Pharmacy Integration is Starting to Make Sense

I’ve been writing about the need for pharmacy integration for years. Most of it negative, and deservedly so because it’s been lousy.

With that said, things appear to have changed in recent years. Integration, it seems, has slowly become a thing. Maybe because I’ve been out of general pharmacy practice for so long that it seems decent, or maybe it’s getting better. Hard to tell, honestly.

Pharmacy systems aren’t really talking to each other better than before, per se, but the number of disparate systems seem to have decreased over the years. Once there were many, now there are seeming few. Once, everything was “best-of-breed”, now things are moving to one system to rule them. Case in point, electronic health records. (EHRs).

I always thought pharmacy integration would take place from the inside out, i.e. pharmacy systems would integrate with other systems and drive information sharing across the hospital. Not even close. Instead, pharmacy systems have become more integrated by being consolidated and sucked into the EHR.

The advent of EHRs has done more for system integration in healthcare than just about anything else. I have plenty of negative things to say about EHRs, but it’s clear that they’ve changed the way we practice, forever.

The way I see things – at least now – most healthcare systems have fallen into two large buckets: 1) documentation – clinical and other; and 2) operational logistics.

Clinical Documentation: Clinical documentation used to take place in “the chart”, among many other places. The chart was nothing more than a binder filled with dividers, separating one bit of information from another. Think of a Trapper Keeper, minus the cool picture on the cover. Paper was everywhere. If you wanted to read something about a patient, like a progress note or radiology report, you had to go to the chart, which wasn’t always easy. They had a way of walking away with physicians and not making their way back to the nursing station.

This all changed when EHRs hit the scene. Everything from demographic data to notes, lab values, medication information, and so on is at your fingertips. If you need information, all you do is log into the EHR and go hunting. Admittedly, it’s not as easy to navigate as a paper chart, but it’s a heck of a lot more data rich and never walks away.

Most of the information coming out of hospital pharmacies these days can be found in EHRs. That includes medication distribution information, pharmacist notes, barcode archives, and so on.

Operational Logistics: Think Amazon warehouse. That’s the easiest way I can explain pharmacy logistics. You buy something from a third party, store it in the pharmacy for a period of time, and send it to a patient when it’s ordered. Simple, really. We’re still not very good at it, but that’s the gist.

For the most part, pharmacy logistics has maintained its distance from the influence of EHRs. Instead, inventory management has been driven largely by a other, non-EHR companies: CareFusion, Omnicell, and to a lesser extent, Swisslog. These companies have grown and expanded over the years, increasing their portfolios to cover more and more areas of the pharmacy.

I’ve mentioned the “four areas of pharmacy” many times: standard storage, refrigerated storage, controlled substance storage, and the iv room. The first three areas are still dominated by these companies. Carousels, inventory software, refrigerators, various cabinets controlled by remote locks, and automated packagers can be found in most large pharmacies. All of which are offered by the aforementioned companies. There was a time when it was common for any number of these products to be supplied by different vendors. Not so much anymore.

These days, it’s all about integrated systems from a single vendor. When given a choice, pharmacies are deciding to purchase from a vendor that can “do it all”. For example, CareFusion offers Pyxis ES ADUs for medication distribution at the point of care; Pyxis Logistics software and hardware for medication distribution from the pharmacy; Pyxis CII safe to manage controlled substances; BD Cato for the IV room; and so on.

With that said, the IV room is in a state of flux. The nature of this area lends itself to both operational logistics and documentation, the latter of which seems to be more important now more than before. It may be the only area of the four where inventory management means less than documentation. I expect this trend to continue.  

Surprisingly, I really have seen better integration amongst pharmacy systems these days. I fully expect it to improve even more as EHRs expand and eventually creep into operational logistics. At least one EHR vendor has already made a significant impact in the IV room. Eventually, pharmacy will be just another department within the EHR’s web of control. I see both good and bad in such a future, but that’s a blog post for another time.

Disruptive technologies in pharmacy, reality or myth?

There was an interesting thread in one of the ASHP practice forums recently. Someone asked whether or not pharmacists were “ready for the future that the opportunities these disruptive technologies offer”. This in reference to technologies that they saw in the exhibit hall at ASHP Midyear.

