Epic will eventually control IV workflow management

Pulling another article from the notebook archive, penned March 20, 2020.

I have seen the future of IV workflow management systems (IVWFMS). Spoiler alert, EPIC wins. And before people start calling me an Epic fanboy, I should make it clear that I do not like Epic, as a company or a product. I believe healthcare will rue the day they relinquished all their power to a single company. 

Those that know me or have read anything I have written in the past decade, know that I am an advocate for technology in the IV room. People are imperfect creatures, they make mistakes. Don’t believe me? Google Emily Jerry death or St Charles rocuronium. That will tell you all you need to know about the dangers associated with injectable medications. Compounded sterile preparations are the most dangerous medications within the four walls of a hospital. Seems logical that such dangers would receive the utmost attention. Inexplicably, they do not. Many reasons are given for ignoring the issues, but it boils down to poor planning and the inability to prioritize in the face of budgetary and political restraints. 

Technology, while far from perfect, adds a level of protection to a complex, error-prone, and dangerous process. Adding a little common-sense technology to the IV medication process, like an IVWFMS*, is the quickest and most cost-effective way to improve safety.

Implementing these systems is a no-brainer, but that hasn’t stopped people from ignoring them. The problem has been, at least from my perspective, a complete failure by pharmacy leadership to recognize and prioritize IV room safety and efficiency. Nowhere else but in the IV room can a single mistake result in significant harm or death. Yet the IV room seems to get a fraction of the attention it should. Unfortunately, it often takes a tragic error like those noted above before folks take notice. 

With that said, there is some good news. I have witnessed an uptake of IVWFMS in recent years. More hospitals seem to be adding these systems to their workflow. While a welcome trend, the increased numbers don’t appear to be secondary to some altruistic good will or common sense, but rather because of Epic. The monolithic EHR vendor has unwillingly changed the landscape of the IVWFMS market, forever. Big pharmacy technology companies refuse to admit it, but the writing is on the wall. When asked what technology a hospital is using in the IV room, I used to hear “nothing” or “DoseEdge” with an occasional “MedKeeper” thrown in. Now, more often than not, I hear “Dispense Prep”.**

Why the shift? No mystery here, the answer is simple: the barrier to entry is low and the integration within the platform is amazing. 

For healthcare systems already using Epic, it is as easy as flipping a switch. The implementation requires a bit of legwork, and some minor equipment, but nothing like that required when implementing a third-party system like DoseEdge, BD Cato, etc. I have been involved with both Epic and third party IVWFMS implementations, there is little comparison in time, energy, effort, and cost. Epic Dispense Prep (EDP) wins in all those areas, easily, every single time. 

The ease of EDP implementation is tied directly to the modularity and integration of the overall system. It shares databases, labels, user experience, dashboards, and so on. EDP is already part of the EHR, so it requires no additional contracts, no additional maintenance agreements, no third-party vendor helpdesks, no “integration” within the EHR, no crazy implementation schedule and checklists, no weird upgrade schedule or downtime, and so on. 

EDP implementation requires far fewer pharmacy resources than other IVWFMS and has the added benefit of being nearly transparent to pharmacy personnel. Most of the build is handled behind the scenes by dedicated IT resources — the ever present Epic Willow Build Team. Pharmacy resources are kept to a minimum, which decreases impact on the department. Contrast this to something like DoseEdge, which requires a significant investment in time and effort from pharmacy personnel. I can attest from personal experience that the overhead for a third party IVWFMS implementation can be hundreds of hours of dedicated pharmacist time. EDP, on the other hand, requires a fraction of that time. This alone makes it an easy choice for pharmacies strapped for resources, which describes nearly all inpatient pharmacies. 

None of this means that EDP is the best IVWMS on the market. Not even close. While it offers full integration across the entire enterprise, barcode scanning, image capture, robust tracking, and is seamlessly tied into the billing system — something I care little about but is a top priority for healthcare systems — it falls short in other areas. As I write this, I can think of at least three products off the top of my head that I believe are better than Dispense Prep. They are more flexible, more feature rich, have better hardware, have better software, and so on. Most even eclipse EDP in the quality of the basics, like image capture. But it doesn’t matter if they are never implemented. The best IVWFMS is the one you are using. While Dispense Prep may not be the best, it is better than nothing. Love the one you’re with, you know?

