Hospital Pharmacist
Vol 12 No 1 p27-30
January 2005

American Society of Health-system Pharmacists

Changes in the health care environment and the pharmacy supply chain were covered at the ASHP midyear clinical meeting. Gareth Jones, Christine Clark and Laurence Goldberg report

Three big issues in health care: manpower, money and quality

Money, manpower (or talent) and quality are the three things that keep health care leaders awake at night and affect health care workers on a daily basis. This is according to the conference keynote speaker, Connie Curran, executive director of C-Change, an organisation of leaders from the US government, business, and non-profit sectors which presents a vision of the future of health care.

Quality of health care, and patient safety in particular, is an area that has become more important in the US, as well as the UK. It is exactly five years since the Institute of Medicine published its report “To err is human: Building a safer health system” report at the American Society of Health-System Pharmacists (ASHP) in 1999. This report suggested that 98,000 patients died as a result of medical errors every year in the US. This figure dramatically exceeds that for motor vehicle accidents (43,458), breast cancer (42,297) and AIDS (16,516). Two out of every 100 admissions involve a preventable adverse drug event affecting inpatient costs of $2bn (£1bn). These events should and could be prevented, stated Ms Curran. One way to do this would be to use computerised physician order entry (computerised prescribing) systems, as this can cut drug errors by 50 per cent.

Even at the top hospitals in the US, care varies greatly, said Ms Curran. For example, the Mount Sinai Hospital in New York and the Mayo Clinic are two of the most respected health care institutions in the US. However, patients stay at the Mount Sinai twice as long as they stay at the Mayo Clinic. It has also been shown that, in hospitals where more tests are undertaken, the quality of care is no better. In some cases, high intensity care for terminally ill patients can increase mortality. She suggested that these quality disparities between hospitals should not exist.

Turning to the issue of money in the US health system, Ms Curran said that one-third of hospitals in the US made an operating loss in 2003. This was because of an over-reliance on providing acute care which is expensive, she said (eg, intensive care costs $3,000/patient day and acute care costs $1,000/patient day). Demand is increasing and the ageing “baby boomer” generation is straining hospital capacity. Hospitals became less profitable in the late 1990s. They are now focusing on patient mix to ensure that they have enough profitable surgical work to balance their budgets.

Regarding the cost of prescription drugs, Ms Curran defended the work of pharmaceutical companies. She felt that pharmaceutical companies did not take enough credit for the significant investment they put into research and development. She said that it was important for health care workers to explain to patients (and society) the benefits of drugs and the resulting costs. However, there is concern that prescription drugs are more expensive in the US than the rest of the western world. In 2003, US consumers paid an average 81 per cent more for patented brand-name drugs than consumers in Canada and six European countries.

Negligence claims are increasing and this also has a negative affect on the financial state of the health sector. Increasingly, insurance premium increases are being cited as reasons for physicians to retire or not enter an area of practice, said Ms Curran.

A problem specific to the US is the average cost of purchasing annual health care insurance for a family, which has increased by over a quarter in the last two years to over $10,000 (£5,000). Health insurance inflation is currently running at five times the rate of wage increases. This has resulted in many smaller companies withdrawing from providing health care as a benefit to employees or requiring patients to make a large contribution if they use a service. As a result, over 50 million Americans are now without health care cover.

In relation to manpower, Ms Curran said that there is a shortage in all health care professions. The pharmacist vacancy rate in US hospitals is 12.7 per cent. She predicted that trade unions would become more involved in the workplace to promote better working conditions for health care professionals. This is partly because health care workers are in a stronger position than many workers as their jobs cannot be outsourced overseas. Another concern is the lack of young nurses, since the average age of a hospital nurse is 47.

Ms Curran also encouraged hospital managers to aspire to be the employer of choice (ie, the preferred employer) and recruit and retain the right staff. She asked participants to consider the realities of why staff sometimes left (ie, bad management, lack of development, poor career opportunities, poor culture and better rewards elsewhere).

On the issue of training, Ms Curran praised the pharmacy profession for raising its entry level qualification. The entry level degree in the US is now a doctorate in pharmacy.

Concluding, Ms Curran urged participants to initiate the process of turning their institution into a “magnet hospital”. Magnet hospitals must meet stringent quantitative and qualitative standards that define the highest quality of nursing practice and patient care. She also urged participants to substitute capital for labour, where possible. She explained: “If a machine can do something, then let it. You can then spend more time with your patient.”

Pharmacists improve outcomes by managing drug therapy clinics for heart disease

A seven-year study of clinical pharmacy interventions at the US managed health care company Kaiser Permanente has shown that pharmacists, technicians and nurses can improve clinical outcomes and reduce costs in the treatment of dyslipidaemia as secondary prevention for coronary artery disease and hypertension.

