III The Neuenschwander Company, Inc Summary Findings and Recommendations for City of Hope’s Hospital-Wide Bar-Code Point-of-Care Initiative 20 February 2008 This report was prepared exclusively for City of Hope employee. Contents may not be shared in any way with anyone outside City of Hope, including, but not limited to any vendors and consultants whose services City of Hope may retain, without the written permission of The Neuenschwander Company.
Transcript
I I I The Neuenschwander Company, Inc
Summary Findings and Recommendations for City of Hope’s
Hospital-Wide Bar-Code Point-of-Care Initiative
20 February 2008
This report was prepared exclusively for City of Hope employee. Contents may not be shared in any way with anyone outside City of Hope, including, but not limited to any vendors and consultants whose services City of
Hope may retain, without the written permission of The Neuenschwander Company.
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Table of Contents Objectives 5 Methods 5 Deliverables 6 Findings 6 Vision 11 Guiding Principles 11 RECOMMENDATIONS 12 PRELIMINARY RECOMMENDATIONS: In process 13
A. Complete plans to include bar codes on all specimen labels and begin scanning all specimens as the enter the lab 13
B. Complete Hospital Information Management’s plans in process for applying bar codes to forms 14
PRIORITY-ONE RECOMMEDATIONS: Do without delay 15
Group A: Build BPOC-Support Infrastructure Now 16
1. Appoint motivated and motivating leadership to shepherd the BPOC Initiative 17
2. Refine bar-coded patient wristbands 20
3. Retrofit caregiver ID badges with usable barcodes 23
4. Select point-of-care data-collection devices according to user needs and preferences 25
5. Develop process-design and user-training programs 28
Group B: Implement These BPOC Applications as Soon as Possible 29
6. Implement bar-code scanning for glucose monitoring 30
7. Issue bar-coded Hope Cards to all patients 31
8. Implement bar coding for specimen collection 33
9. Implement bar coding for blood transfusions 35
10.Implement bar-code scanning in outpatient pharmacy 36
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PRIORITY-TWO RECOMMENDATIONS: Do soon—in preparation of KBMA 37
11.Review and refine inpatient drug distribution process 37
12.Implement a process for ensuring that all drugs products have bar codes when dispensed 39
13.Implement bar-code labeling of IVs 41
14.Implement bar-code labeling of investigational drugs 41
15.Facilitate positive drug-ID all the way to the patient 42
16.Test RF network for reliability 43
17.Define vision for integrating KBMA with smart-infusion pumps 43
18.Synchrobuild KBMA with Sunrise Pharmacy 44
19.Bring up KBMA on the heels of Sunrise Pharmacy 44
20.Bring up eMAR with (not before) KBMA 45
21.Utilize bar-coded-patient verification before surgery 45
PRIORITY-THREE RECOMMENDATIONS: Do after KBMA is live and validated 46
22.Utilize KBMA data for process improvement 46
23.Implement bar coding for vital-sign collection and reporting 47
24.Implement bar coding for anesthesia and implants in OR 47
25.Apply bar-coding in radiology 47 PRIORITY-FOUR RECOMMENDATIONS: Considerations for down line 47
26.Medication charge capture 47
27.Referral specimens 47
28.Meal trays 48
29.Supply charge capture 48
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30.Bar coding during surgery 48
31.Tracking, assets, patients, and caregivers 48
32.Bar-code assisted medicine disposal 48 Addendum A: City of Hope Departments and People Visited 49 Addendum B: Site Visits and Other Meetings 53 Addendum C: State of Eclipsys’ KBMA and Ramifications 54 Addendum D: Recommendations for Scanners for Printers for Lab Clerks 56
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The Neuenschwander Company (TNC) has been engaged by the City of Hope (COH) to advise them concerning their hospital-wide bar-code1 point-of-care (BPOC) initiative. In the process we spent six days on campus meeting with over 75 COH personnel (see addendum A, page 49) and we made two site visits to learn more about vendors and products relevant to this project (see addendum B, page 53). OBJECTIVES
1. Arrive at an in-depth understanding of COH’s current point-of-care processes and technologies (e.g. medication and IV-use, specimen collection and tracking, blood drawing, tracking and transfusion, respiratory therapy, glucose monitoring, etc.)
2. Discern COH’s unified vision for BPOC solutions, incorporating the best thinking of pharmacy, nursing, information systems, blood bank, respiratory, and laboratory leaders and clinicians
3. Identify potential for other BPOC applications throughout the system 4. Recommend a plan to help ensure that COH sets the right priorities
and outlines effective and efficient processes for achieving said vision. METHODS TNC’s interdisciplinary consulting team2 visited COH during Q4 2007 for firsthand observation of workflow and in-depth interaction with numerous stakeholders germane to the BPOC initiative.
1. Firsthand observation of departments, care areas, and activities to understand COH’s
a. Current and anticipated utilization of medication-
distribution/dispensing systems b. Current and anticipated medication-administration and
documentation processes and technology c. Current and anticipated utilization of smart-infusion pumps,
including potential integration with bar-code applications, and d. Other points of care to which COH has applied, plans on applying,
or should consider applying bar-code technology
1 While bar codes will be the primary identifiers utilized by the technologies under consideration, it is understood that other auto-identifiers including various printed machine-readable symbols and implanted radio-frequency ID chips may be used as well. Nevertheless, we will use “bar coding” as a generic term for purposes of simplicity. 2 Mark Neuenschwander, President; John Tourville, Pharm D, FCCM, Director of Pharmacy Consulting Services; and Debbie Daspet, RN, Director of Nursing Consulting Services.
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2. Formal meetings with key personnel (e.g. administrators, directors, leaders, clinicians, and technicians) across departments and disciplines that will be utilizing and/or be impacted by BPOC
Following our onsite visits, TNC took the following steps before making the summary findings and recommendations contained in this report.
3. Investigation of applicable technologies with vendors and users to discern potential issues that could impact COH’s successful implementation of BPOC across the spectrum of care
4. Conceptualization of a plan for approaching, prioritizing, and staging
implementation of BPOC technologies
5. Confirmation that our recommendations and vendors’ capabilities and commitments line up in a way that predicts success for COH in moving ahead with their BPOC initiative
DELIVERABLES
1. This written report of findings and recommendations—along with rationale for each
2. An interactive oral report of findings and recommendations to the
appropriate individuals and groups at COH (TBA) FINDINGS General Findings We found COH caregivers and all who support them to be competent, compassionate, and conscientious. All are concerned about doing the right things for their patients in the right ways. Nevertheless, the individuals and teams with which we met generally expressed concern about actual and potential errors in their departments. Almost everyone we met with believed that bar coding would significantly decrease medical and medication errors and was enthusiastic about the hospital’s BPOC initiative. More often than not, we heard them say, “The sooner we apply bar-coding technology the better.” We found that the higher their level of leadership, nurses seemed to have a clearer understanding and a stronger conviction about BPOC value, along with a greater sense of urgency about getting it done. There is more work to be done in communicating the vision to and gaining ownership of colleagues at the user level.
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We met a few would-be users who showed a bit of reluctance to the idea. For example, one nurse expressed concern that bar coding seemed to be “a bit Orwellian.” She feared it could be used to track nurses mistakes for the purpose of placing blame and taking punitive action. Our experience shows that BPOC-initiative planning and execution has the greatest success in the context of an intentional nonpunitive culture. A recurring sentiment among various departmental leaders included doubt that COH would indeed follow through on bar coding in the near future. We heard a doctor, a number of nurses, and a few pharmacists comment that we had been here before and nothing happened. They would believe it when they saw it. As anticipated, our investigational methods provided information and motivation to the people with whom we met, which we believe helped convince skeptics and create excitement among believers. There appears to be an overwhelming consensus at every level of leadership in the organization that COH is ready for this hospital-wide initiative. Limited Bar-Code Presence We discovered that COH is currently utilizing bar codes in a limited way with some success.
• Laboratory tracks specimens through the testing process by reading Sunquest-generated bar codes, which are applied to specimens at their point of entry to the lab. While Sunquest (formerly Misys) has attempted to sell COH on their point-of-collection bar-code labeling system, up to this point this option has been declined. This appears to be because COH is interested in making decisions that take the greater context of bar-code applications into consideration.
• Admitting has begun applying linear bar codes on patient wristbands
since our investigatory visits. While more study will be required for arriving at the long-term solution for bar-coded patient identification, this move positions COH to begin at least one BPOC solution in the immediate future, namely glucose monitoring.
