While Emory Healthcare’s hospital systems and outpatient cancer center (Winship) implemented bar code medication administration (BCMA) in fiscal year 2014 (Emory Libraries and Information Technology, 2016), the Emory Clinics have yet to do so. In accordance with Emory Healthcare’s system wide use of Cerner, Emory Clinic would benefit significantly from implementation of Cerner’s BCMA system. This paper will discuss this implementation, rationale for use, functionality, return on investment (ROI), feasibility, potential issues, and relationship to safe, timely, effective, efficient, equitable, and patient-centered care (STEEEP) analysis.
Overview of Technology, Users, Uses, and Vendor
BCMA is an electronic scanning system utilized in healthcare for compliance with the Five Rights of Medication Administration. The Five Rights of Medication Administration are the right 1) patient, 2) medication, 3) route, 4) time, and 5) dosage. Users of BCMA include the healthcare professional administering the medication and pharmacy staff. A nurse, or other healthcare provider licensed to administer the medication, scans the bar code on the patient’s wristband to verify the right patient. The nurse then scans the bar code on the medication to verify the right medication, dose, time, and route before administering. Usually, BCMA is used in conjunction with electronic medication administration record (eMAR) systems. An eMAR serves as the communication tool that automatically documents the medication administration into the electronic health record (EHR). Conjoining BCMA and eMAR allows medication administration information to be captured much faster than manual documentation. BCMA systems are also utilized by pharmacies for stocking and retrieval processes, to help avoid dispensing errors (Leapfrog Hospital Survey, 2016). Cerner is the vendor currently utilized for Emory Healthcare’s eMAR and inpatient BCMA services, and would be the logical vendor for
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The Emory Clinic’s implementation of BCMA as well. Cerner, founded in 1979, serves as one of
the leading publicly traded information technology companies and was ranked number one in ambulatory EHR for interoperability, connectivity, and communications in 2016 (Cerner Corporation, 2016).
Rationale for Use
Medication administration is a complex process that requires safe and correct performance of multiple steps. Each step allows opportunity for error, due to complexity, interruptions, using a workaround, or not following the Five Rights of Medication Administration. Errors lead to patient harm through adverse events and complications and also cost the nation $2 billion each year. Approximately 7,000 deaths occur annually due to preventable medication errors. BCMA is a technology solution strategy for reducing these medication errors (Bowers, et al, 2015).
In every healthcare setting, patient safety is the most important foundational concept in provision of care. Utilization of BCMA significantly reduces errors associated with medication administration and therefore allows for safer care. When a unit using BCMA was compared with a unit not using BCMA, the unit using BCMA had a 41.4 percent reduction in timing errors with medication administration. The incidence of medications to be administered either early or late decreased by 27.3 percent. There was also a 48.5 percent reduction of potential adverse events with a severity rating of significant, a 54.1 percent reduction in those rated serious (Poon et al., 2010).
Adverse events related to non-timing errors reduced by 50.8 percent in the BCMA unit. Also, the unit using BCMA had zero transcription errors compared to an error rate of 6.1 percent in the non-BCMA unit. Errors among subtypes of non-timing errors also reduced. Wrong medication errors were reduced by 57.4 percent, administration documentation errors by 80.3
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percent, and wrong dose errors by 41.9 percent with use of BCMA. Potential adverse drug events
associated with administration documentation errors reduced by 80.3 percent and potential wrong dose errors reduced by 33 percent in the BCMA unit (Poon et al., 2015). These statistics provide rationale for BCMA to be implemented in The Emory Clinic setting.
Rationale for use is further emphasized by examining the gaps BCMA would fill in The Emory Clinic. One gap involves cumbersome communication between clinic and pharmaceutical staff. Currently, nurses manually count patient medications each week and report anticipated dispensing needs to the pharmacy for the upcoming week. Problems with this process include wasted nursing time and inaccurate inventory management. A second gap is created by inefficiency in electronic documentation that would be closed with automatic BCMA utilization. Currently, providers and nurses manually enter medication administration documentation, including lot numbers and expiration dates. BCMA automated documentation would eliminate this slow manual and duplicate process. A third gap filled by BCMA would be in patient safety related to errors with The Five Rights of Mediation Administration. Error would be significantly reduced in all steps of the medication administration process with a computerized checks and balance system such as BCMA.
