The ultimate challenge was balancing two fundamental regulations — a requirement that drugs in the OR be immediately and readily available, and another necessitating medication security at all times.
One of the most logistically challenging areas of the hospital for medication distribution is the operating room (OR). This is particularly true for institutions such as the Erie County Medical Center (ECMC), with service lines that necessitate 24/7 OR capabilities.
To an outside observer, ensuring that medications are available and that products provided to a patient in support of surgery are accurately billed to that patient would seem rudimentary. In actuality, these two seemingly simple requirements are entangled in a web of regulations, technologies, logistical issues and provider expectations.
ECMC, located in Buffalo, N.Y., is the adult regional trauma center for the western eight counties of New York. Ten operating units function around the clock processing approximately 12,000 cases annually, 52 percent performed on outpatients. Challenges faced by the pharmacy and anesthesiology staffs included accurately capturing charges, enhancing patient safety and meeting Joint Commission and Centers for Medicare and Medicaid standards related to medication security and administration. Neither medication availability nor rapid operating room turnaround could be compromised.
“It became apparent that automated dispensing cabinets within the operating rooms would enable our facility to more fully meet these challenges by providing medications at the point of care,” says Randy Gerwitz, director of pharmacy at ECMC.
The ultimate challenge for Gerwitz was balancing two fundamental regulations — a requirement that drugs in the OR be immediately and readily available, and another necessitating medication security at all times. In addition, the physical environment itself is limited both in terms of space and accessibility.
Historically at ECMC, the operating rooms functioned only on paper, with a limited understanding of, and little tolerance for, electronic-documentation systems. Additionally, ECMC had a long-standing history of autonomy among surgeons, anesthesiologists and their respective residents, and billing for products administered had always been challenging.
Prior to this project, the level of customer service provided by pharmacy to the anesthesiology staff was sub-optimal, Gerwitz says. A single bank of automated dispensing cabinets in the OR core served as a repository for all medications, both patient-billable and floor stock items.
“The existing anesthesia carts were in need of repair and did not provide convenient secure storage for medications prepared for the upcoming cases,” he says. “The dated carts and associated procedures hampered work flow and challenged infection control. This system also necessitated a paper-reconciliation process for narcotics that deviated from the hospital norm of electronic documentation via automated-dispensing cabinets.”
Gerwitz identified the OR as a key target for maximizing charge capture while enhancing efficiency. At the time, estimates of charge capture for medications administered by anesthesiology were in the range of 10 percent to 15 percent.
Gerwitz and a group from pharmacy and anesthesiology addressed the core issues of revenue capture in the OR — medication security, enhanced patient safety and accurate billing — while also providing a teaching environment for the anesthesiology residents.
Gerwitz also recognized an opportunity to assist the anesthesiologists in meeting a goal established by the Centers for Medicare and Medicaid — the Surgical Care Improvement Project. This quality-improvement project includes proper presurgical antibiotic administration. Antibiotics securely stored at the point of care ensured the anesthesiologists could reliably and conveniently administer the mediations within the established time frames.
A clinical team was assembled to select a vendor and to begin the work-flow and financial analysis. ECMC had a relationship with one of the vendors, Omnicell, and a proven interface between that supplier and the hospital information-management system. The clinical team determined that automated-dispensing cabinets on the market had similar capabilities and storage capacities, and recommended expanding Omnicell's product line to include the anesthesia cabinets.
“We decided to tackle billing in outpatient procedures, which made up over 50 percent of the caseload,” explains Gerwitz.
While most inpatient surgical case costs are included in the diagnostically related group (DRG) payment, outpatient cases may allow for additional payment for medications. As a disproportionate-share hospital, ECMC is eligible for discounted drug pricing for medications administered to outpatients under the 340B program. Detailed audit trials, driven by billing data, are required to purchase drugs under this program.
Assuming an increase in charges captured from 15 percent to 90 percent, Gerwitz and the clinical team projected positive return on investment with the automated cabinets.
ECMC went live with Omnicell 10 anesthesia cabinets in each OR suite. According to Gerwitz, the team decided early on to standardize the medications stocked in each cart, which eased the training and implementation process.
“The pharmacy goals in this project were clearly defined from the outset: update and modernize equipment, improve charge capture, enhance medication availability and security, and provide a higher level of customer service to anesthesiology,” Gerwitz says.
Superior billing documentation allowed for increased purchasing under the 340B program. Gerwitz understood the importance of frequent and open communication throughout the implementation phase in achieving the goals at ECMC. Additionally, an unforeseen outcome of this project was the positive impact on pharmacy—anesthesia relations, according to Gerwitz.
“The implementation of the automated-medication system improved operating room efficiency for anesthesiology and pharmaceutical services,” he concludes. “Accurate tracking of medications for federal reimbursement programs and patient safety was enhanced through the secure storage of anesthesia medications at the point of care. We also improved the charge capture in the OR, leading to an increase in hospital revenue.”
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