Computerization of the Medication Circuit: A Strategic Lever for Quality of Care and Hospital Streamlining
The "medication circuit" within healthcare facilities represents a set of complex and interdependent processes, essential to patient care. Its optimization is a major challenge, as it aims simultaneously to improve the quality of care and streamline the logistics and economics of hospital structures. Faced with this complexity, computerizing this circuit has become a preferred way to modernize practices and guarantee greater safety for patients.
Historically, the medication circuit in hospitals and clinics has operated in a heterogeneous manner, often raising questions about the quality of care, with analyses reporting discrepancies of up to 10% or 20% between the prescription and the actual administration. The Directorate of Hospitalization and Healthcare Organization (DHOS) of the Ministry of Employment and Solidarity initiated an in-depth study to encourage reflection on best practices in IT implementation. This study, based on the "value analysis" method, aimed to measure the qualitative and quantitative returns expected by the various stakeholders, regardless of whether IT implementation was total or partial. This article explores the key concepts, economic issues, types of projects that can be considered, their benefits and costs, based on the conclusions of this fundamental study.
The context and challenges of computerizing the medication circuit (HAS Mandatory Criterion 3.6.2)
The medication circuit encompasses a multitude of steps: prescription, its analysis and validation, preparation, delivery, distribution and administration of the medication, as well as pharmacy orders, activity analysis, and the management of expired medications and batch recalls. These processes require interoperable and communicating hospital information systems for effective cooperation.
Computerizing this circuit is much more than simply automating existing procedures. It requires essential reflection on the organizational structures to be put in place. For approximately five years prior to the publication of this study (May 2001), multidisciplinary teams—comprising hospital directors, physicians, pharmacists, nurses, and IT specialists—worked to define the conditions for the success of this computerization, notably by formulating recommendations for adapting hospital information systems. The objective was to obtain concrete, quantifiable data to inform decision-makers about the anticipated costs and benefits. The report resulting from this study is intended for hospital directors, information systems managers, prescribing physicians, hospital pharmacists, and nurses. It aims to be a useful tool for initiating reflection on the objectives and methods of computerization, offering an original methodological approach to the return on investment of this process, whose main purpose is to ensure patient safety.
The method of analyzing the Value
The study was based on the "value analysis" method, a technique frequently used in industry for product or service renewal, and which has been adapted to administrative and software processes. According to the X50.150 standard, value analysis is a organized and creative competitive method aimed at satisfying user needs through a specific design approach that is functional, economic, and multidisciplinary. It is used to help imagine and choose solutions, with a dual purpose.
The approach is:
- Functional: It expresses the action of a product or its components in terms of purpose, without reference to solutions.
- Economic: It requires numerical values to quantitatively assess "value". Value is a judgment about the product based on user expectations, increasing with the satisfaction of the need or the reduction of expenses.
- Multidisciplinary: It relies on working groups including operational departments, specialized facilitators, and decision-makers.
The study was conducted with the active involvement of three institutions (a university hospital, a general hospital, and a psychiatric hospital). A multidisciplinary working group, including directors, administrative staff, IT specialists, physicians, pharmacists, and healthcare professionals, was mobilized.
The work process unfolded in three phases:
- Phase 1: Identification of functions, levels, and challenges.
- Phase 2: Assembly and analysis of solutions.
- Phase 3: Synthesis of lessons learned.
A detailed functional framework was used during this work to structure the analysis.
Understanding the medication circuit: physical flow and information flow
For a comprehensive understanding, it is important to distinguish two main circuits within the medication process:
- The physical circuit of medication: This refers to the "material flow," that is, the actual movement of the medication. It comprises three main stages:
- Delivery of ordered medications to the pharmacy and their storage.
- Dispensing of medications to the wards, including preparation and transport.
- Administration of medications to patients, with the management of returned medications not administered. The physical circuit has two main variations: global distribution (from the pharmacy to the wards) and individualized dispensing.
- The information circuit for medication management: This concerns how information circulates around the physical flow. The information system is divided into two relatively independent subsystems, with a potential interface between them: A system focused on ordering and storing pharmacy medications, often linked to the hospital's financial management system. A system focused on managing prescriptions and the medication circuit between the pharmacy and the wards, using a specialized product or a unit management tool. It is important to clarify the terminology: Dispensing is defined as all the tasks including the analysis, validation, preparation, and delivery of medications. Distribution only covers the physical phases of preparing and delivering medications. A key point is that dispensing is only possible if... knowing the prescription information. While distribution can be global or individualized, dispensing, if individualized, very likely implies knowledge of the prescriptions.
