Automating the Pharmacy Medication Cycle in Acute Care Settings

Transcription

1 Automating the Pharmacy Medication Cycle in Acute Care Settings Costs, Benefits and Potential Unintended Consequences Enterprise Information Systems Steering Committee Nursing Informatics Committee and Pharmacy Task Force January 2010

2 Goals Rationale and strategies for automating inpatient medication movement and related asset tracking Costs, benefits, unintended consequences Potential business case for pharmacy related automation in acute care settings 2

3 Pharmacy related Automation Technologies Auto ID Inventory Management Unit Dose Packaging Barcoding/Labeling IV Compounding, Bag/Syringe Filling, Infusion Robots Pharmacy Robotic Dispensing Systems Decentralized Automated Dispensing Cabinets Barcode Medication Administration 3

4 Inpatient Medication Management 4

5 Automating Medication Movement in Acute Care Settings 5

6 Beginning with the End in Mind Five rights of medication administration right patient right drug right dose right time right route 6

7 Auto ID: Identifying People and Things Barcode scanning mature, cost effective, in common use Radiofrequency identification (RFID) emerging technology, beyond line of sight identifies every tagged item in range read/write, real time location Proximity card authentication, access 7

8 Auto ID: Identifying People and Things Wi Fi, infrared, ultrasound Triangulation, room level location Magnetic strip cards What you have authentication Biometric Who you are authentication Fingerprint readers Voice recognition 8

9 Benefits of Auto ID Documentation accuracy, completeness Manufacturer, lot number, expiration date, formulation, date/time, etc. Workflow efficiency System sign on/off time Identify, authenticate items, persons Location, flow of patients, equipment, supplies 9

10 Potential Adverse Consequences of Auto ID Bad tag Wrong data entered originally Data not readable (smudged, faded, wet) Bad placement Wrong item, place, patient Bad reader Malfunction, misplacement, interference 10

11 Auto ID: Costs and Business Case Cost varies widely (scope, technology) Can be in the millions for large, multipurpose deployments Business case strongest for barcodes, magnetic strip badges, fingerprint readers, proximity cards RFID costs still high 11

12 Automated Pharmacy Inventory Management (PIM) Continuous drug quantity monitoring Electronic ordering based on MAXimum and MINimum levels 12

13 Benefits of PIM Right wholesaler orders, right time Tighter inventory dollar control Adequate drug supplies at all times Better inventory turns, fewer expired meds Improved staff efficiency More accurate drug expense reports 13

14 Potential Adverse Consequences of PIM System information accuracy Monthly cycle counts needed Back ups in case of data corruption Interface challenges Data feeds to/from other med cycle solutions Picking repackagers, carousels, robots Medication administration records (emar) 14

15 Automated PIM: Costs and Business Case Cost depends on scope and degree of integration with other solutions Can exceed $100,000 Annual costs run 15% 20% of initial cost Business case (case study examples) First year savings >$300,000* $600,000 reduction in inventory** * ** 15

16 Drug Unit Dose Packaging Re package bulk meds single doses Available for tablets, capsules or liquids USP compliant unit dose packages Facility compatible barcodes Pharmacy IS interface capability Robot ready 16

17 Benefits of Drug Unit Dose Packaging Staff efficiency Solid packaging labor reduced by 65% Reduce ADC fill time by 70% Inventory control When used with inventory carousels Wholesale drug costs Bulk medications vs. single unit doses 17

18 Potential Adverse Consequences of Drug Unit Dose Packaging Package integrity and printing quality Frequent cleaning, calibration Adequate training: loading packaging, ink Proper inspection prior to dispensing Medication mix ups Human error Second verifier, pharmacist integrity check 18

19 Drug Unit Dose Packaging: Costs and Business Case Costs Oral solid repackagers ~$200,000 initial ~$30,000 annual maintenance ~$0.02 to $0.04 per dose Liquid repackagers ~$20,000 initial cost ~$0.05 to $0.08 per dose 19

20 Drug Unit Dose Packaging: Costs and Business Case Business case (case study example)* 75% staff technician time reduction in selecting refill medications Converted to packaging technician who streamlines packaging, does barcoding QA Net decrease in technician time needed for the pharmacy operation support of bedside barcode medication scanning * _Products_by_Michele_Weizer_(Sep2006).pdf 20

21 Pharmacy Barcoding/Labeling Dominant, well established form of auto ID Machine readable information about object or person Format determines amount of encoded information Enabling technology for every major step of medication handling 21

22 Benefits of Barcoding/Labeling Help fulfill the five rights Right patient, medication, dose Reduce typing, populate EHR, perform cross checks Reduce dispensing errors Improves tracking and accuracy, faster medication inventory updates 22

23 Potential Adverse Consequences of Barcoding/Labeling Assuming barcode is always correct Lack of manufacturer barcode standards hospital specific barcode may be needed specialized printers, label printing trays Workflow workarounds Significant maintenance costs Complex, interacting systems 23

