Computerization of the Medication Process: A Strategic Tool for Improving Care Quality and Streamlining Hospital Operations
The "medication circuit" within healthcare facilities comprises a set of complex and interdependent processes that are essential to patient care. Optimizing this circuit is a major challenge, as it aims to simultaneously improve the quality of care and streamline the logistics and economics of hospital operations. Given this complexity, computerizing the medication circuit has become a preferred approach to modernizing practices and ensuring greater patient safety.
Historically, medication management in hospitals and clinics has been inconsistent, often raising questions about the quality of care, with analyses reporting discrepancies of up to 10% or 20% between prescriptions and 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 comprehensive or limited. This article explores the key concepts, economic issues, types of projects that can be considered, and their benefits and costs, based on the conclusions of this fundamental study.
The context and challenges of computerizing the medication process (HAS Mandatory Criterion 3.6.2)
The medication process involves a number of steps: prescribing, reviewing and approving prescriptions, preparing, dispensing, and administering medications, as well as processing pharmacy orders, analyzing pharmacy activities, and managing expired medications and product recalls. These processes require interoperable and interconnected hospital information systems to ensure effective coordination.
Computerizing this process involves much more than simply automating existing procedures. It requires careful consideration of the organizational structures that need to be established. 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 necessary 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 Value
The study was based on the "value analysis" method, a technique frequently used in industry for product or service renewal, which has been adapted to administrative and software processes. According to the X50.150 standard, value analysis is a structured and creative competitive method aimed at meeting user needs through a specific design approach that is functional, cost-effective, and multidisciplinary. It is used to help identify and select solutions, with a dual purpose.
The approach is:
- Functional: It describes the purpose of a product or its components, without referring to specific solutions.
- Economic: It requires numerical values to quantitatively assess "value." Value is a judgment about the product based on user expectations, increasing as needs are met or costs are reduced.
- Multidisciplinary: It involves working groups comprising operational departments, specialized facilitators, and decision-makers.
The study was conducted with the active participation of three institutions (a university hospital, a general hospital, and a psychiatric hospital). A multidisciplinary working group, comprising directors, administrative staff, IT specialists, physicians, pharmacists, and healthcare professionals, was formed.
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 in this study to structure the analysis.
Understanding the medication circuit: physical flow and information flow
For a comprehensive understanding, it is important to distinguish between two main pathways in the medication process:
- The physical flow of medication: This refers to the "material flow," that is, the actual movement of the medication. It consists of three main stages:
- Delivery of ordered medications to the pharmacy and their storage.
- Distribution of medications to the wards, including preparation and transport.
- Administration of medications to patients, including the handling of returned medications that were not administered. The physical distribution process has two main components: bulk distribution (from the pharmacy to the wards) and individualized dispensing.
- The information flow for medication management: This refers to how information circulates in conjunction with the physical flow of medications. 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 flow 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 tasks involving the analysis, validation, preparation, and delivery of medications. Distribution covers only the physical phases of preparing and delivering medications. A key point is that dispensing is only possible if... the prescription information is known. While distribution can be global or individualized, dispensing, if individualized, very likely requires knowledge of the prescriptions.
The economic implications of computerization
Computerizing the medication process involves initial costs (software licenses, hardware, network infrastructure, services, training, configuration, and maintenance). In return, it is expected to yield improvements, some of which are "qualitative" and others "quantitative" (or "economic benefits") because they can be measured. The study identified three main types of economic benefits: Time savings, or productivity gains, through efficiency in the processing and handling of information. These gains affect several groups: Pharmacy staff: Particularly through the calculation of drug interactions. Without a computerized system, comprehensive monitoring of these interactions would be virtually impossible, requiring the equivalent of several full-time pharmacists in each hospital.
The following estimates of the amount of time spent on medication-related tasks have been reported:
- Up to 50% of nurses' time in non-computerized wards is spent on information processing and data entry tasks.
- Each prescriber spends between 30 minutes and 1 hour per day prescribing medication.
- In a 20-bed care unit, preparing medications can take up to two hours a day for a team of two nurses.
- In a 500-bed hospital with individual medication dispensing, the workload transferred from nurses to pharmacy technicians can amount to 15 to 25 full-time equivalents (FTEs).
- By encouraging the use of less expensive options for a similar level of consumption.
- By influencing the overall volume of medication use. Reductions in medication costs of 10% to 20% have been observed, depending on the hospital, the department, and their initial organization. The main principle behind this reduction is based on providing departments with 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 benefits stem from the improved quality of patient care achieved by preventing 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 account for lifelong consequences. The study applied these concepts to a hypothetical 800-bed hospital (500 of which were for short stays), with an annual budget of 500 million francs and an annual payroll of 350 million francs. The orders of magnitude of the annual economic stakes are as follows:
- Time spent on medication management: Approximately 10% of the hospital's resources are devoted to these tasks, representing a cost of 35 million francs per year.
- Medication expenses: These account for approximately 6% of the budget, or 30 million francs per year.
- Consequences of serious incidents: For 25,000 admissions per year, approximately 500 incidents occur, of which 167 are serious (one-third of the incidents). The economic cost is estimated at between 1.5 and 2 million francs per year (based on 10,000 francs per preventable serious incident).
- P1: Renewal of the hospital's Economic and Financial Management (EFM) system.