• Admitting has also begun applying linear bar codes to patient labels
that are preprinted for applying to collected specimens.
• Blood Bank labels all virtually blood products with barcodes.
• Radiation Oncology issues bar-coded cards to patients, which include their medical-record numbers (MRNs). When patients arrive, they present their cards to the receptionist for scanning, which pulls up their names on the computer screen and places them into the care queue. This simple technology has solved the problem of patients
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getting lost in the system—waiting in vain while no one knew they had arrived—and serves as a promising model for other patient-entry points across the system.
• Security applies bar codes to employee ID badges, which will be
discussed later in this report. Enough for now to say that these bar codes are utilized rarely and for limited applications.
• Pharmacy has conducted tests to demonstrate that their system can
generate bar code labels for unit-dose packages and IVs. For oral solids, pharmacy borrowed the bar codes on the bulk bottles from which they came. For IVs, pharmacy utilized bar codes containing patients’ MRNs. It is understood that neither of these is appropriate and they were printed only as tests.
Specific Commitments We discovered that COH has committed to several specific BPOC action steps. Hospital Information Management: HIM has been studying and is committed to implementing a plan for applying bar codes to forms used for patient records. Hospital Information Management: New Patient Services is now producing bar-coded patient wristbands. Bar Codes on Specimen Labels: Patient-specific specimen ID labels are now being printed with barcodes for scanning by clerks upon arrival at lab. KBMA: City of Hope’s commitment to a full Eclipsys CIS implementation includes Knowledge-Based Medication Management (KBMA)—Eclipsys’ bar-code-enabled medication-administration application. We are aware of no other commitments to bar-code solutions. Other Findings Most of our findings are included in the rationale statements that accompany our recommendations later in this report. However, there are a number of findings that we feel worthy of separating out before moving into said recommendations. Vision Ownership: In past years, pharmacy initiated movement toward BPOC. However, COH made a wise decision not to move ahead independently of a unified CIS vision. While BPOC now resides under the CIS umbrella, COH’s
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hospital-wide BPOC initiative is neither officially owned by any identifiable group nor headed by a champion. Determination and Prioritization: COH has neither fully determined nor prioritized the BPOC applications they will implement. Admitting and Check-In: We discovered that the hospital admitting and clinic check-in processes are neither as efficient nor as effective as they could be. These processes take longer than necessary, and after reporting in, patients sometimes wait in vain because they were not put in queue as all thought they were. Specimen Collection: We concur with the parties we talked with that the specimen collection process is not as safe as it should be. Storing preprinted labels on the wards in room-designated cubicles is a high-risk practice. These cubicles are not always cleared when patients are discharged, and they are sometimes confused with other labels prepared for newly admitted patients. Additionally, too many specimens leave the OR without proper identification. We affirm COH’s new practice of applying barcodes on preprinted specimen labels, which will be scanned for verification at the lab point of entry. However, the current storage system does not address the problems noted in the previous paragraph. Dispensing Automation: We discovered that COH’s use of automated-dispensing cabinets (ADMs) is not as efficient as it could be and that some attempts to improve efficiency have resulted in unsafe practices. For example, having ADMs in medication rooms that are shared by north and south units requires nurses to walk a great distance to obtain medications from ADMs. Distance encourages the high-risk practice of obtaining more than one patient’s medications per ADM visit in order to save time. Attempted solutions to these inefficiencies have included deactivating electronic locks on refrigerators and removing doors from Pyxis towers—granting open access to medications without user sign-on and patient-profile control.
Clinics: In most clinics we found that the volume of patients, cramped space, workflow processes, and hectic pace create opportunities for errors, which bar coding could significantly reduce. Pharmacy: Overall, pharmacy is enthusiastic about the Initiative and has taken a number of measures to fulfill their role for a successful implementation. Remaining gaps need to be identified and filled in a timely manner so that all medications are ready for scanning when KBMA is ready to go live and to avoid unnecessary delays. Pharmacy has a reasonable understanding of what medications and IVs are ready for scanning (approximately 70-75 percent) and what preparations
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need to be made to ensure that the remaining items are properly bar coded. They are interested in exploring outsourcing options for preparing unit-dose packages of medications, which are available only in bulk. While pharmacy has demonstrated that they can apply bar codes to IVs, more work is required for success with bar-code label management of patient-specific admixtures. Pharmacy has plenty of work ahead in building and maintaining drug databases that will accurately map NCD numbers with the hospital’s drug formulary. This work must be done in advance of the KBMA implementation. Pharmacy is also facing contract renewal with Pyxis MedStations, the sun setting of some Pyxis products, and possibly reevaluating the volume, configurations, and locations of ADMs for the future. Pharmacy demonstrates a willingness to reevaluate and revamp COH’s drug-distribution processes to enable success with BPOC. Outpatient Pharmacy: The outpatient pharmacy is not utilizing bar-code verification scanning, but their information system would be capable of such functionality with software upgrades. Investigational Drugs: IDS does not appear to share the enthusiasm for the BPOC vision and their part in making it successful. Blood Bank: The blood bank properly labels all blood products with ISBT bar codes and later this year will be migrating to bar-code labeling stem-cell products, once standards have been confirmed. Positive donor and recipient verification does not currently involve bar-code scanning. Everyone we talked with in this department wants universal BPOC protection from vein to vein for all blood and stem-cell products. Point-of-Care Data-Collection Devices: COH has not determined which BPOC user data-collection device(s) will best serve the goals of the initiative, with the exception of Life Scan glucose-monitoring devices currently utilized. Eclipsys Readiness and Progress: We are not certain of Eclipsys schedule for developing KBMA’s full functionality concurrently and synchronistically with Sunrise Pharmacy. (For an expanded discussion of our findings and thoughts related to Eclipsys and KBMA, see addendum C on page 54.)
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VISION City of Hope has a high-level unified vision for implementing BPOC solutions across the spectrum of care. Top-level leaders, directors, department heads and staff want to do bar coding and do it well at every point of care where it makes sense. Now the time has come for this vision to be clarified—to delve into the details. To this end, TNC offers the following recommendations and rationale for consideration. Once this vision is clarified it must be communicated to the COH community in general and to those who will be executing it in particular. And finally, it must be carried out in an appropriate sequence and at a realistic pace. All this will require the formation of a BPOC executive-oversight team (BOT), which will be discussed in more detail below. GUIDING PRINCIPLES FOR RECOMMENDATIONS We realize that there is more to be done than can be accomplished all at once. So we used the following principles to guide us in forming and prioritizing our recommendations:
• SAFETY
At what points are patients, caregivers, and COH at greatest risk of harmful error, which could be significantly reduced by implementing BPOC systems? Which technologies are ready for implementation? What steps are required before these implementations can be carried out?
• EFFICIENCY
What points of stress are making things more difficult for caregivers than they need to be and pose a threat to patient safety? Which stress points should be addressed to ensure the most success for this initiative?
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RECOMMENDATIONS Demonstrating a commitment to patient safety, bundled with their employee ID badges, COH personnel carry yellow cards outlining The Joint Commission’s (TJC) 2008 National Patient Safety Goals—the number one of which is to “improve the accuracy of patient identification.” TJC Safety Goals “highlight problematic areas in health care.” The fact that this is the fifth year this particular goal has held the number-one position is disturbing and suggests healthcare in America has made little progress in this problematic area—COH included. This being the case, we expect TJC to become more aggressive in holding hospitals’ feet to the fire in improving the accuracy of patient identification. Nothing could contribute more to achieving TJC’s first goal at COH than implementing BPOC technologies and utilizing them the right way with
• Administered to patients (e.g., medications, IVs, chemo, TPNs, blood, bone marrow, meals, etc.)
• Any procedure performed with patients (radiation, diagnostic imaging, surgery, implants, physical therapy, etc.)
To these ends TNC offers recommendations with rationale:
• Preliminary: Already recommended and almost completed
• Priority One: To be done without delay
• Priority Two: To be done soon in preparation for implementing Eclipsys Knowledge Based Medication Management (KBMA)
• Priority Three: To be done after KBMA is live and validated
• Priority Four: To be considered down line
In Context with CIS Initiative It is understood that any recommendations in this report that are accepted should be carried out in complete accord with and not independently of the City of Hope’s overall CIS initiative.