The simple answer is no. Pharmacists are barely ready for technology that’s 20 years old, much less anything that is disruptive. In support of my quick answer, I give you a brief conversation I had with one of the most progressive pharmacy operations people I’ve ever known (paraphrased, of course):

  • Me: “See anything cool in the exhibit hall?”
  • Them: “Yeah, a change in software that will allow me to capture more 340B costs in the OR.”
  • Me: “Really? What about Kiro, IntelliGuard, and PharmID?”
  • Them: “That stuff? I don’t care about that stuff. It’s meaningless to me because it doesn’t help me. Not to mention that my organization will never go for it.”

The ASHP forum thread produced some interesting responses. One pharmacist pointed out that healthcare disruption will come from outside of healthcare. I agree with that opinion 100%. However, someone responded that they didn’t think this was “… a foregone conclusion” because they think that “…in the short to medium term, in order to actually make meaningful improvements in outcomes, healthcare needs to be disrupted from within”. I almost snorted coffee out of my nose when I read that. It was that funny.

I’ve been a pharmacist for more that 20 years. In that time, pharmacy hasn’t disrupted anything. Nothing. Nada. Pharmacy departments are so busy keeping up with regulatory requirements and chasing elusive “clinical activities” that they don’t have time to innovate and disrupt.

I went back through some of my posts from the past few years. Here’s what I found:

03/02/15: 5 years later, my thoughts on pharmacy practice
“Pharmacy is the same as it was when I left. It’s the same chaotic, messy thing that it’s always been…. Five years out of the game and I don’t feel like I’ve missed much.”

06/04/15: Pharmacy – entrenched in outdated dogma
“…you should be using the most complete solution possible in the i.v. room, and you need to get over the idea that a PharmD is required for a “final check”.”

09/20/15: Will healthcare disruption come easy and fast?
“There are many things being developed to improve healthcare, but the innovation is coming from outside sources. People are literally leaving healthcare to innovate things for healthcare.”

01/08/16: Is nearly universal prospective order review (NUPOR) really necessary? — “… NUPOR is … expensive, time-consuming, and unnecessary … NUPOR is an antiquated practice that needs to be done away with.”

11/10/16: Someone please disrupt controlled substance storage technologies — “Management of controlled substances inside acute care pharmacies is a mess… Based on my observations, the technology is outdated, difficult to use, and has failed to improve the process in any appreciable way. It remains unclear to me what advantage these systems offer.”

04/20/17: A cautionary tale for healthcare. A lesson for pharmacy.
“The pharmacy practice I returned to … appears to have been frozen in time.”

09/21/17: It’s time to disrupt pharmacist order verification   —
“It’s an antiquated process that’s long overdue for an overhaul. The time has come for healthcare systems to make better use of their personnel.”

And that’s just flipping through my posts from the past few years. I can’t imagine what I’d find if I went all the way back to the birth of this weblog in 2009.

I used to think about disrupting healthcare all the time. I recorded my ideas in notebooks and spent years pitching my ideas to companies in the hopes of building a new and exciting pharmacy practice. But it went nowhere, and became nothing more than an exercise in futility.(1)

Is there a healthcare company out there that will disrupt pharmacy? Not likely. As a really smart lady once told me, no one wants to be in this space because it’s hard and you can’t make any money. What about companies from the outside? Also not likely for the same reason.

If it sounds like I’m bitter about all this, it’s because I am. Pharmacy practice could be so much more if we’d just crawl out of our holes and do something different from time to time.

Here’s the bottom line, pharmacy needs to be disrupted — desperately. However, it’s not going to happen. The best we can hope for are iteratvie changes, at best.

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(1) I’ve actually had a few ideas turn into real products. Nothing earth shattering, but cool nonetheless.






Robots in the IV room, still not ready for prime time

I love pharmacy IV room workflow and technology, but I don’t get to talk about it much anymore. Most of my conversations these days are focused on IV room regulation, i.e. compliance with USP <797>/<800> and Board of Pharmacy rules.
So you can imagine my surprise when two people approached me on two completely different occasions at two unrelated events asking my thoughts on IV room technology. Awesome! Then they asked me what I thought about using robots in the IV room. Bummer. Of all IV room technologies, robotics is my least favorite.

Image owned by Jerry Fahrni, Pharm.D. Taken February 12, 2014.

