By Noel Hodges, RPh, MBA

In the move to barcode medication administration (BCMA), many hospitals face common challenges. Because point-of-care barcode systems work well only if they are supported by real-time medication order entry, to get the maximum benefit of a BCMA system requires having a pharmacist  available 24-hours per day. There are two solutions for hospitals facing this challenge: Hire enough pharmacists for 24-hour staffing or consolidate medication order entry and review into a central facility that provides 24-hour staffing to multiple hospitals.

Adding pharmacists to provide 24/7/365 order entry review at the local level may be practical for a large institution. But it is an inefficient use of resources for a hospital that generates a handful of orders during the times that the in-house pharmacy is closed. For these smaller hospitals, partnering with another institution and developing a central order entry (COE) system can provide clear benefits.

In the HCA Capital Division, which includes hospitals in Indiana, Kentucky, New Hampshire and Virginia, we have found that the benefits of COE can also extend to larger institutions. With 16 facilities ranging from a 50-bed standalone psychiatric hospital to an 800-bed acute care facility in the HCA system, we needed a single solution that covered our entire range of facilities. We wanted a central order entry system that would benefit any size hospital.

Needs Assessment
We were looking for a system that would be flexible enough to fully support any of our hospitals during off-peak hours while also handling 70% of orders during peak periods. Additionally, it had to work without any interruptions across the entire medication order and administration process. We established a straight forward measure of success for the system: If the physician writing the order and the nurse administering it could not tell whether the order was entered down the hall or across the country, then the system would be a success.

Increase in Productivity
The need for COE was evident in 2003 as HCA moved to point-of-care barcode medication administration, because the nurses needed to have the medication order on the patient profile in order to perform the five rights of medication administration with BCMA. In our facilities without 24-hour pharmacies this important safety process was bypassed.

With support from pharmacy, information services, quality control, and risk management, we launched a pilot project in mid-2004 and received Virginia Board of Pharmacy approval to proceed in 2005. By October 2005 we had rolled out COE to six hospitals in Richmond and now have 17 institutions in six states on board with more on the way.

Our goals in creating a COE system were to assure round-the-clock coverage for all of our hospitals while also relieving the burden of order entry during peak times. We were pleasantly surprised to find the COE system provided additional benefits we had not expected. Our COE pharmacists can review 60% more drug orders than our local, on-site pharmacists. This increased productivity has reduced turnaround time for drug orders, which, in turn, means we can get medications to the floor faster and administered to patients sooner. This is a benefit appreciated by the nursing staff.

The increased efficiency in order entry has allowed us to shift pharmacist utilization. We have decreased the number of full-time equivalents in order entry while increasing the number of FTEs in direct patient care (clinical activities) without changing our total pharmacist headcount. Giving more pharmacists more time with patients has also enhanced safety and increased positive outcomes.

Pilot Lessons
Our initial vision of COE was simple: Connect six hospitals to a central location. But questions concerning connectivity arose almost immediately. We were concerned with how to connect multiple institutions and whether we could fax orders to COE the same way we faxed orders within institutions.

Given the volume of orders we anticipated sending to COE, we realized that the pharmacists there would have to handle each individual fax and then file a flood of paper. Sending faxes to email (converting each fax to an electronic document attached to an email) was ruled out as equally cumbersome. We needed an automated medication order system.

With an automated medication order system, the orders are scanned to create a PDF image, which is sent directly to COE for processing. There is no additional paper or emails, just a stream of orders waiting to be entered, reviewed, and authorized, all of which happens electronically.

System in Action
Because automated medication order systems were generally designed to centralize order entry within a single institution, we were concerned that connecting six hospitals meant linking six distinct order entry systems with redundant hardware, redundant software, redundant log-ins, and certain chaos. Therefore, we challenged our vendor to create a single system to serve multiple institutions. Today, we have one system with one server and one electronic queue, or in-box, at our central order entry facility in Richmond, Virginia, serving hospitals as far away as Utah.