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PRELIMINARY RECOMMENDATIONS: In process
A. COMPLETE PLANS TO INCLUDE BAR CODES ON ALL SPECIMEN LABELS AND BEGIN SCANNING ALL SPECIMENS AS THEY ENTER THE LAB
Before we concluded our information gathering and report-writing processes for this engagement, TNC concurred that COH was on the right track of including bar codes on all lab-specimen labels and implementing bar-code scanning of all specimens as they are checked into the lab. Rationale Up to this point, lab clerks have been manually entering seven-digit ID numbers from preprinted labels, which are applied to specimens at the point of collection. The seven digits are comprised of six-digit medical-record numbers (MRN) plus one check digit. For a number of years, this check-digit system has proven itself a reliable safety net for ensuring accurate manual data entry for checking specimens into the lab. However, the system-wide Eclipsys implementation calls for the MRN to jump from six to eight digits. This numbering scheme not only removes the check-digit safety net, it also increases chances of error by increasing the number of digits that must be manually entered by lab check-in clerks. TNC affirmed the consensus we met at every turn by recommending that bar-code data entry be put in place and that it go live for lab clerks at the same time the check digits were dropped. Progress Currently all preprinted specimen labels include MRNs in bar-code format. ITS is in the process of selecting and installing bar-code readers in the specimen-receiving area. Conclusion Because scanners do not misread barcodes this practice is actually safer than the old manual-entry practice, even with its check digits. Note: On November 9, 2007, TNC provided recommendations, which are included in addendum D on page 54 of this report.
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B. COMPLETE HOSPITAL INFORMATION MANAGEMENT’S PLANS FOR APPLYING BAR CODES TO FORMS
Frankly, we lack expertise in this area and will not offer advice beyond our understanding or convictions. However, it appears to us that assigning patient-specific bar codes to patients’ forms would be wise. Next Steps To serve the overall BPOC initiative, we believe that the data strings in the barcodes utilized on forms should include lead digits to identify that they are forms so they cannot be confused with barcodes on patient wristbands. To accomplish this, team process coordinators from HIM, ITS, admitting, and others deemed necessary should work in concert with PDT for arriving at and recommending a system to BOT for assigning bar codes to forms with the above considerations in mind.
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PRIORITY ONE RECOMMENDATIONS: Do without delay This section outlines high-priority steps for instituting bar-code point-of-care (BPOC) systems, which TNC recommends COH take as soon as possible—concurrently and in concert with other CIS initiatives. Group A focuses on building BPOC-support infrastructure now in order to avoid delays in implementing BPOC applications as they are ready. Group B focuses on implementing certain BPOC technologies as soon as possible, which will immediately result in increased patient safety and satisfaction. Decisions made in the one group will impact the other. For example, decisions related to bar codes for wristbands will be informed by what bar codes the BPOC applications under consideration are capable or incapable of reading. Therefore actions resulting from group A and group B recommendations are best carried out with each other in mind.
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Group A: Build a BPOC-Support Infrastructure Our experience demonstrates that building the support infrastructure outlined below will ensure a successful hospital-wide BPOC initiative at City of Hope.
1. APPOINT MOTIVATED AND MOTIVATING LEADERSHIP TO SHEPHARD THE BPOC INITIATIVE
2. REFINE BAR-CODED PATIENT WRISTBANDS
3. RETROFIT CAREGIVER ID BADGES WITH USABLE BAR CODES
4. SELECT POC DATA-COLLECTION DEVICES ACCORDING TO USER
NEEDS AND PREFERENCES
5. DEVELOP PROCESS-DESIGN AND USER-TRANING PROGRAMS
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1. APPOINT MOTIVATED AND MOTIVATING LEADERSHIP TO
SHEPHERD THE BPOC INITIATIVE
A successful initiative will require shared vision and enthusiasm that starts at the top and works its way through the entire organization. Our experience demonstrates that successful BPOC initiatives are owned and articulated by the highest levels of leadership. Executive Oversight Team We recommend that a barcode oversight team (BOT) be appointed to ensure that the entire organization is pulling together to fulfill the mission of:
Applying bar-code technology and practices to all pertinent points of care appropriately—all for the purpose of preventing caregivers from committing errors and protecting patients from harm.
It is essential that this mission govern every selection, implementation, and utilization decision made under BOTs leadership. Champion/Chairperson BOT will require a chairperson who is clearly motivated and highly motivating around the values of the initiative—COH’s BPOC champion. Members We recommend that the BOT be comprised of senior executives from each of the service lines in the organization (e.g., nursing, pharmacy, lab, blood bank, respiratory therapy, medical staff, HIM, others whose areas are impacted by the initiative). BOT must also include the process design team manager (see below) General Charter BOTs will serve as
• Shapers and keepers of the vision and priorities • Shepherds of the initiative • Communicators of the vision throughout the organization
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Specific Responsibilities
• Appointing a process design team (PDT) coordinator (see below)
• Requiring regular reporting from PDT coordinator and team at designated milestones throughout the design, implementation, and optimization processes
• Making shared decisions required for fulfilling the BPOC mission
• Managing change: Building excitement about the initiative; anticipating and dealing with obstacles and points of resistance; structuring a realistic adoption pace; and, ensuring that there are adequate resources for systems and process development, training, etc.
Process Design Team Manager (PDT Manager)
• Appointed by and member of BOT • Responsible for orchestrating interdisciplinary teams from
the various care and service areas impacted by the initiative so that the result is harmonious
• Reports to BOT at designated milestones throughout the design, implementation, and optimization processes
• Brings matters to the BOT for resolution and decision Process Design Team (PDT)
• Organized and led by the PDT manager • Comprised of process coordinators (PCs) from all care and
service areas impacted by the initiative (e.g., nursing, pharmacy, lab, blood, RT, ITS, etc.).
• Responsible for coordinating fellow clinicians and staff for accomplishing BPOC initiatives in their departments
Process Design Team (PDT)
The success of the BOT and PDTs, in large measure, will depend assessing and communicating the benefits of BPOC in each area of application. Success will also depend on how thoroughly resistance and obstacles are anticipated and addressed and plans are developed for overcoming them. This is essential not only in planning but also during the implementation and optimization phases throughout the course of the initiative. Success will require skilled change management.
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Utilize Experienced Assistance It is recommended that the BOT, PDT manager and process coordinators have access to advisors who are experienced in assisting hospitals through successful BPOC initiatives. It is important that these advisors have expertise in change management, BPOC-system implementation, and end-user training. Such qualified process support will help stakeholders anticipate, avoid and work through the many inevitable obstacles and points of resistance, which are not easily foreseen. It is important the COH does not expect vendors to provide this level of assistance in these critical areas.
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2. REFINE BAR-CODED PATIENT WRISTBANDS
The bar-coded wristbands currently issued to patients should be considered a short-tem solution. There is more work to do in evaluating patient, nursing, and technology requirements and researching suitable options before selecting final wristbands for long-term application. To this end, we recommend that a team of process coordinators be assembled from nursing (from general and specialty areas), ITS, admitting, patients, finance, HIM, and others seen as essential, for arriving at appropriate solutions for bar-coded patient wristbands. Careful consideration should be given to: Material and Print Bands selected must meet the needs of both patients and caregivers. From the patients’ perspective, bands need to be endurable—not irritable. Given their small wrists, infants will have special needs, which may require a different type band than adults. From the nurses’ perspective, all bar codes on the bands must be readable and durable. Thus, adequate testing should confirm the same before committing to a vendor or product. (see “Durability and Longevity” below). Symbology Selection The bar code(s) on wristbands must be readable by the various POC devices that will be used to scan them. Thus, glucose-monitoring, specimen-collection, blood-transfusion, respiratory-care, and medication-administration computing/scanning devices must be considered and tests conducted to confirm that each could read the same patient-ID bar code(s). We highly recommend, whenever possible, that COH elects to utilize imagers for point-of-care devices. In addition to being capable of reading linear codes, imagers can read newer multidimensional symbologies (e.g., DataMatrix, Aztek, etc.). These will become increasingly common in the days ahead. Among other advantages, multidimensional codes have higher first-read/fast-read rates and tend to keep their read integrity when damaged. However, for the foreseeable future, some point-of-care devices employed will be capable of reading only linear codes. This is true
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of current glucometers, for example. Thus, while linear codes must be retained, multidimensional codes may be added to patient wristbands. While the later symbologies may contain more information than the first, both will contain patient ID codes in their data strings and scanning either will satisfy one of the two positive patient ID requirements. Durability and Longevity Thorough testing should be conducted to demonstrate the durability of printed bar codes and the longevity of their readability. Such testing should involve IS staff, nurses, and patients. The greater the stress to which the bar codes can be exposed and the more real-life situations in which the bands can be tested, the more valuable the exercise. Data Strings in Codes Encounter numbers should be embedded in the barcode(s) on patient wristbands. Additionally, we highly recommend that these barcodes contain lead digits, which would differentiate them as residing on wristbands. This makes it more difficult for caregivers to complete point-of-care transactions via workarounds involving the scanning of surrogate bar codes away from the patient. However, there is always the option of caregivers photocopying the bar codes on the wristbands for this very purpose. RFID The value of COH utilizing RFID-imbedded patient wristbands is something that should be explored more fully. The benefits are interesting and may or may not be compelling enough to move ahead this time. Unlike barcodes, RFID chips cannot be photocopied, mitigating the possibility of caregivers making surrogate wristbands for scanning away from the patient. Additionally, it can be argued that scanning RFID wristbands is easier for caregivers and less intrusive for patients. RFID bracelets cost more than conventional wristbands (roughly $1 vs. 25 cents each) but the benefits may outweigh the cost. If and when COH elects to use employee RFID tags for caregiver sign-on (see recommendation 3), the same technology could also read patient-RFID tags. There is certainly no need to waste money on RFID-embedded wristbands until this function is ready to go live.
