• Home
    • » e-Newsletters

Hospital Pharmacy Regulation Report, April 2006

Hospital Pharmacy Regulation Report, April 1, 2006


Surveyors quiz TN pharmacy on night access, labeling of medications

JCAHO revises medication storage, night access MM standards

Use common sense when designing med rec process

MI medical group converts to electronic prescribing

Planning: The key to bar coding success

Five more steps to a smooth CPOE transition

VHA issues quality guidelines for bar coding


Unannounced survey monitor

Surveyors quiz TN pharmacy on night access, labeling of medications

With Tennessee Christian Medical Center expected to be sold in the near future, Pharmacy Director David Kellogg, DPh, MS, had a feeling that JCAHO surveyors would show up unannounced sooner rather than later. In mid-February, he was right.

Three surveyors arrived at the 273-bed hospital in Madison, TN, (a suburb of Nashville) for what turned out to be a five-day visit; one surveyor was assigned to Tennessee Christian’s home health facility and left after a few days. “From the surveyor’s schedule, we knew the first day [that] the pharmacy wasn’t going to be in any meetings,” says Kellogg. “We looked at the intranet at midnight each night to learn if they would be at our hospital that day.”

The sale to Hospital Corporation of America (HCA) is expected to take place this spring, which made Kellogg believe that surveyors from the JCAHO and state board of pharmacy would survey the hospital before it was absorbed into a new system. With the JCAHO beginning its unannounced survey process in January, Kellogg knew the facility needed to be prepared for anything.

“We did as much education in our department as we could,” he says.

In addition to the JCAHO’s medication management standards, one area of focus was refreshing the staff’s knowledge of the Institute for Safe Medication Practices’ safety standards and the improvements made during the previous year to comply with these standards, Kellogg says.

Focus on talking to staff

Unlike during past surveys, Kellogg found that the surveyors were less interested in asking him questions and more likely to question staff about various issues.

“[As director,] surveyors specifically asked me not to talk,” he notes. “They wanted the assistant and especially the staff pharmacists to talk.”

Kellogg oversees a seven-pharmacist staff, with two pharmacists working during the day and an overlap pharmacist coming to work in the afternoon.

In addition to holding a one-hour meeting with the pharmacy department management, surveyors visited the pharmacy as part of a patient tracer. In keeping with the staff focus, the surveyors bypassed Kellogg’s office and went straight to the staff pharmacist, who answered questions about the pharmacy-patient process.

“My perception is they’re there to see how you implement this order,” says Kellogg. The tracer visit to the pharmacy took 15 minutes.

In the specific pharmacy visit, surveyors met with Kellogg and the pharmacy’s supervisor to ask specific questions about the department. The discussion went well, he says. “We did have a chance to rebuff a couple of things they did and we’re in good shape.”

Labels, night access were major concerns

Kellogg says the surveyors wanted to see patient-specific labels on respiratory therapy medicine. Tennessee Christian does not have automated drug-dispensing machines that could be used to label such medicine, but Kellogg says the problem will be addressed once the sale is complete. HCA facilities have drug dispensing machines and may add some to Tennessee Christian. Another option is to provide those services at different facilities.

Surveyors stressed the reduction of night access to the pharmacy. Tennessee Christian had already made good progress in this area, going from 113 entries per month a few years ago to 12 per month when the surveyors arrived, Kellogg says.

After the survey ended, the pharmacy changed the procedure to require the night supervisor to make a mandatory phone call to the on-call pharmacist prior to entering the pharmacy after hours, says Kellogg. The night cart was enhanced to include more pre-mixed IV fluids to decrease the night supervisor’s necessity to enter the pharmacy at that time.

Another major issue was alerting staff to look-alike/sound-alike drugs to avoid medication errors, says Kellogg. “Whatever you determine in your hospital to be a look-alike/sound-alike drug, you must be prepared to tell what safety precautions you take inside and outside the pharmacy.”

Tennessee Christian sends high-alert stickers with each drug that falls into the category of look-alike/sound-alike medications. One sticker goes on the patient’s chart, and the other goes on the drug itself. “We named insulin as one of our look-alike drugs,” and used labels to indicate that, but the surveyors suggested keeping the drugs in separate bins on nursing floors, Kellogg says.

