Q&A: Barcoding and Ministry — from Preacher to Barcode Evangelist


Barcoding and Ministry—from Preacher to Barcode Evangelist


Mark Neuenschwander of Bellevue, Washington, is considered by many to be the world’s leading expert in the field of drug dispensing automation and barcode point-of-care systems. His firm, The Neuenschwander Company (www.hospitalrx.com), provides reports, consulting services, lectures, and seminars that promote and facilitate wise development and sound deployment of medication-use automations—with particular attention to point-of-care safety systems. An engaging communicator, Neuenschwander lectures frequently to professional societies, hospital leaders, and numerous organizations. His blog, “I’ve been thinking…” is featured at the PointofCareForum.com, and he is co-founder of the annual unSUMMIT for Bedside Barcoding. In addition to articles for professional journals, Neuenschwander has contributed the chapter on “Dispensing Automation and Medication Errors” for the first edition of Michael Cohen’s seminal book, Medication Errors, and a chapter for the HIMSS award-winning book, The Impact of Information Technology on Patient Safety.

The Institute for Safe Medication Practices (ISMP) has announced that it will honor Neuenschwander with its Lifetime Achievement Award for his extraordinary contributions to mediation safety. Neuenschwander will receive the award at ISMP’s 2010 Cheers Awards Dinner in December (http://www.ismp.org/cheers/invite.asp).

Neuenschwander spent the first 20 years of his career as a pastoral minister, before changing careers in 1992 and immersing himself in the world of automated medication dispensing systems. Robert Wachter, MD, has said that, “Mark, in particular, is an unusual guy: a former minister who has a preacher’s passion for barcoding.”

PSQH Editor Susan Carr talked with Neuenschwander recently to find out more about what the “barcode evangelist”—as he is sometimes called—is thinking about.

Susan Carr: I attended your unSUMMIT for Bedside Barcoding in May of this year and was impressed that fundamental principles of patient safety were woven seamlessly throughout the program. You’re best known as an expert in automating medication processes. Have you always been interested in larger patient safety principles, too?
Mark Neuenschwander: I changed careers in the early 1990s and dove into the world of automated drug dispensing systems. At the time, the benefits we focused on had little to do with safety. We talked mostly about capturing lost charges, more efficient distribution, and along with that, tighter narcotics control. But I became fascinated with barcode-literate robots and robotic storage-and-retrieval systems that not only replaced human activity, but did so with lower error rates! That was my introduction to the concept of medication errors and the potential for clinicians to scan barcodes on wristbands and medications at the point of care (POC) to avoid errors. That made a lot of sense. Barcoding is improving accuracy everywhere in our world. Why shouldn’t we have it at the bedside?

Carr: You’ve frequently argued that barcoding impacts patient safety beyond medication administration. How important is it to look at all the pieces together?
Neuenschwander: Barcoding is relevant for the entire medication use process, from the time medications enter the hospital to the time they enter the patient. We should be using it to verify and document along the way that we have the right products, in the right places, with the right caregivers, being given to the right patients, and so on. But barcoding has a role to play beyond the medication process, in ensuring proper patient identification (ID) at every point of care. ID errors can happen throughout care delivery, not just with medications; that’s why I prefer the term BPOC—barcoding at the point of care—rather than BCMA—barcoding for medication administration. It’s significant that improving patient ID remains The Joint Commission’s number one National Patient Safety Goal.

Anytime we need to know, “Who is this patient?” and match them with anything we do to them, give to them, take from them—medications, blood, nutrition, milk—we must insure proper identification. The safety of barcoding goes well beyond medication errors.

The truth is, most hospitals have barcoding… in the gift shop. The vision is to move it beyond the gift shop to the point of care. In my experience, any BPOC application in a hospital is potentially the camel’s nose in the tent. The goal is to get its whole body in the tent. I’m happy to see barcoding implemented in any area where we can improve the identification of the patient we’re with; nevertheless, I think it’s best when hospitals can take a step back and think about their entire identification enterprise. I want them to think about the ID of caregivers, patients, and products as a unified vision, not in silos. When systems play well together, rework and redundancies are avoided, and system efficiency is enhanced. I recommend limiting the number of disparate systems and vendors. Capitalize on the synergies in a unified vision.

Generally, hospitals start with parts rather than the whole. Sometimes they can move successfully from one part to another, to another, but if an organization can look at the whole enterprise and then approach pieces in relation to the larger vision, I think they’ll be further ahead. Certainly, that’s what I try to do with my clients.

Carr: Medications have carried barcodes for 20 years, but adoption has been slow. Why is that?
Neuenschwander: While it’s true that the first barcodes appeared on medications almost 20 years ago, in 1991, getting all the pieces to play well together didn’t happen until about 2000. In 2001, barcoding for medication had been adopted by only about 2% to 3% of hospitals in this country. The problem was that drug companies said, “Why should we put barcodes on medications if nobody is scanning?” The hospitals said, “Why should we buy scanning systems if there are no barcodes on medications?” Manufacturers were caught between, able to envision the application but not able to convince the hospitals or the drug manufacturers to commit. Adoption was held up by indecision and lack of leadership. Eventually realizing that the FDA might break the log jam with regulation, many of us appealed directly to them to do it. Finally, in February 2004, following a series of hearings, and in the best interest of the public, the FDA required barcodes on all medications by April of 2006.

The FDA exercised the wisdom of Solomon with the barcoding reg. Everyone had a great rational for what they wanted or didn’t want. In the end, the FDA came up with a good, sound regulation. I had wanted more from them, but the fact that all they required was the NDC number in a simple linear barcode was ingenious. If it had been more than that, I believe it would have taken even longer; we might never have gotten there. This was a tipping point.