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If and when COH elects to utilize RFID, the wristbands would still need to be redundantly imprinted with bar codes. This is for backup in the event of damaged chips but more importantly, it is also for devices whose scanners cannot read chips, only barcodes (e.g. glucometers). Bifunctional modality offers the freedom to create policy that would require caregivers to read RFID primarily and bar codes secondarily—only when RFID is not available or chips have been damaged. In either instance, the wristbands will always have human-readable print identifying the patient. Process and Policy Design The wristband process coordinators should also develop and recommend comprehensive policy and procedures that include, but are not limited to, processes for issuing bar-coded wristbands upon admission and transfer, replacing wristbands wherever and whenever necessary (on all shifts) due to damaged barcodes, patient discomfort, etc. Process should also be outlined for providing replacement wristbands based on length of stay. Implied Commitment That Should Be Kept Putting bar codes on wristbands intensifies the implied commitment to scan them. The longer the delay in using bar codes, the more likely people will assume that COH is dragging its feet with BPOC. Lack of execution will be discouraging to caregivers and send a confusing message to patients. Summary Scanning auto-IDs on wristbands should be required wherever BPOC systems have been implemented and will serve as one of the two identifiers to satisfy JTC standards and COH safety policies.
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3. RETROFIT CAREGIVER ID BADGES WITH USABLE BAR CODES
The Employee ID badges currently issued to caregivers must be retrofitted before BPOC solutions can be implemented. To this end, a process coordinator’s group should be assembled with representatives from security, ITS, and nursing for arriving at a satisfactory solution for bar-coded caregiver ID badges. This project group should consider: Bar Codes Caregiver badges must be imprinted with bar codes containing stings of data that represent caregivers’ ID numbers. Currently, the backs of COH caregiver ID badges are imprinted with barcodes for purposes unrelated to patient care and are rarely used. These black barcodes are printed on a dark gray background. We are told this low-contrast format was selected for security reasons—making it impossible to duplicate the bar codes on photocopy machines. However, when it comes time to read bar codes on caregiver ID badges at the point of care, low contrast barcodes could be problematic for most scanners. This will require testing ahead of time, which we anticipate will demonstrate the need for the badges bar codes to be printed in a high-format (i.e. black on white). We expect that this would require discussions and decisions involving security before moving ahead. In selecting bar codes for caregiver ID badges, it will be important to verify that all point-of-care scanners are capable of reading the selected symbology. Caregiver ID badge barcodes should be limited to one symbology that all BPOC systems can read—a simple linear bar code. Bar-Code Placement Consideration should be given to the placement of barcodes on badges (e.g. front vs. back, horizontal vs. vertical orientation).
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Nonemployees A database and process for assigning bar-code and RFID numbers to caregivers must be designed to accommodate nonemployee caregivers (e.g. temps, students vs. instructors, etc.). RFID Chips Currently, employee ID badges are embedded with RFID chips that contain, among other things, caregiver ID numbers. These are presently used for opening doors and a few other identifying functions not related to points of care. We assumed that some COH’s point-of-care applications sooner or later will be capable of reading RFID chips. If and when BPOC devices include RFID readers for scanning caregivers, their ID badges must continue to bear barcodes as redundant identifiers. Once chip readers are operational, we expect caregivers will generally prefer RFID reads over bar-code scans for sign-on. However, in some applications a barcode scan may be required, as particular BPOC applications will not be capable of reading RFID. Single Sign-On
The above steps should be synchronized with COH’s single sign-on plans for other applications including accessing computers, and applications (e.g. CPOE, BPOC systems, automated-drug and supply cabinets, etc.). In Summary
Every barcode or chip, when scanned, should appropriately grant or deny access to BPOC applications.
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4. SELECT POC DATA-COLLECTION DEVICES ACCORDING TO USER NEEDS AND PREFERENCES
Careful consideration must be given to selecting POC devices that will meet the needs of multiple applications (e.g. specimen collection, blood transfusion, medication administration, etc.) and caregivers (e.g. nursing, phlebotomy, lab, RT, etc.). Next Steps We recommend that the PDT assemble a group tasked with determining the best type of device(s) for COH’s point-of-care data-collection devices. While we recommend the selection process should be owned primarily by end users this group should include process coordinators from ITS, phlebotomy, lab, environmental services, and infection control in addition to RTs and staff-level nurses. A primary task of this team is to work through the five rights of device selection, understanding that device form-factor decisions will have a great deal to do with the success or failure of the BPOC initiative.
Right Devices Depending on the applications and the users, devices preferred might be handhelds, tablets, or full screens. In any instance, devices need to have user-friendly graphical-user interfaces that are intuitive and easy to read. Some applications will function on only one form factor. Where possible, it is advisable for various applications to function on a single platform so nurses do not have to tote multiple devices to the point of care. At the same time it is advisable for an application to be capable of functioning on multiple form factors for adapting to the need of the moment. For example, nurses may prefer laptops for most medication administrations but handhelds when administering meds in an isolation room.
Right Location
Should the devices be resident in the rooms, toted from room to room via carts, or carried by hand? If they are in the rooms, should the devices sit on carts or be mounted on walls? What is preferred in a typical patient ward may differ from what works best for ICU, OR, or a clinic.
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Right Access
If devices do not reside in rooms, they should be readily available and easily portable. BPOC adoption will be a challenge and work-arounds will be tempting if caregivers have to share or look for devices. It is important to have an adequate number of devices available at all times.
Right Workflow
One device will not do all. Some devices are exclusive to an application (e.g. glucometers). Some software can function on multiple devices. In such cases one device may be generally preferred for specimen collection and another for medication administration. If laptops are generally preferred for medication administrations, handhelds might be preferred for specific use in isolation rooms. Some professions, like respiratory care, may only require a limited set of software and therefore will not need a full-functionality device, as will nurses.
Right Task-Support Tools To ensure positive bar-code drug ID all the way to the point of administration, work currently done in the med room will be moving to the bedside. Therefore totes or carts for transporting pill crushers, tubes, alcohol swabs, printers, etc., will be required for use at the bedside.
The device selection team would be responsible to outline and conduct an evaluation process with applicable data-collection devices.
Device Requirement Review Conduct a requirement review for each of the key anticipated POC applications (specimen, blood, KBMA, etc). Consider workflow where it intersects and where it stands alone. For example, medication administration could intersect with a blood transfusion, while a blood draw and a transfusion would not likely occur together.
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Consider special needs for the task. For example, labels and the items required for blood draws call for providing phlebotomy trays that could house printers if they are not built into the devices.
Testing and Validating
Because scanning devices are not created equal it is crucial to test the various applications and devices for successful scanning of bar-coded drug products and wristbands selected (see recommendation 2 above) and for user acceptance before committing to full house-wide contracts.
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5. DEVELOP PROCESS DESIGN AND USER-TRAINING PROGRAMS
The success of bar coding will hinge on how well COH does with formulating policies and procedures, developing and executing training modules, and promoting compliance. This will be simpler with the beginning BPOC applications and will become increasingly complex up through KBMA. Next Steps The PDT must form and commission a team comprised of project coordinators from nursing, respiratory care, pharmacy, ITS and other areas impacted to outline best practices for each application and to develop a training program for each. Rationale There are no shortcuts. Doing this work ahead of time and in conjunction with the configuration KBMA and the systems needed to support it will prepare COH for prompt and successful rollouts of bar-code scanning technologies throughout the hospital. Failing to do this work well would result in disaster.
