Realistic view of medication reconciliation?

Hospitals & Health Networks: “Despite progress, medication reconciliation remains a bitter pill. Un-intended changes in medications occur in one-third of all patients transferred between hospital departments, and in 14 percent of patients at hospital discharge, according to the Agency for Healthcare Research and Quality.

Most medication inconsistencies could be avoided if reconciliation were performed at patient admission, transfer and discharge. Hospital information systems are helping some wired hospitals rdo this across the care continuum despite the lack of a universal solution.

Medication reconciliation was designated a 2005 National Patient Safety Goal by the Joint Commission, which recommended that organizations accurately and completely reconcile medications across the continuum of care. In 2009, however, the commission announced it would no longer score medication reconciliation during on-site accreditation surveys, because of difficulties with implementation strategies. Then, in December 2010, the commission announced a new version of the NPSG (08.01.01), to be effective July 1 of this year. According to the commission, the new streamlined version focuses on critical-risk points in the medication reconciliation process.

The Institute for Safe Medication Practices still is disappointed in the current status of medication reconciliation. “It’s not what we expected for a process that on the surface seems so simple,” says Stu Levine, an ISMP informatics specialist.”

I received a link to this article through the Healthcare IS – Pharmacy IT/Pharmacy Informatics CPOE Group on LinkedIn. The article is titled “Medication Reconciliation Only as Good as the IT Allows”. I find the title a little strange, and a bit misleading. Consider that the medication reconciliation process is best handled by diligence among healthcare providers, not IT. The technology to provide clinicians with medication lists is only a tool to make the process easier. Reconciling a patient’s medications is at best a difficult task. The “general public” knows surprisingly little about their own medications; including the simplest of things like names and doses. Getting physicians to reconcile a medication list isn’t much better. More often than not they simply sign the “transfer med list” without really scrutinizing what’s on it.

Unfortunately the article makes it sound like a simple process of looking at the medication list on admission, transfer and discharge. It really isn’t as simple as that. We utilized this process at my previous hospital and I can tell you that we were lucky to have a patient medication list that was accurate. Most were haphazard attempts that lead to confusion and lots of phone calls and clarification.

Pharmacists and medication adherence

WSJ: “”Retail pharmacists appear to be able to play a really substantial role in encouraging patients to use their medications better,” says William Shrank, an assistant professor of medicine in the division of pharmacoepidemiology at Brigham and Women’s Hospital in Boston. “They are an underutilized resource.”

A study by researchers at the Walter Reed Army Medical Center in Washington, D.C., published in the Journal of the American Medical Association, found that a pharmacy-care program for 200 people age 65 and older who were taking at least four medications for chronic conditions boosted adherence to 97% from 61% after six months. Patients were educated about their medications, including usage instructions; medications were dispensed in blister packs that made it easier to keep track of whether they had taken their pills for the day; and pharmacists followed up with patients every two months.

After 12 months, those who continued to get the pharmacy care kept their adherence at about 96%, while adherence among those for whom the program was discontinued dropped to 69%.”

This ties back in to what I was talking about on Saturday, i.e. that better use of pharmacists in the community practice setting might be a good thing. And one way to get community pharmacists to spend more time with patients is to get them out from behind the counter and away from the phones using better automation and technology. The inability of a patient to adhere to their medication regimen costs the healthcare system in the United States millions of dollars each and every year, but for some reason we continue to sit idle and allow it to continue.

Where will automation and technology make the biggest impact in pharmacy?

I was planning on writing a rant this morning about lack of motivation, leadership and dumbasses – hey, I was in a fould mood when I got up – but then I opened an email from a friend. He asked me “How can retail pharmacists get involved in this [pharmacy informatics] industry?”. My first thought was to say that retail pharmacy would be the death of our profession and that they have no business getting involved in pharmacy informatics. Harsh I know, but I told you I was in a foul mood.

Then I did something I rarely do, I thought about the question a bit more before answering. After some time I came to the conclusion that retail, or more generally outpatient, pharmacy is exactly where more automation and technology is needed. I follow a few retail pharmacists on Twitter and one generalization I can make from reading their Tweets is that they all pretty much hate their jobs. Why? Because they spend precious little time working as pharmacists, instead spending most of their time physically filling prescriptions, chasing insurance claims, etc.

