Implementing Bar Code Medication Administration BCMA Using a Legacy System

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History. Started 2004 Early 2006 Decided to Develop in Health Evaluation through Logical Processing (HELP)Implemented in 2007- Opening of IMC. Advantages of Legacy System. Database Model Already ExistedAgile Development Process/Release ScheduleNurses Already Familiar With Current e-MAR C

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Implementing Bar Code Medication Administration BCMA Using a Legacy System

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1. Implementing Bar Code Medication Administration (BCMA) Using a Legacy System By Dawn Fell CIS, Project Manager/Analysis

2. History Started 2004 Early 2006 Decided to Develop in Health Evaluation through Logical Processing (HELP) Implemented in 2007- Opening of IMC First I would like to give you a brief time line as to how long BCMA has been in the sights of IHC. IHC began looking at BCMA in early 2004 to look at what platform we were going to develop BCMA. After multiple discussions. In Early 2006 It as decided to implement in our legacy system – which is known as Health evaluation through Logical Processing. (HELP) a pilot was done in MICU at LD in 2006. Testing the application and different types of scanners. The MICU was considered live in December of 2006 Further implementations quickly followed. The goal of our implementation was to first implement all care units moving to Intermountain Medical Center that was planned to open Oct 29 2007. So we ended up implementing 17 units in 8 months time. Dec-Jul. August was spent setting up IMC for opening. First I would like to give you a brief time line as to how long BCMA has been in the sights of IHC. IHC began looking at BCMA in early 2004 to look at what platform we were going to develop BCMA. After multiple discussions. In Early 2006 It as decided to implement in our legacy system – which is known as Health evaluation through Logical Processing. (HELP) a pilot was done in MICU at LD in 2006. Testing the application and different types of scanners. The MICU was considered live in December of 2006 Further implementations quickly followed. The goal of our implementation was to first implement all care units moving to Intermountain Medical Center that was planned to open Oct 29 2007. So we ended up implementing 17 units in 8 months time. Dec-Jul. August was spent setting up IMC for opening.

3. Advantages of Legacy System Database Model Already Existed Agile Development Process/Release Schedule Nurses Already Familiar With Current e-MAR Charting. Because the database model already existed, after the decision was made to develop in HELP. It only took 2-3 weeks to have a prototype. we could really focus on the BCMA flow and make improvements quickly. met regularly to reassess data flow and changes where made the system with a quick turn around A biggie the nurses were familiar system and behaviors of the HELP systems. We could really focus in on just the application of BCMA. Because the database model already existed, after the decision was made to develop in HELP. It only took 2-3 weeks to have a prototype. we could really focus on the BCMA flow and make improvements quickly. met regularly to reassess data flow and changes where made the system with a quick turn around A biggie the nurses were familiar system and behaviors of the HELP systems. We could really focus in on just the application of BCMA.

6. Required components PC at Bedside Scanner Barcode on the Medication Barcode on the Patient Identification Band Required components needed in order to have BCMA work for our corporation is We need to have the pc located in all patient rooms. Scanner one per room Barcodes must be on both the Medication and Patient. Required components needed in order to have BCMA work for our corporation is We need to have the pc located in all patient rooms. Scanner one per room Barcodes must be on both the Medication and Patient.

7. Bedside PC Not All of the Facilities Were Identical If the Facility Used HELP If the PC Was Missing Where Did We Place it Close Proximity of the Patient We initially thought that all of the patient care rooms had pcs in the rooms but as we started to move through the facilities. It was apparent that there were a lot of inconsistencies. We had to physically assess each room to ensure a pc was present. If not we needed to ensure one was ordered in time for the scheduled go live. Or the project would fall behind schedule. We initially thought that all of the patient care rooms had pcs in the rooms but as we started to move through the facilities. It was apparent that there were a lot of inconsistencies. We had to physically assess each room to ensure a pc was present. If not we needed to ensure one was ordered in time for the scheduled go live. Or the project would fall behind schedule.