The economic stakes of computerization
Computerizing the medication circuit generates initial expenses (software licenses, hardware, network, services, training, configuration, maintenance). In return, it is supposed to bring improvements, some being "qualitative" and others "quantitative" (or "economic stakes") because they can be quantified. The study identified three main types of economic stakes: Time savings, or productivity gains, through efficiency in the processing and manipulation of information. These gains concern several groups: Pharmacy staff: Particularly through the calculation of drug interactions. Without a computerized system, comprehensive control of these interactions would be virtually impossible, requiring the equivalent of several full-time pharmacists in each hospital.
Orders of magnitude of time spent on medication-related tasks have been noted:
- Up to 50% of nurses' time in non-computerized wards is spent on information processing and manipulation tasks.
- Each prescriber spends between 30 minutes and 1 hour per day on Medication prescription.
- In a 20-bed care unit, medication preparation can take up to two hours per day for a team of two nurses.
- In a 500-bed hospital with individual dispensing, the workload transfer from nurses to pharmacy technicians can represent 15 to 25 Full-Time Equivalents (FTEs).
- By encouraging the use of less expensive forms for a similar volume of consumption.
- By influencing the overall volume of medication consumption. Reductions in medication expenses of 10% to 20% have been observed, depending on the hospital, the department, and their initial organization. The main principle of this reduction is based on delivering to departments the medications they have actually prescribed, which is made possible by the pharmacy's knowledge of prescriptions, whether through individual patient dispensing (DJIN) or bulk distribution. The economic consequences are linked to the improved quality of patient care, achieved by avoiding incidents and errors. It is essential to distinguish between "medication errors" (errors in prescribing, transcription, dispensing, and administration) and "medication incidents" (adverse events resulting from an error). Computer systems aim to reduce errors and, consequently, incidents, either by preventing them or by intercepting them before they cause an adverse event. The economic consequences are linked to incidents, not errors, although intercepting errors does consume time. This phenomenon is neither negligible nor insignificant: a 1997 report by the French Medicines Agency (ANSM) indicates that 10% of hospitalized patients experience an adverse drug reaction, a third of which are serious (death, life-threatening, prolonged hospitalization). The economic consequences of serious incidents include additional days of hospitalization, further examinations, stays in intensive care, overconsumption of medication, and lost workdays for the patient. Studies have estimated the average cost of a serious medication incident at between $2,000 and $2,500 (14,000 to 18,000 francs) in the United States, and up to 50,000 francs for cases treated in intensive care in France. A gastroenterology study of patients over 65 years of age showed an average cost of 20,602 francs per patient for drug poisoning, 12.6% of which was due to drug interactions. These figures are minimums because they do not take into account lifelong consequences. The study applied these concepts to a hypothetical 800-bed hospital (500 of which were for short stays), with a budget of 500 million francs per year and a payroll of 350 million francs per year. The orders of magnitude of the annual economic stakes are as follows:
- Time spent on the medication circuit: Approximately 10% of the hospital's energy is dedicated to these tasks, representing a stake of 35 million francs/year.
- Medication expenses: These represent approximately 6% of the budget, or 30 million francs/year.
- Consequences of serious incidents: For 25,000 admissions per year, approximately 500 incidents occur, of which 167 are serious (1/3 of the incidents). The economic stake is estimated at between 1.5 and 2 MF/year (based on 10,000 F per preventable serious incident).
- P1: Renewal of the hospital's Economic and Financial Management (EFM) system.
- Economic Challenges: The major benefits are not intrinsic to this project, unless the new system offers significant productivity gains for pharmacy staff or high-performance specialized modules (discussed in P4). Savings on IT maintenance costs may also be observed.
- P2: Batch Recall Management.
- Economic Stakes: Productivity gains are possible if the pharmacy can selectively alert the relevant departments via internal messaging, without having to manually manage batch numbers (a tedious task).
- Valuation of Gains: The evaluation is done by measuring the workload required to alert all departments vs. Selective alerting, and the time saved by not managing batch numbers for all medications.
- P3: Expiry Management.
- Economic Stakes: The objective is to reduce the annual budget for expired medications, which can reach tens of thousands of francs. Computerizing expiration date management is one approach, but other organizational actions such as low stock levels, rapid turnover (FIFO), and eliminating "wild stock" in departments are also effective.
- P4: Adding Additional Functions to the EHS System.
- Economic Stakes: These projects bring productivity gains for pharmacy staff. Examples:
- Barcode scanners: Facilitate the management of stock entries and exits, and inventory.
