Jerry Fahrni

Author: Jerry Fahrni

  • Effect of med reconciliation on med cost after hospital D/C [article]

    The Annals of Pharmacotherapy March 20121

    BACKGROUND: Medication reconciliation aims to correct discrepancies in medication use between health care settings and to check the quality of pharmacotherapy to improve effectiveness and safety. In addition, medication reconciliation might also reduce costs.

    OBJECTIVE: To evaluate the effect of medication reconciliation on medication costs after hospital discharge in relation to hospital pharmacy labor costs.

    METHODS: A prospective observational study was performed. Patients discharged from the pulmonology department were included. A pharmacy team assessed medication errors prevented by medication reconciliation. Interventions were classified into 3 categories: correcting hospital formulary-induced medication changes (eg, reinstating less costly generic drugs used before admission), optimizing pharmacotherapy (eg, discontinuing unnecessary laxative), and eliminating discrepancies (eg, restarting omitted preadmission medication). Because eliminating discrepancies does not represent real costs to society (before hospitalization, the patient was also using the medication), these medication costs were not included in the cost calculation. Medication costs at 1 month and 6 months after hospital discharge and the associated labor costs were assessed using descriptive statistics and scenario analyses. For the 6-month extrapolation, only medication intended for chronic use was included.

    RESULTS: Two hundred sixty-two patients were included. Correcting hospital formulary changes saved €1.63/patient (exchange rate: EUR 1 = USD 1.3443) in medication costs at 1 month after discharge and €9.79 at 6 months. Optimizing pharmacotherapy saved €20.13/patient in medication costs at 1 month and €86.86 at 6 months. The associated labor costs for performing medication reconciliation were €41.04/patient. Medication cost savings from correcting hospital formulary-induced changes and optimizing of pharmacotherapy (€96.65/patient) outweighed the labor costs at 6 months extrapolation by €55.62/patient (sensitivity analysis €37.25-71.10).

    CONCLUSIONS: Preventing medication errors through medication reconciliation results in higher benefits than the costs related to the net time investment.

    Based on the exchange rate mentioned in the study (EUR 1 = USD 1.3443) the six month savings associated with medication reconciliation was about $75 U.S. per patient after factoring in labor. Not exactly earth shattering, but nothing to turn your back on either. At least there’s a positive ROI.

    I would have liked to have seen the authors take the study one step further by linking the medication reconciliation savings back to hospitalization readmission and/or effect on the patient’s lifestyle/activity. Once in a while optimizing a patient’s therapy might mean trading a more expensive drug for ease of use or improved patient compliance.

    ———————————

    1. Karapinar-Çarkit F, Borgsteede SD, Zoer J, Egberts TC, van den Bemt PM, van Tulder M.Effect of medication reconciliation on medication costs after hospital discharge in relation to hospital pharmacy labor costs. Ann Pharmacother. 2012 Mar;46(3):329-38. Epub 2012 Mar 6. PubMed PMID: 22395255.

  • Physician dispensing, that’s some bad mojo right there

    Physician dispensing is a hot topic for several reasons. And while I’m not opposed to the use of medication kiosks to dispense medications to patients, I believe that their use must be carefully defined and continuously monitored. As I said in a post in September 2010 “Under the right set of circumstances, and with thoughtful implementation, kiosks could free up pharmacists to spend more time with patients in emergency departments and urgent care clinics across the country. After all, don’t pharmacists argue for more clinical face time with patients and less association with the physical medication dispensing process? That’s what I’ve been hearing from pharmacists for years.” The key part of that quote is “under the right set of circumstances”. You cannot remove the pharmacist form the medication use process. It would be a mistake to do so, and I believe ultimately would lead to increased patient risk. I’ve worked in retail, long-term care, home infusion and acute care pharmacy, and let’s face it, physicians struggle at times to get things right. That’s why God made pharmacists. While I’m not naive enough to think that a pharmacist has to speak to each and every patient about every medication they use each time they receive it, I do think there should be some oversight of the process; regardless of the method of distribution.
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  • Physician shares thoughts on using tablet PC in the field

    Mobile Healthc Computing.com: “Dr. R. Dale Walker, from the Cherokee Tribe of Oklahoma, is a professor of Psychiatry, Public Health and Preventive Medicine as well as the director of the Center for American Indian Education and Research at Oregon Health and Science University and director of the One Sky Center.