8. Scanners Users Survey – Not Users Preferences. 1D-2D Scanning Ability Wireless -vs- Wired Number of Scanners For Use on Units. Scanners where demoed in the pilot and the nurses submitted a survey choosing the scanner they felt worked the best. After a long discussion of possible future use of the scanners the Committee decided to use a scanner other than the users preference. It came down to the decision of 1D scanning verses 2D scanning. Because 2D scanning can hold more information about a patient in a smaller area we thought a 2D scanner would provide more flexibility for future projects. It would give us the ability to move forward. In addition the scanners we choose came in a wireless solution and a wired solution We had to decide which scanner to use. We actually have a fair number of both, but the wired solution is the solution that currently works best for our users We also looked at the number of scanners we would use per unit. Initially thinking to use a model of one per nurse per shift. So if I could only have 7 nurse and respiratory therapist working on one given shift then that unit would only have 7 scanners for that unit. We analyzed it and decided to use one per room. Which increased the budget significantly. Scanners where demoed in the pilot and the nurses submitted a survey choosing the scanner they felt worked the best. After a long discussion of possible future use of the scanners the Committee decided to use a scanner other than the users preference. It came down to the decision of 1D scanning verses 2D scanning. Because 2D scanning can hold more information about a patient in a smaller area we thought a 2D scanner would provide more flexibility for future projects. It would give us the ability to move forward. In addition the scanners we choose came in a wireless solution and a wired solution We had to decide which scanner to use. We actually have a fair number of both, but the wired solution is the solution that currently works best for our users We also looked at the number of scanners we would use per unit. Initially thinking to use a model of one per nurse per shift. So if I could only have 7 nurse and respiratory therapist working on one given shift then that unit would only have 7 scanners for that unit. We analyzed it and decided to use one per room. Which increased the budget significantly.

9. Limitations of Scanners Room Size Responsiveness Learning Curve Ergonomics The reason we went with 2 different scanners was because of some of the limitations. If we went with all wired scanners then room size became an issue. At cottonwood the patients where two to a room –meaning another computer would have to be placed and a scanner. At IM the rooms are much bigger than any of the other hospital rooms in the region. Not to mention the number of IV lines and tubes. Some of the issues if we went with all wireless. There is a significant learning curve involved in using the wireless solution. Because it captures the data similar to taking a picture then transfers if to the modem, scanning must be done with a steadier hand. With the initial thinking to have the nurses carry a scanner there was many complaints of the scanner not working. It wasn’t very ergonomically correct. We then decided to purchase battery handles for each wireless scanner. The reason we went with 2 different scanners was because of some of the limitations. If we went with all wired scanners then room size became an issue. At cottonwood the patients where two to a room –meaning another computer would have to be placed and a scanner. At IM the rooms are much bigger than any of the other hospital rooms in the region. Not to mention the number of IV lines and tubes. Some of the issues if we went with all wireless. There is a significant learning curve involved in using the wireless solution. Because it captures the data similar to taking a picture then transfers if to the modem, scanning must be done with a steadier hand. With the initial thinking to have the nurses carry a scanner there was many complaints of the scanner not working. It wasn’t very ergonomically correct. We then decided to purchase battery handles for each wireless scanner.

10. Medication Barcoded - Pharmacy Prep Partial Doses ½ tabs and ¼ tabs Partial liquids Tabs ( 1-2) Range Doses Insulin Orders the 3rd requirement is to have a barcode on every or almost every medication. In the early implementations there were a lot of concerns as to how we were going to ensure this was done. This question needed to be answered even though the FDA requires NDC codes to place on all manufactured medications. We had to deal with partial tablets. Sometime ½ tabs or ¼ tabs were used to fill the order. Partial liquids were a problem Medication ranges giving 2 or 3 tablets to fill an order. In addition we had range doses like insulin and morphine - (could only match and verify correct medication Not amount) IV, IM & SQ There were some vendor packaging issues – but most have been resolved the 3rd requirement is to have a barcode on every or almost every medication. In the early implementations there were a lot of concerns as to how we were going to ensure this was done. This question needed to be answered even though the FDA requires NDC codes to place on all manufactured medications. We had to deal with partial tablets. Sometime ½ tabs or ¼ tabs were used to fill the order. Partial liquids were a problem Medication ranges giving 2 or 3 tablets to fill an order. In addition we had range doses like insulin and morphine - (could only match and verify correct medication Not amount) IV, IM & SQ There were some vendor packaging issues – but most have been resolved