While not an accident per se, I believe Epic won the battle of IV workflow management systems without trying. Several large IDNS have already converted to Epic, giving them an obvious competitive edge in the IV room. As facilities with Epic gravitate toward Dispense Prep for the reasons outlined above, the market will inevitably begin to contract, forcing third party vendors to compete against one another for a smaller piece of the pie. It may take some time – things always do in healthcare – but companies marketing IVWFMS will feel the pressure. I believe some already have. I have personally witnessed facilities that have uninstalled DoseEdge in favor of EDP, and some that have elected to with Epic over an outside vendor. The pressure is on. 

To the IVWFMS out there, I wish you good luck. The long game is not in your favor.

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*Robotics has its place in the IV room. Products continue to get better every year. While it may not be for everyone, I can see use cases where robotics would be a viable option. 

**EPIC Dispense Prep (EDP) is the IVWFMS module inside the Epic EHR System. It is an incredibly well integrated piece of the overall Epic medication distribution model. Dispense Queue [a dashboard of everything waiting to be prepared] → Dispense Prep [capture all data during compounding] → Dispense Check [Pharmacist Review] → Dispense Tracking [track product from pharmacy to bedside]. While I do not care for Epic, in general, one has to admire the vision and design.

Is BD Pyxis Logistics inventory management any good?

Full disclosure, anyone reading this should take it with a grain of salt. I used to work for Talyst as a product manager for their acute care product line, and I’ve recently been involved with a Pyxis Logistics implementation. With that said, forward.

In short, yes, BD Pyxis Logistics (“Logistics) is quite good. BD is doing something that pharmacy has needed for a long time, embracing the concept of “the enterprise” with integration across multiple areas in and out of the pharmacy. BD, as a company, has been busy over the past few years piecing together products to create a cohesive strategy. Someone has been paying attention.

Are they there yet? Not yet, but they are on their way. To paraphrase my brother, they’re currently the worst they’re ever going to be, i.e. their products and strategy are only going to get better and mature over time.

You’ve heard me talk about the four areas of pharmacy many times: standard storage, refrigerated storage, controlled substance storage, and the iv room.

Basic storage are those basic shelving units that most people think of when they walk into a pharmacy. It’s where you’ll find unit-dose and bulk room-temperature items. Logistics is squarely focused on this area of the pharmacy. It works well and, at least in my opinion, does a good job of addressing inventory across multiple pharmacies. Throw in that Logistics is web-based, and it’s compelling.

Refrigerated storage is, well, where you put things when you want to keep them cold. Same as basic storage, only refrigerated. BD doesn’t offer anything specific for this area, but Logistics handles refrigerated items just fine. It basically treats refrigerators the same way it treats static shelving and carousels. It’s just another storage area.

Cleanroom/IV Room is where you’ll find all the supplies for compounding sterile medications. The IV room has been getting a lot of attention lately, but that has nothing to do with inventory management. Most pharmacies treat the IV room as a black hole for inventory, i.e. they lose visibility of their inventory when it crosses the threshold into the land of sterility., BD has had a product called Cato for many years. It’s now called BD Pyxis IV Prep and I’ve always been a fan. Pyxis IV isn’t fully integrated with Logistics, but they’re working on it.

Controlled substance storage is where you’ll find all your opioids, benzodiazepines, and so on. Anything the DEA, Board of Pharmacy, and any other regulatory agency considers a diversion risk. I have a love-hate relationship with controlled substance management. This area is long overdue for improvement. With that said, I’m happy to report that BD is making inroads. The latest version of their CII safe software is integrated with Logistics, meaning no more disparate systems for controlled and non-controlled meds.

What I like about Pyxis Logistics

  • Multiple pieces of the pharmacy puzzle. When looking at the BD Pyxis lineup, the four areas of pharmacy are closer than ever.
  • Integration that is getting better and better all the time. BD not only has the pharmacy covered — Logistics, CII Safe, IV prep — but think about their dominance in the automated dispensing unit (ADU) market. Integration is hard, but getting ADUs and pharmacy inventory seamlessly talking to one another is something I’ve been pining after for a long time.  
  • Handhelds. BD offers a handheld for Logistics. I haven’t had one in my hands but the device and functionality look good, shortening the inventory gaps even more. Talyst had a handheld device for AutoPharm years ago. Wonder what became of it?
  • Good folks to work with. I have nothing but good things to say about the people from BD that I’ve worked with. They want to do a good job.
  • Improvements are rapid and obvious. That’s the thing about most companies, they want to improve their products and keep customers happy. Improved products and happy customers equal increased adoption, which in turn leads to more sales, which leads to more money, and so on down the rabbit hole.