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Group B: Implement These BPOC Applications as Soon as Possible We recommend COH implement the following BPOC applications as soon possible and simultaneously with developing the infrastructure outlined above, regardless of where things are with Eclipsys implementations. We believe that these applications should be rolled out in the order presented, with the understanding that there could be some overlap in implementation.
6. IMPLEMENT BAR-CODE SCANNING FOR GLUCOSE MONITORING
7. ISSUE BAR-CODED HOPE CARDS TO ALL PATIENTS
8. IMPLEMENT BAR CODING FOR SPECIMEN COLLECTION
9. IMPLEMENT BAR-CODE SCANNING FOR BLOOD TRANSFUSIONS
10.IMPLEMENT BAR-CODE SCANNING IN OUTPATIENT PHARMACY
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6. IMPLEMENT BAR-CODE SCANNING FOR GLUCOSE MONITORING
We advise that COH pick the low-hanging fruit. Now that patient wristbands are imprinted with bar codes and glucometers are equipped with bar-code scanners, caregivers should be trained and required to utilize point-of-test bar-code scanning whenever monitoring glucose. Next Step Appoint a project team to outline a sound process for glucose-monitor scanning and to formulate and execute a program for training caregivers to succeed. Rationale In addition to the obvious safety benefits, this practice will add momentum to the entire BPOC initiative. Caregivers will get used to scanning and this will transfer over to other applications as they are rolled out. Patients will also notice and appreciate the scanning process. This will show BPOC progress to all stakeholders.
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7. ISSUE BAR-CODED HOPE CARDS TO ALL PATIENTS
It is our understanding that receptionists may enter either names or MRNs into computers to find patients in the system. We see no reason why these workstations could be not retrofitted with barcode scanners allowing users to find patients in the system by scanning bar codes on Hope Cards as their data strings contain MRNs. This being the case, we recommend that all patients, when initially admitted to City of Hope (whether as inpatients or outpatients), be issued Hope Cards. These plastic cards would bear the COH name and logo, along with individual patient names and medical record numbers (MRN) (in human-readable format) plus barcodes containing their MRNs. Upon subsequent visits, patients would present their Hope Cards to receptionists would scan the cards to pull up their names and place them in queue (e.g. for readmissions, clinic visits, outpatient pharmacy pick up, etc.). Recurring visit rate is estimated to be above 80 percent. Welcome Kiosks and Greeters Eventually, these cards could be utilized at welcome kiosks (like self check-in kiosks at airports), which COH has entertained. Or for a personal touch, greeters could approach people upon arrival and scan their cards with handhelds. Rationale Using welcome cards will keep patients from getting lost in the waiting room shuffle, while relieving reception-staff stress and maintaining things on schedule. Hope Cards will give patients a more definitive point of entry and should give them a greater sense of belonging, not to mention that they will introduce patients to bar codes in the medical-center context from the get-go. In addition to increasing patient satisfaction, we believe Hope Cards will send a highly visible signal to the entire COH community (patients and caregivers) that the hospital is serious about moving to bar coding at all points of care.
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Implied Commitment However, understand that the very presence of bar codes on Hope Cards will imply a commitment to use them. Therefore, COH cannot afford to drag its feet with scanning without losing some credibility related to its BPOC intentions.
Warning It should be understood that Hope Card scans would not satisfy patient-identification requirements of The Joint Commission and COH’s safety policies. Before any treatments or procedures are performed, positive ID must take place between patients and caregivers with at least two acceptable identifiers. Hope Cards must never be utilized for positive patient ID, nor should Hope Card scans activate any point-of-care system. Requirements Bar codes on Hope Cards must meet all criteria established by predetermined policy. In addition to account numbers, the data strings in the bar codes should have a leading digit to indicate that they are Hope Cards and to differentiate them from wristbands so that the two could never be confused. RFID There is no reason Hope Cards could not also be embedded with RFID chips in the future. However, there is no need to go beyond barcodes at this time in order to realize the value outlined above. In the years to come, Hope Cards will become smart cards, containing additional patient data. It will be a long time before they are capable of being passively read throughout the facility for perpetual location tracking. Next Step We recommend that PDT assemble a team of process coordinators from admitting, ITS, and others deemed essential to execute the above recommendations.
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8. IMPLEMENT BAR CODING FOR SPECIMEN COLLECTION
We recommend that COH continue using Sunquest (formerly Misys) for tracking specimens within the laboratory. However, we recommend that all specimen labels be generated and applied at the point of collection with bar codes that are generated by scanning patient wristbands. To this end, we recommend that highest priority be given to selecting, validating and implementing a BPOC specimen-collection system as soon as possible. Rationale COH’s specimen-collection process exposes serious vulnerability. The current system of printing labels and sending them with charts to the floor for placement in patient-specific cubicles is dangerous. Labels are too easily placed in the wrong patient’s cubicle or remain in cubicles after patients have been discharged—endangering the next patient. Next Steps We recommend that PDT immediately assemble a team for undertaking a thoughtful process of selecting, validating, and purchasing the right BPOC specimen collection system as soon as possible. This team would consist of process coordinators from lab, ITS, phlebotomy, nursing, respiratory care, and others deemed necessary. In addition to obtaining the right products, we recommend that this team outline sound processes for collecting and labeling specimens in the hospital (e.g. clinics, patient wards, OR, etc.) as well as for receiving and labeling specimens from sources outside the hospital (e.g., histocompatibility, etc). We also recommend that this team ensure that all users of these systems are appropriately trained. These processes will vary by environment. It is one thing to collect specimens in patient rooms and clinics. It is another to collect them in the OR. Isolation areas have their own peculiarities to consider. Attention should be given to discerning how to use the tools in different settings, outlining the procedures and policies for each, then training caregivers and holding everyone to accountability.
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Options Eclipsys KBMA does not have, nor are they developing a specimen collection application. COH has at least two viable options. One is Sunquest Collection Manager (CM). The other is Care Fusion’s Specimen Collection Verification (SCV). Extending Sunquest Lab application to the point of collection would offer the advantage of an integrated software structure. However, it is not essential that that the two be integrated. A standalone POC system such as Care Fusion could work just as well and have additional benefits. While the particulars are still being worked out, Eclipsys and Care Fusion have agreements that make it advantageous for Eclipsys customers to utilize Care Fusion SCV. Customers could expect interface cooperation between the parties. Additionally, our exposure to Care Fusion products, their track record for solid implementations, and user satisfaction lead us to recommend Care Fusion SCV for COH’s specimen-collection system. Employing Care Fusion SCV would offer additional integration advantages if COH plans call for implementing other Care Fusion point-of-care products (e.g. blood-transfusion verification, vital signs, etc.).
Recommending specific products goes beyond the scope of this engagement. However, the homework we did for this engagement gave us sufficient exposure to COH needs and Care Fusion’s SCV that we are ready to make this above product recommendation.
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9. IMPLEMENT BAR CODING FOR BLOOD TRANSFUSIONS
The COH blood center conscientiously applies bar codes on all blood in compliance with regulatory and best-practice standards. Soon they will be doing the same with stem cell products. While we believe that great care is taken to get the right products to the right patients, bar-code verification should be added to all points of blood transfusion to help ensure that no patient gets the wrong product. We believe this system should also be capable of bone marrow transplant (BMT) verification and documentation. Next Steps We recommend that PDT immediately assemble a team for outlining and executing a process of selecting, validating, purchasing, and implementing a bar-code point-of-transfusion verification system. Additionally this team would be responsible to see that caregivers are properly trained and required to utilize it for all transfusions and BMTs as soon as possible. We recommend that this team consist of process coordinators from pathology (including the blood center), nursing, medical staff, and others deemed necessary. Considerations Eclipsys KBMA does not have, nor are they developing a blood transfusion application. While recommending specific products goes beyond the scope of this engagement, we recommend that COH consider Care Fusions Transfusion Verification (TV) application. This recommendation is based on our exposure to Care Fusion products, their implementation track record, user satisfaction, and Care Fusion’s business relationship with Eclipsys. Selecting Care Fusion’s TV would offer additional integration advantages if COH were to implement Care Fusion’s products at other points of care (e.g. specimen collection, vital signs, etc.).
NOTE: We predict that implementing the above BPOC technologies would create momentum contributing to a more rapid implementation of Eclipsys’ Knowledge-Based Medication Administration (KBMA) application once Sunrise Pharmacy goes live and has been validated.
