Technology

By Paula DeJohn

In the quest to further reduce human error in medication administration, it's no longer about the cabinets. According to industry experts, it is the rare nurse who has not used a controlled-access cabinet to obtain medication at or near a patient's bedside, and the resistance that marked the early years of computerization has diminished.

Yet, errors still occur. The next step, say experts, is to create an unbreakable link from the doctor to the pharmacist to the nurse to the patient. This requires equipment and software and databases that communicate smoothly and are easy to use.

Most hospitals are not there yet, for the usual reasons: expense, departmental variations in choice of systems, differing priorities. Still, with the spotlight on safety in health care, dozens of consultants, vendors and industry groups are ready to help hospitals build effective systems.

In 2007, the American Society of Health-System Pharmacists (ASHP) surveyed approximately 4,000 hospital pharmacy directors on their use of information technology, including use of medication dispensing equipment. Here's what the researchers found:

• 82.8 percent have automated dispensing cabinets.
• 10.1 percent have robots.
• 24.1 percent use bar codes for medication administration.
• 12 percent have computerized pro­vi­der order entry systems.
• 5.9 percent have completely adopted electronic medical records.

The researchers concluded: "Many of these technologies were not optimally configured, and significant advances must be made for hospitals to fully realize the benefits of these technologies."

Deploy enough equipment

Pharmacist Donald Harry agrees. After managing hospital pharmacies for many years, he joined VHA Inc., Irving, Texas, seven years ago as a consultant. He sees varying degrees of adoption, but nearly all clients have some form of controlled-access medication storage, he says.

"We see them almost everywhere we go," Harry says. "But one problem is often they don't have enough machines to do the job. Nurses are waiting in line, or have to walk too far. It's very important to have enough machines strategically located on nursing floors."

He recommends installing a main console, auxiliary console and tower for every 15 to 20 beds. "It's a lot of equipment, but there are a lot of benefits."

Harry compares the cabinets in function to a bank ATM, and says nurses have come to accept the technology and to see its benefits. Any discontent, he notes, tends to be a result of poorly placed or insufficient numbers of cabinets. "My experience," he says, "is if it is properly set up, nurses are generally positive about the concept when they get used to it."

Mary Ann Holt of IMA Consulting, Chaddsford, Pa., says that to be truly effective, dispensing controls should be more than lockboxes for drugs. "The idea is not just to use technology to work more efficiently, but to use it to redefine workflows."

She is referring to the fact that a truly integrated system will change the jobs of many people, from pharmacy techs to doctors to nurses.

In her visits to hospital clients, she still sees some employee resistance, but attributes it to lack of commitment from top management. "People feel they can do workarounds," she notes. "There are ways people can manipulate pharmacy dispensing products." In some cases, she adds, those workarounds could violate narcotics laws.

Emphasize planning

Holt uses standard project management concepts to design and upgrade pharmacy distribution systems for her hospital clients. The first step-initiation-includes drawing up a request for proposals and selecting a vendor and product. It also includes documenting a "baseline" of medication use (to establish par levels for stocking) and error rates. The development team should include pharmacy buyers, nursing, anesthesia, information technology and facilities management. Some members, Holt notes, should be at the staff level because they "know how the work is done."

Some hospitals tap into the contract negotiation expertise of their materials managers, she says, but many let pharmacists handle this type of project. Part of the reason is that the pharmacy may already contract for prepackaged medications and that will influence the type of cabinet to be chosen.

The second, and longest, step is planning. This includes everything from designing logistics to conducting a pilot test in one or two units and typically takes six months to a year.

With the system in place, the focus changes to monitoring use of the equipment, compliance with procedures, and reports of medication use and any errors that occur. Hold managers accountable for compliance by using system reports to show how it affects the quality of care. "Staff respond to data," Holt says.

Ongoing training should be available, and Holt recommends rewarding employees for good results. She says some hospitals have used their results to obtain credit under Medicare pay-for-performance programs.

Change pharmacy logistics

Until 1989, drug distribution was manual. Pharmacies stored medications and were responsible for keeping some refrigerated and others locked up. Pharmacy techs hand- carried drugs, in response to physician orders, directly to nursing units.

In that year, Pyxis Corp. introduced a controlled-access cabinet designed for placement on nursing floors (later, the company added controlled-access supply-dispensing cabinets). The result, as the concept caught on with hospitals during the 1990s, was a revolution in pharmacy logistics. Medications could now be tracked, via electronic identification, to specific nurses and patients, creating accountability and capturing patient charges directly.

The dispensing units are replenished daily based on par levels. Only on the rare occasions when a needed drug is not available must the nurse call a pharmacy tech for delivery. As Holt says of the new system, "It's easier for the pharmacy, but it's more labor-intensive for nurses."