Ten years ago, I was optimistic about IV room robots. Today, not so much. If I could sum up my opinion in one sentence, it would be that highly-automated robotic systems for sterile compounding are not ready for prime time.
Note that I said highly-automated and not fully-automated. Even though robots replace human hands for the actual compounding process, they are dependent on human hands for moving products in and out of the robot before, during, and after the compounding process.
When considering IV robotics, one should always think about:

Patient safety – Can robots reduce CSP errors? Certainly, but so can most any IV room technology that utilizes bar-code scanning, gravimetrics, imaging, etc. Often times people will tout robotic systems for consistently compounding drugs within 5% of the prescribed dose. It’s not really a big deal. Doses slightly outside the 5% range are not clinically significant, and getting it within that range is not important enough by itself to warrant the investment in a robotic system. Given proper guidance and a system for compounding, particularly an IV workflow management system, humans can easily be as accurate.

Worker protection from hazardous drugs (HDs) – There is no question that IV robots have the potential to reduce worker exposure to HDs during the compounding process. Then again, new USP <800> guidelines do the same. Ever heard of a CSTD?

Workflow efficiency – Not sure a robot brings you increased efficiency unless you’re talking about single batch high-volume IV production. I sat for hours watching IV robots doing their thing in pharmacy cleanrooms across the country. I don’t think I ever thought to myself, “dude, that thing sure makes things easier/better”.

Cost reduction from moving outsourced CSPs back in house, i.e. no longer having to purchase CSPs from a third party – Not specific to robots. Perhaps for single batch high-volume IV production, but doubtful.

Reduced waste from discontinued orders falling off work queues before they are filled – Sure, a robot can help with this, but the same is true for almost any IV workflow management system.

Comprehensive documentation for regulatory compliance – These systems certainly collect lots of data but how easy is it to use? Just because the system collects info doesn’t mean you can get it out when you need it. I’ve seen things. Just sayin’.

Return on investment (ROI) – What do these systems give back? There are few pharmacies where IV room robots will result in a positive ROI. I’ve seen pharmacies try. While their arguments may sound good on paper, in practice they are as thin as the paper they are written on. The only time these systems yield a real ROI, in my opinion, is when they are used to repetitively compound the same few items over and over again – in other words, batch compounding for high-volume items. All of the systems have roughly the same throughput, which is much lower than that of a highly skilled technician. IntelliFill i.v. is the fastest of all the robots I’ve seen, but it is limited in scope to syringes.

Formulary limitations – One of the major limitations of IV robots is the number of formulary items they can handle. During visits to facilities using IV robots — San Francisco, CA; Asheville, NC; Baltimore, MD; Madera, CA; and so on — I saw very few medication “line items” assigned to the robot. The largest number I witnessed was somewhere around 10, and the smallest number was two. Two! Someone had a million-dollar robot making CSPs out of two drugs. Hospital formularies are large and diverse. They include all kinds of IV products: piggybacks, large-volume parenterals, syringes, and so on. Not to mention that formularies change all the time. The inability of these systems to manage a large number of different CSPs at one time is definitely a limitation.

Maintenance – What does it cost to maintain these bad boys? They don’t operate on a zero cost. They also don’t maintain themselves. Operational resources required for things like robot maintenance, formulary maintenance, product changes, and so on are important considerations to keep in mind when purchasing a robot. Who is serving who…. or is that who is serving whom? I can never get that right. Anyway, the time, energy, and effort required to keep an IV robot at peak operational efficiency simple isn’t worth it. At least not in my opinion.
In a nutshell, I’m just not a fan of the current crop of IV robots. Does that mean that there is no future for robots in sterile compounding? On the contrary, I think we must move toward a future where all CSPs are made by robots. It’s the only thing that makes sense. Unfortunately, that future is still far off.
I’ve had the opportunity to peak behind the curtains at a few robots currently under development. There are some great products coming down the pike, but we are going to have to wait a while. Apparently, building robots with creative new features is hard.

Google improves symptom search

I’m sure most of you have Googled for medical advice at one time or another. I know I’ve performed quick Google searches for healthcare information, including specific drug information.

It turns out that a lot of people search for symptoms online, and the information isn’t always helpful. Sometimes a little information can send people’s minds cascading into full panic mode, i.e. get a tension headache, search for symptoms and end up thinking you’re dying from a brain aneurysm.

