Pharmacy Technology Report - September 2021 by McMahon Group

Best practices in automation, informatics and patient safety

SEPTEMBER 2021 • Vol. 7, No. 1

Solving the Barcode Scanning Bottleneck Page 12

Specialty pharmacy embraces telehealth during COVID-19 Page 3

Making the case for IV robotics Page 8

Software trims millions from drug budget Page 16 Supplement to

Homegrown dashboard streamlines care Page 18

Cost Saving Time Saving Waste Saving Life Saving

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PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2021

Pharmacists lean on EHR, telepharmacy during COVID-19

Maintaining Best Specialty Care Virtually

oing virtual during the COVID-19 pandemic has not diminished the ability of health-system specialty pharmacies to meet their patients’ medication needs and provide quality care, according to the experience of several large centers. In fact, telemedicine has helped improve communication among clinical pharmacy specialists, patients and providers at some institutions. The flexibility of telemedicine, and “the convenience of providing patients with education while they are at home, has facilitated greater contact between pharmacists and specialty patients,” said Diane Kim, PharmD, a clinical pharmacy specialist at Penn Presbyterian Medical Center (PPMC), in Philadelphia.

Off-site EHR Improves Communication Dr. Kim said there are four specialty pharmacies located at PPMC specialty clinics. Pharmacists there do everything from confirming the appropriateness of a specialty drug to ensuring medication access, providing medication counseling, monitoring adherence and identifying drug–disease and drug–drug interactions. Like so many others around the country, the health system’s pharmacists moved off-site in March 2020 due to COVID-19. Since then, they have been using PPMC-issued mobile phones and laptops to remotely access the electronic health record (EHR; Epic), Dr. Kim said. Pharmacists also use these devices to call patients, access HIPAAcompliant video conferencing platforms and participate in collaborative team meetings, she noted. “Remote EHR access is our primary means of documentation both among pharmacists and with providers, so having access to the EHR has been key to a seamless transition to telemedicine,” Dr. Kim said, adding that pharmacists have also been using the EHR to see scheduled appointments and respond to clinical questions from providers, or to requests for patient education. The switch to telemedicine has not slowed specialty pharmacy operations, Dr. Kim stressed. She and her colleagues found new specialty prescriptions increased by 12% between February and July 2020, compared with the

EDITORIAL STAFF David Bronstein, Editorial Director

‘[Injection training] was a particularly tough challenge in the beginning, when strict restrictions were in place at the hospital and clinics and pharmacists worked fully remotely, or in many cases patients were fearful of coming into the clinic or hospital.’ —Diane Kim, PharmD six months before. Dr. Kim said this increase was likely due to a higher specialty prescription capture rate from PPMC physicians, which itself was a result of a “strong relationship between pharmacists and clinic providers, consistent communication with the clinics during these unprecedented times and thorough patient education for new medications as well as medication reconciliations,

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DESIGN/LAYOUT STAFF Frank Tagarello, Senior Art Director/ Managing Director

see VIRTUAL SPECIALTY, page 4

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PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2021

VIRTUAL SPECIALTY continued from page 3

which specialty patients and providers find valuable.” Medication refill rates have remained unchanged thanks to an established workflow that includes specialty pharmacy patient outreach phone calls and courierdelivered medications, she noted. “Essentially, the only services that have been impacted are the face-to-face injection training [sessions], along with a shift to telephonic medication counseling and medication reconciliation,” Dr. Kim said. She acknowledged that some patients find it difficult to learn injection techniques virtually, because they “just naturally communicate and learn better face-to-face, not to mention there are distractions at home.” Dr. Kim added: “This was a particularly tough challenge in the beginning, when strict restrictions were in place at the hospital and clinics and pharmacists worked fully remotely, or in many cases patients were fearful of coming into the clinic or hospital.” Patients who have difficulty learning injection techniques over the phone or through video conferencing are directed to online instructional videos and can speak with a caregiver at their convenience for further guidance, Dr. Kim said. However, at press time, PPMC specialty pharmacies had implemented safety protocols and were offering in-person appointments as an option, she noted.

Vanderbilt Embraces Telepharmacy Steve Burkes, PharmD, a clinical pharmacy specialist at Vanderbilt University Medical Center’s adult endocrinology clinic, in Franklin, Tenn., said his pharmacy now provides remote patient education for many specialty medications.

“The majority of my telemedicine visits with patients are to review new starts, and I have demos of most of our medications as well as some educational tools I use to help patients see what to expect, and to help them understand the purpose of their particular specialty medication,” Dr. Burkes explained. Like Dr. Kim, he said some patients have found it difficult to learn how to use their devices remotely and visit the clinic for in-person device training. Dr. Burkes said many patients now prefer the convenience of a remote visit and his team will continue to offer telehealth as an alternative to in-person visits. Dr. Burkes’ colleague, Johnna Oleis, PharmD, a specialty pharmacist in the Vanderbilt HemostasisThrombosis Clinic, in Nashville, Tenn., said her team has been performing most of their annual comprehensive patient examinations remotely during the COVID-19 pandemic. Dr. Oleis has found that implementing a telemedicine approach has not only allowed her team to continue providing the care patients expect; it also has come with additional advantages, such as saving time. “Patients are scheduled for a two-hour, in-person visit with individual members of their care team, but with the telemedicine option, we all get on the same 30-minute call,” she said. Through these team–patient encounters, Dr. Oleis and her colleagues realized that “providers do a lot of repeating of the same information” in their separate appointments. “In after-appointment meetings for in-person visits, we often find that a patient has given different information to different providers, so it’s been good to get the same information from the patient during the one call.” —David Wild The sources reported no relevant financial disclosures.

