Jerry Fahrni

Tag: Pharmacy Practice

  • Kit Check goes in at CaroMont Regional Medical Center in North Carolina

    PRWeb: “CaroMont Health (formerly Gaston Memorial Hospital) became the first hospital in North Carolina to adopt Kit Check™for hospital pharmacy kit processing.

    CaroMont Regional is a 435-bed, not-for-profit general and acute care facility. Kit Check™ provides cloud-based software that leverages RFID technology to reduce pharmacy kit replenishment from an average of 30 minutes to 3 minutes. CaroMont installed Kit Check™ in mid May and after 10 weeks of operation has already tagged and tracked more than 10,000 medications used in 206 emergency pharmacy kits.”

    I know some pharmacists at CaroMont. They’re good people and are always looking for a way to utilize technology to improve operations.

    I wrote about Kit Check back in January 2012. I’m a big fan of using RFID technology to manage niche items like medication trays. It makes sense to me. Barcoding works, but sometimes it’s just easier to use technology like RFID.

    Is RFID the future of heathcare? I don’t know, my crystal ball recently stopped working. The technology itself is quite mature, but hasn’t really caught on in healthcare. With the advent of smartphones and tablets with built-in NFC technology I have to believe that some innovative company will take the queue and continue to develop the concept.

    Things I’ve written about RFID can be found here.

  • Pharmacist remote order verification, i.e. checking something from afar

    The current pharmacy practice model utilizes pharmacists to check everything that leaves the pharmacy. Right or wrong that’s the way it is. I don’t think it’s necessary, but I’m not the guy in charge of such things.

    Pharmacy has tools to help get pharmacists out of the physical pharmacy, namely tech-check-tech and remote order verification, but I don’t see such things used with consistency. My position on tech-check-tech is well documented; it’s underutilized. Using technicians “at the top of their license” would go a long way in freeing up pharmacists to do other things. The problem at the moment is that many pharmacists don’t want to relinquish the “final check” responsibilities. It’s silly, but true.
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  • Stanford University Medical Center Pharmacy site visit [07 31 2013]

    I just rolled in the door from Palo Alto, where I spent most of the morning visiting the Stanford University Medical Center inpatient pharmacy. And why not, I didn’t have anything else to do today. I picked up the phone, connected with the Director of Pharmacy, Mike Brown and was on my way.

    First and foremost, the inpatient pharmacy at Stanford is nice. It’s also quiet, which is a bit unusual for a pharmacy servicing such a large facility. Interestingly enough most of the non-IV related medication distribution is handled with the use of very little automation; there’s an interesting story to go along with that.

    The pharmacy at Stanford has a large investigation drug service (IDS) area, which is responsible for handling approximately 300 active drug trials at the moment. Impressive. They use IDS management software called Vestigo integrated with Epic to manage everything. It’s pretty slick.

    My reason for the visit wasn’t for the non-IV medication distribution or IDS, however. What I really wanted to see was their IV room, and the associated distribution process. I’d heard through the grapevine that they were using a product called Phocus Rx to manage their chemotherapy preparation. I wrote about Phocus Rx in March of 2012. I’ve heard a lot about the system over the past year, but had yet to see it action.

    The IV room didn’t disappoint, it was great. They let me change into scrubs, gown up and spend about 90 minutes in the cleanroom watching the pharmacist and technicians run through the process. It’s been a long time since I’ve done anything like that. It felt good. There was something right about it.

    As far as Phocus Rx goes, in my mind it’s basically a less feature-rich version of DoseEdge (post Feb 2010). Both systems use cameras and software to manage workflow, but that’s about where the similarities end. Phocus Rx uses a different camera setup than DoseEdge, i.e. the camera is located outside the hood versus inside the hood, respectively. The other differences include how information is sent to the IV workflow system, different approaches to barcode scanning, inclusion/exclusion of clinical decision support tools, and their inclusion/exclusion of gravimetric analysis for dose verification. Phocus Rx is “considerably less expensive” than DoseEdge, although the exact dollar figures remain a mystery. Which one is better? Impossible to say. That question is completely subjective and depends on your needs.

    The visit was interesting, and eye opening. The pharmacy personnel in the cleanroom were courteous, professional, and quite knowledgeable about the system. It was impressive to watch. I also learned a lot, which I will now add to my ever expanding personal database of IV room technology.

  • Pre-packaged unit dose from the manufacture or repackaging yourself?

