Simple Guide to Managing Drug Shortages in Willow
Constant drug shortages have been a major problem and a perpetual source of frustration for hospitals over the past few years. No department is hit harder by this epidemic than the pharmacy, which often gets unjustly blamed for manufacturer shortages. Having been on the receiving end of a frustrated physician’s tirade in the past, I know first hand the plight of drug shortages. It doesn’t help that drug companies are less than transparent about the reason for the shortages, leaving pharmacists scratching their head trying to comprehend a sodium bicarb shortage due to “lack of raw materials” when they just bought a box of Arm and Hammer last week for a dollar. While it’s obviously more complicated than that, the feeling persists.
What sometimes goes unnoticed is the strain drug shortages put on the Epic Willow team. The barrage of help tickets that come with each new shortage are, of course, high priority and take precedence over any other projects. While each request on its own is usually a fairly simple fix, the sheer number of tickets and the interruption factor prevent the team from working on much more meaningful projects. The guide below will help liberate the Willow team from the tyranny of drug shortage tickets while helping pharmacists waste less time with the technical and clinical challenges manifested by drug shortages.
Partial or packaging shortages
From a pharmacy standpoint, these types of shortages are easier to manage because the drug is still available, just not in the preferred concentration or form. However, these types of shortages are typically much more challenging for the Willow team due to the specificity necessary in Epic. Here is a recent example:
Precedex comes in 4 mcg/mL premixed vials meant for patient administration, and concentrated 100 mcg/mL vials which need further dilution. The premixed vials have been on shortage intermittently over the past few months, with hospitals able to get limited supply from time to time.
In the old days, this would be no big deal. When the premix was available, slap the label on the side of the vial and send it up to the floor. When the premix was out, have the technician mix up a bag with the concentrated vials. Two products, same label.
Now, with things like BCMA, Dispense Prep, and production labels, the premix is no longer interchangeable with the mixture. For a hospital that uses the premix as a default, the pharmacist would have to manually re-enter any Precedex order and change it to the mixture record, as opposed to the premix. Any time that an order has to be re-entered for a non-clinical reason introduces unnecessary risk to the patient, which is unacceptable. This means that the Willow team gets a ticket to change the default product to the mixture, and then another ticket to change it back when more of the premix product becomes available. The whole process repeats itself once the premix supply is exhausted. This vicious cycle continues until either the shortage is over or the pharmacy gives up on the premix product entirely.
Luckily, there is a way to eliminate this back and forth burden on the Willow team while simultaneously eliminating the risk that comes with pharmacists re-entering orders. By building orderables and allowing pharmacy teams to manage their own medication list, these types of drug shortage tickets can be reduced from many to one. Here’s how:
1. Build your orderable
We are going to use an often forgotten feature of dispensable mapping to automate dispensable selection based on the central pharmacy med list. For examples like the Precedex one above, there may already be an orderable in place. It is crucial to build the orderable according to how the pharmacy would operate if there was not a shortage. Premix products first, and mixture products second. Fairly simple, right? But how does that help in a shortage? That brings us to step two:
2. Give the pharmacy admin access to the medication lists
The thought of giving admin access to end users is enough to give Epic builders of any application chest pain. The truth is that pharmacist end users will not even realize that they have been given admin access and do not care to poke around to find out. Smarttext and Reporting Workbench are two great examples of pharmacists having access to customize incredible productivity tools and not having the slightest inclination to use them at all. The pharmacists who show an interest will use them, and the pharmacists who do not will operate as if those features are not even there. The same can be said for the med list admin activity. Those pharmacists who are trained to use it will use it, and those who are not will be oblivious to their enhanced access. If not convinced, med list access could be given to select individuals only, but that really only leads to more maintenance burden on the Willow team without any real benefit of enhanced security.
My recommendation would be just to update the pharmacist template to include admin access. This can be done by simply changing two security points to allow the pharmacist template access to the medication admin activity, and to turn off read only access to all admin activities.