Telehealth Spurs Naloxone During COVID-19

gainst the backdrop of a dual opioid epidemic and COVID-19 pandemic, institutions have been rolling out telehealth programs to prescribe and dispense naloxone. At one health system, a telehealth-based naloxone program increased dispensing of the lifesaving antidote by 40%. “It’s become much more difficult for patients who need abuse prevention and treatment programs to participate in them during the COVID-19 pandemic,” said John Beyer, PharmD, a pharmacy informatics manager at the University of Iowa Health Care, in Iowa City. Dr. Beyer said tele-naloxone dispensing helps address barriers to care, and “the pharmacist is at the center of our program, providing the education to the individual, making sure they’re trained to use naloxone appropriately and shipping out kits from our pharmacy to the recipient.” He and his colleagues developed their telehealth-based naloxone dispensing program just ahead of the pandemic,

in December 2019, but it became markedly more relevant after COVID-19 took over, leaving those with substance use disorders at home and sometimes alone. Now, individuals—including patients, friends, family, community first responders, and law enforcement or fire department staff—can request naloxone by calling the University of Iowa Health Care pharmacy or submitting a form on a website that was created with the Iowa Department of Public Health (www.naloxoneiowa.org/telenaloxone). The pharmacist then schedules a video appointment with the person, using a HIPAA-compliant platform (Vidyo), during which they provide education about opioid overdoses and naloxone and instruct the individual on proper use of the kit (Figure, page 6). In the month after the team rolled out the program in mid-December 2019, the number of dispensed naloxone kits rose from an average of 35 per month to 50 per month. see TELE-NALOXONE, page 6

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PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2021

1. First, call the number below, or fill out the form to have someone call you.

2. Then, an appointment for a video visit will be scheduled for you.

3. Next, chat with a pharmacist using the video chat feature to request naloxone.

4. Then, you will receive a naloxone kit in the mail at no cost to you.

5. If you use your naloxone, just call back to schedule an appointment and get another free kit.

Figure. University of Iowa Health Care naloxone telepharmacy protocol.

TELE-NALOXONE continued from page 4

Dr. Beyer said this increase correlated “100% with our outreach efforts,” including radio advertisements and flyers distributed at pharmacies throughout the state. “Marketing this service to make sure community providers and patients know about it has been key; it’s not guaranteed that if you build it, they will come.”

‘Being able to remove obstacles to prescribing naloxone through initiatives like tele–naloxone dispensing is a life-or-death matter.’ —Sarah Cloud, MBA, MSW After an initial learning curve, pharmacists at the University of Iowa Health Care have become efficient at the process and now send out most naloxone kits within 24 hours of a video appointment, Dr. Beyer said, adding that the average time between first contact and an appointment is two days, while the time between first contact and dispensing averages three days. “Most of the time that our pharmacists spend on the initiative involves counseling and ensuring individuals meet eligibility requirements, and the dispensing itself is now part of their business as usual,” he said. Although his team has not tracked whether their program affected opioid overdose–related deaths, Dr. Beyer said one of the program’s successes has been its reach. People from 41 counties in Iowa have obtained naloxone kits, and the demographics have reached a wide range of patients across all demographics.

“One thing we are really excited about is that patients themselves have been calling for an appointment, which tells us we’ve been able to break through the stigma that usually keeps them from seeking care for an opioid use disorder,” Dr. Beyer said. Shifting the focus of the campaign from opioid misuse to safety and preparedness has likely helped destigmatize the issue, he noted, adding that patients also might be finding it less stigmatizing to receive care without having to see a pharmacist in person in their immediate community.

Eliminating Barriers Sarah Cloud, MBA, MSW, the director of social work at Beth Israel Deaconess Hospital–Plymouth, in Massachusetts, and a member of the hospital’s pain stewardship committee, said data indicate a clear need to use tools such as telehealth to get more naloxone kits into the hands of community members. Specifically, her institution’s own research found that 29% of naloxone doses administered in 2020 in Plymouth County were administered by a third party—such as a family member or friend—before a first responder arrived at the scene. “Using telehealth and other approaches, we will continue to flood the area with naloxone kits and train community members appropriately, and we expect the numbers of non–first responders administering naloxone will increase as we do this,” Ms. Cloud said. She added that the value of tele-naloxone dispensing in eliminating some significant barriers to naloxone access—such as transportation and need for time away from work or family—has been invaluable. “Being able to remove obstacles to prescribing naloxone through initiatives like tele–naloxone dispensing is a life-or-death matter,” Ms. Cloud said. —David Wild

The sources reported no relevant financial disclosures. Dr. Beyer presented his study at the ASHP 2020 Midyear Clinical Meeting and Exhibition.

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PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2021

Allegheny Makes a Case for IV Robotics

utsourcing sterile IV medications can put a big dent in a hospital’s drug budget. Allegheny General Hospital, in Pittsburgh, for example, had been paying 503B outsourcing facilities about $2.6 million per year for compounded IV products, according to Arpit Mehta, PharmD, MPH, MHA, the director of pharmacy. But that was before the hospital’s first compounding robot recently went fully live. Now with the arrival of a second Omnicell IV robot, which will double the hospital’s automated nonhazardous dose output to around 100,000 bags and syringes per

previously acquired from a 503B facility. But according to Dennis Wright, MBA, Omnicell’s senior director of central pharmacy product marketing, the literature makes a strong case for the risks inherent in manual compounding. He pointed to one widely cited study showing a 9% error rate for manually prepared admixtures (Am J Health Syst Pharm 1997;54[8]:904-912). Mr. Wright said Omnicell’s “whole goal is to remove humans from those areas where they can introduce risk, either by making mistakes or introducing potential contamination, and apply robotics, which [provides] automated safety checks and a standardized compounding workflow in a completely isolated ISO Class 5 environment.”

