Five Questions With: Leroy Kromis, Lehigh Valley Hospital

In using information technology to ensure medication safety, Lehigh Valley Hospital has enjoyed dramatically improved patient outcomes and nationwide recognition as a leader in mobile health care technology. In fact, for eight consecutive years, the American Hospital Association named Lehigh Valley Hospital among the “100 Most Wired” and “25 Most Wireless” hospitals in the U.S. in 2009.

Further evidence of the hospital’s commitment to protecting patients is Leroy Kromis, Pharm.D. Kromis is a clinical pharmacist at Lehigh Valley Health Network and one of the few medication safety officers in the country. He is an expert in the newest systems that reduce medication errors including electronic barcoding, computer-assisted physician order entry (CAPOE), pharmacy robots and automated medication-dispensing cabinets. HealthcareGoesMobile.com talked with him recently about the hospital’s use of technology to support his office’s mission of medication safety.

HCGM: What is technology’s role in medication safety?

Kromis: I always point out that people care for our patients, but technology allows us to do it more safely; technology does something well that people don’t, and that’s repetitive tasks. [In completing competitive tasks] our brains shut down to lower functioning levels and we’re much less able to catch errors. Cognitive and creative functions are what humans are great at, but our brains zone out when we do repetitive things. Computers will do it over and over again without faltering. People are good for judgment and cognitive skills; a computer is good for lower skills. The two complement each other, as in a marriage.

HCGM: How have Lehigh Valley’s investments in mobile health care technology supported your office’s mission of medication safety?

Kromis: The investments provide low-level support but can also support high-level safety efforts. For example, before, the pharmacy would call if it detected an error in an order; now CAPOE helps with clinical decision support, which reduces errors. [When using CAPOE] the physician gets alerted by rules he didn’t get before; the computer will say something like, “You shouldn’t give Metformin to someone with a serum creatinine higher than 1.5.” The computer will ask them if they really want to do that. It gives decision-making assistance at that point in the process.

If we said 99 percent is a good accuracy rate, I would say that’s great in most cases, but at Lehigh Valley, when we dispense medications 8 million times per year, that’s not good; we need to get down to Six Sigma-type error rates, as in one in a million.

One thing we’ve looked at carefully with CAPOE and barcoding is their effect on harmful error rates since we implemented them in 2003. In the first two years, our results weren’t as good as we’d hoped, but mostly it was a problem of adoption—we found out it was poorly utilized. We got a mandate from the Senior Vice President of Patient Care Services that if you don’t barcode, you don’t work here. The CEO mandated that physicians use CAPOE. Management offered incentives to help out, but gave staff until 2006 to comply. By 2006, 92 percent of meds were barcoded and 95 percent of the orders were entered via CAPOE. By the next year, we saw a 92 percent reduction in our harmful error rate. As our utilization rates went up, our error rates went down. The two technologies together have really helped us. We would have harmed 155 patients if we hadn’t used CAPOE and barcoding.

HCGM: What have been some of the biggest challenges in deploying these mobile health care technologies?

Kromis: We had big challenges with barcoding. We tested a lot of different scanners in the barcoding process. We started out with a wireless scanner that used NiCad batteries, but that was a problem because the scanner would be in the charging cradle too long and would ruin the batteries, so it wasn’t charging. We briefly switched to a wired scanner, but now there are new battery technologies, so we are back to wireless. Certain kinds of lights would have problems. Some of the medication packaging was light foil, which would reflect the barcode light in a way that caused reading problems. But most of those problems have been worked out in the last five years. Scanners used to be more laser-based, but now they’re more optically based, so they take a picture rather than work with reflected light.

One of the things that helped was real-time statistics reporting. At first, we couldn’t get to the root of the problem when we reported statistics on monthly basis, but now the statistics update at midnight every day, helping us identify the problems more precisely, whether it’s a finicky scanner or a new 3D barcode that is failing in the system. And then we set up a hotline where [staff members] can call with their problems or fill out a form and have the problem addressed immediately.

HCGM: Were there any challenges related to staff adoption of the new technologies? If so, what has Lehigh Valley Hospital done to help staff members with the transition?

Kromis: At first, from many people we heard things like, “I’ve been doing this for 20 years. I don’t need this.” We worked with the nurses, and many of them had “a-ha” moments when the scanner caught one of their mistakes. We also made our improvement in harmful errors known to staff.  Along with it came the message that this is why we barcode at the bedside and it is the expectation. Now we’ve gone from 39 percent barcoding compliance to 97 percent compliance.

For CAPOE, we can build order sets that are tailored to physicians. They don’t want their screens so full that they can’t use it, so we limit it to the most commonly prescribed meds. We also take out overly complicated features to maximize utilization.

Back when I worked in another hospital using an early version of CAPOE, the physicians were using wired computers. They’d have to use it, unplug it, then go to another room, repeat. When we implemented CAPOE here, we decided that physicians had to have their own computers and they had to be wireless. We allowed physicians to test and choose the portable PCs they’d use, including laptops and tablets. The ones we ended up using had the perfect combination of weight and size. And you could walk from the ICU to med-surg without having to log in every time. We gathered a lot of user feedback before investing in a fleet of them. Every physician on staff got their own. It was a significant investment, but then there was no excuse for the physician not to be able to do this. It was completely mobile. That was a huge part of our success.

For barcoding, we created a 24-hour barcoding hotline I mentioned previously, so if someone was having a problem with it, we could fix it immediately, not the next day or the day after that. We also created a system for daily statistics reporting, so that the next day I could ask a nurse why she used it 40 percent one day and 80 percent another day, and she might say “I had a problem with the scanner.” We could spot-check problems and barriers and fix them right away.

We also check usage not just by nurse but by drug. For example, Heparin wasn’t being used in the barcoding system very much at one point. It turns out the companies were changing the packaging so often, our system couldn’t support it. We worked with the wholesalers to have them send only certain versions of the packaging. We have one person who’s responsible for tracking down these changes.

If we can’t identify such barriers, then it’s an issue of accountability. That’s where the mandates come in. Between the mandate and the incentives, we’ve gotten to that 97 percent rate of adoption, as close to that 100 percent as we can expect. Yesterday our percentage was 97.4%. I can break it down by unit, nurse and drug, every day.

HCGM: What advice do you have for other hospital systems considering the kinds of mobile technology upgrades Lehigh Valley has implemented?

Kromis: You have to do your homework, which is the key to the successes we’ve had, because with a lot of these systems, you have to know how they’re going to interact with what your hospital has already deployed – for example, how our ED charting system interacts with our pharmacy system. I think that’s why there’s more of a trend to go to a single vendor for all products, so the different pieces can all talk to each other.

Be strategic in deciding what your plan is going to be. Evaluate all technologies and vendors to make sure they will interact smoothly. Get input from all departments, or you may get systems that don’t talk to each other well. Some systems take info in nicely but they don’t send info out nicely, so make sure that they work well in both ways. Have a global plan for what you want to do, so when you evaluate these systems you know they’re going to work nicely together.