Pharmacy

Automation & Informatics

Kirby N. Connolly, PharmD, BCPS
Pharmacy Informatics Analyst and Clinical Pharmacist
Baycare Health System
Kirby.Connolly@baycare.org
Objectives
 Define informatics, EHR/EMR, BCMA, MAR and eMAR
 Compare and contrast medication errors via written vs. electronic methods
 Review methods to reduce errors in healthcare
 Analyze the medication dispensing process
 Determine challenges related to BCMA
 List the five rights of medication administration
 Differentiate between what is and is not a medical device
Informatics Overview1

 Informatics: The use of computers to manage data and information

 Pharmacy Informatics: the use and integration of data, knowledge,
and technology involved with the medication use process to improve
outcomes
 Automation/technology for safe and efficient medication management
 Information technology to inform and improve information management
and decision making
Why the need for informatics?
Outpatients:
“The old
way”
Why the need for informatics?8
Inpatients:
“The old
way”
Old healthcare ways
 Lack of communication between providers
 Primary MD, Covering MDs, Consulting MDs, RPhs, nursing, dietary, RT, PT, OT, etc…
 Lack of information
 Missing pages/incomplete documentation
 Historical procedures, lab draws, etc.
 Too much information
 Often hundreds of pages
 Hard to find desired information

 Therapeutic Duplication
 Duplicate BP meds, pain meds, drug interactions, etc.
 Lack of follow-up
 Referrals and results may take a long time
 No system to remind patient or MD to follow-up
 Errors
 Many different methods and levels of severity
Error Reduction Methods

 Improving safety, cost, and efficiency

 Electronic Medical Records (EMR, EHR)
 Barcoding (BCMA)
 Electronic Prescribing/Computerized Physician Order Entry (CPOE)
 Alerts/Clinical Decision Support (CDS)
 Reporting and Accountability
 Electronic Medical and Health Records
 Electronic Medical Record (EMR): Digital version of a paper chart from one
practice

 Electronic Health Record (EHR): Digital version of all patient’s health

records across a health care organization
 Demographic Information
 Problem Lists
 Information from both Outpatient and Inpatient visits
 Progress Notes and Consultations
 Laboratory and Diagnostic Results
 Inpatient Medication Administration Record (MAR)

EMR Types
 “EMR” and “EHR" are basically interchangeable Infographic
Electronic Medical Record (EMR) Example
 EHR/EMR benefits

 Information sharing between disciplines

 All (most) patient information in one place
 Searchable information
 History of testing, MD visits, compliance; a holistic view of patient
 E.g. Problem list may provide more information than list of medication therapy

 Drug tolerance, effectiveness, history of use

 What therapy to consider at what dose

 Better long-term monitoring

 Monitor Parameters Long-term (BP, Blood Sugar)
 Identify Needs (Vaccinations, Health Screenings)
 Electronic Health Records pitfalls
 Order entry errors
 Wrong patient
 “Didn’t mean” to enter it like that
 Polypharmacy
 “Don’t call me” med list
 Too much information
 How to find the information you need/where to look
 Electronic documentation resistance
 Usually older practitioners
 Interface problems
 Compatibility & downtimes
 Unforeseen issues
 “Sticky notes”
 Sometimes hard to follow the “narrative” of a patient’s visit
 “7 AM - patient fine, 8 AM - patient fine, 9 AM - patient deceased”
Bar Code Medication Administration
(BCMA)6
 BCMA is designed to make sure that the right drug is given to the right
patient via the right route at the right dose and at the right time
 The "Five Rights“

 Each drug in the hospital is labeled with a unique barcode

 When a patient is prescribed medication, it is sent electronically to the
hospital's pharmacy verified by a pharmacist
 The pharmacist dispenses the barcoded dose of the drug to the patient's
floor
 When administering the medication, the RN uses a scanner to scan barcodes
 Identification badge*, the patient's wristband, and drug
 If the barcode system cannot match the drug to the order in the system, it
alerts the clinician visually
 Can be overridden
 Streamlines billing and reduces errors
 BCMA and the Medication Dispensing Process

Drug is stored within the pharmacy and

Drug is received into retrieved once an order for it is placed
pharmacy via barcode
Drug is checked and placed in a
medication storage cabinet
(or a patient label is attached)

RN removes
medication
RN scans patient wristband and medication from storage
barcode and administers medication to patient cabinet
BCMA and the Medication Dispensing Process1