Striking a Balance Between Manual and Robotics

year, Dr. Mehta expects the outsourcing bill to drop to $500,000, saving more than $2 million. (Chemotherapy and other hazardous drugs are compounded manually for specific patients, he said.) It’s not just cost reduction that has elevated the robots’ value, Dr. Mehta said. “From a patient safety perspective and error prevention in general, it has been fantastic. Leveraging the IV robotic technology has truly allowed us to have full visibility of the compounded medications we’re using in our critical care units and operating rooms [ORs]. And it gives us the flexibility to make the quantity we need on time, without running into any shortages or quality assurance issues.” Compounded IV bags include vasopressin, norepinephrine, phenylephrine, fentanyl and hydromorphone, he said, and neostigmine, ephedrine and ketamine are among the syringe-containing medications compounded for the OR. “From a patient safety perspective, [using compounding robots] is leaps and bounds ahead of where we were before,” he said. “And from the viewpoint of employee safety, it eliminates touch contamination and it makes our process much more efficient.” Dr. Mehta said he didn’t have baseline safety or error data because the robotically compounded drugs were all

At Allegheny General Hospital, about 30% of the 360,000 IV doses administered each year are compounded by the robot, Dr. Mehta noted. Most of the balance still needs to be compounded manually, he said, because Allegheny’s Omnicell robots are not equipped to handle individual dose variations. Small quantities are still outsourced “from strategic partners whom we have visited and know the quality of their products meets the standards,” he added. But even for manually compounded medications, Dr. Mehta said the pharmacy is bolstering preparation accuracy and safety by converting to the Omnicell IVX Workflow system, which integrates barcode scanning, gravimetric or volumetric verification, multispectral imaging, photo documentation and label printing into the compounding process. Robotics also enhance Allegheny’s ability to meet the documentation standard of USP General Chapter <797>. “That process is now 100% automated,” he said, “so we don’t have to have a person manually tracking any information. If there’s a recall or other concern, we can pull data pretty much all the way to the individually compounded bag or syringe level and assess it for any concerns.” For Allegheny General Hospital, the conversion to robotics and IV automation paralleled the opening of new state-of-the-art pharmacy on the third floor of its landmark “skyscraper” building in Pittsburgh. The move doubled the size of the old pharmacy on the floor below and allowed the installation of a new larger and betterequipped cleanroom facility that adheres to USP <797> safe compounding standards. In its automation startup, Allegheny has relied on what amounts to a partnership with Omnicell. Mr. Wright explained that the company had “changed the traditional model of just selling an IV robot and having the customer figure out how to optimize it to where we now bundle it into a complete service offering” that provides “the technology, tools and resident expert operators who are colocated with the technology.” see IV ROBOTICS, page 21

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PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2021

EHR Data Drive Better Diabetes Care

pharmacist-led inpatient diabetes stewardship program, guided in part by electronic health record (EHR) data, cut the number of hypoglycemic events at one hospital by 75%, shortened hospital stays by 0.46 days and saved roughly $690,000 annually in inpatient spending. “Given the unique skill sets and diverse knowledge base of our profession, pharmacists can serve as the leaders to champion change and deliver upon interventions to improve patient care,” said lead researcher Jon Knezevich, PharmD, a clinical pharmacy specialist at Nebraska Medicine, in Omaha. The program targets an important national concern, because “many health care organizations are finding it difficult to address the increasingly acute medical needs of the

tool to capture interventions. Because improving management of glycemic events requires a multidisciplinary effort, Dr. Knezevich and his team also educated front-line nurses and other relevant clinical disciplines within the organization on diabetes best practices. They also helped create institutional policies and procedures for acute glycemic management and revised EHR-integrated order sets related to treatment of these events. Between 2015 and 2020, the percentage of inpatient days with hypoglycemia dropped from 5.4% to 1.3%. The percentage of critical care patient hospital stays including a hypoglycemic event dropped from 10.9% to 3.9% between 2017—when the pharmacist credentialing competency was rolled out—and 2020. The researchers also reported that there was a drop from 12.1% to 6.2% in the number of noncritical care patient stays with a hypoglycemic incident. Cost analyses indicated that Nebraska Medicine has saved more than $690,000 annually as a result of fewer hypoglycemic episodes, fewer insulinrelated adverse events and hospital stays that are an average 0.46 days shorter. Dr. Knezevich added, “Much of the success of the program is a result of an empowered clinical pharmacy team.”