What retail pharmacy needs is a super-sized dose of pharmacy automation, technology and greater pharmacy technician involvement. Nowhere in pharmacy is there a greater need for automation and technology than outpatient services. Much of what’s done in the outpatient pharmacy setting does not require a pharmacist. This echoes the words by Chad Hardy last week on the RxInformatics website. Chad states “The longer we rely on pharmacists to run the entire supply chain, the higher our risk of obsolescence.” He’s absolutely right, although the article he references insinuates that pharmacists will become obsolete secondary to technology. Nay, I say. Technology in the outpatient arena can offer pharmacists the opportunity to break away from the mundane and do a little more hands on patient care. In addition, the drive to implement automation and technology in the retail setting creates the perfect job opportunity for pharmacists interested in informatics.

Of course we’ll have to prove to the retail boys upstairs that they can save money by using pharmacists in a more clinical role, but that’s what business cases are for. Unfortunately I couldn’t write a business case to save my life. In fact, a colleague of mine told me that pharmacists are terrible at creating business cases. I suppose that’s true as most of us didn’t become pharmacists to practice business. Instead we became pharmacists to provide patient care. Go figure.

Tablet tid-bits

This morning at breakfast I sat across the table from an older gentleman in an Air Force flight suite. He was eating his cereal, drinking his coffee and playing with his iPad. I don’t often see older men in flight suites using an iPad so I felt compelled to strike up a conversation. I simply asked him what device he was using and what he was doing with it. I find that it’s better to play dumb in situations like these as people tend to open up a little more.

Anyway, I found his responses fascinating. He said that he uses his iPad in the cockpit of his aircraft to replace an “entire bag full of papers and books”. He was using an application to file his flight plan, check the weather, handle some flight calculations and review his “alternate” landing sites. In addition he was reading the New York Times and checking his email all while enjoying breakfast.

We talked a bit about the features of the iPad and how he liked it. He indicated that he used to have an iPhone and thought it was similar enough that he didn’t have much of a learning curve.  Before leaving he finished up the conversation by saying “it lets me keep everything in one place” before turning back to finish his meal.

The short conversation got me thinking about the often overlooked value of the new generation of tablet design. In this case it was an iPad, but it could have been an Android device, BlackBerry PlayBook, or HP TouchPad. Three things struck me:

First – The importance of the tablet form factor. Everything the gentleman was doing on his iPad could have easily been done on any computer. However, during our conversation he said that he used to use a laptop in the cockpit, but found that it was awkward. He liked the form factor of the iPad much better. Slate tablets are lighter, smaller and have better battery life. It’s hard to beat that combination of features for quickly viewing information.

Second – Standardized user interface and user experience. The fact that his learning curve for the iPad was improved by his previous use of an iPhone didn’t escape my attention. Android smartphone and tablet manufacturers should make note of this. The current trend with Android tablets is to create a customized user interface that overlays the “stock” Android UI. As cool as I think the aftermarket user interfaces are, they have the potential to create a bit of a dilemma for the end user. Keep it standard across the board boys and girls. From what I’ve seen of the TouchPad it looks like HP is trying to keep the experience similar across its line of devices.

Finally – Availability of key pieces of software and applications. Consuming information on a mobile device certainly took center stage for this gentleman as he was using his iPad to take the place of more than one item that he previously carried in his bag. It’s hard to say if all tablet manufacturers will have enough software and applications to make their devices as compelling as the iPad. Only time will tell.

When our conversation was over and the gentleman had finished his cereal he simply picked up his coffee cup in one hand, his iPad in the other and walked out the door. I suppose that just about sums up the value of utilizing technology in a mobile form factor.

“What’d I miss?” – Week of March 13, 2011

As usual there were a lot of things that happened over the past week, and not all of it was related to pharmacy automation and technology. Here are some of the things I found interesting.
Continue reading “What’d I miss?” – Week of March 13, 2011

How not to design an application for pharmacy

I’ve used Pyxis PARx before, but only in combination with a carousel storage system. I recently had the opportunity to play with the standalone version of PARx and all I have to say is yikes!