- Order recommendations: The system calculates stock levels and suggests orders in the GEF system, reducing order creation and entry time.
- Receiving invoices via EDI (Electronic Data Interchange): Avoids manual re-entry of invoices and speeds up payment processing.
- Economic Stakes: These projects bring productivity gains for pharmacy staff. Examples:
- A1: Projects with a purely organizational component.
- Presentation: Reject verbal prescriptions, encourage legible handwriting, create structured and complete prescription forms, develop a therapeutic booklet and hospital treatment protocols, implement mechanical dispensing systems (elevators, remote-controlled cases) and a system for the systematic analysis of medication incidents.
- Economic stakes: These projects contribute to reducing medication expenses, improving the quality of care (readability, completeness), and saving time. Although not directly related to computerization, they can be an essential prerequisite.
- A2: Projects with an IT component, but without prescription management.
- Presentation: Type prescriptions before signing, use an internal messaging system between pharmacies and prescribers, distribute the therapeutic booklet and drug databases (Vidal, Thériaque) via the hospital network, and provide access to patient information (civil status, medical history, allergies).
- Economic stakes: Typed prescriptions avoid misinterpretations and save time (no more deciphering or requesting confirmations). The messaging system saves time on information exchange. Access to patient information reduces confusion and errors.
- A3: Make drug databases available.
- Presentation: Make the Vidal or Thériaque online, accessible from any computer connected to the network.
- Economic benefits:
- Time savings for consulting information (no need to travel to find a paper copy).
- Savings on the acquisition of paper copies.
- Benefits from the constant updating of information, reducing errors due to outdated data.
- Reduction in errors of prescription and administration because prescribers and nurses have constant access to up-to-date information.
- Valuation of gains: The study proposes formulas to estimate these gains, combining purchasing savings (G1), time savings (G2) and the reduction of iatrogenesis (G3). Online information is the most significant benefit, even without direct integration into prescription software.
- B1: Centralized entry of prescriptions upon arrival at the pharmacy.
- Presentation: The software is deployed only at the pharmacy, where staff enter the prescriptions received (paper, fax).
- Economic stakes:
- Pharmacy knowledge of prescriptions: Allows for the dispensing of prescribed medications and reduces visibly the medication expenses.
- Automatic calculation of drug interactions: The software can perform systematic and exhaustive checks of interactions, even in real time. This benefit is considered a significant improvement in the quality of care rather than a productivity gain, as exhaustive manual checks would be impractical. Such checks would be equivalent to the workload of 40 to 50 full-time pharmacists for a hypothetical hospital.
- Disadvantages: Requires re-entry of prescriptions by pharmacy staff, a considerable workload (estimated at 7 data entry operators for a 500-bed hospital). The system does not guarantee correct patient/prescriber identification, does not offer real-time feedback to the prescriber, and may generate data entry errors.
- B2: Decentralized Prescription Entry in Departments (Specialized Software).
- Overview: Prescribers create and enter prescriptions directly with the help of the computer system, which can interact in real time. The prescription is immediately sent to the pharmacy via the network.
- Economic Stakes:
- Time Savings and Quality of Care: Although data entry may initially take more time than handwriting (120% to 150% of the time), the advantages outweigh the benefits. The prescriber and patient are definitively identified, the prescription is complete and legible, reducing time wasted deciphering or searching for missing information. Nurses no longer need to retype administration plans. Prescription history is accessible online.
- Data entry protocols and shortcuts: Significantly reduce data entry time (15% to 40% reduction in data entry activity) by automating common prescriptions.
- Automatic retrieval of administrative information: Saves 4 to 9 minutes per incoming patient.
- Discharge prescriptions: Estimated time savings of 15% to 20%.
- Overall time savings: High-performance software with these enhancements can make data entry faster than a handwritten system.
- During home visits (portable terminals): Contributes to physician buy-in and reduces time spent, although the costs are higher.
- Reduced Medication Expenses: Same as B1, a reduction of at least 10% in the hospital medication budget.
- Reduced Medication Incidents (Iatrogenesis): Up to 50% of iatrogenic medication incidents can be avoided with the best IT system, with approximately half of these preventable with a B2 or B3 project. This includes the gains related to systematic interaction checks.
- B3: Prescription entry in a unit management software (integrated HIS).
- Economic Stakes: The advantages are the same as for B2, with additional gains related to full integration into the Hospital Information System (HIS). This avoids re-entry or copy-pasting between systems, multiple identifiers, and facilitates the consolidation of care plans and patient information. Time savings are greater with successful integration.