The programme involves nurses performing an initial patient assessment. Pharmacists then initiate drug therapy and laboratory tests according to a protocol, monitor blood pressure and laboratory results and adjust drug therapy accordingly. Pharmacy technicians are also involved in communicating with patients on maintenance therapy.

Low-density lipoprotein values of less than 130mg/dL were achieved in 93.6 per cent of patients in the programme compared with 66.9 per cent in a control group. Control of hypertension as measured by a blood pressure of less than 140/90mmHg was achieved in 69.7 per cent of patients in the programme compared with 66.6 per cent outside. Other benefits included an 8.8 per cent reduction in visits to the emergency department and a 21.7 per cent decrease in hospital admissions. Satisfaction among 6,000 patients in the programme was 99 per cent. Labour costs involved in managing drug treatment reduced significantly on implementation of the new model from $720 in 1997-8 to $105 in 1999.

Pharmacist Ming-Ming Tung-Edelman and colleagues of Kaiser Permanente argued that the use of team-based care, clear entry and exit criteria and a robust clinical record contribute to the programme’s operational efficiency and sustainability.

The care model was first set-up in response to a challenge to demonstrate the value of clinical pharmacy resources in response to a shortage of pharmacists and increasing salaries. The historical model of pharmacists setting priorities based on requests of the health care team was deemed to be no longer viable.

Kaiser Permanente is a managed health care organisation which has recently established a presence in the UK (Pharmaceutical Journal 2004;272:601). Its philosophy is that a hospital admission indicates that the systems of prevention and treatment in the community has failed. It actively manages patients and promotes self-care and shared-care.

The authors of the study were presented one of this year’s American Society of Health-System Pharmacists (ASHP) Pfizer best practice awards for this work.

Award for scheme to reduce errors by focusing on key drugs

Adverse drug events in a group of US hospitals were reduced by 51 per cent over 10 months after the introduction of a patient safety system that focused on the prescribing of high-risk and frequently used medicines (ie, anticoagulants, sedatives and insulin). Initiatives undertaken as part of the project included the validation of a tool for classifying the severity of reported adverse events and the appointment of a medication safety co-ordinator. Mechanisms were developed to ensure that adverse drug events were consistently identified. Other developments included the creation of a pharmacy practice and medication safety residency. There has also been a move towards viewing adverse drug events as system rather than individual failures.

OhioHealth, where the project has been undertaken is a health system which consists of 13 hospitals with over 70,000 non-obstetric admissions annually. The project team was awarded the first American Society of Health-System Pharmacists Research and Education Foundation Excellence in Medication-Use Safety Award.

In the same award scheme, Fairview Health Services, Minnesota won a runner-up prize. Among the initiatives implemented at this health service was the involvement of pharmacy technicians in the medication history process resulting in a 82 per cent reduction in incomplete histories. A pharmacist-led anticoagulation clinic resulted in a 76 per cent reduction in the incidence of supra-therapeutic international normalised ratios. Procedures for standardising prescription orders and checking high-risk medication were also implemented.

Laboratory results generate pharmaceutical care alerts

Laboratory data indicating that a patient has experienced a myocardial infarction is used by pharmacists at the Barnes-Jewish Hospital, St Louis, Missouri, to improve compliance with clinical guidelines for these patients.

When a troponin level of greater than 1.4mg/dL within 24 hours of a patient’s admission is detected on the hospital’s computer an alert is sent to a clinical pharmacist. The pharmacist then intervenes and makes recommendations to the patient’s physician about appropriate therapy.

Data were collected before and after implementation of the new system. Before the scheme started, aspirin, statins, beta-blockers and angiotensin converting enzyme inhibitors were prescribed in only 88 per cent, 80 per cent, 71 per cent and 60 per cent of patients respectively. Secondary prevention guidelines recommend these therapies as they reduce the risk of subsequent cardiac events and death. At discharge, average prescribing rates have increased to 98, 97, 98 and 94 per cent respectively. The programme has now been running for over two years and the improvement in the percentage of patients discharged on appropriate post myocardial infarction medication has been maintained.

The project authors were presented one of this year’s ASHP Pfizer best practice awards for this work.

How to eliminate waste from the supply chain

Understanding and deploying an effective, benefit-based hospital supply chain will significantly eliminate waste and enhance health care quality while reducing costs. This is according to Mitch Javidi, chief executive officer and president, Digiton Corporation, Holly Springs and director, Pharma Forum, College of Management, North Carolina State University. For the past few years, health costs have risen as a proportion of gross domestic product and hospitals in the US are now under great financial pressure.