What I don’t like about Pyxis Logistics

  • Reports and analytics appear weak. The system offers many canned reports and access to the company’s Knowledge Portal, but overall, it feels like they’re behind in this area. From what I’ve seen, it’s just not there. When compared to something like the analytics software from Swisslog — still don’t know the name of the product…. Pharmacy Analytics? I mentioned it here — it feels miles behind. What’s worse is that what I saw at ASHP Midyear back in December doesn’t make me feel any better about it.
  • Piecemeal products. It’s obvious what BD is doing. However, buying products and folding them into your portfolio can make things feel like they’re bolted on instead of feeling like they’re an integral part. It’s only going to get better, but one has to be willing to ride through the rough patches to get to the smooth road.
  • Lack of product maturity. “Pyxis”, the ADUs, is a very mature product that’s used in thousands of facilities. Logistics and IV Prep, not so much, and it feels like it.

Overall, it seems as though BD is heading in the right direction. It will be interesting to see where the company ultimately goes with their strategy.

ASHP Midyear 2018: Initial Thoughts

I recently returned from the 2018 ASHP Midyear Clinical Meeting, i.e. “Midyear” in Anaheim, CA. This year was a bit different for me as it was the first time in many years that I attended the meeting as a regular pharmacist, i.e. not tied to a pharmacy automation company as an employee or as a consultant. As such, I had no constraints on what I could see, do, or say. It was invigorating, to say the least.

I attended several educational sessions, mostly on USP <797> and <800>. However, most of my time was spent in the exhibit hall wandering from booth to booth checking out all the cool products. It was great.

As much as it pains me to say, not a lot has changed since the last ASHP Midyear Meeting I attended in December 2016.* Many of the products and vendors were exactly as I remember them. With that said, here are a few things that caught my attention:

  • The “Big 3”: Omnicell, BD, and Swisslog all had a big presence on the exhibit hall floor. All three companies appear to be vying for pharmacy supremacy as they continue to grow and gobble up small companies. The Omnicell booth was giant and seemed to always be full. Oddly, it was the only booth I walked into where someone from the company didn’t engage me in conversation.
  • IV workflow management (IVWFM): No longer a hot topic. It appears that the market is slowing as pharmacy leaders turn their attention to other things. Quite a dichotomy from what ISMP and ASHP continue to recommend, i.e. the use of technology during sterile compounding. Apparently patient safety is important, unless it’s inconvenient. Pharmacy is weird.
  • Drug Diversion: Unlike IV workflow management, drug diversion was a hot topic. It seems as though everyone has a software solution to help root out those pesky diverters.
  • Kiro Oncology by Grifols: I wrote about Kiro Oncology back in 2015. At that time, I didn’t think much of the product. It had some serious shortcomings, at least in my opinion.  The robot lacked speed and a drug dictionary that would make it useful. Now, not so much. I was impressed with how far Grifols has come with Kiro Oncology. The speed has significantly improved and they’ve worked with their partners to build an impressive oncology drug dictionary from which sterile compounds can be made. I spent quite a bit of time speaking with a Director of Pharmacy at a facility that is using Kiro. He mirrored my thoughts, i.e. not great to start but significantly better now. Given the new focus on hazardous drug compounding, my thoughts on Kiro have changed. There is great potential here. I may write more about this later.
  • PharmID: PharmID is a product that uses Raman Spectroscopy to identify drug waste. If you’ve been following my blog over the years then you know that I like Raman Spectroscopy. It makes a lot of sense when you want to know what’s in a clear fluid. Before PharmID, the company was trying to fit the technology into the sterile compounding space. That didn’t make sense to me, but this does. Given the focus on drug diversion and the inherent problems tracking waste in the OR, something like PharmID has great potential. Now all they need is something like the now defunct  BD Intelliport to automatically record the volume. If you can do that — identify the drug, measure the concentration and volume — you’re all set.
  • IntelliGuard: In the Summer of 2017, IntelliGuard got a new CEO and then abruptly went dark. The company disappeared from view. After visiting the IntelliGuard booth at Midyear, it was apparent why. They’ve completely revamped their image, created an entirely new marketing strategy, built some new products, improved on old products, and created an integrated platform message. I’ve always liked RFID technology for certain niches within healthcare, and IntelliGuard makes some great RFID products.
  • Swisslog: Some people feel that I’ve been a little hard on Swisslog over the past couple of years. I for one, am not one of the people. I call it like I see it. And my opinion is exactly that, my opinion. When Swisslog acquired Talyst, I was skeptical. Nothing has changed, I remain skeptical. However, Swisslog has two products that I really like. The first is their analytics software. I don’t know the name of the product and can’t seem to find it on their website. Regardless, I’m impressed by the vision that the company has with the product and the number of disparate systems they’ve managed to tie into it. I would love to see it in the wild. The second product is the Relay Robot. Love that little bot. I can see so much potential.
  • DrugCam: DrugCam is an IV workflow management system. I first saw the product at the ASHP Summer Meeting in Minnesota way back in 2013. DrugCam uses computer vision technology that automatically detects items and fluid volumes during the compounding process. As the user passes components in front of the cameras, the system automatically identifies them. If the system doesn’t recognize the item, the user is notified via visual cues on the screen. I’m not entirely sure how it works, but it is pretty interesting. The company had a presence in the exhibit hall but there was no hardware to look at, only a video set on a continuous loop in the background. I was really high on this technology when I first saw it. It would be good to see it in action. There’s an article from April 2016 in the International Journal of Pharmaceutics should you be interested in reading more about it.

