yakima is in the process of writing advanced rules against their pharmacy system to track patients receiving warfarin therapy with no INR within the previous 24 hours. The warfarin monitoring is necessary to meet National Patient Safety Goal 3E. Much of the information is practical and can be reproduced at my facility.

Hitting the Mark with MAK! – Everyone wants to learn more about MAK, Siemens BCMA solution, and there have been presentations on just about every aspect of the system. This was no exception as the entire presentation was on how to develop a project plan for MAK implementation. This one nearly put me to sleep.

Leveraging MAK/MAR Integration to Achieve Increased Operational Efficiency – Centra State Healthcare System has done some pretty amazing things with their MAK data and the electronic medication administration record (MAR) found in Soarian. Soarian is Siemens system for collecting and displaying clinical information such as labs, allergies, patient assessments, physician notes, etc. Centra managed to create an integrated solution that offers physicians a one-stop-shop for clinical information as well as previous, current, and future medication administration. I was impressed. It appears I have a little reading to do when I get home.

I spent most of the afternoon talking with other pharmacists about computerized provider order entry (CPOE) and pharmacy automation. One pharmacist from CaroMont Health in Gastonia, NC was particularly interesting as his facility uses almost the exact same setup as ours; Siemens Pharmacy, Pyxis, and Talyst automation. He and I shared quite a bit of information. The time spent talking with other pharmacists was very valuable, possibley more valuable than all the presentations combined. 

Tomorrow is the final day of Innovations ’09 with more of the same on my agenda. Sessions on my radar for tomorrow include: Extending Patient Safety with MAK Beyond the Acute Inpatient Setting, Building the Bridge between MAK and Soarian, and Raising the Bar for Patient Safety. After that, it will be time to pack up and head for the airport; until then.

My first session today was an update on various future enhancements to both the Siemens Pharmacy System and their barcode medication administration system (BCMA), fondly referred to as MAK. The future enhancements bring much needed functionality to a system that, in my opinion, wasn’t ready for prime time.

Enhancements presented include:

The rest of my day was spent listening to presentations on BCMA. While the information was good, there wasn’t anything that I hadn’t heard before.

Best quotes of the day:

“It’s a great system, but you can’t get away from the human factor.” I believe this down to my core, but I also believe you can limit the human factor by making the system so easy and intuitive that the user would have to go out of their way not to use it. In other words, make it easy to do the right thing and hard to do the wrong thing.

“People still have accountability and responsibility.” If you hold people accountable for their actions, they’re more likely to think before they leap.

A perfect example of this is the use of acetaminophen for mild pain as well as temperature. Do you know how often acetaminophen is used in hospitals? It’s a lot. Differences in frequency, route and reason for use can easily add up to several hundred PCO entries for acetaminophen alone. Multiply that by the number of medications used in a hospital setting and you’ll get a large number of PCOs used both as shortcuts for order entry as well as building blocks for order sets.

PCO descriptions typically include the medication name, dose, route, frequency and reason for use, which can make searching for a specific PCO confusing and frustrating. There are several systems used to decrease the number of irrelevant PCOs appearing when performing a search, however only my method is presented here.

Naming a PCO – When a PCO is part of an order set, use the first few letters of the order set name as the first part of the PCO name. For example:  acetaminophen 650mg po every 4 hours prn temp > 100.4 found in the Antepartum Admit Orders (AAO) order set would be AAOACE650PO. AAO for Antepartum Admit Orders, ACE for acetaminophen, 650 for the dose, and PO for the route. Other PCOs developed for the same order set would use a similar naming convention (i.e. AAOBETAIM for Betamethasone IM, AAOCLI900PB for Clindamycin 900mg IVPB, AAOLR for Lactated Ringers infusion, etc.). The ‘AAO’ prefix keeps the Antepartum Admit Order PCOs together when listed alphabetically.

PCO Description – Begin all PCO descriptions with ‘OS’, for “order set”. This excludes the PCO from search strings containing only a part of the medication, i.e. ‘ace’ for acetaminophen. For the acetaminophen in the Antepartum Admit Orders example above, the description would read: ‘OS APAP 650mg PO Q4HP T>100.4′.

The system is far from perfect, but works well for me.