Google understands the problem and has improved symptoms search.

Roughly 1 percent of searches on Google (think: millions!) are symptom-related. But health content on the web can be difficult to navigate, and tends to lead people from mild symptoms to scary and unlikely conditions, which can cause unnecessary anxiety and stress.

So starting in the coming days, when you ask Google about symptoms like “headache on one side,” we’ll show you a list of related conditions (“headache,” “migraine,” “tension headache,” “cluster headache,” “sinusitis,” and “common cold”). For individual symptoms like “headache,” we’ll also give you an overview description along with information on self-treatment options and what might warrant a doctor’s visit. By doing this, our goal is to help you to navigate and explore health conditions related to your symptoms, and quickly get to the point where you can do more in-depth research on the web or talk to a health professional.

As I mentioned above, I’ve used Google to look for pharmacy specific drug information. Most of my colleagues do the same thing on a regular basis. It’s amazing what can be found with a few key words and the click of mouse.

We live in a digital world. Information has never been more accessible nor more overwhelming. Clinicians have unfettered access to information that one couldn’t have imagined just ten years ago. Information has become cheap, plentiful, and readily available to anyone with internet access. Journals, reference books, provider forums, clinical trial hubs, drug monographs, study data, and so on can be accessed anytime, from anywhere. This thanks to the development of cellular networks and mobile devices. Everything is simply a click away.

I still work an occasional per diem shift at a local hospital, and take my word for it when I say that it’s never been easier to access information. When I compare this to how I gathering information when I became a pharmacist some twenty years ago, my head spins.

I’ve always wondered what it would be like if one were to give Google access to all the currently available literature and reference material in real time. The idea of such a vast amount of knowledge at one’s fingertips is mind boggling, to say the least.

Cool Pharmacy Technology – Aesynt REINVENT [it’s about the data]

Data surrounds us. We’re deluged by it in every facet of our lives, from the bank statements we receive in our personal life to the mountains of data collected in healthcare. Regardless of the data collected, there are basically three things that can be done with the information. It can be ignored, archived, or used. Unfortunately only one of those three things is truly meaningful, using it.

Many, especially in pharmacy, chose to ignore or archive data rather than use it. That’s not because the information isn’t valuable, but rather because they are overwhelmed with the amount of information they receive and simply have no idea what to do with it. Throw in the fact that the more data we collect, the more useful it becomes, and things get weird. Seems counterintuitive, but data collected from a single source, say one pharmacy i.v. room, offers little value.

Single source data creates several problems, such as potential bias, the inability to find trends that may be available in larger data sets, and failure to create usable comparisons to others that may offer insight into improved operations. Only when data is collected from several different sources does one truly begin to understand its value.
Continue reading Cool Pharmacy Technology – Aesynt REINVENT [it’s about the data]

Is pharmacy informatics defined well enough to be a specialty?

Pharmacy informatics remains in its infancy as a profession. What started out as a job for tech-savvy pharmacists with working knowledge of pharmacy has turned into an ever expanding career field.

I’m looking through the ASHP Summer Meeting Informatics Institute schedule and the topics are varied. I see something on human factors, information management, clinical decision support, and e-prescribing. And that’s only on first glance.

If you look at job descriptions for healthcare systems seeking informatics pharmacists you’ll see everything from involvement in strategic development of services to data entry by monkeys, and everything in between. There’s little consistency in what one facility is looking for versus another. That point alone is telling.

This reminds me of pharmacy practice in acute care facilities 20 years ago. Outside of academic medical centers pharmacists were largely involved in operations, and only slightly involved in other care activities. That’s all changed as pharmacists practice in many different areas today and can specialize in a variety of disciplines, i.e. infectious disease, cardiology, etc.

I think we’re heading in that direction with informatics as well. The field is so vast that being a informatics generalist will soon be impossible because the information will be more than one person can reasonably be expected to handle. The influx of consumer technology and the need for better interoperability between systems will ultimately drive informatics pharmacists to specialize in one, or perhaps a few, specialized areas.

I consider myself an informatics generalist, but wonder how long before I won’t be able to keep up with new developments in the field. I’m already seeing signs of specialties within pharmacy automation and technology, it won’t be long now until we see it in other informatics areas.