    … “When out in the field, you want to eliminate as many things that could go wrong as possible, and the J3500 Tablet PC does just that with its battery life, ruggedness, power and performance,” said Dr. Walker. “Consumer tablets just can’t compute like the Windows®-based Motion Tablet PCs, and who wants to carry around multiple systems when you have everything you need in one device?”

    According to Dr. Walker, using the J3500 Tablet PC is just like taking notes on paper, but much more efficient. An hour’s worth of notes can be converted to text and emailed out in just minutes. “The ability to capture information, report back on my findings and share knowledge in near real time is an invaluable capability,” said Dr. Walker.

    The tablet serves as a desktop replacement or portable library, helping Dr. Walker look up, verify or access educational tools on the fly, which proves extremely valuable considering the often remote locations of the communities. The access to information also reduces the amount of time spent on each subject, meaning more time to cover more topics. “It’s giving them the gift of information,” said Dr. Walker.”

    The article reads a bit like a propaganda piece from Motion Computing, but I agree with pretty much all the highlights. I’ve been a fan of the Motion J3500 for a while. I’ve written about it before and stand by my opion. The only negative to the device is the price tag. In this day of inexpensive consumer tablets it’s difficult to swallow the price tag, which is a staggering $2-3K. You get a lot for your money, but it’s still hard to swallow.

  • Cool Pharmacy Tech – T-Haler

    The T-Haler is a training device developed by Cambridge Consultants to help asthma patients learn how to use their inhalers. Why is this such a cool piece of technology? Because patients invariably do a crapy job using their inhalers.

    I used to ask asthma patients to demonstrate how they used their inhalers, and I was almost always disappointed by what I saw. Most patients don’t understand how to properly use these simple little devices, which ultimately leads to treatment problems, and in worst case scenarios poor control of their asthma.  This is especially true in pediatric patients. Asthma education was a big part of the pharmacist’s job when I worked in a pediatric hospital.

    From the Cambridge Consultants site:

    Cambridge Consultants developed the T-Haler concept, a simple training device. Interactive software, linked to a wireless training inhaler, monitors how a patient uses their device and provides real-time feedback via an interactive video ‘game’. T-Haler provides visual feedback to the user on their performance and the areas that need improvement. These tools could help the estimated 235 million asthma sufferers worldwide to get the most from their inhaler, and potentially reduce the millions spent annually on asthma-related emergency room admissions.

    More than 50 healthy participants, aged 18-60, took part in a recent study conducted by Cambridge Consultants to test the efficacy of T-Haler. Before using the training system, the average success rate of the group in using an inhaler correctly was in the low 20% range – in line with numerous other studies carried out. The participants had no prior experience with asthma or inhalers and were given no human instruction beyond being handed the T-Haler and told to begin. The on-screen interface walked the group through the process, which takes just three minutes to complete.

    The T-Haler measures three key factors for proper inhaler use. First, whether the patient has shaken the inhaler prior to breathing in; second, the force with which they breathed in; third, when they pressed down on the canister (the step which releases the drug). These three variables can determine the efficacy with which drugs are delivered in a real metered dose inhaler (MDI) device.

    As healthcare trends toward a focus on preventive care and devices which offer greater consumer appeal and compliance, innovations such as the T-Haler may soon become the norm in doctors’ offices, pharmacies and clinics.

  • RFID technology to monitor football players to prevent overheating on the field

    This is simply cool. There’s no other way to put it.

    Barcode.com: “On the football field, for example, heat prostration has led to several fatalities over the past few years. The problem starts during pre-season practices that take place under the intense summer sun. Identec has already developed a headband with an embedded heat-sensing chip. The RFID chips embedded in helmets developed by HotHead Technologies, combine RFID with a heat-sensing thermistor, offering plenty of range.”