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10.IMPLEMENT BAR-CODE SCANNING IN OUTPATIENT PHARMACY
The current version of the outpatient pharmacy’s PDX workflow software does not have bar-code verification. PDX offers a software upgrade that allows pharmacists to scan NDC bar codes on drug products to ensure accurate dispensing. Unfortunately, the upgrade eliminates the option of being able to view the original prescription on screen as electronic documents. We understand and appreciate the value the outpatient pharmacy places on being able to view original prescriptions on screen. However, our understanding is that bar-code verification scanning of prescriptions would give the pharmacy a more effective tool for eliminating errors then the imaging functionally does. Therefore we recommend that the upgrade be accepted and that products bar codes begin as soon as possible. If seeing the original order is still desired, third-party options could be considered to support original prescription viewing including, but not limited to, Pyxis Connect (currently utilized for inpatient pharmacy services).
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PRIORITIY-TWO RECOMMENDATIONS: Do soon—in preparation for KBMA
It is assumed that COH is committed to Eclipsys’ Knowledge-Based Medication Administration (KBMA) product, which cannot be implemented before Sunrise Pharmacy has gone live and been validated. In the meantime, we recommend that the following steps be taken soon to prepare for a successful KBMA implementation and to prevent its delay.
11.REVIEW AND REFINE INPATIENT DRUG-DISTRIBUTION PROCESS
Before implementing KBMA, we feel it is essential that COH revisit and refine the hospital’s drug-distribution process, giving attention both to the technologies used and how the technologies are used. Distribution and point-of-care systems must play well together. Next Steps Appoint a team of process coordinators comprised of process coordinators from pharmacy, nursing, RT, ITS, and others deemed necessary to conduct a thorough evaluation of benefits, problems, and potential with automated-dispensing machines (ADMs) utilized throughout the facility.
It will be important to consider the types, configurations, number, and placement of devices on patient-care units, as well as how they are used by pharmacy, nursing, and respiratory care—how ADMS help and how they hinder those who rely on them (including patients as well as caregivers). Furthermore, we advise these issues be tackled before Pyxis contracts come due and as MedStations approach sunset or require upgrades. It is important to be proactive rather than reactive on these issues. Even before acquiring new ADMs, we recommend that COH weigh the options with Cardinal for implementing MedStation bar-code verification functionality to help insure accurate loading of cabinets. No matter what, we believe it is critical that bar-code scanning functionality for loading drawers be obtained and utilized in the next generation of ADM technology at COH.
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Rationale We advise COH to address number of issues related to current drug distribution/dispensing technology and user practices. These include the distance that caregivers must travel to get medications, the redundancy of nurse and respiratory care cabinets, doors having been removed from Pyxis towers and locks from refrigerators in response to user logjams, as well as a lack of barcode scanning functionality in the loading of machines. The safety, efficiency, and staff-motivational issues created by these problems will not go away and are likely to intensify while moving to BPOC and will work against a successful implementation. Improving distribution efficiency will make the medication-retrieval process easier for nurses, which will help pave the way to a less stressful and more successful BPOC implementation. As for safety, the fact that BPOC technology can prevent errors at the administration step of the medication-use process is no excuse for failing to do everything possible to prevent errors at each step of the distribution process. ADM Interfaces to BPOC Nursing efficiency may be improved if KBMA were interfaced with ADMs for directing caregivers to the locations of medications required to fulfill patients’ orders. Generally, this underwhelms nurses we have talked with. They believe they know where the meds are and it would add little value. At the same time, they do admit it could be useful to temps and newcomers. However, we imagine that once they used drug-locator functionality, even the veterans would appreciate the assistance when it is needed. While we could argue that it is preferable, we don’t believe KBMA interfacing with dispensing technology is critical. Nevertheless, we recommend that the COH talk with Eclipsys and Cardinal about the potential for this functionality between their systems.
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12.IMPLEMENT A PROCESS FOR ENSURING THAT ALL DRUG PRODUCTS HAVE BAR CODES WHEN DISPENSED
COH’s pharmacy understands the necessity and has made good progress toward ensuring that all mediation packages have appropriate bar codes. Nevertheless, a thorough assessment is advised to identify any remaining gaps. Next Steps Pharmacy will need to refine some systems, policies, and procedures for ensuring that all products have readable and correct bar codes for successful scanning at all points of care.
Drug-Specific Labeling
• Bar-coded manufacturer unit-dose medications should be utilized whenever possible and must be tested for readability after they arrive in the pharmacy and before they are put into stock. It should be noted that because many drugs in the hospital formulary arrive from various manufacturer sources with differing NDC numbers, a system must be established for mapping each to the correct item in the hospitals formulary (see “Mapping” below).
• Medications that are not available in bar-coded
manufacturer unit-dose packaging will need to be repackaged/relabeled with bar codes either in-house by the pharmacy or outside by qualified packaging services.
• A thorough assessment of in-house packaging requirements
should be made. This assessment may reveal that additional technology should be purchased. If so, this team would do diligence in determining what technologies are best suited for COH needs.
• In any instance, policies and procedures for in-house
packaging operations need to be in place to ensure that pharmacy-produced medications are accurately labeled with human-readable print and that appropriate bar codes are applied in an efficient manner.
• As with manufacturer-packaged meds, all drug-specific
packages prepared in-house must be tested for readability and accuracy before they are put in stock or sent to points of care.
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Patient-Specific Labeling
• All patient-specific medications must also be labeled with appropriate bar codes before they leave the pharmacy. To achieve this, a database must be established along with safe practices and procedures for issuing serialized bar-code labels and tracking them to the correct patients and orders.
• Systems will need to be in place for managing all prepared
• All bar codes on specially prepared patient-specific products
must also be tested for readability and accuracy before they are put into patient bins or sent to any point of care.
• Standardizing doses can help reduce the number of specially
prepared medications required. Mapping Regardless of how many drugs have been bar-code labeled, all must be mapped to the hospital formulary. This is no small task.
• For this reason we recommend that COH pharmacy immediately designate a keeper of the bar codes (keeper) along with an informed and authorized assistant (both RPhs) supported by a data-entry technician.
• The keeper and his team are responsible for building and
maintaining a database of NDC numbers and aliases, which they will assign to all in-house medication-specific packages and which must accurately map to the hospital’s drug formulary. They will also be responsible for mapping manufacturer-packaged drugs with multiple NDCs to correct line items in the formulary.
• At least one of the bar-code keepers should be available to
address barcode problems at all times.
• Presently, our understanding is that Eclipsys’ SCM requires manual entry of all NDC numbers. This will continue until the Eclipys solution allows automatic NDC updating from third-party database solutions (e.g., Multum, pharmacy wholesaler interfaces, etc.). COH will need to plan for the labor required to enter these numbers and keep this database.
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13.IMPLEMENT BAR-CODE LABELING OF IVs
Processes must be established to ensure that all IVs (including TPNs and piggybacks) are properly bar coded. Some will come from the manufacturer with bar codes containing NDC numbers. These are ready for scanning at the point of care. Others require special preparation in the pharmacy where patient/order-specific labels with serial barcodes must be generated and applied. We recommend that COH utilize workflow software for IV preparation that issues bar-code labels for application at the point of preparation. IVs should be labeled one at a time in the clean room where they are prepared. We recommend that COH workflow software be linked to IV status reader boards, which pharmacy personnel can access inside and outside the clean room (even remotely by computer).
14.IMPLEMENT BAR-CODE LABELING OF INVESTIGATIONAL
DRUGS A successful KBMA implementation will require the ability to scan investigational drugs. Currently, investigational drugs are not bar coded. However, IDS will soon be implementing WebIDS a software program that will generate bar codes. KBMA and WebIDS must be interfaced to (1) ensure correct bar coding, (2) protect all study blinding, and (3) improve the accuracy of documentation in these studies. Next Steps Within the pharmacy, we recommend that ITS and IDS pharmacists develop and implement plans for bar-code labeling all investigational drugs that map drug packages to the patients for whom they have been prepared without compromising study blinds.