Ultimately pharmacy informatics cannot be a specialty as the subject area by definition requires generalist knowledge. Eventually I think we’ll see practice specialties like we do in pharmacy practice today. Until then creating a pharmacy informatics specialty makes little sense.

Update on unique device identifiers (UDI) from the FDA’s Jay Crowley, a webinar

This could be worthwhile, and it’s free. Information from the email I received below.

Just follow this link if interested in registering.

unsummit_webinar

 

Continue reading Update on unique device identifiers (UDI) from the FDA’s Jay Crowley, a webinar

IT pharmacists need more practical pharmacy experience

I’ve laid out my pharmacy career on this site many times in the past. In a nutshell I’ve been a pharmacist for about 16 years. The first 10 years was a mix of “clinical pharmacy” and operations. The last 6 have been spent on the technology side of things; IT pharmacist for about 3 years followed by approximately 3 years with a pharmacy technology vendor.

I will state this as clearly as possible: the time I spent as a clinician combined with my time in operations made me a better IT pharmacist.

Continue reading IT pharmacists need more practical pharmacy experience

Center for the study of pharmacy automation and technology [idea]

MadScientistEarlier this week I put up a post about a Prezi created by Dr. Robert Hoyt called Evidence Based Health Informatics: Replacing Hype with Science. It was a great presentation about a lot of the technology that healthcare has adopted over the years without any real evidence to back it up. I wish you could all see it, but it appears that someone has pulled it down. The link I have for the Prezi is dead. Bummer

Anyway, the Prezi got me thinking about how we have many technologies in pharmacy that have precious little, or no data to support their use. We use carousels, high-speed packagers, tabletop packagers, robotic medication distribution, robotic IV preparation along with other IV room technologies, smart IV pumps, automated storage cabinets, and so on. The data we do have for these items is typically provided by the manufacturer’s themselves, which makes it biased in the best of situations and completely worthless in the worst cases.

Pharmacy is in desperate need of an academic center for the study of pharmacy automation and technology. The center would study the use of pharmacy technology in different use cases, collect data, and provide the pharmacy community with the information. Look at robotics versus carousels for distribution. Analyze cross contamination in high-speed packagers versus tabletop models. Perform time-motion studies on cart fill vs. automated dispensing cabinets for medication distribution, and compare the safety of one over the other. Analyze pharmacy inventory costs of one technology over the other. And so on, ad infinitum.  Conclusions wouldn’t be necessary as simply presenting the information in an easy to understand format would suffice. Let the end users draw their own conclusions. Every practice setting is slightly different, and what may work for one may not work for another. But understanding how a piece of technology or automation fits into a particular practice model might be a significant benefit to many.

The center would tear the automation and technology apart, both figuratively and literally to unveil all there is to know about each and every piece.

Such a place would have to exist at a well respected academic research center as it is the only way to ensure some semblance of impartiality.

How would it be funded? Ah, there’s the rub. Getting funding for such an endeavor would be difficult at best. A lot of this equipment is expensive. Of course the best place to troll for money would be the pharmacy technology vendors themselves. After all, they have all the equipment that would be needed to perform the research. Unfortunately this is unlikely to happen as most companies will not be willing to drop resources into a project that they have no control over. What if the outcome of such research reflected poorly on their products? That would not only be embarrassing, but could potentially hit them in the pocketbook. No, they couldn’t risk it. How about the federal government? Perhaps, but that might be like getting blood out of a turnip these days.

Getting the equipment and funds would definitely be the hardest part. There’d be no shortage of pharmacists interested in doing that type of work. What pharmacist could resist playing with giant toys all day long?

Time to get out my crayons and start drafting a proposal….

Great Prezi on Evidence Based Health Informatics

Thanks to Tim Cook over at Google+ for the lead on this one.

I’m familiar with Prezi’s, but have never created one. I played around with the technology once, quickly became frustrated, and gave up. Anyway, the Prezi below from Dr. Robert Hoyt - Evidence Based Health Informatics » Replacing Hype with Science – has a lot of great information in it.

Update 3/13/2013: Looks like the presentation was pulled down. Not sure why, but the link is dead. Unfortunate as it was a great presentation.

Update 8/21/2013: The presentation is back! Dr Hoyt left a comment on this post letting me know that the presentation is up with new and improved content.

You can see the full presentation here or view it below.