1. Medication Received and Stored

 Barcoding assists with inventory management
2. Medication Ordered and Retrieved
 Pharmacist verifies order on computer
 Label prints to alert technician to fill
 Technician scans medication and patient label
3. Medication Verified by Pharmacist
 Correct product on label
4. Medication Delivered
 Added to automatic dispensing cabinet OR tubed to
floor via pneumatic tubes
 Much of the delivery process is still on paper
5. Medication Administered
 RN scans medication and patient bracelet
Bulk vs. Unit-dose packaging

 Hospitalized patients need a unique method of

dispensing medication
 Short stays
 Several medication dose/freq/type changes

 Solution: unit-dosed medications

Unit-dosed oral liquids

Patient-specific
(label added)
Commercially available
 Medication Prepacking Process

Pills are
packaged
Drug is delivered to individually
pharmacy in “bulk” and heat-
bottle wrapped

Medications are
now labeled for
individual use
BCMA up-keep and challenges

 Barcodes must be constantly updated

 Different manufacturers
 New products
 Shortages
 Non-formulary medications
Electronic Medical Record (EMR) Example:
adding orders electronically
Computerized Physician Order entry (CPOE)
Computerized Physician Order entry (CPOE)
Computerized Physician Order entry (CPOE)
Computerized Physician Order Entry
(CPOE)1
 Has been shown to markedly decrease prescribing errors
 Excludes many errors from poor handwriting/transcription
 Drug product selection according to pharmacy formulary
 Non-formulary medications are not orderable (Pro vs con)
 Dose standardization
 Commonly ordered route, dose, and frequencies are shown (Pro vs con)
 Errors or confusion can occur when desired order sentences are not
available

 “Core measure” and “Meaningful use” requirements

 Plans can be built to enable practitioners to order required items
 Decreases “fall outs” which can decrease reimbursement

 Clinical Decision Support (CDS) can help direct prescribing

Pharmacist Prescription Review1
 Analyses and assessment
 Allergies
 Indication
 Dose
 Route of administration
 Instructions
 Drug interactions
 Side effects
 Lab results
 Intolerance
 Clinical objectives
 Duration
 Expected outcome
Medication order pitfalls1
 Written orders
 Illegible handwriting
 Look alike/sound alike drugs
 Unit of measure errors (mcg vs. mg)
 Pharmacist lack of background knowledge
 Physician education
 Electronic orders
 Wrong patient
 Polypharmacy
Pharmacy Verification System
Electronic Medical Record (EMR) Review
Interfaces

Pharmacy
Electronic
Order
Health
Entry
Record
System

Medication
inventory
management
system

Medication
storage/dispensing
cabinets
Clinical Decision Support (CDS)
Alerts
 Based on Pharmacy Drug References
 Lexi-comp, Clinical Pharmacology, etc.
 Reduces prescribing errors
 Allergies, Duplicates, Drug interactions, Lab interactions,
Incorrect dose/freq, etc.
 Allows documentation for physician or pharmacist override
 All alerts and overrides can be reviewed and assessed
 Effectiveness
 Error review and prevention
CDS Alert Optimization: Alert Fatigue

 Alert fatigue aka “information overload”

 An unintended consequence of CDS
 A systematic review2 of computerized reminders found only minor
improvements in process of care
 Found alerts to be only modestly effective at best

 Very common
 Clinicians override the vast majority of CPOE warnings, including “critical” ones

 Increases with heavier use of CPOE/increased exposure to alerts

 Implication: without system redesign, the safety consequences will likely
become more serious
CDS Alert Optimization: Alert Fatigue

 Alert Fatigue has be implicated as a significant cause in

several high-profile errors
 Reports of a hospitalized teenager receiving a 38-fold overdose of
an antibiotic
 The ordering physician has been advised by colleagues to “just ignore
the alerts”
CDS Alert Optimization

 How can we reduce the number of “nuisance” alerts?