‘Impressive’ Research

growing diabetic patient population they serve,” he said. When Dr. Knezevich began to create a diabetes stewardship program at his institution, he found that it was challenging to “quickly and effectively identify, triage and intervene in real time.” To overcome these challenges, he worked with the hospital’s EHR system analyst to develop a dashboard that uses real-time EHR information to identify and display patients experiencing glycemic excursions and those receiving insulin, which Dr. Knezevich noted is a high-risk medication. Dr. Knezevich cited another challenge: Although the diabetes stewardship dashboard “served as a novel and effective tool to manage acute glycemic variability,” positive outcomes “would only be achieved by also educating and empowering our highly motivated pharmacy staff,” he said. With that in mind, in 2017, he and his colleagues developed and rolled out an acute glycemic management credentialing competency module for their clinical pharmacists. They also created a related pharmacy rounding checklist and a quick prescription documentation EHR

The diabetes stewardship program that Dr. Knezevich and his team developed is “impressive and led to meaningful impacts on inpatient hypoglycemia, lengths of stay and costs,” commented Joshua Neumiller, PharmD, the vice chair and Allen I. White Distinguished Associate Professor in the Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences at Washington State University, in Spokane. “Importantly, use of a rounding checklist for pharmacists, as well as an EHR tool to document their interventions, seem to be important components of the program’s success,” said Dr. Neumiller, who was not involved with the research. Equally important to the success of the program was their “holistic approach,” Dr. Neumiller stressed, pointing to the interprofessional educational components of the initiative, as well as efforts to optimize nurse-delivered education to patients. Dr. Neumiller added that the approach “can be readily adopted by other institutions and is also translatable to other high-risk patient groups.” —David Wild

The sources reported no relevant financial disclosures. Dr. Knezevich’s research, a Best Practice poster (No. 4), was presented at the ASHP 2020 Midyear Clinical Meeting and Exhibition.

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PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2021

Breaking Through the Barcoding Bottleneck

houghtful planning, staff engagement and carefully crafted messaging were the significant factors in a successful rollout of medication dispensing barcode scanning at the University of Michigan’s Mott Children’s and Women’s Hospital, in Ann Arbor. According to one of the project’s leads, this multipronged approach resulted in a high level of barcoding use in the pharmacy and nearly eliminated errors in dispensing. “Technology implementation requires a culture change that occurs over time and must be cultivated. It’s not a one-time thing,” said Paul Workman, PharmD, a clinical pharmacist at Mott who helped spearhead the IT barcoding initiative. Although they had a scanner in the pharmacy prior to their project, Dr. Workman said the single device was not widely used because of its location in the pharmacy and “weak messaging regarding the value of using it.” He and his colleagues decided to install more scanners throughout their pharmacy in light of a 2013 multicenter, two-phase prospective study that included their institution, in which rates of dispensing errors fell from 0.7% with visual pharmacist checking to 0% when barcode scanning was used (Am J Health Syst Pharm 2016;73[2]:69-75). “Because barcoding is a low-cost and easy-to-implement technology with high impact, we saw it as an attractive way to improve the safety of the medication-use process,” Dr. Workman said.

Pharmacy intern Anastazia Capparelli, BSc, scans a label that tells the system what order to bring up. Next she scans the drug, and the system checks it against the order to ensure correct dispensing.

Implementing barcode scanning in their pharmacy was particularly easy to do because it was an optional functionality built into their existing electronic health record (EHR) system (“Dispense Prep” in Epic) for dispensing.

PDSA Cycles Help Improve Barcode Scanning Adherence Plans for implementing barcode scanning should not stop after a facility’s go-live date. To ensure staff will use the technology as much as possible, pharmacy leaders should consider using a Plan-Do-StudyAct (PDSA) cycle, which can help identify areas where end-users may fall short. That’s the approach taken at Mott Children’s and Women’s Hospital, in Ann Arbor, Mich. “We gathered data on our scanning and analyzed it to identify opportunities for further interventions,” said Paul Workman, PharmD, a clinical pharmacist who was part of the rollout team. As an example, they analyzed the first two months of scanning data by medication type, shift time and individual medications, and found that 12% of their preassembled IV “piggybacks” were not being scanned. “We looked closely at our process for these medications and discovered that when they were put together in the cleanroom, there was no opportunity for technicians to scan them before they left the pharmacy,” Dr. Workman said. To address the problem, Dr. Workman’s team added a pharmacy-specific barcode for these labels, which allowed them

to be scanned into the electronic health record (EHR) in the cleanroom. “A small process change in the labeling of these products and clear communication with staff on this change allowed us to scan them more frequently,” he added. The PDSA tool also showed that a specific type of heparin flush bag they were compounding in-house due to a manufacturer shortage could not be scanned in their system, because the EHR system was only programmed to recognize manufacturer barcodes. Dr. Workman said it is possible to add new barcodes to the EHR, but shortages of this product were intermittent and it was not feasible to change the barcode every time this product went out of stock. To remedy the problem, they worked to resolve the shortage as soon as possible and stay with the manufacturer-provided barcode. “PDSA cycles have helped us systematically plan and implement an intervention with retraceable steps, and tracking the impact allowed us to fine-tune our effort in an ongoing manner, which has led to ongoing highly reliable improvement,” Dr. Workman said. “This process never stops.” —David Wild

PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2021

The barcoding team began the project by addressing potential bottlenecks that would prevent staff from using the technology. For example, they looked at their floor plan and determined the optimal locations for the 11 scanners they added, so that medications could be scanned anywhere a dose was prepared, with minimal interruption to the workflow. They also started engaging staff early in the lead-up to barcoding implementation. “We first highlighted the dispensing errors that were occurring and shared these in daily staff huddles and weekly communications, and then we introduced the concept of barcode scanning and why we thought it could help us,” Dr. Workman said, adding that staff also were notified of go-live dates well in advance.

Enlisting Stakeholders To ensure staff were on board with the use of barcode scanning in their workflow, Dr. Workman and his colleagues assembled a coalition of influential people in the pharmacy, including staff from all levels of the department, such as managers, front-line pharmacists and technicians. “If you’ve ever tried to make a change in the pharmacy that didn’t have buy-in from key players, you know it’s almost impossible to tip the scales in that situation,” he said. “So, we created a group including staff with the greatest influence on their colleagues.”

