Better Workflow Through Informatics; A MAJOR Automation Implementation Can Work Miracles

Duane E. Machaj, R.Ph., Thani Misra, Pharm.D., Sherry Mason, C.Ph.T., Isabel Sanvanson, Pharm.D., Jesse Brown VA Medical Center, Chicago Illinois

BACKGROUND:

Back in the “old” days for inpatient medications, our utilization of automation equipment, data interfaces, co-ordination of VistA software packages, and workflow processes were “comfortable” (routine). We always did it that way, but why not find a way that utilizes resources more effectively, more efficiently, enhances patient information accessibility, and improves patient safety? It’s a major challenge to a get a large multidisciplinary team of pharmacists, technicians, nurses, physicians, etc. to modify their routines in search of the “better way to do it”.

The starting point of this transition can be described as follows: • Centralized cart fills every 24 hours.

• Pharmacy technicians performing cart exchanges with multi-dose items transferred manually at time of exchange.

• New orders and change orders delivered by pharmacy every 2 hours.

• Minimal ward stock. Mostly controlled substances maintained in the Pyxis medstation of the 3000 system. • The only interface was patient demographics so the nurse or provider could just pick a patient from the list. • Medication orders were not displayed so user could remove any controlled substance. • This version of automation did not authenticate correct drug by bar codes when stocking .

This serves as the initial build of the new Pyxis drug file along with drug classes and dosage forms directly from Vista drug file

Methods: The Informatics Inc. Interface software

was purchased. This required approval at the VISN level as this is commercial Class III software. This interface was customized to the specifications of our site.

In addition to the patient demographics provided by the previous interface, we now received patient specific medication orders in real time on each designated workstation. Under this interface, we were able to add profiling for outpatient areas (such as the Emergency Department) which were not available previously.

We ran the Pyxis 3000 system until the day of conversion. The new drug database was built to coincide with similar data fields in the VistA drug file. This included generic name, dosage form, and therapeutic class obtained using fileman templates from the Vista drug file. The drug identification number in Pyxis 4000 would now be the IEN number from the VistA drug file.

Tallman lettering was also applied to appropriate medications to eliminate any potential “look alike – sound alike” errors.

A second spreadsheet was prepared to identify each synonym (NDC number) that corresponded to that EIN number in the VistA drug file. This allowed Pyxis to auto-populate their drug file with all the necessary synonyms and make all our drugs immediately bar code readable in the new system.

OBJECTIVES: Our goal was to transition to a “point of care”

system which would expedite the availability of medication from ordering through administration. We wanted to also enhance the safety of medication handling by providing bar code checks when stocking the cabinets and patient specific medication profiling to ensure the correct medication was removed for the correct patient. Since automation and informatics have advanced significantly over the years, we intended to maximize their role in the new process to better utilize our “human” resources for hands on patient care.

The new process was built as a “parallel” system to the current workflow. A commercial profiling interface software was purchased, customized, and tested with the new dispensing cabinets. The drug database for the new system was built from scratch utilizing drug classes, EIN number, synonyms (for bar codes), etc. extracted from our VistA system. All unit dose, ward stock, and controlled substance software were modified to maximize their role in the new process. Wards were simultaneously brought down in the old system when they were initiated in the new system.

The second overlay of the Pyxis drug file added potential for barcodes Standard Configuration of New Medstation

RESULTS:

• Medications available to nurses within minutes of pharmacist finishing order.

• Dispensing cabinet software identifies stock needs quicker at a central location • Medications are removed from cabinets specifically by patient profile ensuring patient has order for that medication.

• The profiling system provides better handling of IMO orders in clinics and emergency department and prescription dispensing from CBOC’s.

• Significant reduction in missing or late doses.

• Greater security and accountability of multi-dose medications.

• Improved team morale with the overall workflow process.

Conclusion:

Many times a long establish process may never get reviewed or questioned unless there are specific negative issues or concerns which prompt such a review. With advances in technology leading to better computerization and automation, we must continue to incorporate these effectively into our daily workflow. Ultimately the organization, staff and patients all reap the benefits which include cost avoidance, improved efficiency, and enhanced patient care.

Pyxis 4000 Implementation Plan