Medication turnaround time is the interval from the time a medication order is written (manually or electronically) to the time the medication is administered.1 Monitoring medication delivery turnaround time in acute care settings allows departments to measure the impact of system and process efficiencies in the context of patient care.2 While medication tracking technology can focus on both patient-specific and unit-of-purchase medications, this article will focus on the former. When properly implemented, these systems can provide pharmacy and nursing with immediate visibility into all medication orders throughout one or multiple facilities while improving visibility to department and institutional leadership.
St. Jude Children’s Research Hospital (SJCRH) is a premier basic science research center and one of the largest centers in the world for research and treatment of pediatric cancers and other life-threatening diseases of children. The hospital’s mission is to advance cures and means of prevention for catastrophic pediatric diseases through research and treatment. The Pharmaceutical Department, a clinical and academic department within the institution, contributes to this commitment by providing advanced practice pharmaceutical services that individualize care for each child at St. Jude while supporting a collective research endeavor.
The SJCRH team first implemented medication tracking technology in 2016 following a “big bang” approach across all areas in which medications are prepared and/or administered. The Pharmaceutical Department chose to pursue medication tracking technology to improve operational efficiencies and reduce waste while increasing transparency to frontline staff and nursing customers. This implementation effort began as a resident project.
When considering medication tracking technology, selecting a system, planning for implementation, and adjusting workflows are critical to success.
Selecting a Vendor
There are several important questions to ask when selecting a system. Compared to many types of automation, support contracts for medication tracking technology are often significantly less costly as they rely mainly on software and some form of mobile device. As part of the assessment process, consider how the solution will utilize existing medication labels, provide a new label, or utilize a hybrid approach wherein a sticker is placed on the existing label. This element becomes extremely important from a technology governance and change management perspective. The vendor selected by SJCRH utilizes existing medication labels supported by a unidirectional HL7 interface. Other hospitals do not utilize an interface and generate tracking labels manually. It is also important to note that several of the major commercial EHR vendors currently offer this functionality out-of-the-box, with some level of customization available.
Pharmacy leaders should ask if the selected solution can interface with other technologies in the medication distribution system. Some systems communicate with pneumatic tube technology, and others utilize a bidirectional interface to update the medication location in the EHR. At least one system on the market can connect with a medication preparation solution so products that have not been verified by a pharmacist cannot be delivered, which is a huge benefit for patient safety. Additionally, users may explore how the vendor’s technology infrastructure will support their respective pharmacy operations. Cloud-based solutions offer more straightforward pathways to implementation, scale well to additional sites, and often incorporate single-access sign on. Orders and admit-discharge-transfer (ADT) interfaces may be used across multiple sites as well. When contracting, be sure to contemplate future needs and consider replacement of devices that may fail through heavy use and/or redeployment. Also evaluate if the solution will allow login or delivery by scanning user badges through an interface to the single sign-on system, as this has proven useful for the SJCRH team.
Depending on the health record utilized, creating a unique dispense identifier for each dose can be challenging, and this was the case for SJCRH, leading to multiple doses of the same medication holding the same identifier; two doses from the same batch would look like one dose. In practice, this could lead to doses appearing in a confusing manner (ie, out of sequence). The implementation team created more frequent batches to nearly eliminate this issue by separating doses that could have duplicate identifiers if printed within the same batch. This design was used successfully for several years until the EHR vendor addressed the underlying design issue. Sites should consider the level of granularity for scanning requirements. For example, staff could scan when medications leave the pharmacy for delivery and/or only when they are delivered to the patient care area. Additionally, technicians could scan when they return to the pharmacy from delivering. Scanning doses that are returned to stock versus those that are wasted will be required if waste data is to be captured.
The SJCRH team worked with technicians to identify all locations for potential medication deliveries and then created bar codes for these areas. The decision was made to track patient-specific doses when they were prepared, out for delivery, delivered, or returned, and that doses would be tracked to the nursing unit level (not the patient-specific bin level). Bar codes for nursing units were placed in consistent areas throughout the facility and staff was educated on where to place stickers of bar codes for scanning. Typically, the technology implementation can take place in a matter of weeks to months, despite any site-specific hurdles that may develop from interface development and deployment.
This technology is only useful in combination with strong supporting workflows. Thus, from a change management perspective, developing workflows that reduce confusion or bottlenecks while creating value for frontline staff is critical. Bins must be scanned back in after delivery as available; for some deliveries, the technician may be outside the pharmacy for an extended period before this step can occur. Note that this challenge may lead to some workarounds in which certain steps are skipped; technicians who are only delivering one item may skip scans and only scan the final delivery. Initially, motivating technicians to scan as “out for delivery” required quite a bit of reinforcement.
Another potential benefit of medication tracking technology is the access for nursing team members and other professional services to follow the progress of their required medication. Considerations for a user-facing dashboard that shows real-time medication location include access from a workstation vs a physical display in a unit, login access type, and initial and ongoing education for nursing team members. If physical displays will be installed in patient care units, consider if any patient information will be visible with regard to HIPAA requirements. SJCRH provides access to the dashboard via a desktop shortcut on all computers in clinical areas. Ideally, this information can be interfaced back to the EHR for easy access by nursing staff.
SJCRH has made major enhancements to the technology each fiscal year following go-live. A 2017 optimization connected the interface to the pneumatic tube system. Doses were scanned to a bar code on the pneumatic tube, equipped with a passive RFID chip embedded within the tube. Thus, the tube system updates the medication tracking system when the dose has been delivered to the nursing unit. An additional optimization in 2018 allowed badge scanning both for login and for capturing information from the pharmacy technician delivering the medication and the nursing team member receiving the medication. This function is utilized for high-cost and oncology agents. In 2019, further customization allowed individual line items from the health record to be tagged with a specific code that adds guardrails for how certain medications can and cannot be delivered. For example, investigational agents must be delivered directly to a nursing team member with a badge scan and cannot be scanned to the pneumatic tube station. This functionality helped digitize the legacy “do not tube” list.
The following benefits were realized after implementation:
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Conclusion and Next Steps
Pharmacy staff recognizes the benefit of the ability to identify if items are out for delivery or have been delivered in order to follow up on nursing calls or medication requests. Because the scan actions provide a timeline for delivery, medication tracking technology is also useful in following up on medication delay reports. While nursing team members have been trained to use the dashboard to follow the medication’s delivery progress themselves, as of yet, it has not become a standard part of nursing workflow and continues to be an opportunity to reduce unnecessary, interruptive phone calls. While there is an operational investment in tracking medications, the return on nursing satisfaction and the time saved in looking for medications has improved staff satisfaction and delivered cost savings.
David Aguero, PharmD, MSTL, dPLA, is the director, medication systems and informatics, and residency program director, PGY2 Pharmacy Informatics, at St. Jude Children’s Research Hospital. He is also assistant professor at the University of Tennessee Health Science Center.
Cindy Brasher, PharmD, MS, BCPS, is manager, compounding, at St. Jude Children’s Research Hospital.
Implementation Pearls for Medication Tracking Technology
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