Positive experience

A point of pride came when the surveyors mentioned that “this is the only hospital they’ve seen that didn’t have any unapproved abbreviations in the hospital itself,” notes Kellogg.

At the same time as the survey in the Madison facility occurred, JCAHO surveyors visited Tennessee Christian’s 50-bed hospital in Portland, TN, Kellogg says.



JCAHO revises medication storage, night access MM standards

As of July 1, several revisions to the JCAHO’s medication management (MM) standards are scheduled to take effect, including standards covering medication storage and locking the pharmacy at night.

Here’s what you should know about the revisions, says Elizabeth DiGiacomo-Geffers, RN, MPH, CNAA, BC, a healthcare consultant based in Trabuco Canyon, CA:

  • MM.2.20—Requires the proper and safe storage of medications.

    The JCAHO added a rationale for this standard that explains that medication storage will help maintain medication integrity, promote medication availability, lessen the risk of drug diversion, and cut down on dispensing errors.

    An element of performance (EP) was added for this standard that requires a written policy addressing medication storage between when an individual healthcare provider receives the medication and when the drug is administered.

    The policy should address safe storage, safe handling, security, and disposition of the drugs, including returning them to the pharmacy at the end of the individual’s shift.

    “The real issue is how you educate the staff on what the policy is,” says DiGiacomo-Geffers.

    Tip: After you train staff on the policy, conduct a posttest with a defined pass rate to see how well they understand the policy, she suggests.

    “After the test, go out and see how they’re complying with the policy,” says DiGiacomo-Geffers.

    The trouble spots that surveyors usually check include radiology, labor and delivery, perioperative, the intensive care unit, and physical therapy, during which topical steroids may be used to treat patients but not locked after use, she says.

  • MM.4.20—Calls for the safe preparation of medications.

    Revisions to the EP for this standard include requiring a written policy addressing the safety and use of drugs acquired by a provider from nonhospital sources for use on patients in the hospital.

    The policy would address whether these medications may be used and, if so, would detail a process to evaluate the integrity of medications brought in by a practitioner before they are used on patients.

    With this standard, the hospital must decide whether to allow the use of nonhospital medications, says DiGiacomo-Geffers. If such use is allowed, have a process in place to ensure the drugs’ integrity and follow up to ensure that the policy is followed.

    Tip: If your policy allows the use of these medications, then make sure you have a communication process in place if practice does not follow policy, suggests DiGiacomo-Geffers. You may want to implement a gatekeeping process.

  • MM.4.50—Requires that the hospital establish a system to provide medications for patients when the pharmacy is closed.

    The EP covering safeguards for allowing nonpharmacist healthcare professionals access to medications after the pharmacy is closed were revised to require that the pharmacy make available a limited set of approved medications. The drugs are stored outside of the pharmacy and locked.

    “This process is already implemented in many healthcare organizations,” says DiGiacomo-Geffers. “The issue is to review what medications are accessed after-hours to see if the pharmacy needs to adjust par levels. In addition, the pharmacy needs to have a process to review what medications were ordered after-hours and if the correct medication was obtained. This is generally done on the next business day.”

  • MM.8.10—Requires that the hospital evaluate its medication management system to improve safety.

    The JCAHO added EPs that require the hospital to implement medication management improvements based on an evaluation of the system, a review of available new technology, external data, and best practices that are proven to boost safety efforts.

    The new EPs also call for the measurement of the performance of the new med management system and the use of data analysis to determine new changes to improve medication management.

    This standard says that “any evaluation of a system should include data collection, analysis, and actions to improve,” DiGiacomo-Geffers says. “It’s inherent in performance improvement.”



    Use common sense when designing med rec process

    Some hospitals have struggled with how to meet the intended scope of the JCAHO’s medication reconciliation National Patient Safety Goal (NPSG), which took effect in January.

    The concern lies in how to implement a system that reconciles medications across the continuum of care, including ambulatory, emergency and urgent care, long-term care, home care, and inpatient services, says John Rosing, practice director of accreditation and regulatory compliance at The Greeley Company, the Marblehead, MA–based consulting division of HCPro, Inc., this newsletter’s publisher. The accreditor’s January Sentinel Event Alertabout med rec has only heightened the anxiety for hospitals.

