It’s 2 a.m. and a patient in a hospice inpatient unit is experiencing breakthrough pain. She already has an order in for morphine, so her nurse heads to the automated dispensing system (ADS). The nurse punches in some information on a keyboard and a flashing light shows which drawer to open. Another light indicates the compartment holding the requested medication at the requested dose. It can seem like magic, but a lot of work went in to making it happen.
That’s where Enclara Pharmacia comes in. Whereas hospitals have an in-house pharmacies managing automated dispensing, most hospice inpatient units don’t operate at a scale that would support that. Enclara’s remote administration makes it possible for these hospices to experience the benefits of an ADS. With access to medications for each patient during scheduled med passes, the ADS drives a reduction in med errors, waste and diversion. That translates to better compliance and lower costs for the IPU.
Multiple Enclara teams with staff at several locations come together to make it all happen. At the center of all these efforts is Enclara Director of IPU Operations Ealia Washington, PharmD, BCGP, BCACP. “There are a lot of moving parts. This is a very high touch model,” Washington said. “We have built this program from the ground up, one client at a time. I’ve seen this service grow out of its infant stage to a full grown adult.”
Washington has spent over 15 years at what is now Enclara Pharmacia, working her way up from a pharmacist in the call center to her current position leading multiple teams crucial to implementing and maintaining automated dispensing systems. The program has grown with her. When she started, the team supported only one vendor’s system, BD Pyxis®, but today they also support Omnicell®. Her team has also expanded the number of states in which they can operate, which can sometimes be a heavy lift.
“This is really one of the areas where we’re pushing the envelope and leading the industry,” said SVP, Chief Ethics and Compliance Officer John Loxterman. “In many cases, it’s a sort of an advocacy partnership with the client to go before the board of pharmacy to get approval for remote automated dispensing and really make the case for how it can improve patient safety and reduce risk of medication diversion.”
Loxterman and Washington have sometimes had to get creative to design solutions that would meet a state’s requirements. That has included partnering with local pharmacies and even having Enclara’s pharmacists obtain licenses in another state. That’s just a piece of how Enclara has worked to build programs to meet the unique needs of over 30 clients in over 50 locations.
“What makes Enclara’s IPU support unique is our ability to meet client needs through customization, leveraging our interfaces and our technology,” Washington said. “We review the different options based on each client’s needs and the regulations in their respective state. Then we perform a general assessment of their workflow to understand their pain points, concerns and what they are hoping to achieve. We’re always looking to explore unique solutions we can offer to meet clients where they are.”
A lot of effort goes into just putting together a proposal, but once a contract is signed and the client has secured ADS equipment from the manufacturer of their choice, the real work begins. Much of that work falls to ADS Implementation and Support Supervisor Andrea Rogers. Like Washington, she has been with the ADS program almost since the beginning. She started out as a pharmacy technician, loading ADS machines in hospitals. Over time, she became more and more interested in the potential for automation, reporting and process improvement the technology represented. Now she travels all over the country building out workflows, training nurses and doing compliance checks. In between, she’s on the phone with colleagues and clients for troubleshooting and process improvement. Part of what keeps her going is the impact she achieves for nurses and patients.
“Often they have been spending too much of their time on paperwork, pill counts and keeping track of keys,” Rogers said. “With the ADS unit in place, they are doing more of the patient care they actually signed up for. Everything is tracked automatically, so there’s greater transparency and less chance for errors.”
Implementation is a process that starts up to four months before a hospice starts using the system and continues for 90 days after, during which time the IPU team works with the hospice to fine-tune processes, adjust restocking schedules based on utilization, and provide general training and support. Servicing the client after implementation is its own challenge. That falls to IPU Manager Krupa Patel, PharmD, BCGP, and her team of pharmacists and pharmacy technicians. New orders come in 24/7 and must be processed and approved for dispense before drugs in the ADS unit can be accessed.
“A lot of my staff come from the retail pharmacy world, so I tell them to treat every request they get by electronic fax the same way they would a customer standing at the counter waiting for their prescription,” Patel said. “The reality is that even if they are 1,000 miles away, they really are waiting.”
Patel’s team works under two metrics: accuracy and speed. They know there’s a patient in need of immediate symptom management. They also know that once they authorize the dispense, the medication may be administered in a matter of minutes. There is no room for error. Every request is reviewed by a technician and a pharmacist for accuracy, appropriateness, allergies and potential interactions.
Between the highly detailed nature of the work and the fact that the team is active 24/7, maintaining consistency requires a lot of communication. Patel provides targeted communications for each shift. She also holds small group meetings when introducing new standard operating procedures. That means committing to multiple meetings around a single policy, but it helps ensure both engagement and the opportunity for meaningful feedback.
Enclara’s hospice ADS support is unmatched in the industry thanks to lessons learned over two decades as well as a commitment to continuous improvement. The IPU team is currently gearing up to support an additional BD Pyxis platform. Longer term, they plan to enhance their integration with electronic prescribing platforms and Enclara’s extensive electronic medical record interfaces to improve the client experience. One thing that won’t change is the customized service they provide.
“You may want to have things as standardized as possible, but because of the different regulations, and specific workflows at each hospice, it does have to be customized. That’s what we’re good at,” Washington said. “At the end of the day, a nurse just wants to obtain the medication as quickly as possible and keep the patient comfortable. Building workflows that meet their needs, minimizing risk and everything in between? That’s our job.”