    Like it or not barcoding at the point of care has slowly become a standard of practice in acute care pharmacies all over the country. The question is no longer whether or not we should use barcoding technology, but rather how do we use it. And with that comes the need to make sure that all medications dispensed from the pharmacy have a machine readable barcode for nurses to scan at the point of care, i.e. at the patients bedside.

    The concept is simple, but causes a lot of headaches inside the pharmacy. While a lot of oral solid medications are available from the manufacture in pre-packaged unit dose packages, some aren’t; sometimes oral solid medications are available in both pre-packaged unit dose as well as bulk.

    When oral solid medications are available in both pre-packaged unit dose and bulk containers pharmacies are forced to make a choice. It’s always been a no-brainer for me, purchase medications in manufacturer prepared pre-packaged unit dose packages whenever possible. I look at it as a safety issue. Humans make mistakes, and whenever I can remove humans from something like repackaging oral solids I do it. Manufacturers have been known to make mistakes, but their process is much more rigorous than anything you’ll see in a pharmacy. In addition, manufacturers must adhere to good manufacturing practices (GMP), which are quite extensive.

    Recently I’ve come across situations where pharmacies have actively chosen to purchase all oral solid tablets in bulk and repackage the oral solids themselves. I’ve thought about why a pharmacy would make that choice and two things come to mind: cost and efficiency.

    Purchasing oral solid medications in bulk is often less expensive. The advantage may be extended if a single location is repackaging for multiple facilities, i.e. centralized distribution. The same goes for efficiency. Repackaging oral solid tablets from bulk bottles may be more efficient during times of high volume, especially if multiple sites are involved. An example of this might be during ADU replenishment for multiple facilities when thousands of tablets may be needed. Picking 2000-3000 tablets from shelving locations may be less efficient than letting a packager run unmanned.

    Options for repackaging oral solid medications:

    1. High-speed packagers – I wrote about high-speed packagers here in August of 2010 (Automated unit-dose packagers for acute care pharmacy). Little has changed since then so the information may still be helpful.
    2. Tablettop packagers (semi-automated) – I wrote about tabletop packagers here early this year in January. (Pharmacy tabletop unit-dose packager comparison). You wouldn’t want to use tabletops for large jobs as they require closer monitoring than high-speed packagers.
    3. Manual packaging – There are several out there. One that comes to mind is MTS. There is no way you’d want to use a system like this for any kind of high volume packaging. They work well for niche packaging like chemotherapy, high risk items, etc.

    The choice to repackage oral solid medications from bulk or purchase them in pre-packaged unit dose packages from the manufacture is yours. Patient safety, cost, and efficiency should all be considered. In my opinion patient safety should trump cost and efficiency in the thought process, but then again that’s only my opinion.

  • Fresh application of older healthcare technology

    I came across an interesting article in the July issue of Pharmacy Practice News. The article describes some of the posters presented at the 2013 ASHP Summer Meeting in Minneapolis. The technology covered is relatively old, and a little antiquated when you look at much of the technology floating around the world these days. Nonetheless, this technology still represents opportunity in healthcare.
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  • Purdue University develops tablet-based pharmacy tool for catching medication side effects

    Tablets are changing the way healthcare professionals practice medicine.

    Purdue.edu: “Matthew Murawski, a Purdue University associate professor of pharmacy administration, created a new tool that presents patients with a five-question checklist that catches up to 60 percent of all known medication side effects….”This tool makes the few minutes available for counseling much more rewarding. The checklist results allow the pharmacist to immediately see side effects the patient is experiencing and target their time to solving these problems and improving the patient’s quality of life.” …Murawski’s method, named Pharmaceutical Therapy-Related Quality of Life or PTRQoL, began as paper checklists that took up multiple file folders behind a pharmacist’s desk.”

    Purdue University does some cool stuff around the practice of pharmacy. The only thing that makes me cringe is the line “patent pending” (approx. 1:05 into the video). Nothing that is developed utilizing University resources should ever be allowed to be patented. It should all be open source.

  • Inhaled Corticosteroid Adherence and Emergency Department Utilization Among Medicaid-enrolled Children with Asthma [article]

    J Asthma. 2013 Jun 5. [Epub ahead of print], Rust G, Zhang S, Reynolds J.

    Abstract
    Objectives: Asthma is the most prevalent chronic disease among children enrolled in Medicaid. This study measured real-world adherence and outcomes after an initial prescription for inhaled corticosteroid therapy in a multi-state Medicaid population.