    For example, Rosing’s consulting clients have asked whether they’re required to reconcile medications for every patient encounter for an outpatient lab test or imaging exam. “My advice is that common sense must prevail,” he says. “If no medications are given during the encounter, then no medication history or reconciliation need occur. That exempts routine outpatient testing and therapy visits.”

    As for contrast media used in some imaging examinations, “by definition, contrast media is inert and not absorbed by the body, thus no reconciliation need occur,” Rosing says. “The JCAHO is clear: Organizations are free to specify in policy a reconciliation opt-out clause for those transitions/encounters involving no new medication orders or rewritten orders.”

    Address the ED setting

    In the emergency department (ED) or urgent-care setting, hospitals should already routinely record a list of current medications that details their dosage and schedule (including when they were last taken) along with any drug allergies or intolerances during the history portion of the patient’s intake process, Rosing says.

    If medications are given during an ED/urgent-care visit, the physician will take into account the medication history before ordering the new medication, he adds. “This step, if performed consciously, accomplishes the reconciliation requirement at the time of order,” says Rosing. “So no change in process is likely required to this point.”

    But after the patient is discharged from the ED/urgent-care setting, the new expectation is that hospitals provide the patient and next provider of care a list that includes current medications and any new meds the patient must take after discharge, Rosing notes. Patients should receive instructions on how and for how long to take the new medication in addition to explaining how this affects their existing medications.

    Develop a form for new meds

    Although it’s not required by the JCAHO, Rosing suggests creating a new form for recording of medication history and new medication orders to facilitate the step of providing the patient with a copy of the list of continuing and new medications.

    The form should include the following options:

  • “Yes, continue”
  • “No, discontinue”
  • “Check with your primary care physician as soon as possible.”
  • “Check with your primary care physician during your next scheduled visit.” n



    Case study

    MI medical group converts to electronic prescribing

    More than 500,000 prescriptions have been filled by a Michigan medical group that piloted an electronic prescribing (e-prescribing) initiative in 2005, resulting in substantial reductions in adverse drug interactions and costs.

    In February 2005, the Henry Ford Medical Group in Detroit and Health Alliance Plan (HAP) began the Southeast Michigan E-Prescribing Initiative (SEMI) at the request of the big three automakers—General Motors, Ford, and Daimler Chrysler—to cut prescription costs and improve quality.

    Medco Health Solutions developed e-prescribing, a technology solution that lets physicians use a personal computer or wireless device to order or refill prescriptions and transmit them to retail and mail-order pharmacies.

    Beginning with 60 physicians, the pilot quickly was rolled out across the Henry Ford Health System and is now being used by 300 primary care physicians in 24 medical centers. In addition, all medical specialists at Henry Ford are scheduled to begin using e-prescribing by the end of the year.

    In addition to avoiding drug interactions, the initiative saved money through the use of generic instead of brand-name medications, according to Henry Ford and Medco officials.

    The results of the Henry Ford pilot included the following:

  • More than 80,000 prescriptions were changed or cancelled because of drug interaction alerts, and e-prescribing warned physicians about 6,500 potential allergic reactions
  • More than 50,000 prescriptions were changed or cancelled because of formulary alerts, which increased the use of generic drug.
  • The pilot led Henry Ford Medical Group to increase its overall generic use rate by 7.3%, resulting in $3.1 million in pharmacy savings during a one-year period

    Although the program focused on outpatient care, hospital pharmacy directors benefited through the comprehensive drug profile developed by the system, says Richard Datz, product manager for SEMI. The profile provides an up-to-date look at a patient’s inpatient and outpatient pharmacy activities.

    Slow growth

    There are several e-prescribing initiatives nationwide, with more than 12,000 physicians writing more than four million electronic prescriptions, says Michele Glynn, senior director of product business development for Medco.

    “It’s approaching the toddler years,” she says of e-prescribing’s adoption. “It’s not necessarily in its infancy . . . It’s rapidly growing, but there’s a wide variety of solutions the physicians need to choose from.”

    As a technology, e-prescribing has been around for about four years and the range of adoption is 5%–15%, says Datz. Although the percentage is small given the number of years, Datz notes that early e-prescribing systems weren’t as stable as the current versions and the costs have decreased.