    From the hotheads technology website:

    The H.O.T. System is a patent-pending, two-component package that embeds a heat sensing unit inside the helmet of an individual and collects and relays periodic temperature readings from that person’s skin to a portable data collector (A ruggedized PDA or Laptop Computer). The portable device is used to alert the individual or an observer that the person has exceeded an allowable temperature while the subject’s helmet is on.

    If skin temperature ranges outside of the set parameters then the data collector will alert the sensor unit in the helmet to take temperature readings at a faster rate. The alert will be displayed on the data collector so the operator of the data collector can make a decision on whether to stop the current activity and seek to receive further observation from a professional and take measures to cool their temperature down. The alert will be automatically removed from the data collector as soon as the skin temperature falls back into the normal parameters.

    There’s also a short video that shows the basic idea here.

  • EHRs may not be all that after all

    The New York Times: “Computerized patient records are unlikely to cut health care costs and may actually encourage doctors to order expensive tests more often, a study published on Monday concludes.

    …research published Monday in the Journal Health Affairs found that doctors using computers to track tests, like X-rays and magnetic resonance imaging, ordered far more tests than doctors relying on paper records.

    The use of costly image-taking tests has increased sharply in recent years. Many experts contend that electronic health records will help reduce unnecessary and duplicative tests by giving doctors more comprehensive and up-to-date information when making diagnoses.

    The study showed, however, that doctors with computerized access to a patient’s previous image results ordered tests on 18 percent of the visits, while those without the tracking technology ordered tests on 12.9 percent of visits. That is a 40 percent higher rate of image testing by doctors using electronic technology instead of paper records.”

    I can’t say that I’m surprised by this. I remember something similar when I was working as the night pharmacist at Salinas Valley Memorial Hospital in Salinas, California. Physicians that were using pre-printed order forms to admit patients – now considered the standard of practice – almost always wrote for more PRN medications than those that didn’t use pre-printed order forms. We used to call them “don’t call me orders” because they covered every possible what-if for the patient, i.e. what if they have pain, what if they get a fever, what if they get indigestion or constipation, and so on. And why did they do that? Because it was easy to check a box, that’s why.

  • The insidious nature of ignorance and my curiosity

    There’s been a Tweet flowing through my Twitter stream for a few days now and I’ve avoided clicking on the link because I knew it would be something totally ridiculous, misleading and meaningless. Unfortunately it was a quiet Sunday morning, and while I sipped my coffee and waited for the rest of my household to come to life, I succumbed to human nature and clicked the link.

    Grrr! I knew it. Something totally ridiculous, misleading and meaningless. What was I thinking? Why do I torture myself this way? One can only speculate.

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  • Shareable Ink plus EHR equals interesting alternative

    EMR Daily News: “Shareable Ink®, an enterprise cloud computing company that transforms paper documentation to structured data, today announced three new partnerships with leading EHR vendors that will further the company’s reach in delivering a reliable, portable and easy to implement electronic data capture solution that works with existing physician workflows. The agreements with Greenway Medical Technologies, Inc., NextEMR, VoiceHIT, and an existing partnership with Allscripts, signal the demand within the physician practice marketplace for a flexible technology that can be used in any care setting to help compliance with Meaningful Use (MU) requirements.”

    I think highly of Shareable Ink. I like the concept and think it provides a nice bridge between where we are today and where we need to be. I first mentioned Shareable Ink back in November 2009. It was a good idea then, and it’s a good idea now.

  • Failure to use “low concentration” alerts properly leads to errors [ISMP Safety Alert]

    When I read the headline in the most recent ISMP Medication Safety Alert! – Smart pump custom concentrations without hard “low concentration” alerts – I didn’t really get it. So what if a smart pump doesn’t stop you from programming “low concentrations”? Well after reading through the article, and the examples, it made perfect sense.