The system utilizes an older version of Windows Mobile on a clunky Motorola handheld. To get from log-in to a useful place in the application required me to go through no less than four screens. The touch screen was unresponsive and difficult to use, the device was painfully slow and the connectivity was lacking.

So, to sum up my experience with PARx – used with carousel technology it’s great, but try to use the standalone product and you might find yourself spewing profanity.


Cool pharmacy technology – UCSF Robotics

UCSF: “Although it won’t be obvious to UCSF Medical Center patients, behind the scenes a family of giant robots now counts and processes their medications. With a new automated hospital pharmacy, believed to be the nation’s most comprehensive, UCSF is using robotic technology and electronics to prepare and track medications with the goal of improving patient safety.

Not a single error has occurred in the 350,000 doses of medication prepared during the system’s recent phase in.

Robotics is nothing new, but it seems like everyone is taking notice of the new robotics in the pharmacy at UCSF. I suppose all the people pointing it out to me has something to do with the fact that UCSF School of Pharmacy is my alma mater, but you never know. Anyway, I’m pleasantly surprised to see UCSF taking such an active role in advancing pharmacy practice. When I spoke with some colleagues sill working for UCSF a little over a year ago they were still practicing pharmacy invented in the dark ages. Not any more.

Now I’m trying to get a hold of someone at UCSF that will let me stop by for a tour, and all of a sudden no one knows me. Poetic justice I suppose.

Lenovo continues to impress

Electronista: “Lenovo gave its ThinkPad X series a major refresh on Tuesday with a generational leap. The X220 notebook and X220t tablet both use a newer 12.5-inch, IPS-based rich color display but thrive with a new external ThinkPad battery pack. They can last up to nine and eight hours respectively on extended internal batteries, but the battery pack pushes them up to 15 hours on the X220t and a full 24 hours on the X220.

X220t owners also get their own touches with a much brighter 300-nit touchscreen that uses Gorilla Glass to improve their resistance to shattering or just casual scratching. The X220 notebook is the lighter of the two at under three pounds, where the swiveling display adds an extra 0.9 pounds to the X220t.”

I purchased a Lenovo X201 tablet back in November 2010. It’s a fantastic machine and I haven’t regretted the purchase for a moment. I consistently get about six hours of battery life out of the extended battery pack. The idea of getting more than double that with the new X220t is mind boggling. Throw in an extra 0.4-inches of brighter touchscreen and the strength of Gorilla Glass and I think Lenovo has another winner on its hand.


FMEA and BCMA, two acronyms that work well together

During my time as an IT pharmacist I was fortunate enough to be part of two Failure Modes and Effects Analysis (FMEA) groups; one for CPOE and another for BCMA. The FMEA process is labor intensive and time consuming, but well worth the effort in my opinion. In both the CPOE and BCMA instances several important pieces of information were discovered that may have otherwise gone unnoticed.

I don’t often see articles that talk about using FMEAs, which is a real shame secondary to their value. So it was a pleasant surprise to see a recent article in Pharmacy Purchasing & Products on the use of an FMEA post BCMA implementation. I’m not familiar with using an FMEA after the fact, but it makes more sense to me now after reading the article.

According to the author, they “had conducted an FMEA prior to initially employing BCMA; however, we never performed any post implementation follow-up on the system.” An all too common occurrence in healthcare, i.e. implement and forget. We did something similar at Kaweah Delta when I worked there, but we referred to the process as a gap analysis rather than calling it an FMEA. Regardless of the verbiage, the results were similar.

The reason cited for the second FMEA was an increase in errors associated with the BCMA system. “Errors were primarily due to unscannable bar codes, mislabeled medications, the wrong medications being dispensed, and most commonly, nursing staff’s failure to scan.” This sounds familiar. The errors cited are simply side effects of the implement-and-forget mentality. Regardless of the system in place, humans inevitably develop bad habits and workarounds. We need to be constantly reminded to do the right thing. Implementation is only a small part of the work involved with any new system. Follow-up, maintenance and optimization is when the real work begins.

And the results of the second FMEA? “Three months after completing the FMEA, the team compared the before and after scan rates. We found significant improvements in the scanning of both the patients and the medications throughout the system. In addition, we have witnessed a culture change: nurses now become anxious if they cannot scan a product.” Not bad.

Read the article, it contains some good information.