    Costs depend on how much hardware physicians currently have in their offices; the less equipment that’s already in place, the higher the cost is.

    Datz says costs can range from $50 per month for licensing fees if the medical group has a thin client system to $300–$400 per month for hardware and licensing fees.

    Many vendors will allow physicians to use the system for free for a year to entice them into paying later, Glynn adds.

    Hospitals are slower to adopt e-prescribing because many are still trying to adopt computerized physician order entry (CPOE) systems.

    If a hospital is in the middle of a CPOE project, it may want to wait until that’s off the ground before moving to an electronic prescribing initiative, Datz says.

    Looking to 2008

    In addition, the Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS) are heavily promoting e-prescribing, but many hospitals are waiting.

    “Right now, most players in e-prescribing are anxiously awaiting 2008, when CMS and HHS come out with the final standard on e-prescribing,” says Glynn. “Some vendors are waiting and watching, [and] some are jumping right in. After 2008, if CMS and HHS make final standards, that’s when you’ll see a big push for e-prescribing.”

    Congress included a provision in the Medicare Prescription Drug, Improvement and Modernization Act of 2003 that requires HHS to adopt national standards for electronic prescriptions in the Medicare program by April 2008.

    Glynn expects the governmental pressure to continue. “The folks at CMS are so committed to this, and they have so much riding on e-prescribing driving down healthcare costs,” she says. However, she adds, “e-prescribing is part of a much bigger healthcare [information technology] picture.”

    Medco and CMS have launched a two-year, government-funded study of the effect of e-prescribing on reducing medication errors and associated costs. Glynn expects the report to be released this summer.

    Physician resistance is a factor

    The biggest challenge facing the e-prescribing initiative was physician resistance to switching to an electronic system, Datz says.

    “You have to make sure there’s adequate time for training,” he adds. A physician has to scale down the number of patients seen in the first few weeks to learn how to use the prescribing device.

    The key points that SEMI emphasized to physicians was that the system would clinically improve care, make physicians’ lives easier, and save money, says Datz.

    Depending on how comfortable physicians are with technology, training could be completed anywhere from within a day to two weeks, Glynn says.

    At Henry Ford, influential physicians were asked to serve as champions for the e-prescribing initiative, says Datz. This approach was effective because “docs listen to other docs,” he adds.



    Book excerpt

    Planning: The key to bar coding success

    Understanding the drivers for adoption and the technologies available for improving patient safety are important precursors to implementing a bar code point-of-care (BPOC) system, but having a sound plan for the implementation project is also critical to success. In fact, it’s probably more important to create and execute an excellent project plan than it is to have an expert’s understanding of BPOC technology. Obtaining expert resources can be a key component of the project plan if required, but having a poor plan will almost certainly result in a suboptimal project outcome. The following outlines the essential steps for devising and executing such a plan.

    Strategic planning

    The first step in planning is to fully understand the hospital information technology (IT) and patient safety strategy. An increasing number of systems today have far greater functionality than simple bedside medication administration or are one module of a much larger, integrated hospital care management system. Thus, connecting the BPOC project to the master strategic plan is critical to short- and long-term operational effectiveness, patient safety and management, and return on investment.

    Assess the investment

    Hospitals can use various approaches to assess a potential BPOC investment. In many cases, it simply determines that a BPOC installation will be initiated based on the external evidence of dramatic safety results achieved due to installation. Other factors that support this type of decision as a foregone conclusion bordering on a mandate include issues that were also previously outlined, such as the FDA regulation that will deliver more bar codes on medications and the many competitive and liability issues.

    Although this type of mentality can make for a simpler and clearer path toward implementation, it can also foster a climate in which multiple problems can arise. The most obvious of these is a rushed, near-sighted implementation that does not account for the issues that may be encountered and the opportunities that may be seized in a “wide-eyed” BPOC project. Another problem is that under these circumstances, a BPOC system is more likely to be sourced and implemented into the existing care processes and procedures, rather than treated as an opportunity to reengineer processes for a complete improvement in safety, care, and efficiency. Additionally, such a predetermined decision may result in the acquisition of a system that ultimately is limited and does not connect well to existing systems, processes, and the future.