Messaging, Messaging, Messaging

benefits of barcode scanning, pointing out situations in which the technology would have saved errors and time. The team also linked the initiative to Mott’s institutional values—integrity, teamwork, innovation and caring. That helped staff see the importance of the project, he said. Dr. Workman’s group developed short and simple messages that conveyed why the workflow change was taking place, when it would happen and how it would affect staff. “We were honest and straightforward about the fact that it would be a new step that could be perceived to slow them down at first,” he said. “We kept linking it to patient safety and tried to highlight the benefits on the back end, such as reduction in wrongly dispensed medications, fewer patient safety reports to deal with, and less time spent determining if we ever filled a dose, because we were now going through the EHR.” These messages were repeated often in group huddles and department meetings, because “if the message can’t be communicated succinctly in a five-minute huddle, it may be too long and staff may tune out,” Dr. Workman noted.

Implementation Day After obtaining widespread buy-in, the team trained staff to use the technology and gave them the opportunity to identify workflow challenges, which Dr. Workman and his colleagues addressed before the go-live date. “It doesn’t matter how long you spend in a planning see BARCODING BOTTLENECK, page 14

Dr. Workman said he emphasized the patient safety

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Figure. Barcode scanning compliance at Mott Children’s and Women’s Hospital. PDSA, Plan-Do-Study-Act

PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2021

BARCODING BOTTLENECK continued from page 13

committee in a room, there’s always going to be something you haven’t thought of,” he said. They went live with barcode scanning in October 2019, implementing it in three phases. First, they asked staff to scan all batched oral medications, then unit-dose cart fills, and finally batched IV medications. After the rollout, they continued to improve the use of the technology with Plan-Do-Study-Act (PDSA) cycles (sidebar, page 12). Dr. Workman’s team efforts paid off. In October 2019, when there was a single barcode scanner in the pharmacy, technicians were scanning approximately 6% of all dispensed doses. After the first phase of implementation, that number rose to roughly 45% of all scannable medications, increasing further to 75% when they rolled out the second and third phases (Figure, page 13). “After we implemented interventions using our PDSA analyses, the scan rate has remained close to 90% since June 2020,” Dr. Workman said. The initiative also led to a decline in dispensing error rates, from an average of four errors per week in October 2019 to an average of one error weekly by June 2020. “The reason we haven’t been able to eliminate all errors is that we haven’t implemented barcode scanning inside our cleanroom for IV preparations, but we plan on doing so in the fall of 2021,” Dr. Workman noted.

Importance of Safety in Pediatric Patients Medication safety tools like barcode scanning “are crucial for preventing harm in all patients, but they are especially important in our most vulnerable pediatric patients,” said Lisa Hanlon Wilhelm, BSPharm, RPh, the medication safety and compliance specialist in the Department of Pharmacy at Penn State Health Milton S. Hershey Medical Center, in Hershey, Pa. Dispensing medications for pediatric patients is a more error-prone process because stock solutions often need to be diluted, and the harms to children of an error can be

more severe, she noted (JAMA 2001;285[16]:2114-2120). “Successful adoption of technologies like barcode scanning takes input and buy-in from front line staff,” Ms. Wilhelm said. “All of the strategies used by the Mott group led to a more successful implementation.” However, Ms. Wilhelm cautioned that despite the potential for safety improvement, new technologies “can be so cumbersome that workarounds are created, and that can lead not only to errors and wasted resources, but the technologies can end up being a huge dissatisfier for staff. “To prevent workarounds, it is critical to stress that barcoding is a medication safety system first and a documentation system second.” It is also important, she stressed, “to create a culture of safety around this technology by emphasizing the value of the technology in medication safety talks with staff.” Ms. Wilhelm said designing barcoding workflows with input from end users can help them better understand how the technology works, which also can help prevent workarounds before they become a problem. “But because some workarounds are inevitable, make sure there are adequate checks in the process to catch human error, such as image-based or gravimetric verification for compounding.” Dr. Workman acknowledged there were instances early on in the use of the technology at his pharmacy where staff overrode error messages, but with additional education, they learned to notify pharmacy leadership about these alerts. “The issue was passed on to the information technology department and they sorted out technological issues relatively quickly,” he said. “And there were several instances where the system was working perfectly and the issue was human error. Eventually staff learned that if there is a scanning error, there is something wrong that should not be overridden without consultation with the pharmacists on duty.” —David Wild The sources reported no relevant financial disclosures. Dr. Workman presented his research at the ASHP 2020 Midyear Clinical Meeting and Exhibition.

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PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2021

Partnership Yields Rx Cost-Savings Tool

hree years ago, the Medical University of South Carolina (MUSC) trimmed several million dollars from a multimillion-dollar drug budget by using a pharmacy-designed algorithm that searched the complex drug pricing universe to bring the best values to the surface. The software engine that drove those savings has since been spun off by MUSC into a separate enterprise called QuicksortRx, and its pharmacy spending benefit has been expanded to other health systems and hospitals nationwide. Now, QuicksortRx aims to extend its reach. The Charleston, S.C.–based pharmacy technology company recently formed a partnership with ASHP that will offer “next-generation pharmaceutical software and analysis” to additional health systems struggling to cope with the lack of drug pricing transparency. “One of the things that was really challenging to us was knowing when a price changed. That has never been very transparent,” said Paul Bush, PharmD, MBA, BCPS, ASHP’s vice president of Global Resource Development and Consulting, who was the chief pharmacy officer at Duke University Health System for a decade before joining the association. Dr. Bush said although the price changes “would be recorded on the specific line item, the individual responsible for drug procurement in the pharmacy department could not easily see them. Days could go by when we’d be paying a higher price.”