3. Train pharmacists on the process
Great, the orderable is built and the pharmacists have admin access to their med list. Now what? The process is very simple and with explicit instructions to the pharmacist staff, will be very easy to follow. The explicit instructions piece is extremely important, to the point where the process needs to be defined on a single sheet of paper affixed to the computer screen.
First, the pharmacist needs to properly identify the exact drug that is going out of stock. The best way to do this is to use the Validate Barcodes activity. The pharmacist can scan or punch in the NDC of the drug that is going on shortage to identify the exact ERX. Second, the pharmacist finds the drug on the central pharmacy med list. This is an important point to stress to the end users that they must be working off of the central pharmacy med list and not the facility list. Once they find the medication, the pharmacist will click into the medication detail screen. Then, the pharmacist clicks the check mark next to the drug to remove it from the central pharmacy med list. When the drug comes back into stock, the pharmacist will re-check the medication to return it to the central pharmacy med list.
How it works
Dispensable mapping evaluates each dispensable record in the orderable according to many criteria. One of these criteria, is whether or not any component of the dispensable is on the central pharmacy medication list. If any ERX contained within a dispensable is not on the central pharmacy list, that dispensable is skipped. That’s it. As long as the central pharmacy med list is accurate and the orderable records are built correctly, the system will always select the correct dispensable.
It is a pretty simple concept, but depends heavily on proper execution. The pharmacy team must be committed to maintaining their own med list and training enough personnel to cover most shifts. The build team has to have a complete understanding of the products and practices of the pharmacy to properly build the orderable. If both of these things are done, the system will always automatically select the correct products that are currently available.
All out drug shortages
This is the worst kind of drug shortage. There is absolutely no form of a drug available, and there is nothing you can do to get it. Do not pass Go, do not collect $200. There are few calls a pharmacist wants to make less than the call to a physician telling them they cannot order a drug, even though it is completely appropriate. It isn’t a recommendation that the physician can ignore, it is simply a statement. In this case, the pharmacist has to have an answer to the inevitable question, “well what am I supposed to do?” Fortunately, Willow has a way to completely avoid these uncomfortable interactions by using Alternatives.
Alternatives are decision support tools that were initially developed to manage non-formulary home meds that were ordered upon admission during med rec. It’s a great idea in theory, but in practice they are relatively poorly received by physicians. Most hospitals build out Alternatives based on auto-substitution policies approved by the P&T committee. As far as the physicians are concerned, why should they be bothered with an Alternative when the pharmacy is just going to change it anyway? Because of this pushback, Alternatives are relatively under-utilized in many organizations.
However, Alternatives prove to be much more useful in drug shortage situations. Drug shortages happen relatively quickly, and often there is not enough time to belabor all of the options with a P&T committee. This is important because the pharmacy does not have the scope of practice to automatically substitute therapy just because a drug is on shortage. However, clinical pharmacists can more often than not agree on a standard alternative therapy to recommend to physicians in the meantime.
The actual build of the shortage Alternative is effectively the same as it would be for a therapeutic interchange. Build the recommendations as SmartGroups to present to the ordering provider with as much detail as possible, including dosages and frequencies. One crucial difference with the shortage Alternative is to uncheck item 140, “Allow continuation with original selection”. If this is left checked, then the physician can continue ordering a drug that is completely out of stock, effectively defeating the purpose of creating the Alternative in the first place and forcing the pharmacist to make that uncomfortable phone call anyway, wasting the time of several expensive clinicians.
The beauty of using Alternatives for drug shortages is that they can be activated and deactivated according to the status of the shortage. If a drug temporarily becomes available, the Alternative can be turned off until the drug goes back on shortage, at which point the Alternative can be turned back on with no further build necessary.
There you have it, a simple but effective guide to managing drug shortages in Willow. Through a user managed med list and effective use of Alternatives, the pharmacy can reduce the technical and operational burdens imposed by drug shortages.