    Even if the decision to invest in a medication administration system is relatively a fait accompli, following a full planning methodology for the project is strongly recommended.

    Set up a plan

    Strategic planning and project management expertise are not absolutely required because there are many sources of knowledge and assistance on this subject, including, ultimately, the BPOC vendor selected. Again, however, setting up a project plan is directly related to the eventual success of the implementation process. See p. 8 of the PDF of this issue for a useful strategic planning worksheet.

    A strategy is generally based on a one- to three-year target and included in a hierarchical “tree” with goals between the high-level vision and mission of the organization, the action plan(s), and results tracking. One excellent resource for guidance specific to hospital medication safety strategic planning is www.medpathways.info, on which you can find documents created by a collaboration of the American Hospital Association, Health Research & Educational Trust, and the Institute for Safe Medication Practices.

    Editor’s note: Get the nuts and bolts that you need to help you successfully implement a bar coding system in your facility with Bar Coding Basics: Implementation Strategies to Improve Patient Safety by Michael Gallo. For more information about purchasing this book, call HCPro customer service at 800/650-6787.



    Five more steps to a smooth CPOE transition

    Editor’s note: This article is the second in a two-part series.

    As the push for a universal electronic health record (EHR) and computerized physician order entry (CPOE), a core component in providing real-time electronic data, intensifies, hospitals nationwide will have to gear up for the biggest change since the inpatient prospective payment system took effect.

    Last month, we brought you the first five make-or-break steps that your hospital needs to take to make sure that the transition to CPOE goes as smoothly as possible—all learned from executives at seven hospitals that have successfully automated physician orders. Following are the final five lessons that these executives have to share:

    1. Set a deadline and mean it. A tight roll-out schedule might seem counterintuitive for a difficult technology like CPOE, but hospitals that get order entry to work set one. Several months prior to launch, University of Pittsburgh Medical Center (UPMC) St. Margaret began a poster campaign that advertised the number of days remaining to the impending switchover. And Evanston (IL) Northwestern Healthcare, a three-hospital integrated delivery system, publicized its hospital-by-hospital targets during roughly a 30-month period.

    Keeping the implementation dates front and center accomplishes two goals, experts say. First, it reinforces the seriousness of the project. Second, it keeps staff focused on an institutional makeover that could easily lose momentum.

    “You need to say that CPOE is going to work and [that] this is how you are going to get there,” says Arnold Wagner Jr., MD, a practicing OB/GYN who doubles as a chair of the medical informatics committee at Evanston (IL) Northwestern Healthcare. “You need a tight timetable to keep the enthusiasm up. There can be no dawdling around and no diffusion of effort. You can’t committee it to death.”

    That’s not to say that successful CPOE projects are rush jobs. During the orders installation phase of its three-year upgrade, Cincinnati Children’s Hospital ran dual paper and electronic records for about eight months. And UPMC St. Margaret spent one year analyzing workflows, building order sets, and training users before it began its staged rollout, which it completed ahead of schedule, says Joel Diamond, UPMC’s chief medical information officer (CMIO).

    Although tech staff may relish the project, maintaining physician interest during a one-year period is no easy task, says Bill Fera, MD, a family physician who uses CPOE at UPMC St. Margaret. With physicians, honesty is the best policy. “We told the docs up-front that CPOE would take more time initially and that it would not be an easy transition,” Fera says. “We urged people to not be too ‘physician-centric’ and instead focus on the benefits to the patients.”

    2. Training is key. Behind every stalled CPOE project lurks inadequate training. “It’s not a ‘fire-and-forget’ application,” cautions Stephen Smith, former chief technology officer at University of Pennsylvania Health System, which is wrapping up its CPOE installation across three hospitals. Having trainers and support staff available around the clock is critical, Smith says, adding that his support crew fielded 40 calls per day.

    “Once a hospital becomes dependent on CPOE, it raises the bar for the IT [information technology] department. There is absolutely zero tolerance for down time. You need to support the application or you will pay a price,” Smith says.

    Hospitals with successful adoption of CPOE usually begin training staff well before the launch and then maintain a highly visible support presence during the transition. Others, such as Duke, build call-for-help buttons right into the system.