That lag time is the target of QuicksortRx’s supply chain purchasing tool. “We find all of those places where switching products would save money,” said Matt Hebbard, PharmD, QuicksortRx’s vice president of sales and accounts. “And we use historical purchase data and current pricing as well to project the impact of switching. We take the largest of those opportunities and we surface them to a dashboard, where they can be seen as an alert: ‘Here is something you can act on today to save your hospital significant costs.’” Being able to monitor fluctuating drug prices in close to real time—especially in the 340B space, where there is lots of movement—“is really important,” said Richard Montgomery, BSPharm, MBA, the contracts and operations manager at AdventHealth. “There are a lot of dollars left on the table when you don’t have access to that type of information,” he told Pharmacy Technology Report. At the time of the interview, AdventHealth was close to signing on with QuicksortRx. “We have services and such that do contract utilization,” Mr. Montgomery said, “but there is such a lag time. With Quicksort, you’re in the moment and you can act on it and see results within the next day or two.” As one of the country’s largest health systems, with dozens of hospitals across nine states, AdventHealth has an annual drug spend that Mr. Montgomery said was “north of $500 million. We are planning to start with a few select hospitals with a spend of around $60 million.

PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2021

If we can get 1% or 2% off of that, t, it would be a nice win. More than that hat would be great. You know, underderpromise and over-deliver.” The idea for QuicksortRx began an in a chance encounter that Dr. r. Hebbard had when he was work-ing as an informatics pharma-cist at MUSC. “My wife works att MUSC as well,” he told Pharmacy Technology Report. “One of her technicians was telling me about some purchase decisions he had made on oral dosage forms that [had a] pretty low delta in price.” Dr. Hebbard looked into it and realized “there was a lot of value to be gained by reviewing our product purchases more frequently.” But it was a difficult process. Over time, however, through a collaborative effort involving “the pharmacy department and purchasing, we began to do this work with greater efficiency.” Dr. Hebbard said he ran into J Jonathan Yantis, th Y nti now QuicksortRx’s CEO but then a network engineer at MUSC, who was looking for an innovative project to develop. The price search work being done in the pharmacy department seemed to fit the bill. Together, Dr. Hebbard and Mr. Yantis approached MUSC’s chief innovation officer seeking support for their project. They brought “proof-of-concept” numbers showing some “significant savings—a couple of hundred thousand dollars with a couple of days work in spreadsheets,” Dr. Hebbard said. They received the resources to push the concept forward. “And then as this progressed from spreadsheets to automation,” he added, “we realized that these opportunities arrive much more frequently than we thought. We ended up saving MUSC several millions the first year.”

The Beginnings of a Business Spin-off It also occurred to them that a technological tool that produced such results for MUSC had tremendous value as an intellectual property that could form the basis for a MUSC spin-off. So, they partnered with the MUSC Foundation for Research Development, which manages the patenting, licensing and royalty functions for the university’s startup properties, to form AscendRx, as the company was known before the name was changed to the much more descriptive QuicksortRx. The ASHP collaboration began initially at the South Carolina Society of Health-System Pharmacists’ annual meeting in March 2020, where Drs. Hebbard and Bush,

who also once served s as MUSC’s director of pharmacy se services, discussed the work that QuicksortRx was doing to reduce Quic medication costs. med In a follow-up phone call, “we talked about how we could work together,” Dr. Bush said. “One of the things we do at a ASHP Consulting Services is work with knowledgeable consultants that help health co systems improve their processsy es. We were so impressed with Quicksort’s tool in terms of optiQu mizing the drug spend by buying mi the right drugs at the right time that we knew this was a natural relationship that we should try to relat structure. So, we did.” struc —Bruce Buckley As the vice president and co-founder of A Quicksor QuicksortRx, Dr. Hebbard has an equity position in the c company. Dr. Bush and Mr. Montgomery rep reported no relevant financial disclosures.

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PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2021

Pharmacy Analytics a Boon to Operations

well-constructed data analytics program can help pharmacies optimize their operations and workflow and improve clinical interventions, according to a team at UC Davis Health, in Sacramento, Calif. The Department of Pharmacy Services at UC Davis Health decided to build its own data analytics service line after watching valuable data in their electronic health record (EHR) system sit with unrealized potential. “Not having access to that data really left us guessing as to our pharmacy’s performance, and we felt we weren’t meeting our needs as best we could,” said Ryan Cello, PharmD, the pharmacy supervisor–automation and technology at the health system. Among other goals, the pharmacy services department wanted to use hard data to fine-tune its operations and optimize par levels for its automated dispensing cabinet (ADC) use, Dr. Cello said.