    Failing to employ available dose error-reduction software (DERS) as intended and to heed important clinical alerts are common contributors to these errors. In particular, the misuse of custom concentration options (i.e., user must fill in the concentration) that do not employ a hard (requires reprogramming) minimum concentration limit is a prime example. This issue contributes largely to preventable errors with smart pumps given the counterintuitive, inverse relationship between concentration and volume. More concentrated drugs require less volume to deliver a specified dose; less concentrated drugs require more volume to deliver a specified dose. When using “fill-in-the-blank” custom concentrations, the concentration must be programmed into the pump so it can calculate the volume needed to deliver the prescribed dose. If the programmed concentration is lower than the actual concentration in the infusion bag or syringe, the pump will deliver an overdose. If the programmed concentration is higher than the actual concentration in the bag or syringe, the pump will deliver an underdose. Without a hard minimum concentration limit, the former scenario has led to life-threatening events, such as those described below.

    Here’s a great example from the article that made the light bulb go off in my mind:

    A physician prescribed IV HYDROmorphone 20 mg/100 mL (0.2 mg/mL) to infuse at 2.5 mg/hour. In this hospital, the standard concentration for this infusion was 0.1 mg/mL, so the custom concentration of 0.2 mg/mL had to be entered into the smart pump. The nurse selected the custom concentration option then mistakenly entered 2.5 mg/100 mL as the concentration instead of 20 mg/100 mL. Given the erroneously programmed concentration of 0.025 mg/mL, the pump issued a soft (can be overridden) low concentration alert. The nurse overrode the warning, mistakenly believing the warning was inconsequential. Based on the erroneous concentration, the smart pump infused the drug at a rate of 100 mL/hour, while the intended rate was 12.5 mL/hour. The pump delivered the entire bag of HYDROmorphone 20 mg to the patient in 1 hour.

  • #HIMSS12 Day 3

    Actually Day 3 was yesterday, but I’m just now getting around to putting some thoughts on paper.

    Best session I attended was Care Coordination in Practice: Managing Data Volume and Data
    Reconciliation    . The presentation was all about big data and how we’re failing to use it appropriately in healthcare. The slide deck was great. It’s available here if you’re interested.

    A couple of things I found interesting in the presentation:

    1. There are approximately 1-2 billion clinical documents produced in the United States each year. That’s mind boggling if you stop and think about for a minute.
    2. More than 60% of key clinical data are not found in coded lists.The remainder of the information is found in free text, scanned documents, etc. That’s a problem because a lot of clinical decision support is based on information in coded lists. So what are we missing? A lot.

    The takeaway from the presentation: “Get massive amounts of data flowing, then build structure slowly and incrementally. Don’t wait.” The presenter referred to this as “the Google approach to data”. I’m a fan of all things Google so that works for me.

    I had coffee with Pauline Sweetman yesterday (@psweetman). Pauline is a pharmacist from the UK that I’ve been tweeting back and forth with for a couple of years. We had a pretty interesting conversation around the differences and similarities between hospital pharmacy practice in the U.S. and UK. Good stuff.

    I also had a great conversation with Dr. Heather Leslie (@omowizard), a physician out of Melbourne, Austrialia that’s doing a lot of work with the openEHR project. During our short visit she persuaded me to participate in their Adverse Reaction archetype review; as a pharmacist of course.She’s always looking for additional help if anyone is interested. It’s a worthwhile project so at least have a look.

    I spent more time roaming around the exhibitor area, specifically looking at RFID technology. I’m a fan of RFID, but it doesn’t seem to be catching on in healthcare. There are several reasons why, but we should still be looking hard at it’s application. I’m not sure whether RFID will become important or it it’s a bridge technology to something else. But the only way to find out is start using it and see where it goes.

    One product that uses RFID technology that I found particularly interesting comes from a company called MEPS Real Time, Inc. Their product features a dispensing cabinet with real-time RFID driven inventory management to go along with a RFID med tray tracking system. Of course you wouldn’t use RFID for everything because it would be labor intensive and expensive, but for high dollar drugs it might make sense. It was pretty impressive.

    MEPS_HIMSS12