Functionality, Return on Investment, and Feasibility
The functionality of BCMA, as mentioned previously, ensures safer medication administration, more accurate documentation, and provides necessary information to pharmacies for restocking and dispending purposes (Leapfrog Hospital Survey, 2016). Similar to the inpatient process, the healthcare professional must input an order in the patient’s EHR. Then, the professional to administer the medication (usually the nurse) must retrieve the medication from a computerized medication dispensing system. The nurse then scans the patient’s identifier barcode (which must have been assigned to every outpatient) and scans the medication to ensure
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the Five Rights for Medication Administration prior to administering. This automatically
documents the administration in the EHR and sends the information to the pharmacy stocking the dispensing system. This process has proven successful in Emory Healthcare’s inpatient settings and would likely be a feasible change in the clinic setting as well. This is especially likely because Emory outpatient nurses and physicians waste time with duplicate and inconsistent medication administration and documentation.
In the hospital setting, the cost of implementing BCMA (including pharmacy management and drug repackaging) over five years is between $35,600 and $54,600 per BCMA enabled bed. This would cost a 100 bed hospital over $3 million in the first five years of BCMA implementation (Sakowski ; Ketchel, 2013). There is minimal literature estimating the cost of implementing BCMA in the outpatient setting, but considering the significantly reduced need for equipment, the cost would be substantially less. In one of Emory Clinic’s departments, for example, The Emory Spine Center, one scanner and medication dispenser per floor (five total) would likely be sufficient. If each BCMA enabled floor cost the same amount as a BCMA enabled bed in the hospital, the cost over five years would be between $178,000 and $273,000 in this department. The financial feasibility of this implementation is reasonable.
According to Sakowski and Ketchel (2013), implementing BCMA has good return on investment. Sakowski and Ketchel’s research suggests that BCMA is an effective and cost- saving tool that prevents the costs and harm associated with medication errors. The cost of $2000 per harmful medication averted by utilization of BCMA is less than the cost of $3100 to $7400 cost of a harmful error, in Sakowski and Ketchel’s hospital study. It is reasonable to suggest that the costs of implementing this safety tool in the clinic setting would be less than the cost of harmful errors, as well.
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Despite the significant patient safety and cost benefits, there are several barriers and issues with BCMA implementation. BCMA implementation requires redefinition of caregiver workflow and responsibilities, which requires intense training and demonstration. Staff sometimes resist BCMA implementation because it adds extra steps and requires additional time, thus adding burden to preexisting busy schedules. While the cost-benefit ratio is in favor of BCMA implementation, many facilities perceive the cost as a barrier (Leapfrog Hospital Survey, 2016).
While commitment to proper training and justification for cost are logical solutions for two main barriers, addressing the workflow issue for nurses is more challenging. Unreadable medication barcodes, non-barcoded medications, failing batteries, troublesome wireless connectivity, and emergencies are just a few examples of barriers that cause nurses to use workarounds with BCMA. Additional issues include BCMA’s design, implementation, and workflow integration. Possible consequences include administration of wrong medication, doses, times, and formulations (Koppel et al., 2008).
For pharmacy staff, barriers to BCMA implementation include process issues such as training requirements and flow issues, technology such as hardware, software, and vendor roles, and resistance to changing roles, communication issues, and negative technology perceptions. Solutions for these issues include adequate training, adaptation of workflow to address perceived barriers, and continuous improvement. Additionally, ongoing vendor involvement, acknowledgment of technology limitations, and attempts to address limitations are also possible solutions. Clear communication, emphasis of new information provided by the system, collaboration, and identifying champions (Nanji et al., 2009) are also solutions that could be applied across all interdisciplinary teams in BCMA implementation.
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STEEEP, Trends, and the Future
BCMA implementation in the clinic setting addresses STEEEP analysis as follows. BCMA allows for safe and timely medication administration. BCMA is effective in administering medications according to the Five Rights of Medication Administration, immediate and correct documentation, and providing dispensing information for pharmacies. BCMA is equitable as it is not limited to any one race, gender, ethnicity, or income. BCMA is patient centered as its primary purpose is to improve the quality of patient care (Institute for Healthcare Improvement, 2016).
With healthcare focus transitioning toward improved quality rather than quantity of care, BCMA implementation and adoption is trending in facilities across the nation. Leapfrog Group, an organization with the mission to improve safety, affordability, and quality in healthcare, has developed a standard for adoption of BCMA in hospitals. These standards address full facility implementation and compliance, structures to monitor and reduce workarounds, and decision support for best practice (Leapfrog Hospital Survey, 2016). It is likely for this standard to reach outpatient centers and clinics as well, as trends of BCMA implementation continue to expand.
BCMA implementation in The Emory Clinic would improve the outpatient medication administration process for patients and healthcare professionals, as it has done in The Emory Healthcare inpatient process. BCMA offers safer and more efficient care that improves quality and, in the long run, reduces costs. With adequate, thorough planning, training, education, and continuous feedback processes, transitioning to BCMA implementation would be an effective technology improvement to the clinic setting.