Why DIY Made Sense He and his colleagues chose to develop their own data analytics system after realizing there were several disadvantages in contracting with a data analytics vendor. For one thing, “you are likely locked into a multiyear contract and are limited by their software build, which may not meet all your needs in your current state,” Dr. Cello said. “Also, client requests may not be prioritized among all the other customer requests.” As a first step in developing their system, the department hired a pharmacist trained in data analysis who could offer guidance on which data points and metrics to prioritize. For example, because the pharmacy wanted to make its central pharmacy operations more efficient, they chose

‘When a drug is in short supply, we can see which units use that drug most often and focus on educating those providers and pharmacy service lines on the use of alternative agents.’ —Ryan Cello, PharmD to track and analyze dispensing volume, compounding speed and ADC use. In subsequent stakeholder meetings, they verified that these metrics and the dashboards they designed indeed met everyone’s needs, Dr. Cello said. The team chose Tableau (www.tableau.com) as their dashboard system partly because it was already being used at the health-system level and by other departments. One process that Dr. Cello said has been very valuable, both in the initial phases of the project and in the management of ongoing requests for data reports, has been to ask people to draw a workflow diagram showing what they want to measure. “We use that to make sure everyone agrees on the definitions of the metrics and what question these metrics will be used to answer,” he said.

Applying the Dashboards

Since developing the system, the pharmacy has found that data reports and dashboards have become an indispensable part of daily operations, Dr. Cello said. For example, central pharmacy staff receive an email every day with a dashboard laying out data trends for everything from dispensing of oral liquids and premade IV formulations, to the number of messages received at specific times of the day. “We can drill down and add filters and use the data to further identify high-traffic times in the pharmacy and then use those insights to drive workflow changes and make modifications to technician shift times,” he said. Besides exploiting the data to improve their daily operations, the pharmacists have used analytics to manage extraordinary circumstances, such as drug shortages and surge planning during the COVID-19 panUC Davis Health uses a central IV mixture workload dashboard to track dispensing volume, demic, Dr. Cello noted. “When a drug compounding speed and other key metrics as part of its homegrown data analytics service.

see ANALYTICS, page 22

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BUYER’S GUIDE 2021 1

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Address: 107 College Road East, Princeton, NJ 08540 Phone: (866) 733-3952 Email: customercare@drreddys.com Website: www.drreddys.com Product Description: Dr. Reddy’s Laboratories announces the launch of Ertapenem for Injection, 1 g/vial, a therapeutic equivalent generic version of INVANZ (ertapenem for injection). Dr. Reddy’s Ertapenem for Injection, 1 g/vial, is available in packs of 10 vials per carton. INVANZ is a trademark of Merck and Co., Inc.

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Address: 125 Technology Parkway, Peachtree Corners, GA 30092 Phone: (833) 916-1554; Fax: (678) 775-7294 Email: econley@brightree.com Website: www.brightree.com/pharmacy Product Description: At Brightree, we bring you better results for your patients and profitability. Built on the industry’s most trusted cloud-based platform, our software significantly reduces the complexities and costs of managing pharmacy and infusion. Workflows are streamlined, referrals are automated and orders and billing are accurate, so you get paid faster and patients get medications more quickly and reliably.

CENTRAL ADMIXTURE PHARMACY SERVICES, INC. (CAPS) 503A / 503B / Consulting Services Address: 6430 Oak Canyon, Suite 200, Irvine, CA 92618 Phone: (800) 853-6498 Email: Marketing@CAPSpharmacy.com Website: www.CAPSpharmacy.com Product Description: CAPS®, a B. Braun company, is the nation’s largest network of outsourcing admixture pharmacies with 22 503A pharmacies and three 503B outsourcing facilities, delivering high-quality, same-day admixture services and solutions for more than 30 years.

20 PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2021

PROGRESSIVE MEDICAL, INC. Vial2Bag Advanced™ Admixture Device Address: 997 Horan Drive, Fenton, MO 63026 Phone: (314) 961-5786 Email: cs@progressivemedinc.com Website: https://www.progressivemedinc.com Product Description: The Vial2Bag Advanced™ 20-mm admixture device enables reconstitution and transfer of a drug between a vial and an IV bag prior to administration to the patient. The innovative needle-free and easy-to-use design is ideal for immediate use and can optimize pharmacy clean room time, while assisting in standardizing admixture procedures to maximize efficiency of pointof-care nursing.

BUYER’S GUIDE 2021 7

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IV ROBOTICS continued from page 8

After-installation services include a formulary tool kit that provides a beyond-use dating (BUD) library. The tool “allows our health system and hospital partners to extend beyond-use dating,” Mr. Wright said. Allegheny fully uses that extended BUD opportunity, Dr. Mehta said. “We follow the normal routine of quarantining the product and sending a sample out to a thirdparty lab for testing because we want that extended BUD for these products. Once the results come back, the product is released from quarantine and it becomes generally available. The majority of medications that we compound in the robot are stored in our automated dispensing cabinets on the nursing units as well as in our anesthesia carts in the OR.” Although robots can seem prohibitively expensive, Dr. Mehta said he expects a net savings of $1.6 million per year once they are both fully operational. That includes, he said, the cost of the medications, the technology, the third-party testing and even the salary of a pharmacist dedicated to managing the program. “It’s not necessarily about the finances,” he said. “There is a safety component and the drug shortage component, and we have control of our inventory. But at the end of the day we do need to justify the investment. And this is a huge financial saving and a benefit to the organization.”