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*I skipped the 2017 meeting due to scheduling conflicts with my new job

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.

Has adoption of IV Workflow Management Systems in hospital pharmacies slowed?

Pharmacy Purchasing & Products (PP&P) puts out a survey each year called The State of Pharmacy Automation (SOPA). The 2017 PP&P SOPA is out and available for your reading pleasure.

The PP&P SOPA survey covers many automation, technology, and practice trends. One item that I look at each year with great interest is the reported IV workflow management system (IVWFMS) adoption rate. I’ve written about IVWFMS many times. I even went as far as to do a podcast dedicated to them back in 2015.*

While reviewing the 2017 SOPA numbers, I was surprised to see that this year’s survey shows no gain in adoption of IVWMS over last year. They appear to be stalled at approximately 19%, same as last year (see graph from PP&P 2017 SOPA below).

While informative, it’s important to take these survey results with a grain of salt. Response rates are incredibly low, for one thing. Results can also be skewed based on participants, i.e. it may not be the same pharmacies responding year over year. This makes it difficult to draw direct comparisons from one year to the next. 

Regardless, I was still surprised to see the flattened curve. I expected to see a sharp uptake. Most facilities I go into these days are using, or in the process of implementing, an IVWFMS of some kind. It’s becoming less common to find a facility not using one of these systems, especially in larger facilities where they seem to be slowly becoming best practice.  

One other item worth mentioning is my belief that last year’s survey overestimated the number of facilities using IVWFMS. So if last year was really 12-15%, perhaps this year’s result is an improvement. That’s purely speculation on my part. I have nothing concrete to back it up other than my sense of the market. Through no fault of PP&P, I feel like these surveys are a poor representation of what’s really going on in the real world.

Other takeaways from this year’s survey:

  • Larger hospitals are adopting IVWFMS faster than smaller hospitals. No surprise here. If you’re a hospital with more than 400 beds and you haven’t implemented one of these systems, you’re wrong and should be embarrassed by your lack of action. “Ninety-nine percent of the failures come from people who have the habit of making excuses.” ~ George Washington Carver. Simple as that.
  • DoseEdge by Baxter is the #1 system in use. Again, no surprise. This corresponds to what I see in the wild. Baxter has been in the game for a while. DoseEdge is definitely the first system that comes to mind when talking about IV room technology. Pharmacy Keeper by MedKeeper at #2 is a bit of a surprise. I have yet to go into a pharmacy that is using it. It’s a less functional system than say DoseEdge or BD Cato, but it’s also less expensive and easier to install, implement, and maintain. I personally believe pharmacies should be looking at systems with proven gravimetrics, but that’s just me. Pick your own poison.
  • DoseEdge by Baxter is the #1 system under consideration for new implementations. BD Cato comes in at #2 by a small margin. DoseEdge at #1 surprises me a bit. Most facilities I go into these days have BD Cato at the top of their list of possibles, and for good reason. BD Cato has a lot to offer, especially now that they are part of CareFusion. Perhaps the survey is a bit behind what I’m seeing out in the wild. Impossible to say.

That’s it. I’m not sure that the raw numbers presented in the survey are helpful, but the information in the SOPA survey goes way beyond the numbers. For instance, the SOPA may introduce pharmacies to vendors and technologies that they’ve never heard of before. I encourage everyone to read through the PP&P 2017 SOPA. Who knows, you might find something new and exciting in there. I’ve been doing this for many years, but I still get surprised from time to time. 

I can’t explain the SOPA survey results, but overall it feels to me that adoption of IVWFMS is still on the rise.

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*Looking back through some of my old posts — and the podcast — it’s amazing how little this landscape has changed.

Quick thoughts on Swisslog acquisition of Talyst

I’m a little slow getting to my thoughts on this deal.