    Evanston Northwestern Healthcare went the extra mile in staff training. It formed an off-campus “training university” that offered mandatory courses for all staff using the various clinical documentation tools from Epic Systems Corporation in Madison, WI. For 14 months, the training center ran 16 hours a day every day of the year except Thanksgiving and Christmas, says Wagner, the physician champion. For physicians, completing the training was a prerequisite for treating patients.

    “A few physicians tried to slide under the radar,” says Wagner. “They chafed at having to do this, but all you need to do is kill them with kindness. You say, ‘Yes, doctor, you will need to call your colleague who is certified as having completed training to treat your patient. How would you like to be trained this afternoon?’ ”

    But even the most exhaustive classroom can’t prepare physicians for using CPOE on the patient floor. That’s why Northwestern Memorial Hospital in Chicago offloaded its training on Long Beach, CA–based First Consulting Group (FCG). FCG provided five trainers who were present as departments began to use the technology. Dubbed the “embedded coaches,” these trainers worked elbow-to-elbow with physicians before, during, and after the launch, says Paula Elliott, FCG’s implementation director. “Most physicians were self-sufficient after two weeks,” she says. “Most coaches were dismissed after three days.”

    3. Exploit physician resistance. Even with training, some physicians balk at doing orders electronically. The solution lies in understanding physician psychology, experts say. Some just need reassurance or a reason to change. When Diamond encountered resistance and UPMC St. Margaret, he met privately with concerned colleagues. “Some had legitimate concerns about patient safety,” he says. “But when you really got them to talk, they were fearful of technology and afraid to admit their lack of skills using computers. Physicians have high-index egos and do not like having their weaknesses exposed.”

    The biggest resisters were midcareer physicians who were worried that CPOE would cut into their productivity, Diamond says. The CMIO played into the competitive nature of these physicians, telling them that mastering the technology is the same as learning a new surgical technique or procedure. CPOE’s reputation as a clerical tool is one of the biggest myths surrounding the technology, he says.

    Other physician resisters grouse for good reasons, adds Brian Jacobs, director of technology at Cincinnati Children’s, who sat down one-on-one with a vocal opponent. “He had refused training, but there were no order sets for the diseases he treated,” Jacobs recalls. “So we built the order sets, and now he is a strong advocate of electronic documentation. You just need to get down and dirty with physicians and find out their issues, not ask the CEO to threaten them with an e-mail.”

    4. Sell the benefits. The benefit of automating orders is usually clear to pharmacists and nurses, who no longer have to interpret barely legible notes or comprehend harried voice messages. But the technology’s benefits are not always as clear to physicians, who describe the technology as initially more time-consuming than scribbling a note. “Physicians are good about complaining about new annoyances,” says Jacobs. “But they don’t recognize when you take away an old annoyance. We try to remind them that’s what CPOE does.”

    For example, after they enter orders electronically, physicians rarely are paged for clarifications or thrust into annoying rounds of telephone tag, says Jacobs, who has the data to back up the assertion. Six years ago, pharmacists, radiologists and nurses paged physicians for orders clarification an average of 80 times a day, he says. “Today, those calls are uncommon.”

    For physicians, the real benefit of CPOE comes when the technology is integrated with other applications, such as nursing documentation and results display, says Wagner. “To get physicians to do order entry, which can be perceived as a scribe job, there has to be a compelling reason,” he says. “Here, the reason is that the system is their cockpit, the place where they write orders, document, and get results back. This is where they communicate with other physicians.”

    Publishing quality improvement data after the launch is another way to maintain physician support, adds Diamond. Six months after its launch, UPMC St. Margaret recorded substantial reductions in prescribing errors, he says. For example, improper dosing is down by 85% and unauthorized dosing has been cut in half, says Diamond, who created the benchmarks by sampling paper records. “Physicians are willing to invest the time to improve quality,” he says. “But if you tell them, ‘This is an IT project,’ they’ll balk.”

    5. Crack the whip. Even hospitals that have done everything right in their CPOE rollout may still encounter intransigent physicians. At some point, CPOE experts say, you just have to get tough. “Read my lips,” says Wagner. “No paper orders.”