11. Medication Barcoded - Pharmacy Prep Labels Zebra Label Printers Medi-Dose McKesson Pack Plus Non Medications Salt Tap Water Point of Care Glucose Scan Some solution were resolved from producing our own labels Currently the pharmacy uses McKesson pack plus to package most of the bulk medications and other NDC codes partial tabs are made using the medi-dose. For any Intravenous solutions mixed in the pharmacy a patient label is made. A patient label identifies that this med order matches the med ordered number for this patient. IV meds such as Antibiotics . Another issues we encountered during the implementations were non medications that were entered on the emar and were not necessarily medications. For example salt, tap water, and point of care glucose scan. our wonderful developers were able to by pass scanning using the f5 function key for these types of items Some solution were resolved from producing our own labels Currently the pharmacy uses McKesson pack plus to package most of the bulk medications and other NDC codes partial tabs are made using the medi-dose. For any Intravenous solutions mixed in the pharmacy a patient label is made. A patient label identifies that this med order matches the med ordered number for this patient. IV meds such as Antibiotics . Another issues we encountered during the implementations were non medications that were entered on the emar and were not necessarily medications. For example salt, tap water, and point of care glucose scan. our wonderful developers were able to by pass scanning using the f5 function key for these types of items

12. Patient Identification Each Patient Had to Have Barcode on the ID Band Initially Tried to Find Cheaper Method NICU – How to Ensure These Patients Have ID Bands With Barcodes Embosser Can Not Use 2D At IHC we looked at many alternatives to the bands to the traditional embossed bands. Tried to find a Cheaper Method for Identifying Patients. We tested American Fork turned out to have more problems. When printed the band was shiny and the barcode was more curved making it more difficult to scan. The bar code wore away quicker than having it printed on the embossed id bands. In the end we stuck with our traditional embossed bands. At IHC we looked at many alternatives to the bands to the traditional embossed bands. Tried to find a Cheaper Method for Identifying Patients. We tested American Fork turned out to have more problems. When printed the band was shiny and the barcode was more curved making it more difficult to scan. The bar code wore away quicker than having it printed on the embossed id bands. In the end we stuck with our traditional embossed bands.

13. Nursing workflow Printed MAR vs e-MAR Prep at bedside Charting in real-time Pharmacy and Nursing communication Some effects on nursing we considered is How was their work flow going to be interrupted. 1 although the nurses have been using this system to give meds. They never used the system the way it was designed. Meaning they would administer the medication then may 4 hour later chart their medication or chart all the medications. 2 The system is designed that the nurses medication prep should take place in the rooms. So the nurse would only go to the medication room to collect the meds and take them to the patient rooms to scan and then open in to the medication cup. All preps are expected to take place. Crushing, cutting and Mixing of medications.; 3 These changes are necessary because the scanning must be done in real time. 4 Communication for nursing and pharmacy had to improve. In order for this system to run well there needs to be contiuous communication when meds are not entered into the system. In many facilities the pharmacists is the 1st line of support to the nurses. Some effects on nursing we considered is How was their work flow going to be interrupted. 1 although the nurses have been using this system to give meds. They never used the system the way it was designed. Meaning they would administer the medication then may 4 hour later chart their medication or chart all the medications. 2 The system is designed that the nurses medication prep should take place in the rooms. So the nurse would only go to the medication room to collect the meds and take them to the patient rooms to scan and then open in to the medication cup. All preps are expected to take place. Crushing, cutting and Mixing of medications.; 3 These changes are necessary because the scanning must be done in real time. 4 Communication for nursing and pharmacy had to improve. In order for this system to run well there needs to be contiuous communication when meds are not entered into the system. In many facilities the pharmacists is the 1st line of support to the nurses.

14. Overriding with double check????? We knew that the system would have to allow the nurse to go into the system and manually enter medication: These overrides would occur in cases where the patient need a med right away. the barcode was missing or not readable. Ect. One nursing workflow changes we introduced with this implementation was having the nurse provide a double check of the medication to be given. But we were more concerned with the with another nurse. The nurse double checking would have to type in her name to for verification. This double check would occurred when the system needed to be overridden. T We knew that the system would have to allow the nurse to go into the system and manually enter medication: These overrides would occur in cases where the patient need a med right away. the barcode was missing or not readable. Ect. One nursing workflow changes we introduced with this implementation was having the nurse provide a double check of the medication to be given. But we were more concerned with the with another nurse. The nurse double checking would have to type in her name to for verification. This double check would occurred when the system needed to be overridden. T

15. Today's Override Screen

16. Training Tools Less Effective Tools: Power Point with screen shots High-level flow charts Effective Tools: Computers on wheels with scanners attached Sample Medications for hands on use Error Alert Tables w/ messages and meanings

17. Training Lessons Learned More Training Scenarios/Test Cases Minimum Training Should be Mandated BEST PRACTICE: Hands on Training by All End Users with Packaging From Real Medications

18. Questions????? (Demonstration)

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