A couple of weeks ago it was announced that Talyst had been acquired by Swisslog Healthcare. I’ve known about this acquisition for a while so I wasn’t surprised when it finally went through. Since the announcement, I’ve reached out to some friends and colleagues on both sides of the fence to get their thoughts and opinions on what’s in store for the future.

My contacts at Talyst have been quite helpful and informative. Swisslog, not so much. In fact, they’ve provided me with no additional information or insight. All they’ve done is sic their marketing department on me, who in turn sent me a bunch of marketing hype that I can find online. Useless. I hope this isn’t a primer on what we can expect from the “new Talyst” moving forward. That would be unfortunate. I suppose this is the difference between a small company and a large company. I’ve always had trouble getting good information from large companies. There are simply too many layers to get through. With small companies, I can often go directly to the CEO. In large companies, I’m met by an army of people designed to keep people like me away from the CEO.

Trying to figure out what Swisslog wants with Talyst has given me much to think about. Talyst is a market leader in certain acute care areas of pharmacy, such as carousels and inventory management software. They aren’t particularly creative or innovative, but rather steady. Talyst knows carousels but that market has kind of run its course unless you’re building a new pharmacy. The high-speed packaging market in acute care pharmacies is basically dead. The company doesn’t offer a competitive controlled-substance management system. They have a solid refrigeration strategy, but it’s not as innovative as something like Evolve. Talyst doesn’t do anything with RFID technology nor do they have a mobile strategy. Their software has good functionality but is antiquated in many ways. So what it is that Swisslog wants? Customer base? Name recognition?

Swisslog doesn’t have much of a footprint in acute care pharmacies except for their tube system, which is basically everywhere. However, Swisslog is creative and innovative. They have some robotic systems like BoxPicker, PillPick, and RoboCourier. They make use of RFID technologies. They have pretty decent integration within their systems and they’re really good at logistics. Honestly, I don’t know as much about Swisslog as I do Talyst. 

In general, I like products from both companies. However, it’s hard for me to imagine where Talyst products will fit into the Swisslog scheme. The items I think Swisslog needs from Talyst will likely be the most difficult to use, i.e. think square peg and round hole. I suppose the existing Talyst customer base is something that Swisslog can take advantage of. Customers using Talyst products could benefit from Swisslog products and better integration across the two platforms. That goes vice versa as well.

Only time will tell, but I’m betting that we won’t see anything significant from this deal for quite some time.

Laying the foundation for your technology implementation team

I’ve been thinking a lot lately about the right way to go about putting new technology into a pharmacy. Making the decision to add technology doesn’t mean running out and purchasing a million-dollar piece of equipment and shoving it in a corner. It’s much more complicated than that. You must first lay the foundation for the work to be done.

Here are some things that I think should be considered before putting new technology in the pharmacy:

Give everyone fair warning of what you plan to do. No one likes to be surprised and people fear change. The best policy is to give people plenty of warning before making a change, which will allow them to get used to the idea. This will go a long way in gaining support for the project. Being aware of what’s coming is always preferable to being surprised by what has already been done.

Gauge user beliefs and feeling. It’s best to take the temperature of pharmacy personnel prior to getting started. Is it going to be an uphill battle? Are the pharmacists and technicians open to the idea of implementing new technology? Is the pharmacy morale where it should be? Does your department fear change?

The success of the implementation depends heavily on how well the department is warned and prepared for the change. People often see technology as a threat to control over their work environment, resulting in pushback. Helping staff understand what it is you hope to accomplish, how it will help them, and offering opportunities for staff to become vested in the project can go a long way in ensuring a successful implementation.

Get support/buy-in for the project. Support for any project is a must. Recruit from the top of the organization to the bottom. Failure to do so may result in a failure to launch.  Whenever possible it is best to have support from the highest level of the organization, executive sponsor or someone from the board if you have one.  Influence matters. And don’t forget to involve all departments that will be impacted by the change, including nurses and physicians when appropriate.

Create a buzz. Create some excitement. Don’t act like the project is required, but rather a choice that’s going to make things better.  This is the power of advertising. We fall for it all the time, from cars to smartphones.

User involvement and participation. When individuals believe that the implementation of technology is relevant, they are much more likely to have a positive attitude toward the project. The best way to get individuals to believe in the technology is to get them involved and allow them to participate in all phases of the project. “Increasing user participation … enhances post-development user involvement and attitude”.(1)

Involve as many people as possible as often as possible. When people are involved, it gives them a sense of ownership, making them vested in the project’s success. It also helps deal with negative vibes that may come from others.