Uptake Still Slow Despite technological advances, hospital adoption of robotic IV compounders has remained relatively limited. According to a recent Institute for Safe Medication Practices survey, only about 8% of hospital pharmacies use a robot to prepare sterile medications (bit.ly/3qN37fF). That rate

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may be expected to increase, however, as the technology continues to progress and vendor competition makes the return on investment more attractive to hospital executives. “Robotic compounding systems are improving all the time,” said Jerry Fahrni, PharmD, a health information technology expert. “They offer improved safety for both employees and patients by removing human hands from many of the steps in the compounding process. This is especially true for hazardous drugs compounding. “Although these robots don’t completely automate the entire CSP [compounded sterile products] process,” he added, “they have automated safety features such as object-recognition, barcode scanning, image capture of critical steps and plus/minus scales.” Those scales refer to a measurement of accuracy obtained via gravimetrics, a technology that is one of the main advantages of IV robotics, Dr. Fahrni noted. Gravimetrics can be used to precisely weigh the ingredients of a prepared drug dose. The final product is considered acceptable by the robot if it falls between plus or minus 5% of the expected weight (J Oncol Pract 2012;8[6]:344-349). “I’ve always liked the idea of using robots for CSP production,” added Dr. Fahrni, a member of the Pharmacy Technology Report advisory board. “But in my opinion they were never quite ready for prime time. Five years ago, I don’t think I would have had much good to say. But times changes and things get better. Overall, one could argue that there is a potentially positive return on investment for compounding robots in specialized situations. They’re not for everyone, but for those situations where they fit, I think they hold value.” —Bruce Buckley Dr. Mehta reported no relevant financial disclosures. Dr. Fahrni reported that he sits on the Omnicell IV Automation Innovation Group.

PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2021

22 PHARMACY TECHNOLOGY REPORT •

SEPTEMBER 2021

ANALYTICS continued from page 18

is in short supply, we can see which units use that drug most often and focus on educating those providers and the pharmacy service lines on the use of alternative agents,” he explained. When the hospital had 200 unoccupied beds in the early months of the pandemic, Dr. Cello and his colleagues used data reports to guide staffinglevel reallocation. They also used UNC Health’s Department of Pharmacy uses Tableau dashboards to track COVID-19 cases reports to make sure ICU providacross its sites of care to better manage resources during the pandemic. ers had access to medications they needed to manage COVID-19 patients through ADCs. advanced analytics and reporting, and they are in a good “When we needed to set up a new ICU ADC in a nonposition to build strong relationships with the hospital’s IT ICU unit in anticipation of a wave of COVID-19 patients, department,” Dr. Vest said. analyzing medication use from ADCs with comparable In terms of applying data, Dr. Vest’s team moniICU patient populations allowed us to install the new ADC tors pharmacy trends to make operational and cliniwith optimized inventory and par levels within a couple of cal changes. For example, as they recently published, days,” he said. tracking antimicrobial use has helped them create At the health system’s retail pharmacy, pharmacists interventions that have resulted in a 6.5% reduction in have been tracking discharge prescription capture rates use of antibiotics associated with Clostridioides difficile and identifying prescribers who are least likely to use infection (Am J Health Syst Pharm 2021;78[1]:65-73). their hospital’s retail pharmacy, Dr. Cello said. Doing so Monitoring parameters such as hemoglobin A1c level has enabled them to provide targeted education regardand blood pressure control also has been useful in ing the benefits of using their retail pharmacy. “For demonstrating the effectiveness of clinical pharmacist example, we emphasize that the retail pharmacy shares interventions and in helping them find ways to better the same electronic health record with providers,” he said. target these interventions, she added. One advantage of having an in-house analytics system “Having a pharmacy-managed data analytics program has been that it allows pharmacists to identify and add has also led to a much faster turnaround time to complete new goals anytime, Dr. Cello said. “Assuming the data are data requests, reports and dashboards, compared to cenvalidated, if we need something changed, we can quickly tralized IT analytics support,” Dr. Vest said. modify the dashboards to help us meet those new goals.”

Tracking COVID-19 Start Small Mary-Haston Vest, PharmD, the clinical manager of analytics and outcomes at UNC Health’s Department of Pharmacy, in Chapel Hill, N.C., advised hospital and health-system pharmacies thinking about building their own analytics program to start small. “Our program began with a 0.5 full-time equivalent position, and growth came as leaders began to recognize the value of the data,” Dr. Vest said. Now, the analytics and outcomes team includes four pharmacists, six nonpharmacy staff and a part-time pharmacy intern, she said, noting that the mix of personnel has been important. “Because most of our pharmacists are also trained in advanced data analytics, they bring both clinical expertise and technical knowledge, while nonpharmacists have the traditional IT [information technology] and data science background and the skill set to further support

UNC also used the Tableau dashboards to track COVID19 cases across its sites of care to better manage resources during the pandemic. When cases started mounting, analytics teams used the technology platform to create new dashboards, starting with reports for executives and leadership teams. The dashboards showcased several key operational areas, including data on testing, utilization, personal protective equipment inventory, available bed space and supply chain vulnerabilities, according to an account of the initiative on the Tableau website (tabsoft. co/3fP33Jl). Clinical teams and hospital administrators also used the data to rank vulnerability for patient cases and managed care delivery priorities. —David Wild

Drs. Cello and Vest reported no relevant financial disclosures. Dr. Cello presented his research at the ASHP 2020 Midyear Clinical Meeting and Exhibition.

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I N J E C TA B L E S

You make Promises. We help you keep them. Your customers and their patients depend on you. High quality, injectable drugs—available when they need it—are not an option. At Dr. Reddy’s, we know what it means to deliver on our promises. We are committed to making affordable and innovative injectable medicines available to our customers. Our promises are backed by high-quality system standards, sophisticated, real-time supply chain technology, and more than 20,000 committed employees who know that Good Health Can’t Wait.

Dr. Reddy’s Laboratories, Inc. | 107 College Road East, Princeton, NJ 08540 | Tel: 866-733-3952