 Does the alert improve safety?
 How can we improve?
 Is it always overridden?
 Is it clinically useful?
 Can we add color, additional reference information, etc?
 Healthcare shift5
 Healthcare organizations (HCOs) invest a significant amount of resources in health
information technology (HIT) initiatives
 Considerable demand for HIT workers with training and skills to create a successful and
safe interface between HIT and the healthcare delivery system
 Pharmacists’ professional identity, education, training, and experience make them
ideal candidates to fill a critical need in pharmacy informatics
 Understanding of core pharmacy operations, clinical practice, the medication-use
process, standards, and regulations
 Path and skills required have varied considerably
 Need to build core competencies and grow number of available programs
 Pharmacy Informaticists’ Role5
 Acquiring professional perspective
 Ensuring that data, information, and knowledge are:
 Accurate, accessible, complete, consistent, current, timely, precise, reliable, relevant, and
understandable
 Readily and rapidly understood and accessed within the workflow
 Validated, integrated, and optimized
 Centrally managed, collaboratively developed, and easily communicated
 Audited, measured, and evaluated for effectiveness

 Analyzing problems
 Evaluation and communication of the potential risks of a newly implemented technology
 Innovating and producing solutions
 Articulating rationale
 Implementing, evaluating, and refining solutions
 Translating user requirements into safe and effective system designs

 Completing maintenance
 Corrective, Customized, Enhancements and Preventive
Medication Administration Record (MAR)7

 A report that serves as a legal record of the drugs administered to

a patient at a facility by a health care professional
 A part of a patient's permanent record on their medical chart
 The health care professional signs off at the time that the drug or device is
administered
 MARs can be referred to as drug charts
 Electronic versions are called e-MARs
 5 rights of medication administration
 Right med
 Right patient
 Right dose
 Right route
 Right time
 (*6- Right documentation)
Electronic Medication Administration
Record (eMAR) Implementation
 Medication errors4
 Hospitalized patients: 1 error per patient per day
 Patient harm results from 450,000 medication errors every year
 Barcode Scanning (BCMA)
 Significant reduction in medication errors
 Downfall: Can be overridden
Electronic Medication Administration Record (eMAR)
Electronic Medication Administration Record (eMAR)
Electronic Medication Administration Record (eMAR)
Electronic Medication Administration Record (eMAR)
Electronic Medication Administration Record (eMAR)
Electronic Medication Administration Record (eMAR)
Medical Device or not?3
TPN Compounding Machine
TPN ordering
FDA oversight

 TPN compounder/order entry software is regulated

 Many “sentinel” events
 Clinical Decision Support is also regulated
 Not currently enforced
 Legal implications of manipulating CDS alerts
Computerized Pumps aka “Smart Pumps”
 Pumps can be used in a variety of ways
 IV infusions, PCA, TPN, Epidurals, Intermittent infusions
 Pumps have medication libraries
 Drug product concentrations for formulary medications
 Intended to reduce complexity and improve safety
 Issues in the event of shortage or product changes

 Standard infusion concentrations and rates

 Titration ability
 Dose/rate alerts
 Different warning limits depending on level of acuity
 Continual updates
 Detailed data can be obtained
 Reporting and assessment of use
Error reduction: continuing processes

 Patient Labels
 Is it clear enough?
 Shands 2007 Error

 Patient charges
 Automatic billing pitfalls
 Reporting
 Med errors
 Sentinel events
 References
1. Brent I. Fox et al. Knowledge, Skills, and Resources for Pharmacy Informatics Education.
Am J Pharm Educ. 2011 Jun 10; 75(5): 93. PMCID: PMC3142977.
2. Shojania KG et al. Effect of point-of-care computer reminders on physician behaviour: a
systematic review. CMAJ. 2010 Mar 23;182(5):E216-25. doi: 10.1503/cmaj.090578. Epub
2010 Mar 8.
3. Course textbook. Chapter 15 Managing Pharmacy Automation and Informatics. Tribble
DA and Ho M.
4. Siebert et al. The effect of electronic prescribing on medication errors and adverse drug
events: a systematic review. J Am Med Inform Assoc. 2008 Sep-Oct;15(5):585-600. Epub
2008 Jun 25.
5. American Society of Health-System Pharmacists. ASHP statement on the pharmacist’s
role in informactics. Am J Health-Syst Pharm. 2007;64(2):200-203.
6. Rouse, Margaret. Bar Coded Medication Administration (BCMA).
http://searchhealthit.techtarget.com/definition/Bar-Coded-Medication-Administration
7. Medication Administration Record.
https://en.wikipedia.org/wiki/Medication_Administration_Record
8. Overview of eMAR Electronic Medication Administration Record.
http://crrtonline.com/prespdfs/winter_emar.pdf. March 2006.