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15.FACILITATE POSITIVE-DRUG ID ALL THE WAY TO THE PATIENT Even when all drug packages are properly bar coded, it is important that the bar code packaging remains in tact all the way to the patient. Therefore we recommend that PDT assemble a team comprised of process coordinators from pharmacy, nursing, RT, and others deemed necessary, to develop and implement a system-wide process for ensuring bar-code identification of all drugs all the way to the patient. We recommend the process include:
• Pharmacy sending bar-code labeled medication-specific exact unit-dose packages to patient-care areas (either manufacturer and/or pharmacy prepared) whenever possible
patient-specific unit-dose packages (including IVs) to patient-care areas
• Nursing ensuring that when dispensed units of use are
different from unit doses prescribed that caregivers be required always to scan bar codes on the unit-of-use packages and prepare the exact unit doses at the actual point of care
• Pharmacy may want to explore options for preparing and
applying transfer labels on such units of use, which would allow for barcodes from unit-of-use vials to be lifted and transferred to syringes at the point of drawing the medications and for scanning at the point of care.
Rationale The value of BPOC depends on actually scanning the medication bar codes at the point of care. This means that all medication packaging must make it all the way to the point of care.
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16.TEST RF NETWORK FOR RELIABILITY
BPOC systems require broad and strong radio-frequency network (RFN). It appears to us that COH is well wired in this regard. At the same time we recommend ITS conduct comprehensive testing to ensure that the network has the bandwidth to handle the heavy traffic that med pass times will require, with particular attention being given to areas that already put high demand on the RFN. It is also important to locate and remedy dead spots.
17.DEFINE VISION FOR INTEGRATING KBMA WITH SMART-INFUSION PUMPS
We recommend that DPT form a group comprised of process coordinators from pharmacy, nursing, ITS, safety, risk management, and others deemed necessary, to discern COH’s vision related to the integration of KBMA and Alaris smart-infusion pumps. If this integration is desired, it should be determined if Eclipsys and Cardinal are capable of and willing to interface KBMA and Alaris pumps. If not, alternatives will need to be investigated. Rationale COH is realizing many safety benefits from using smart-infusion pumps. While smart pumps employ drug libraries with parameters that help caregivers infuse IVs within safe rate and duration limits for specific drugs and patient populations, they do nothing to ensure that IVs are being given to the right patients. BPOC systems can solve this problem by scanning patient wristbands and bar codes on IV products to ensure matches prior to infusions. Additionally, smart pumps are increasingly capable of being programmed via point-of-care computing devices. In such cases, the point-of-care devices nurses use for BPOC medication-administration applications wirelessly transmit proper settings for infusion therapies to pumps—arguably a safer approach than manual programming.
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18. SYNCHROBUILD KBMA WITH SUNRISE PHARMACY We recommend that PDT assemble a team of process coordinators from pharmacy, nursing, ITS, RT, and others deemed necessary to work with and ensure KBMA is built concurrently and synchronistically with Sunrise Pharmacy and Knowledge-Based CPOE. Rationale Building the systems independently of the other could create a Tower of Babel, which our experience shows, at best, would force delay of implementing KBMA. At worst, it would create chaos that could result in a system that is less safe than the system being replaced. Additionally it would hinder momentum and may cause caregivers to lose confidence in the value of the BPOC initiative. A synchrobuild will prevent accepting processes, which may need to be reversed when KBMA goes live (e.g., order-modification process by pharmacy, appropriate-administration timeframes for nursing, proper handling of variable drug dosing, accurate tracking of individual doses from unit-of-use containers, etc.). 19.BRING UP KBMA ON THE HEELS OF SUNRISE PHARMACY Assuming that recommendation 20 (above) has been fulfilled, we recommend that COH bring up KBMA on the heels of Sunrise Pharmacy according to the implementation plan that will have been developed along the way. The goal is for every medication to be scanned for a match prior to administration, regardless of the setting (e.g. clinic, patient-care ward, surgery, etc.). Rationale The longer the delay in implementing KBMA, the greater the risk of harming COH patients and reputation.
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20.BRING UP eMAR WITH (NOT BEFORE) KBMA KBMA may be brought up before eMAR but we recommend against bringing up eMAR before KBMA. An ideal-case scenario would involve a thee-step process. The first step would be going live with a paper-generated MAR, which nurses would complete manually as they do today. This will help with data integrity and build confidence in the new medication administration system and process. It will also allow pharmacy and nursing staff time to work on standard administration times and tools for ensuring rapid and effective communication processes. Second, implement KBMA. Third, migrate to the electronically generated and completed MAR (eMAR). Based on what we have learned about KBMA development and timelines, it might be tempting to go live with eMAR prior to KBMA. We believe moving this direction would be a mistake, as it would put a temporary process for nurses in place that would need to be changed at a later date and unintentionally work against the adoption of KBMA. Scanning with KBMA will ensure real-time documentation of medications when administered as opposed to computer entry that allows for delayed documentation of medications administered.
21.UTILIZE BAR-CODED PATIENT VERIFICATION BEFORE
SURGERY
Prior to entering the OR, we recommend that patients’ wristbands be scanned to verify matches with the procedures to be performed.
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PRIORITY-THREE RECOMMENDATIONS: Do after KBMA is live and validated
22.UTILIZE KBMA DATA FOR PROCESS IMPROVEMENT Steps to Take We recommend that PDT appoint a report-utilization committee to regularly review prevented and potential errors as well as noncompliance events. It is important for the committee to interpret the data in light of real practice. Why did the nurse fail to comply (e.g. no barcode on the medication, unreadable barcode, emergency, etc)? What should be done about it? Significant safety and quality improvements come from utilizing BPOC-usage data. Rationale
• User practice and compliance data will assist personnel in determining individuals needing remedial work to improve system function
• Data from near misses by the system at the moment of
administration will identify process problems, which may be eliminated before getting to the patient-administration level
• Accurate turnaround times from order input until
administration will assist in core measure improvements 23.IMPLEMENT BAR-CODING FOR VITAL-SIGN COLLECTION AND
REPORTING
We recommend the BOT evaluate COH readiness and establish a timeline for implementing bar-code-enabled vital-sign collection and reporting applications. Systems are available (including Care Fusion’s Nurse Data Collection) that allow for scanning patient wristbands and bar codes on DINAMAP devices for collecting vital signs and populating Sunrise Clinical Manager flow sheets.
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24.IMPLEMENT BARCODING FOR ANESTHESIA AND IMPLANTS IN OR
We recommend that plans be made to implement bar-code verification and documentation systems for anesthesia applications in the OR (e.g., IVs, implants, etc). We recommend that bar coding apply to drug administration in the OR as it does throughout the rest of the hospital. 25.APPLY BAR CODING IN RADIOLOGY
We recommend that patient wristbands be scanned prior to all diagnostic imaging to positively ID the right patient and to retrieve the correct patient files before running tests. Ideally, the system would screen patients at the point of scanning for adverse drug reactions. If a radiology order were in the pharmacy system, scanning could trigger screening to reveal issues that need to be addressed prior to continuing the procedure (e.g. decreased renal function, recent administration of metrormin, etc.).
PRIORITY-FOUR RECOMMENDATIONS: Considerations for down line
26.MEDICATION CHARGE CAPTURE We recommend COH work with Eclipsys to ensure that both parties do what is required to enable cost/charge capture at the point of bar-code charting, using charge Data Management (CDM) numbers.
27.REFERRAL SPECIMENS A system for assigning barcodes to sample that have been collected outside the system will need to be developed to avoid duplicates and provide for mapping to original sources. Though the potential is good for this application, resources are limited and this process will need considerable work before it can be use for non-COH obtained specimens.
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28.MEAL TRAYS
We believe there is value in food services applying bar codes to food trays. These bar codes could be generated either by tapping icons on screen shots of meal orders or by scanning bar codes which would be printed on hard-copy meal-order forms. When meals are delivered, patient wristbands would be scanned for matches with bar codes on the trays. 29.SUPPLY CHARGE CAPTURE Most supplies for which charge capture would be of interest to the hospital are currently bar coded. We advise COH talk with Eclipsys to see when their system will be ready to scan supplies for sending charge-data management (CDM) numbers to accounting for charge capture.
30.BARCODING DURING SURGURY
A number of emerging technologies incorporate barcodes and/or RFID chips on implants, surgical instruments, and sponges. We recommend the BCOT investigate these and add them to COH’s timeline as is appropriate. 31.TRACKING ASSETS, PATIENTS, AND CAREGIVERS
Eventually COH will want to look into utilization of active RFID tags for the tracking of assets (e.g. infusion pumps, etc). When it comes to tracking patients and caregivers, passive RFID chips in patient wristbands and caregiver IDs would require scanners being within inches of the tags to get a read. As the technology matures, tracking people with passive RFID tags will be possible. At that time it would be worth investigating its value to the hospital. 32.BARCODE ASSISTED MEDICINE DISPOSAL
Investigate systems and ROI related to bar-code enabled waste applications. These relatively new systems involve scanning bar codes on drug package, which in turn directs users to the proper waste bins for compliance with disposal regulations.