24 Barcoding/Labeling: Costs and Business Case Cost varies widely (scope, technology) Can >$1M for large system implementations Especially if linked to robotic systems Annual maintenance of 15% 30% Business case Safety and quality Averted cost of ADEs Time efficiencies 24

25 IV Compounding Systems & Infusion Robots; Bag & Syringe Fillers IV compounding systems and infusion robots Prepare complex, calculation intensive IV solutions (e.g., TPN) Clinical alerts for safety issues (osmolarity, electrolytes, lipids, precipitation) Automated bag & syringe fillers Load, de cap, fill, recap, label, weigh, deliver sterile syringes Reconstitutes vials, prepares pediatric dilutions 25

26 IV Compounding Systems & Infusion Robots; Bag & Syringe Fillers Benefits: Quick, consistent, accurate, aseptic delivery of product into a final container Improved safety when calculations and clinical screening software is included Less exposure to toxic chemicals Higher efficiency, fewer repetitive task injuries 26

27 IV Compounding Systems & Infusion Robots; Bag & Syringe Fillers Risks Incorrect use of software, compounder Misinterpretation of warnings, clinical flags Contamination Manual task related errors Loading of stock solutions Addition of small volume ingredients Labeling of the final containers 27

28 IV Compounding Systems & Infusion Cost Robots; Bag & Syringe Fillers At least $250K $350K for initial cost Business case Quality, safety, efficiency, worker exposure Paucity of data on financial return on investment (ROI) 28

29 Central Pharmacy Robotic Dispensing Systems Automates storage, dispensing, returning, restocking, crediting of barcoded unit dose meds Dispenses meds into labeled envelope or bin on a fastened, labeled ring 29

30 Benefits of Central Pharmacy Robotic Dispensing Systems Free pharmacists, technicians from errorprone repetitive manual tasks Decrease drug handling mistakes Information tracking (lot numbers, expiration dates, unique dose identifiers) Improve charge capture, billing accuracy 30

31 Central Pharmacy Robotic Dispensing Systems: Risks Mislabeled medications errors Limited capacity robots manual picks Match to desired formulary size Inadequate resource allocation inefficient, inaccurate robot performance Flawed processes workarounds 31

32 Central Pharmacy Robotic Dispensing Systems: Costs, Savings Cost: can be in the millions of dollars Savings: inventory costs, expired meds costs, pharmacist check time, ADEs Revenue benefits: charge capture Vendor estimates of payback periods as short as 1.8 years (no peer review data)* *

33 Decentralized Automated Dispensing Cabinets (ADCs) Secure med distribution, storage Auto ID or password access Nurse selects from list of pharmacist approved patient medication orders Drawers open one at a time prompting nurse to remove meds All user transactions are logged 33

34 Benefits of Automated Dispensing Cabinets Fewer adverse drug events (ADE) Lower medication costs Improved charge capture Higher pharmacy and nurse productivity Compliance with Joint Commission standards, National Patient Safety Goals 34

35 Automated Dispensing Cabinets: Risks Workflow change associated risks Cabinet footprint, drug capacity, location impact on nurse workflow efficiency Over reliance on ADC technology to eliminate medication errors ADC override function permitting dispensing prior to pharmacist review 35

36 Automated Dispensing Cabinets: Cost Costs and Business Case Typical ADC cabinet costs $50K $60K Business case Very limited research on ROI of ADC technology alone Most documented pharmacy automation savings reported include ADC technology 36

37 Barcode Medication Administration and emar (BCMA emar) Facilitates, electronically records bedside med administration Scan caregiver s name badge, patient wrist band, medication Supports accurate assessment of the five rights just prior to administration Links to EHR decision support tools 37

38 BCMA emar Benefits Patient safety Intelligent warning systems duplicate therapies, drug drug, drug lab, drug food, or drug diagnosis risks Documentation for quality and performance improvement initiatives 38

39 Potential Adverse Consequences: BCMA emar Workarounds to avoid efficiency losses Unreadable medication barcodes Malfunctioning scanners Unreadable or missing patient wristbands Non barcoded medications Unreliable wireless connectivity Patient care emergencies 39

40 Cost BCMA emar: Costs and Business Case Varies but typically exceeds $1M initial and ~30% of initial cost per year for maintenance Business case Solid peer review literature supporting positive ROI after first year of full operation* * Maviglia S. et al. Arch Internal Med 2007;167: Mekhjian H. et al. JAMIA 2002;9:

41 Conclusions Medication movement in acute care settings is complex and error prone Pharmacy related IT can help Ensure the 5 rights of medication management Increase efficiency and reduce ADEs Interfaces can increase advantages 41

42 Conclusions Business case ROI analyses are difficult, data are sparse Financial ROI strongest for barcode technology, BCMA emar Potential ROI for inventory management, unit dose packaging systems Soft ROI considerations matter Quality and safety 42

43 Questions and Comments 43