Volunteers only. It is important that all participants be volunteers as mandated participation has been shown to be ineffective and potentially detrimental to the success of this type of project. (2)

Champions. Champions are the people that go above and beyond the general participant. Champions believe in the technology and the benefits it will provide. They can often have a contagious zeal about the project, and are sometimes referred to as “evangelists”, or in extreme cases “zealots”. Whatever you call them, you need them. When it comes to implementing new technology in the pharmacy, champions can be your best source of support and are often useful in putting a spotlight on the project in a positive way while swaying negative feelings about the project. 

Finding Champions shouldn’t be too difficult. There are usually early adopters in every group. They will often present themselves while taking the initiative to learn more about the project without being asked.

Develop rules for participation. This is really quite simple. It is important that the rules for participation be laid out well in advance, and that each member of the team signs off on them. There should be no surprises for what’s expected from participants once the project is underway. The following rules are examples:

  • Be willing and able to engage in the project
  • Be willing to be positive about the project
  • Be willing to work with others to advance the project
  • Be willing to commit to attending meetings
  • Be willing to commit to handling extra work, even if it means staying late or doing some reading at home in the evenings or on the weekends. I understand that no one wants to put in a bunch of unpaid overtime on these projects. However, on occasion, a little extra work needs may need to be done to keep things moving forward. One should enter into participation with the understanding that this could happen.
  • Be willing be engage in every aspect of the project, not only the items that are assigned. It is vitally important that each participant has at least a basic understanding of the overall scope of the project and what each member of the team is assigned to do. Things happen. People get sick, quit their jobs, move to another state, and so on. Such unforeseen events should not completely derail the project timeline or goals. 

Sway the naysayers. Every project has its opposition. As the saying goes, you can’t please everyone all the time. Unfortunately, naysayers tend to be the most vocal personalities in any group. They’re not afraid to say what’s on their mind; whether positive or negative. The downside is that outwardly negative comments about a project have a way of spreading like wildfire. They’re caustic and often seep into the minds of even the staunchest supporter without warning. And once planted, negative thoughts grow like a cancer.

Naysayers and their negative comments have their place. They often point out things that others fail to see, helping avoid pitfalls along the way. The trick is to use the information to your advantage and allow naysayers to offer their thoughts in an environment that won’t bring down the rest of the pharmacy. Give them space to vent, and then do your best to use the information to flip them. If you can show the naysayers in the group that you’re willing to listen to them and take their concerns seriously, you may be able to get them on your side. That’s a huge victory for any project. On the other hand, never force change on a naysayer. Forcing change or mandating them to join your side rarely works. It’s like dealing with a donkey, the harder you pull, the harder they resist.

Build a team with high potential for success. According to Harvard Business Review’s (HBR’s) 10 must Reads On Emotional Intelligence (3), the source of great success lies with teams that can achieve high levels of participation, cooperation, and collaboration among members.

Team members must be chosen carefully and meet three basic conditions:

  1. Mutual trust of one another
  2. Have a sense of group identity – a feeling that they belong and the project is worthwhile
  3. Have a sense of group efficiency – belief that the team can perform well and that the group is better than the individual members.

Collectively, HBR refers to this as the groups “emotional intelligence” (EI). And while the knowledge and experience among group members is important, EI may be more important still. Keep this in mind when you begin building the project team.

Chose a project leader. Being “the leader” is a burden that many well-qualified individuals shy away from. With that said, someone has to be in charge. Someone has to be given authority over the group. Someone has to be willing to make the tough decisions and hold people accountable.

Not everyone is cut out to be a leader. I am of the opinion that leaders are born, not made. You either have it or you don’t. I know because I’ve tried many times to lead and failed. It wasn’t for lack of knowledge or desire, but rather a lack of natural leadership and charisma. On the flipside, I’ve been around many people that just have “it”; “it” being a knack for getting people to follow them and do what they say, i.e. they’re natural born leaders.

What distinguishes good leaders from great leaders is “a group of five skills that enable the best leaders to maximize their own and their followers’ performance.” (3)

The five skills are:

  • Empathy
  • Motivation
  • Self-regulation – controlling negative impulses
  • Self-awareness – knowing strengths and weaknesses
  • Social skill – being able to build a rapport with others to get desired results

Find a project manager. As ridiculous as this may sound, the project manager is an often overlooked position when discussing project teams. Let me go on record now as saying that a good project manager is absolutely vital to the success of any project; arguably the most vital consideration to the success of a project.

It is the job of the project manager to manage all aspects of the project, including the scope, the timeline, the cost, the quality, and the people. They apply their knowledge, skills, tools, and techniques to help projects be successful.