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Addendum A: City of Hope Departments and People Visited The Neuenschwander Company conducted the following meetings and facility/process tours at The City of Hope on Oct 18- 19, 22-23, 29-31, 2007. Transfusion Medicine
• Joy Fridey, MD, Director • Jo Prejean, Safetrace Systems Admin • Linda Aldridge, Technical Director of Lab
Anatomic Pathology
• Lawrence Weiss, MD, Chair Med/Surg Fourth Floor West
• Mildred Ortiz, RN, Clinical Manager • Staff
Outpatient Hem/BMT Outpatient Clinic
• Rae Rapasardi, RN, Clinical Manager
ITS Operations Meeting (Neuenschwander Presentation)
• Liz Dunne, Executive Officer • Charles Boicey, RN, Project Manager ITS • Holly Martin, RN, Director ITS • William Goicochea, Director HIMS • Dennis Rusch, CFO • Janna Hoff, Patient Safety Officer • Sharon Steingass, RN, MSN, Interim CNO • Scott Drugan, RPh, VP • Susan Di Biasi, Director PBS
Inpatient BMT
• Margaret Prior, RN, Clinical Nurse Manager
Security (employee badges) • Bill Bolen, Security Specialist
Material Services
• Bob Cuthbertson, Director
Patient Business Services • Susan Di Biasi, Director
Outpatient Med/Surg
• Kathleen Dorsey, RN
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Health Information Management Services • William Goicochea, Director
Inpatient Med/Onc
• Claudia Garcia, Manager CIS Project Team Meeting
• Alan Wild • Diana Thorton • Galene Reese • Michelle Ramos • Gus Hahn • Michelle • Jason Gutierrez • Carol Hueisman • Lee Marrison • David Tat • Coleen Nydelle
Specimen Labeling Project
• Galene Reese, Project Manager ITS Women’s Health Center
• Joan—Woman’s Health Center • Cheryl—Radiation Oncology Technician • Terry Closson—Patient Access • Cheryl Torricelli—Diagnostic Imaging • James—Physical Occupational Therapy
Apheresis
• Gay Almquist, Director • Staff
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Cytogentics • Popsie Gaytan, Supervisor, • Alan Wild, ITS Project manager
Executive Administration
• Alexandra Levine, MD, CMA • Jim Murry, Sr VP and CIO • Janna Hoff, RN, BSN, VP Quality and Patient Safety and Patient Safety
Officer • Scott Drugan, Pharm D, VP Clinical Diagnostic and Therapeutic
Services • Michael Rabin, VP Managed Care • Dennis Rusch, CFO • Sharon Steingass, RN, MSN, Interim CNO
Anatomic Pathology
• John Palmer, Technology Director HLA Lab
• David Senitzer, Director Social Services
• Nellie Garcia, Director
New Patient Services • Terry Closson, Director • Rosamaria Gonzales-Cobery, Clerical Manager
ITS
• Holly Martin, RN, Director • Charles Boicey, RN, Project Manager • Diana Thornton, Technical Manger
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Addendum B: Site Visits and Other Meetings Site Visits, e-mail exchanges and telephone meetings were conducted for the purpose of clarifying our understanding of Eclipsys and Care Fusion as relates to City of Hopes BPOC initiative. Monday, November 20, 2007, National Institutes of Health, Washington DC
• Bob DeChristiophoro, Chief of Pharmacy • Barry Goldspiel, Assistant Chief of Pharmacy, Oncology Clinical
Pharmacy • Mike Brown, Pharmacy Eclipsys manager
November 29, 2007, Beloit Memorial Hospital
Beloit Personnel: • Doris Mulder, VP CNO • Patricia Brock, Director of Pharmacy • Lenore, Director, Blood Bank • Sharon, ITS
Care Fusion Personnel:
• Joe DiCandilo, VP Care Fusion Products, Cardinal Health • Nick Pavaceivic, Product Development and Sales
Telephone meetings and e-mail exchanges
Eclipsys Personnel: • Jack Hoffman VP Medication Management • Anonymous, Past Eclipsys executive • Anonymous, Eclipsys implementation and nurse training
specialist
Care Fusion Personnel: • Joe DiCandilo, VP Care Fusion Products, Cardinal Health • Nick Pavaceivic, Product Development and Sales • Jeff Patchett, Director of Pharmacy
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Addendum C: State of Eclipsys’ KBMA and Potential Ramifications
• According to our research, at the beginning of 2008, KBMA is live
on only one patient-care unit at one hospital (Methodist Hospital in Houston TX) and which is interfaced with Mediware, not Eclipsys Sunrise Pharmacy.
• We tried repeatedly to set up a site visit or talk over the phone with Methodist’s users to no avail.
• Jack Hoffman, Eclipsys VP of Medication Management, told us that they consider their KBMA to be under general release and not in beta. This causes us concerns, given the state of the product.
• Our experience tells us that it takes more than meets the eye to get BPOC medication applications right and that Eclipsys appears to be behind the development curve.
• Eclipsys’ inexperience, lack of progress, and the complexity of BPOC suggest that it may be a challenge for them to be ready for COH’s timeline.
• We recommend that COH track development progress and be prepared for developing a contingency plan in the event Eclipsys cannot deliver on KBMA adequately within a timeframe that COH deems reasonable.
• Most importantly, we recommend that COH corroborate with Eclipsys to test concurrent functionality between KBMA and Sunrise Pharmacy as the system is being built—including all mapping functionality. (See recommendation 18 “Synchrobuild”)
• We are told that at this point Eclipsys is laptop exclusive. We are told they are moving to handheld capabilities, but we are not sure when, nor are we aware of what handheld(s) they will be able to use. If and when Eclipsys software works on a handheld platform, we assume it will work on devices that are compatible with Care Fusion applications.
• We recommend that you expect and verify that the hardware and firmware of Eclipsys-compatible handhelds are capable of utilizing imaging readers.
• These devices must also be capable of uploading firmware for reading the various symbologies COH will need to scan.
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• We suggest that COH obtain a clear understanding of what data tracking and mining functionality is included in the KBMA package and see that it is progressing concurrently with building and implementing the system.
• In the event that Eclipsys fails to meet City of Hope’s expectations
with KBMA readiness and COH feels the need to move to another option to achieve BPOC for medication administration (short- or long-term), a relationship established with Care Fusion could prove to be invaluable. Similarly, Care Fusion’s relationship with Eclipsys could prove to be valuable for Eclipsys under those circumstances.
• While we cannot see into the future, it appears likely that either
Eclipsys would achieve adequate success with KBMA or they would deepen their partnership with Care Fusion and expand their interfacing capabilities with Care Fusion’s Mediation Management application.
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Addendum D: Recommendations for Scanners for Printers for Lab Clerks Currently, lab clerks hand enter 7-digit numbers. This number is made up of the MRN plus a check digit. The check-digit system has proven to be a reliable safety feature ensuring accurate data entry. When COH moves to the 8-digit MRN, this check digit will go away resulting in a system being implemented that is not as safe as the system being replaced. Therefore, we affirm the consensus we met across the system by recommending that barcode data entry be put in place for lab clerks prior to implementation of the new MRN. To enable barcode data entry for lab clerks in time for this transition, we recommend that COH quickly resolve scanner and printer needs simultaneously as outlined below: SCANNERS PRINTERS 1. Test scanners with current Lab computers and applications • USB-tethered laser scanners that can read simple linear barcodes. • While it is not necessary, if there is not a significant cost differential, we would suggest that these scanners also be capable of reading stacked linear barcodes.
1. Determine if current printers may be upgraded with software that enables producing barcodes on Lab labels • Assuming that current printers can be upgraded with software that will allow for printing linear barcodes, COH should purchase and upload this software on existing printers. • Additional printers should include software capable of printing linear barcodes. • When purchasing additional scanners (while it is not necessary for Lab applications), if there is little cost differential, we suggest that you purchase printers that are capable of utilizing software for printing more complex barcodes (e.g. PDF417, Aztek, DataMatrix, etc).
2. Purchase scanners • Only need scanners for clerks that are presently hand entering the current seven-digit number and relying on the check-digit function to prevent them from entering incorrect data (plus a standby scanner or two)
2. Purchase • Software for current printers • Additional printers—if needed
3. Install and validate scanners on current Lab computers utilized by clerks
3. Install and validate at current Lab printing stations • Software for existing printers • New printers—if purchased