The hospital supply chain presents enormous opportunities for hospital managers seeking to reduce costs and gain new efficiencies. Supply chain managers can contribute to strengthening the financial position of their institutions by leading on cost savings initiatives and making strategic technology investments that drive efficiencies. Too often, supply-chain performance is undermined by the presence of diverse and complex manual processes supported by fragmented technology. Assigning accountability for managing the supply chain will accomplish little if these deficiencies are not addressed,Dr Javidi said.

A number of issues are facing hospital chief executives. Sixty-one per cent of hospitals are losing money or are barely breaking even. Twenty-five per cent of hospital costs are supply-related and there is an estimated $11bn (£6bn) wastage in hospital supply chains. Moreover, counterfeiting is on the increase and labour is in short supply.

Review supply chain

The redesign effort should focus initially on processes, with a review of every step in the supply chain, from cataloguing and tracking products to selecting a vendor. Only when a hospital knows precisely which processes will need to be automated and who the system users will be at each point in the supply chain can it develop a clear view of what information system requirements will be needed.

One of the primary goals of effective product management is to reduce variability of supplies. Too much variability is often the result of excessive differentiation among products which tends to occur when decisions about the products to purchase are based solely on the recommendations of individuals. Although individual views are important, the unfortunate consequence of relying on them may be an over-emphasis on tiny distinctions among products that do not impact product use or outcome.

Counterfeit drugs and product tampering are new problems affecting the supply chain said Dr Javidi. Counterfeit drugs are often visually indistinguishable from legitimate drugs. As part of a recent investigation, the Food and Drugs Administration (FDA) ordered three products from the website of a pharmaceutical supplier that claimed to be “FDA approved” and was apparently based in Canada. When the products arrived they were postmarked Dallas but gave a return address in Miami. The company’s listed telephone number was in Belize and the payment was processed in St Kitts.

Further investigation showed that the server for the website was in China and that the products were counterfeit. “The absence of fully-integrated processes makes you vulnerable to counterfeit products”, said Dr Javidi.

To address all these supply chain problems, a systematic analysis of product options is required. The process should be focused on narrowing the choice to those products that are of the highest quality and that promote the best outcomes. The object should not be to reduce choice but to make choice more rational.

One way to promote product standardisation is to develop a strong supply catalogue. This, complemented by the use of Radio Frequency Identification Devices (RFID) is a highly successful strategy. RFIDs are tiny microchip and antenna units capable of storing and transmitting information. They enable unique identification of the tagged product throughout the supply chain. This ensures products can be tracked and prevents counterfeiting and diversion (theft). The main advantage over bar coding is that there is no need for staff to stop and scan each item individually. A further advantage is that each unit is unique because it is associated with a individual electronic code. Hence different packs from the same batch can be distinguished from each other.

RFID has been slow to take off. Hospitals and suppliers have made a considerable investment in bar code technology and a sizeable investment is required to change to RFID. There is also a lack of uniformity in RFID models. For example, Wal-Mart wants to use 915 MHz while other retailers prefer 13.56 MHz. Hospitals are reluctant to introduce RFID as they think it might interfere with other hospital equipment.

Dr Javidi concluded by offering two strategies for improving supply chain processes. Either focus primarily on improving purchasing through price reductions and realise some immediate benefits that will diminish over time or redesign processes and use technology to automate the new processes and to generate steady annual savings.

Prepare for supply chain crises

Medicines’ supply chain crises should be modelled in a similar way to major disasters, said Charles Daniels, School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego. In this way, procedures to respond to acute supply shortages could be developed and time, effort and risks to patients would be reduced when problems arose.

A recent event served to illustrate how this type of problem could occur. A preservative-free methotrexate injection for intrathecal administration had been ordered. The supplier was unable to provide the original product but the wholesaler’s software was able to suggest alternatives. At least one of the alternatives contained a preservative and a preservative-containing product was supplied. When it arrived, the receiving pharmacy department did not notice that it contained a preservative and it was passed to the dispensing area. Several intrathecal doses were prepared and administered. “Where did the supply chain fail?” asked Dr Daniels.

Supply chain management is more critical now than in the past because few hospitals maintain large stocks and most depend on “just-in-time” delivery. Sometimes the correct product cannot be supplied and sometimes the wrong product may be ordered or supplied because of confusing and inconsistent product descriptions, or because of clumsy technology. Dr Daniels recommended that pharmacists should respond to supply chain failures by reviewing the key events, using root cause analysis to determine what went wrong and, above all, learn from errors and “close calls”. Wholesaler performance should also be monitored. “It makes a big difference when wholesalers know that the pharmacist is watching what they do and asking about their procedures,” he said.