“The role of the project manager is that of an enabler. Her job is to help the team get the work completed, to “run interference” for them, to get scarce resources that they need, and to buffer them from outside forces that would disrupt the work.”(4)

Things to consider when selecting a project manager:

  1. The person must have leadership qualities, have good self-management and time management skills, and be a taskmaster.
  2. The project manager cannot serve two masters. Individuals that serve as a project manager must not be required to do any of the actual work in the project. According to Lewis (4), “as team sizes increase, it becomes impossible to work and manage both[the work and the team], because you are constantly being pulled away from the work by the needs of your team members”. Having project managers attempt to manage the project in addition to working on the project is a recipe for disaster.
  3. The person must have a proven track record. We all know people that can’t manage the paper piles in their office much less a multi-faceted project requiring meticulous attention to detail.

I encourage everyone involved in a large project to read a book or two on project management. Being a project manager is not as easy as it sounds and should be given the respect it deserves.

That’s it. Piece of cake. Go forth and build your implementation team.

  • Vaughan PJ. Internal Report of Information Technology Services. University of Colorado at Boulder. 2000.
  • Hunton, J.E. and Beeler, J.D., Effects of User Participation in Systems Development: A Longitudinal Field Experiment. MIS Quarterly, 21(4), 1997, pp. 359-388.
  • Hbrʼs 10 Must Reads On Emotional Intelligence. 1st ed. Boston (Massachusetts): Harvard Business Review Press, 2015. Print.
  • Lewis, James P. Fundamentals Of Project Management. New York: American Management Association, 2007. Print

Does charge-on-chart hurt or help medication chain of custody?

Historically, hospital pharmacies have used a charge-on-dispense (COD) model for medications. The model charges the patient for a medication when it is dispensed from the pharmacy and credits the medication if it’s returned to the pharmacy unused. Simple, but labor-intensive. The model itself has been around for a long time.

The introduction of electronic health records (EHRs) and electronic medication administration records (eMARs) has pushed the COD model aside in favor of the charge-on-chart (COC) model; sometimes referred to as “charge on administration” (COA). In the COC model, the patient isn’t charged for a medication when it is dispensed from the pharmacy because the charge is captured when the medication is scanned by the nurse and administered to the patient. When the nurse scans the medication, the information is captured by the eMAR and charted, hence the name. There are several benefits to this model, including no need for the pharmacy to credit medications that go unused. Unused medications are simply returned to the pharmacy and folded back into the inventory.

Put simply, the COC model eliminates the need for pharmacies to charge and credit medications as they are dispensed and returned to the pharmacy. But here’s a little untoward side effect of the COC model, it eliminates much of the pharmacy audit trail for medication movement into and out of the pharmacy.

The old COD model wasn’t perfect, and there were plenty of discrepancies, but I wonder if the COC model has created even less transparency regarding inventory reconciliation and the movement of medications throughout the hospital.

Inventory management systems like AutoPharm from Talyst and Pyxis Pharmogistics from Carefusion should, in theory, give pharmacies real-time inventory numbers. But the promise of these systems has fallen short. Both utilize barcode scanning to track inventory, which unfortunately requires humans to be diligent when scanning items in and out of inventory. Human laziness usually prevails, and numbers are frequently inaccurate.

Medication tracking systems are available from a couple of companies, but also utilize barcode scanning, thus fall prey to the same weakness mentioned above. These systems also fall short when following medications throughout the medication distribution process as they typically stop as soon as the medication is delivered to the nursing unit, i.e. they don’t track the return of the medication.

Track and trace regulation, which will require serialized barcodes and tracking from manufacturer to patient, could potentially help with this issue. However, that process has the same weaknesses as those mentioned above, namely human intervention.

RFID technology would surely be better than barcode scanning, except that RFID tags are too costly for use on all medications and drug manufacturers are nowhere near ready to do anything like this.

Currently, the only medications that receive enough scrutiny in a pharmacy to determine location and quantity at any given moment are controlled substances, i.e. morphine, fentanyl, oxycodone, and so on. And this falls short on some level once the medication leaves direct oversight of the pharmacy.*

It’s interesting to think that as much time as we spend managing inventory in a hospital pharmacy, we still have a long way to go.

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*This includes leaving the pharmacy itself as well as storage devices like automated dispensing cabinets (ADC). When a medication leaves the ADC we assume it has been administered to the patient once it has been charted. We cannot confirm this, however. For all we know, the healthcare provider that removed the medication and documented the administration, simply put it in their pocket and walked out with it. You never know for certain.