Cardinal Health, Dublin, Ohio, later acquired Pyxis and on Sept. 1 of this year spun it off, with several other divisions, as a new company called CareFusion that is based in San Diego. Tom Leonard, president of dispensing technologies at CareFusion, estimates that 7-in-10 medication dispensing units installed in U.S. hospitals are from Pyxis. VHA's Harry explains that hospitals often choose dispensing cabinets based on existing corporate contracts, and Cardinal is a major distributor.

David Azlin, director of pharmacy at Edmond (Okla.) Regional Medical Center, offers a case in point. For the past nine years, Edmond has used dispensing units from McKesson Corp., San Francisco. "They've been very effective," Azlin says.

However, the hospital is planning to upgrade the equipment and has decided to convert to Pyxis. The reason is that Edmond's group purchasing organization, HealthTrust Purchasing Group, Brentwood, Tenn., has a corporate contract with Cardinal.

Meanwhile, the dispensing cabinet market has matured to the point where many observers agree that there is little difference from one vendor to the next, either in features or in price.
The major vendors and their signature products, based on information from their Web sites and company sources, are:

• McKesson Corp. (www.mckesson.com): Medication Safety Cabinet System
• CareFusion (www.carefusion.com): Pyxis MedStation
• Omnicell, Mountain View, Calif., www.omnicell.com: SinglePointe patient-specific system, which allows the cabinet to control all of a patient's prescriptions, not only those prescribed in the hospital; Anesthesia Workstation medication and supply dispensing unit; SecureVault controlled-substance management system; and SafetyMed handheld bar-code scanner.
• AmerisourceBergen Corp., Chesterbrook, Pa., www.amerisourcebergen.com: MedSelect medication dispensing system.

The typical system includes a physical cabinet with drawers; a user interface such as a display screen and access point through a keypad, keycard, thumbprint reader or other device; and an interface to the other hospital systems, such as pharmacy and patient records, indicating who should have access to which drugs.

With little variation among cabinets, the next step will be creating compatible devices and software. "Sources of innovation will be less around features and functions and more around enabling customers to take cost out of the supply chain, by helping customers achieve their goals in medication safety," Leonard notes.

To that end, CareFusion will soon introduce the Pyxis Point of Care handheld bar-code reader. Nurses can use it just before administering medication, to double-check the patient and drug identifiers.

That is also the function of Omnicell's SafetyMed scanner, according to Senior Product Manager Jennifer Cartright. She says 25 percent of the company's hospital customers have already purchased the device, and she expects use to increase to 60 percent within the next five years.

Omnicell also is expected to release this month a system called Anywhere RN. It will allow a nurse to find "a quiet place" with a computer to order medications for a specific patient from the controlled- access cabinet. Later, in the busy patient-care setting, the nurse can reach in and obtain only those drugs ordered earlier, further reducing the chance of error.

Currently in a 70-hospital pilot test, Leonard says, is another CareFusion product that will lock down a dispensing unit when a patient's vital signs indicate the prescribed drug is no longer appropriate. Called Pyxis Patient Event Advisor, it consists of integration software that connects patient monitoring equipment with the cabinet. It will be programmed with protocols for use of certain drugs, such as heparin. When the patient's condition changes, the system will lock the doors and post a message on a screen directing the nurse to contact the physician or pharmacist.

"It adds another whole new layer of safety," he says.

Erin Sparnon, a senior project engineer with ECRI Institute, Plymouth Meeting, Pa., agrees with Leonard's assessment about the recent developments: "With more complexity, you get more safety."

Working with David John, a senior health care IT specialist, Sparnon does direct comparisons of technology. She says the dispensing cabinets have gotten more attention recently because of growing interest in electronic prescribing and electronic medical records, which in turn require more sophisticated interfacing to be effective.

"The challenge," Sparnon notes, "is building the interface because the pharmacy information system, patient census and medication cabinets may all be from different suppliers."
John adds, "The ultimate goal is to create a closed loop. This is one component of that."

As manager of ECRI's Select Plus capital planning program, John maintains a price database for about 3,000 hospital subscribers. Depending on the configuration, controlled-access systems can cost up to $10 million. Most of that cost is for software, rather than physical equipment.

Hospitals must also consider construction costs to create room for the cabinets, training costs, and changes in staffing due to the different workflow.

At VHA, Harry says he sees many hospitals elect to lease the entire system. John, however, says he does not encounter many of those hospitals, most likely because his role is to help them benchmark purchase prices. Of the vendors, Pyxis tends to provide the most leases, he notes, with five-year contracts most common, which allows for regular upgrades.

Based on ECRI records, between January 2008 and April 2009, 74 percent of acquisitions or upgrades were direct purchases and 26 percent were leases. As with any other capital purchases, John notes, a hospital should have the opportunity cost of a large investment, rather than spreading the cost over a lease period.

Paula DeJohn is a freelance health care writer based in Aurora, Colo.

This article first appeared in the October 2009 issue of Materials Management in Health Care.

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