- Economic Challenges: The primary benefits are not inherent to this project, unless the new system delivers significant productivity gains for pharmacy staff or high-performance specialized modules (discussed in P4). Savings on IT maintenance costs may also be realized.
- P2: Batch Recall Management.
- Economic Implications: Productivity gains are possible if the pharmacy can selectively notify the relevant departments via internal messaging, without having to manually track batch numbers (a tedious task).
- Valuation of Gains: The evaluation is based on comparing the workload required to notify all departments with that of selective notification, as well as the time saved by not having to manage batch numbers for all medications.
- P3: Expiry Management.
- Economic Implications: The goal is to reduce the annual budget for expired medications, which can amount to tens of thousands of francs. Computerizing expiration date management is one approach, but other organizational measures—such as maintaining low inventory levels, implementing first-in, first-out (FIFO) practices, and eliminating "unaccounted-for stock" in departments—are also effective.
- P4: Adding Additional Functions to the EHS System.
- Economic Implications: These projects lead to productivity gains for pharmacy staff. Examples:
- Barcode scanners: Simplify the management of stock receipts and shipments, as well as inventory.
- Order recommendations: The system calculates inventory levels and suggests orders in the GEF system, reducing the time required to create and enter orders.
- Receiving invoices via EDI (Electronic Data Interchange): Eliminates the need to manually re-enter invoices and speeds up payment processing.
- Economic Implications: These projects lead to productivity gains for pharmacy staff. Examples:
- A1: Projects with a purely organizational component.
- Presentation: Reject handwritten prescriptions, encourage legible handwriting, create structured and complete prescription forms, develop a patient education booklet and hospital treatment protocols, implement automated dispensing systems (elevators, remote-controlled dispensers), and establish a system for the systematic analysis of medication errors.
- Economic benefits: These projects help reduce medication costs, improve the quality of care (readability, completeness), and save time. Although not directly related to computerization, they can be an essential prerequisite.
- A2: Projects that include an IT component but do not involve prescription management.
- Presentation: Enter prescriptions before signing, use an internal messaging system between pharmacies and prescribers, distribute the therapeutic guide and drug databases (Vidal, Thériaque) via the hospital network, and provide access to patient information (personal details, medical history, allergies).
- Economic benefits: Typed prescriptions prevent misinterpretations and save time (no more trying to decipher them or requesting confirmations). The messaging system streamlines the exchange of information. Access to patient information reduces confusion and errors.
- A3: Make drug databases available.
- Presentation: Make the Vidal or Thériaque available online, accessible from any computer connected to the network.
- Economic benefits:
- Time saved when accessing information (no need to travel to find a paper copy).
- Savings on the purchase of paper copies.
- Benefits from the constant updating of information, reducing errors caused by outdated data.
- A reduction in prescription and administration errors because prescribers and nurses have constant access to up-to-date information.
- Valuation of benefits: The study proposes formulas to estimate these benefits, combining cost savings (G1), time savings (G2), and the reduction in 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.
- Overview: The software is installed only at the pharmacy, where staff enter the prescriptions they receive (paper, fax).
- Economic implications:
- Pharmacy knowledge of prescriptions: Enables the dispensing of prescribed medications and significantly reduces medication costs.
- Automatic calculation of drug interactions: The software can perform systematic and comprehensive checks for interactions, even in real time. This benefit is seen as a significant improvement in the quality of care rather than a productivity gain, as comprehensive manual checks would be impractical. Such checks would be equivalent to the workload of 40 to 50 full-time pharmacists at a hypothetical hospital.
- Disadvantages: Requires pharmacy staff to re-enter prescriptions, which creates a considerable workload (estimated at 7 data entry operators for a 500-bed hospital). The system does not guarantee accurate patient/prescriber identification, does not provide real-time feedback to the prescriber, and may result in data entry errors.
- B2: Decentralized Prescription Entry in Departments (Specialized Software).
- Overview: Prescribers create and enter prescriptions directly using the computer system, which enables real-time interaction. The prescription is immediately sent to the pharmacy via the network.
- Economic Implications:
- Time Savings and Quality of Care: Although data entry may initially take more time than handwriting (120% to 150% of the time), the benefits far outweigh the drawbacks. The prescriber and patient are clearly identified, and the prescription is complete and legible, reducing the time wasted trying to decipher or search 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 (a 15% to 40% reduction in data entry) by automating common prescriptions.
- Automatic retrieval of administrative information: Saves 4 to 9 minutes per incoming patient.
- Discharge instructions: 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 (using portable devices): This helps build buy-in among physicians and reduces the time spent, although the costs are higher.
- Reduced Medication Expenses: As in B1, a reduction of at least 10% in the hospital’s medication budget.
- Reduced Medication Errors (Iatrogenesis): Up to 50% of iatrogenic medication errors can be prevented with the best IT system, with approximately half of these preventable through a B2 or B3 project. This includes the benefits associated with systematic interaction checks.
- B3: Prescription entry in a unit management software system (integrated HIS).
- Economic Benefits: The advantages are the same as for B2, with additional benefits resulting from full integration into the Hospital Information System (HIS). This eliminates the need for re-entry or copy-pasting between systems and the use of multiple identifiers, and facilitates the consolidation of care plans and patient information. Time savings are greater when integration is successful.