The scope of IV room errors

There’s an interesting article in Pharmacy Practice News this month (In the IV Room, Robots Come to the Rescue). While the title of the article is a bit misleading – I think ‘rescue’ is a bit strong – it does contain quite a bit of good information.

The article discusses some of the technology being used at Brigham and Women’s Hospital (BWH) in Boston, and the University of California, San Francisco (UCSF) Mission Bay pharmacy. I’ve been in both pharmacies. BWH and UCSF both make extensive use of technology, but believe me when I say that they have very different approaches. Anyway, the article is worth a few minutes of your time.

Deep in the article, the author, Rajiv Leventhal spends a few paragraphs discussing the scope of the problem in the IV room, and some of the challenges of using robotics. Rajiv acknowledges that the iv room is a dangerous place for a host of reasons.

Regardless of the technology chosen, the need to automate IV compounding to at least some degree is hard to dispute, given the relatively high rate of errors that occur when technology is limited. In 1997, when many of the recent advances in robotics were not available, the error rate for IV compounding was 9%—or one mistake in every 11 medications coming out of the IV room.

As for the main cases [sic] of those errors, many factors have been identified, including sterility and other drug safety issues, according to a safety alert released last year by the Institute for Safe Medication Practices. The alert identified five core causes: 1) depreciating importance of the compounding and dispensing processes in pharmacy practice; 2) lack of knowledge and standardization around best practices; 3) training based on traditions handed down from one pharmacist to the next; 4) learned workplace tolerance of risk and routine practice deviations that persist; and 5) a reluctance to learn from the mistakes of others.

It seems intuitively obvious that the use of technologies like iv workflow management software, barcode scanning, gravimetrics, imaging, and even robotics can potentially decrease errors described in the article referenced above (Am J Health Syst Pharm1997;54[8]:904-912 ). However, of the causes identified in the second paragraph, only #2 can really be addressed with the use of technology alone. The rest of the items listed are symptoms of a deep-seeded problem growing in pharmacies today, and that is the failure to understand the need for our profession to provide patients with medications in the most efficient, safe, and economical way possible. Sounds ridiculous, I know, but it’s true nonetheless.

Most (all?) pharmacies I visit these days tout initiatives to improve patient care through increased ‘clinical activities’ of pharmacists, including electronic chart review, ADE follow-up, rounding with the medical team, monitoring and adjusting medications, antibiotic stewardship, and so on. However, I rarely, if ever hear directors talk about efforts to improve operations through streamlined processes, automation and technology, standardization, and heaven forbid, increased use of technicians and non-pharmacist personnel.

Examples of this can be found within open job listings at various healthcare systems. Recently I visited an acute care pharmacy with a large budget for several open ‘clinical pharmacist’s positions’ but no budget for improving operations or automating processes. In this particular case, a fraction of the money being allocated for open clinical pharmacist positions could be used to make significant improvements to the medication distribution process.

It’s an interesting dilemma for pharmacy directors. While spending tens of thousands of dollars on automation and technology to improve operations may not seem sexy, it goes without saying that a vast majority of care for a hospitalized patient involves getting the right drug at the right time. A majority of that falls to nursing staff, but the pharmacy owns a piece of the medication distribution/administration process. Nurses can’t administer medications if they’re not readily available, or wrong.

Regardless of what direction the profession wants to go, it is important that we understand that pharmacy is, at this time, tied to distribution. We must find ways to extricate ourselves from the medication distribution process first before we can begin to truly realize the benefits of pharmacists in patient care. Each time an error occurs for lack of focus, training, or sheer disinterest, the profession suffers. Preventable medication errors involving the pharmacy causes both the public and other healthcare practitioners to lose trust in our ability to get the job done. It’s difficult to recover from lack of trust. Think about it.

Cool Technology for Pharmacy – DOSIS

Not being involved with long-term care (LTC) pharmacies much over the years, I sometimes forget that there’s technology to help with some of the day-to-day operations.

I recently came across an advertisement for a company called Manchac Technologies. The reason it caught my eye is because I had a chance to visit with Manchac several years ago when they were still in their development stage.

Manchac is a company out of Alexandria, LA that specializes in technology designed to automated blister card packaging called DOSIS. “DOSIS products are designed to enhance efficiencies in your pharmacy operations while reducing the opportunities for errors…a robotic solution that fully automates blister cards (filled, sealed, and patient-labeled)”.

Blister cards – aka punch cards, blister packs, etc. – are still prominent in nursing homes and, therefore, a huge part of LTC pharmacies. Large operations will do thousands of blister cards daily. According to information on the DOSIS site, the companies new BP198 machine is “capable of producing 40-55 filled and sealed cards per hour”.