    Methods: We conducted a retrospective study among Medicaid-enrolled children aged 5-12 with asthma in 14 southern states using 2007 Medicaid Analytic Extract (MAX) file claims data to assess adherence and outcomes over the three months following an initial prescription drug claim for inhaled corticosteroids (ICS-Rx). Adherence was measured by the long-term controller to total asthma drug claims ratio.

    Results: Only one-third of children (33.4%) with an initial ICS-Rx achieved a controller to total drug ratio greater than 0.5 over the next 90-days. Children for whom long-term control drugs represented less than half of their total asthma drug claims had a 21% higher risk of emergency department visit (AOR 1.21 [95% CI 1.14, 1.27]), and a 70% higher risk of hospital admission (AOR 1.70 [95% CI 1.45, 1.98]) than those with a controller to total asthma drug ratio greater than 0.5.

    Conclusion: Real-world adherence to long-term controller medications is quite low in this racially-diverse, low-income segment of the population, despite Medicaid coverage of medications. Adherence to long-term controller therapy had a measurable impact on real-world outcomes. Medicaid programs are a potential surveillance system for both medication adherence and emergency department utilization.

    Posted online on June 5, 2013. (doi:10.3109/02770903.2013.799687)

    Two things to consider:
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  • Medication therapy management at TEDxUniversity [video]

    Thanks to Megan Hartranft (@MeganPharmD) and John Poikonen (@poikonen) for tweeting this. It’s nothing earth shattering, but it sums up why pharmacists should be more involved. Tim Ulbrich does a really nice job.

    Pharmacy schools should show this short video to all their pharmacy students before turning them loose on the world. I talked about some of this in my presentation at the HIMSS Southern California Annual Clinical Informatics Summit a couple of weeks ago.

    There was a time when I thought that the best place to engage patients was in the hospital, but I’m starting to rethink that position. If you think about it, engaging patients in the hospital is a bit of a reactive approach. We need to engage patients before they’re hospitalized to get the most bang for our buck.

  • Clinical Dilemmas and a Review of Strategies to Manage Drug Shortages [article]

    Here’s an interesting article in the Journal of Pharmacy Practice. The article, Clinical Dilemmas and a Review of Strategies to Manage Drug Shortages appears online ahead of print (doi: 10.1177/0897190013482332). Unfortunately you’ll hit a paywall, so if you don’t have a subscription all you’ll get is the abstract.

    That’s unfortunate because according to the article “The expanded phased approach outlined here [in the article] provides a consistent, systematic approach for the management of drug shortages“. You would think they’d want everyone to know about the expanded phased approach due to the “health care crisis” created by drug shortages. Just sayin’.

    Abstract
    ———————————————-
    Objective: The objectives of this article are to review the clinical implications of drug shortages highlighting patient safety, sedation, and oncology and introduce an expanded phase approach for the management of drug shortages. Data Sources: Literature retrieval was accessed through a PubMed search of English-language sources from January 1990 through April 2012 using the medical subject heading pharmaceutical preparations/supply and distribution and the general search term drug shortages. Study Selection and Data Extraction: All original prospective and retrospective studies, peer-reviewed guidelines, consensus statements, and review articles were evaluated for inclusion. Relevance was determined considering the therapeutic class, focus on drug shortages, and manuscript type. Data Synthesis: The increased number of drug shortages has created significant challenges for health care providers. Two particularly vulnerable populations are critically ill and oncology patients. A lack of therapeutic alternatives in critically ill patients may impact patient safety as well as treatment outcomes. Similarly, a chemotherapy agent in short supply may contribute to adverse outcomes in oncology patients. Conclusions: The mounting number of drug shortages has created a health care crisis, requiring changes in management strategies as well as clinical practice. The expanded phased approach outlined here provides a consistent, systematic approach for the management of drug shortages.

  • Saturday morning coffee [March 16 2013]

    MUG_ASHPSM2011So much happens each and every week that it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….

    The coffee mug to the right was presented to me as a gift from ASHP for winning the 2011 ASHP Summer Meeting Twitter Contest. Not to be confused with the one I put up last August for the 2010 ASHP Midyear Twitter contest. The mug was accompanied by a $50 Best Buy gift card; very nice. The meeting was held in Denver, CO and was the first ASHP Summer Meeting I ever attended. The Summer Meeting is quite a bit different from the Midyear Meeting held in December each year. Midyear is much larger and has a much wider variety of educational sessions. Midyear also has a bigger exhibitor area. With all that said I found the Summer Meeting quite enjoyable as it had several informatics related sessions that I was able to attend. It was the last pharmacy conference that I was able to enjoy as an attendee.
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