Abstract
Medication errors can result in adverse drug events, with negative impacts on patients including death. Computerized physician order entry (CPOE) and bar code medication administration (BCMA) systems are transforming the approach to prescription drugs in clinical settings and providing considerable information that is used in performance assessment and research. They have been responsible for rapidly decreasing medication errors and transcription errors and are a critical aspect of the patient safety strategy at many hospitals and other clinical facilities, greatly improving patient outcomes. Health information management systems such as automated medication administration have four defined phases. By ensuring that the needs are appropriately assessed through consultation and analysis there is a more successful selection stage. Once the system is selected the preparations for implementation begin, from determining changes to the current network, hardware that is required, training in the use of the system including hardware and software, and other activities. Ideally this is followed by a trouble free maintenance period, where the system is function and administration and use of the system is ongoing. After a time the system may no longer meet current needs or be compliant with standards. The cycle then begins again.
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Medication errors can result in adverse drug events, with negative impacts on patients including death (Truitt, Thompson, Blazey-Martin, NiSai, & Salem, 2016).. Computerized physician order entry (CPOE) and bar code medication administration (BCMA) systems are transforming the approach to prescription drugs in clinical settings and providing considerable information that is used in performance assessment and research. They have been responsible for rapidly decreasing medication errors and transcription errors and are a critical aspect of the patient safety strategy at many hospitals and other clinical facilities, greatly improving patient outcomes (Truitt et al., 2015). Both CPOE and BCMA relate to the reduction of errors relating to patient medications, the first through direct transmission of prescriptions from the physician to the system which provides information management to pharmacy service, and the second by tracking and support processes and decision making while administrating medications. CPOE is a greater challenge as it more expensive and more time consuming to implement ($34,000 per bed in comparison to $3,000 per bed for BCMA (Botta & Cutler, 2014). Ideally the systems work together and also coordinate with other systems such as the electronic medical records of the patient.
Four phases of the HIT lifecycle
The four phases of the HIT systems life cycle are needs assessment, selection, implementation, and maintenance. When a hospital or clinical environment determines that they want to use a BCMA and CPOE systems they must understand their specific expectations of such a system. If systems are already in place, then the needs might include the functions currently served and further functionality which is required. New systems are sometimes needed as systems age because the system might no longer meet security requirements are be compatible with other health information systems in the clinical environment.
Assessing needs
A needs assessment with regard to BCMA will differ depending on whether there is already a BCMA in use or whether the system is being launched for the first time. In the initial launch of BCMA there will be considerable training needs as first time users become proficient in using the system. The training needs cannot be determined until other aspects and expectations of an automated system for medication dispensing and tracking are defined. This is needed in order to fulfill the next phase of selection. One strategy for determining needs is to consult with stakeholders. This would include prescribing physicians, nurses, pharmacists, administrators and other groups. Each group plays a different role in the system of dispensing medication, and therefore has different needs that the new automated process must support. By ensuring that the needs of each group are understood, they can be better met which reduced concerns and problems in the implementation and maintenance phases. There are also linkages to other information systems to be considered, such as data flows between the patient’s record in the Electronic Health Records (EHR) system and well as billing and claims databases. Information is moving both between systems from the CPOE to the BCMA, that information must be linked to the general data about a patient and their condition, and this must be tied to yet other systems which track items such as drugs in order to create the invoices to bill insurance companies.
Steering committee
In order to ensure good decision making practices which reflect the needs of an information system to track and dispense medications a steering committee is needed. Each area which might become involved during a phase should include representatives to the steering committee. This would include finance, who can advise on allowable purchases and affordability; health information management, who will be coordinating and administrating the system; technological services, who will be supporting the network and hardware that supports the new system; pharmacological services, which will continue to receive prescriptions and prepare medications; physicians, who prescribe the medications; and nurse who administrate the medications in direct care to patients.
An example of composition of similar steering committee is the Michigan State University Health Information Technology Committee. It includes all clinical departments, including human medicine, osteopathic medicine and nurse (Michigan State University, nd). Further it includes representatives from information technology services, health information technology, operations and billings, the student health center and the department of radiology (Michigan State University, nd)..
Selection strategies
Any strategy for the selection of a new BCMA system or upgrade will depend first on whether the system fulfills the needs which were defined in the previous phase. Once those systems that meet those criteria have been identified it is necessary to evaluate each on the extent to which it meets or exceeds needs, quality, and costs. In order to determine the extent to which a specific system will meet the identified needs those needs can be summarized into a weighted scoring system. The systems can each then be scored on the basis of each task or outcome that is required from it. Total scores can then be compared between systems. Quality is also an important aspect. A system that requires frequent troubleshooting are has difficulties in operation is not going to be supported by staff for a very long. The costs that need to be considered are two fold, as there are the upfront costs and affordability to consider as well as long term costs of maintenance. The upfront costs can include software customization, hardware requirements (such as bar code scanning wands and tablets), security requirements and sometimes upgrade of the facilities wireless network. The long term costs can include maintenance of hardware, licensing fees and administration costs.
General components of system to be evaluated include the user interface and whether it provides the needed functionality for the user group, usability of hardware such as bar code scanner wands, the extent to which a system has evidence regarding a reduction in medication errors, cost versus benefits and difficulty to implement.
Training needs
When users are properly trained and have reached a certain comfort level errors and workarounds are less likely to occur. Unfortunately many times when BCMA and other automated medication administration systems were implemented nurses were not sufficiently trained, and the result was workarounds which solved problems in the short term but created problems for data and patient monitoring (Rack, Dudjak & Wolf, 2012). Training must be organized according to user groups. The persons who administer the medication to patients do not have the same training needs as information coordinators who might be troubleshooting the system for users. Training needs to be developed for each group which leads to not only understanding of processes in using the system, but motivation to use the system and a general level of comfort with the tool.
Summary
Health information management systems such as automated medication administration have four defined phases. By ensuring that the needs are appropriately assessed through consultation and analysis there is a more successful selection stage. Once the system is selected the preparations for implementation begin, from determining changes to the current network, hardware that is required, training in the use of the system including hardware and software, and other activities. Ideally this is followed by a trouble free maintenance period, where the system is function and administration and use of the system is ongoing. After a time the system may no longer meet current needs or be compliant with standards. The cycle then begins again.
- Botta, M. D., & Cutler, D. M. (2014, March). Meaningful use: floor or ceiling?. In Healthcare (Vol. 2, No. 1, pp. 48-52). Elsevier.
- Michigan State University. (nd). Health Information Technology Clinical Informatics Subcommittee. Retrieved from: https://www.hit.msu.edu
- Rack, L. L., Dudjak, L. A., & Wolf, G. A. (2012). Study of nurse workarounds in a hospital using bar code medication administration system. Journal of nursing care quality, 27(3), 232-239.
- Truitt, E., Thompson, R., Blazey-Martin, D., NiSai, D., & Salem, D. (2016). Effect of the Implementation of Barcode Technology and an Electronic Medication Administration Record on Adverse Drug Events. Hospital Pharmacy, 51(6), 474-483.