Opportunities in computerised prescribing

The implementation of computerised physician order entry (CPOE) in a large multi-facility health organisation represents a significant opportunity for pharmacy staff, according to James Carpenter, Regional Information Services, Providence Portland Medical Center, Portland, Oregon. Pharmacists need to contribute to the design and development of systems that will directly impact on their work. They also need to take on proactive roles in user training and implementation support. Engagement of pharmacy staff is a significant success factor in system implementation because of their comfort with drug therapy and monitoring, which is the most complicated element of CPOE. Other key factors include their familiarity with computerised order entry processes, their understanding of the potential shortcomings of computerised decision support and their involvement in the multi-disciplinary work environment.

Mr Carpenter went on to say that pharmacists’ contribution to the architecture and design of the system ensures a better fit with local pharmacy practice and supports evidence-based medicine use and patient safety throughout the organisation. Pharmacy staff should be encouraged and empowered to participate in all aspects of system roll-out. CPOE breaks down the walls between disciplines but pharmacist engagement in the early design stages ensures successful implementation. He concluded by reminding the audience that workflow patterns change forever and pharmacy’s participation in the maintenance of the system never stops.

Future CPOE systems will be device independent offering web-based, real-time wireless review and update from anywhere in the institution said Ron Robb, pharmacy product manager, IDX Systems Corporation, Seattle, Washington. First generation CPOE systems sought to manage clinical information, and as a by-product, improve legibility, patient safety, completeness of records, timeliness and formulary guidance.

The next generation of CPOE systems will set the stage for the exercise of clinical judgment, explained Dr Robb. The evolution of the next generation of CPOE systems and its effects on the practice of medicine and pharmacy is driven by many organisational, financial, regulatory, and technological factors. Development trends include enterprise-wide systems (eg, a group of several hospitals or clinics), more sophisticated clinical decision support, embedded best practice guidelines, evidence-based medicine, workflow engines, medical vocabularies and web technologies. Evolutionary structural changes will include the integration of smart infusion pumps and the next generation of automatic dispensing robots and improved security by advances in authentication, authorisation and auditing, said Dr Robb. Other likely developments will be improved accuracy and efficiency of therapeutic decision-making, population surveillance, antimicrobial management and formulary checking. Patient safety will also be improved by integrating medicines management, including bar code charting, with e-prescribing. Mr Robb concluded by posing the questions: “What if guideline content became active, offering targeted relevant guidance at the point of care? What if patients were evaluated against proven guidelines automatically? What if key data were presented at critical decision points automatically?” If the answers are affirmative then the next generation of CPOE is already with us, he said.

Project leads to reduced waiting times

A significant reduction in the waiting time for discharge prescriptions was one of the benefits of a project undertaken by Alexa Wall and colleagues at Wishaw General Hospital, Lanarkshire. The main objective of the project was to redesign the medicines’ supply system to use patients’ own drugs throughout their hospital stay and at discharge, supported by one-stop, original pack dispensing.

The time taken to complete the stages of the discharge journey were documented in order to identify the rate-limiting steps. The average waiting time for a discharge prescription was reduced from over three hours to 65 minutes and 72 per cent of discharge prescriptions are now ready at the bedside. Nurses said that more time was available for patient education. The financial analysis of the pilot demonstrated an average saving of £13.23 per patient per admission in primary care and £26.42 to the acute operating division. These figures incorporated the cost of providing original packs.

Electronic prescribing can diminish technician role

Electronic prescribing has reduced the professional role of the dispensary-based pharmacy technician, according to Ann Mold, senior pharmacy technician, City Hospitals Sunderland NHS Foundation Trust. Ms Mold presented a project on pharmacy staff perception of the effect of electronic prescribing on the future role of the pharmacy technician as a poster at the conference. She believes that pharmacy technicians have now likened the dispensing process to a factory production line and suggests that a skill mix review of dispensary staff is needed now that the role has changed.

Ms Mold and colleagues analysed 25 questionnaires returned (40 per cent response). De-skilling of pharmacy technicians was reported as a concern in 64 per cent of responses. An increase in workload was noted by 28 per cent. On the positive side, 66 per cent acknowledged that medication orders are now more legible and there is more time to spend with patients. All responders stated that a ward-based role with integration of the technician in to the ward team would be a future development. A submission of a business case for a pilot of pharmacy technician administration of medicines scheme is now planned for early 2005. A pilot of this project has been previously reported (Hospital Pharmacist 2004;11:209).