    Not all hospitals amend their staff bylaws to mandate use of clinical documentation systems like Evanston Northwestern did. Some, such as Georgia’s DeKalb Medical Center at Hillandale, stop short of using the “m-word,” declining to officially mandate use of any technology. “We tell the medical staff that if they practice here, they must use our technology,” explains Cynthia Davis, vice president of information technology and chief information officer. “But the medical staff [police themselves].”

    Davis plans on using Hillandale’s new digital hospital as a role model for recalcitrant physicians at the delivery system’s other two hospitals that are now preparing for electronic order entry. “We’re going to leverage competition,” she says. “We’ll say, ‘Your colleague has been using CPOE at the new facility. What’s the problem here?’ ”

    At times, it helps to have friends in high places, adds Diamond of UPMC St. Margaret, a community hospital staffed mostly by independent physicians. “We had one physician who said he would not use the system unless we provided a scribe to use the CPOE system for him. Our CEO called his bluff. We gave the physician two choices: either put the order in yourself or quit. He quit. It sent a strong message to the medical staff.”

    But prudent planning can avoid such showdowns, CPOE experts say. “The point is to help physicians make clinical decisions, not turn them into clerks,” summarizes Michael Russell, MD, associate CIO at Duke.

    How one hospital achieved physician buy-in

    When DeKalb Medical Center in Georgia opened its “digital hospital” in July 2005, the last problem Cynthia Davis, vice president of information technology and chief information officer, needed on her hands was a physician rebellion against complex technology.

    Replete with clinical information technology (IT), the hospital offered plenty of opportunity for just that. The new facility, DeKalb Medical Center at Hillandale, includes picture archiving, a clinical data repository, and computerized physician order entry (CPOE), all networked in a complex array of systems linked through some 500 interfaces. It’s a tall adoption order for anyone, which is why Davis cautioned the hospital’s board to expect “physician noise.” But after two months, physicians who practice at the new hospital were entering 70% of orders into the CPOE system from Boca Raton, FL–based Eclipsys Corp. Davis reports little physician resistance to using the technology. “But that’s because we have physician leaders who support it and were involved in the design,” she says.

    An original idea

    However, Davis did not leave the physician leadership factor to chance. In a rare move among hospital IT executives, she hired three physicians to serve as system chief medical information officers (CMIO). Brushing aside any incongruity to having three “chiefs,” Davis says the physician IT executives were critical to the hospital’s smooth opening. “They do the sales and marketing,” she says. But the three CMIOs were far more than IT flag wavers. They divvied up key CPOE responsibilities prior to the opening. For example, each shepherded different categories of order sets through the hospital’s medical staff executive committee, physician hospital organization, and DeKalb Quality Institute, building 150 sets in time for the ribbon cutting. The CMIOs also supervised Hillandale’s CPOE pilot, which took place at DeKalb Medical Center in Decatur, one of the provider’s three hospitals.



    VHA issues quality guidelines for bar coding

    The Veterans Health Administration (VHA) in February issued a directive that provides a set of policies and procedures for establishing a pharmacy bar code quality plan that involves unit-dose packaging and bar-code labeling. The VHA’s directive is intended to improve the scanning quality of bar-coded medications at the point of care. The VHA requires that each facility have a written bar-code quality plan in place within each inpatient pharmacy and that all medications have machine-readable bar-coded labels.

    The VHA piloted bar coding at a medical center in Kansas in 1997 before expanding its Bar Code Medication Administration (BCMA) nationwide to its 173 hospitals in 1999. The system cost $60 million to build. The directive describes quality control procedures that each VHA facility must follow, resources for performing quality monitors, frequency of sampling/reporting to the BCMA multidisciplinary committee, and reporting mechanisms.

    In addition, six quality control monitors are provided to test the quality of

  • pharmacy controlled substance labels
  • manufacturer bar codes
  • IV labeling
  • automated unit-dose packaging
  • medications relabeled by the pharmacy
  • end-user medication labels

    The directive states that the pharmacy chief or designee is responsible for

  • ensuring that medications dispensed have readable bar codes
  • establishing a baseline using data collected from the first quarter and measuring progress over time
  • reporting results and success rate percentages to the BCMA coordinator
  • ensuring follow up on any areas of concern from results reporting
  • ensuring that data collecting, reporting, tracking, and trending is achieved within the prescribed time frame

    The directive expires February 28, 2011. Go to www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1380 to read it.