Physicians write medication orders as they always have. Nurses run orders through what looks like a fax machine, but is actually a multi-function fax/copier/ scanner. Pushing one button scans the order and generates and sends the PDF. If the local pharmacy is closed, the PDF is automatically routed to COE. If the local pharmacy is open, the order can be routed to either the local pharmacy or COE, depending on the workload at that time. Each facility provides the COE times during the day they would like coverage. All the nurse knows is that the order went to pharmacy. For the prescriber and the nurse, there is no special training or learning curve, as there is no change from their standard procedures.

Whether the order is routed to the local pharmacy or COE, it joins an electronic queue and is handled sequentially, on a first-in, first-out basis. Stat orders automatically go to the head of the queue.

Each COE pharmacist works with two screens. One screen displays the PDF of the original order; the second is an order entry screen. As the pharmacist enters the order, the pharmacy information system initiates standard drug utilization review for patient, prescriber, drug, potential interactions, and other factors. Once the order is entered and approved, the drug is released in the appropriate automated dispensing cabinet at the hospital or a label is generated in the pharmacy for preparation and dispensing. And the COE pharmacist is already entering the next order.

Productivity Increases
One of the goals for the COE implementation was to achieve increased efficiency and productivity. However, we were did not expect the dramatic rise in productivity that was delivered by the COE pharmacists. In the hospital setting, our pharmacists generally enter 30 to 33 orders per hour. Our COE pharmacists, on the other hand, average 50 to 53 orders entered per hour. We attribute this increase to the lack of distractions in the COE setting; there are no telephones ringing, no one at the order window asking questions, or any of the other distractions that slow entry and contribute to errors in the typical hospital pharmacy.

Initially, there were concerns that the added productivity would lead to staff cuts. But instead of reducing pharmacist headcount, we have freed up our pharmacists to be more involved with direct patient care. We have been able to reduce order entry FTEs due to the increased productivity realized in COE. We have moved these newly freed FTEs to target areas such as improving CMS core measures, rounding with physicians, managing drug therapy on the floor, and direct patient education.

Future Standardization Plans
We are also devoting more pharmacist time to key COE issues, such as standardizing practice protocols, algorithms, drug libraries, dose ranges and schedules, order sets, and similar practice parameters between sites. We have a uniform formulary and pharmacy information system, but historically every facility has been allowed to modify elements within these systems. The variation from site to site remains a source for confusion and potential error in drug ordering and administration. Increasing standardization will help us further boost productivity and reduce the potential for adverse events.

Inventory
COE has had minimal effect on inventory. The smaller hospitals that can now fill orders at 2:00 am, rather than waiting for morning pharmacy hours, have seen a slight increase in inventory in their automated dispensing cabinets. But, overall, there has been little or no effect on inventories or ordering across the entire system.

Feedback on COE
Our COE service has been well received by the hospitals. Pharmacy directors enjoy the staffing flexibility and benefit of after-hours coverage; staff pharmacists and pharmacy clinical specialists appreciate the ability to focus on patient care activities rather than worrying about the traditional order entry process and nurses are pleased with the quick turn-around-time.  

Summary
Point-of-care barcode medication administration is an important step toward increasing hospital pharmacy efficiency, productivity, and patient safety. To realize the full benefits of a point-of-care barcode system, 24/7 medication order capabilities are required. With a centralized order entry system, participating hospitals will realize a significant increase in productivity, faster medication order fulfillment and dosing, increased pharmacy resources devoted to direct patient care, enhanced patient safety, and better outcomes overall.  

 
Noel C. Hodges, RPh, MBA, has served as the director of pharmacy services for HCA Central Atlantic Supply Chain Services since 2005. Prior to assuming his current post, he was the executive director of pharmacy for CJW Medical Center in Richmond, Virginia. He received his BS in pharmacy from Purdue University and his MBA from Strayer University.