Carr: I see how regulation freed the log jam in this case, but do you think regulation in general is an effective tool for improving safety?
Neuenschwander: Well, it’s beyond the FDA’s jurisdiction to require barcode scanning in hospitals. It’s a lot like seat belts; manufacturers were told they had to include seat belts in cars, but the federal government did not mandate the use of seat belts. States, however, could and did. State hospital boards might require BPOC someday or The Joint Commission could require it for accreditation.

I want to be careful here. Barcoding in itself doesn’t save lives any more than seat belts save lives. Barcoding employed responsibly saves lives. It’s the right thing, but it needs to be done in the right way. Two factors come into play: the use and maturity of the technology. The design of seatbelts improved—for example, with the shoulder belt—and they became more effective. But it wasn’t just the design that improved, utilization had to increase. We have all kinds of incentives for people to wear seat belts: education, ticketing, ease of use, warning systems when we forget. The same can be said for barcoding: the technology is maturing, and our utilization is improving. As a result, more injuries are avoided and more lives are being saved. Hospitals are improving at training end users and holding them accountable. We’re making it easier to do the right thing, harder to do the wrong thing. As for the FDA, I expect they will refine the barcode labeling regulation in the future to require lot number and expiration date. Eventually 2D barcodes will be accommodated, which can contain more information, and are read more quickly and easily than linear barcodes.

By the way, the FDA is currently in the throes of deciding which medical devices should be barcode labled. Once that’s settled, we’ll be asking how to incorporate the scanning of medical devices at the point of care.

Carr: Have the barriers to BPOC adoption changed over the years? What are the current barriers?
Neuenschwander: The barriers have changed some. Of course cost is a barrier, and some hospitals struggle with attention deficit disorder. An institution focuses on barcoding, does their homework, says they are going to barcode, shows it in their top two or three priorities, and then gets distracted. Barcoding gets bumped down by something else, often by CPOE (computerized physician order entry) and recently, by electronic health records (EHRs).

CPOE is not nearly as formidable a barrier now as it used to be. We have nearly twice as many hospitals using barcoding as using CPOE. And, in hospitals using BPOC, we see 90%+ scanning rates, much higher than typical rates for actual CPOE usage for medication orders. A few hospitals are implementing both at the same time, and some are doing barcoding on the heals of CPOE. A good number are doing BPOC first because it’s lower-hanging fruit: quicker safety ROI, not nearly as expensive or as great a culture shift as for CPOE.
But then along comes the EHR… With stimulus funding in the HITECH Act, there’s tremendous emphasis on this right now. Truthfully, I think the EHR is a little like world peace—it’s politically incorrect to be against it, but it’s pretty difficult to pull off.

Let’s not forget that we typically use barcoding at the point of care with an electronic medication administration record, which feeds the EHR. Barcoding is just the interface—I like to call it the synapse between the patient and the EHR. We’re pulling information from the record at the point of care, and we’re recording what we do to the patient, back into the electronic record. Clearly, the electronic medication administration record (eMAR) is a part of the EHR. The record is a true record of what needs to be done prospectively and what has been done retrospectively. BPOC with eMAR can be done with immediate safety benefit, before we get anywhere near having the full EHR.

By the way, BPOC with eMAR not only prevents medication errors, it also prevents documentation errors. This is important not only to the EHR in general, it’s important to CPOE in particular, and thus to the physician. Beyond clinical guidelines, medication lists, allergies, and drug interactions in CPOE, eMAR shows what has and hasn’t been given, and when, so the physician can adjust medications in the context of reality. There’s no CPOE system that can heal poor documentation and insure that the right medication is given to the right patient at the right time, etc. Most people discern the value of BPOC to the patient and the nurse, but we don’t often talk about the value of BPOC from the physician’s perspective, and we should.

Carr: Will barcode adoption get a lift from the stimulus funds available for EHR implementation? Is barcoding included in Meaningful Use requirements?
Many of us pleaded with the ONC (Office of the National Coordinator for Health Information Technology) and CMS (Centers for Medicare and Medicaid Services) to include barcoding—not just from pharmacy but also very strong voices from the IT community. Unfortunately, we were not successful, at least for round one. However, 7 of the 15 measures that hospitals must meet to satisfy Meaningful Use in 2011 involve medication administration. I can’t imagine they can be met without implementing an electronic medication administration record (eMAR), and barcoding is the next logical step. Barcoding is on the “highly recommended” list for phase 2, but ONC is not committing to round 2 requirements at this time. I think, however, the world is beginning to understand that barcoding is a “meaningful” technology whether or not it’s on the ONC list.

The recently published study on barcoding with eMAR at Brigham and Women’s Hospital in Boston (Poon et al., 2010) served to bring barcoding to the attention of the public with extensive coverage in the media. In fact, this study appears to be the second tipping point; the first was the FDA regulation. The study confirmed what we have been hearing from hospitals’ own studies for years about the effect of barcoding on safety, but it hadn’t been verified in a scientific study. The study appears to be convincing two communities that have been outside the BPOC discussion so far: physicians and the public. I’ve heard from Drs. David Bates and Charles Denham that the National Quality Forum may soon consider adding barcoding to its list of Safe Practices. It hasn’t been on the list because, by NQF’s standards, the evidence was lacking. This new study from the Brigham has confirmed what many have observed for years.

Carr: What inspired you to switch careers?
After 20 years in pastoral ministry, it was time for a break. Truthfully I stumbled into medication dispensing automation well before I knew about medication errors rates and understood how technology could reduce them. However, I see all meaningful work as ministry. Whatever I’m doing, I feel called not only to make a living but also to contribute to the well being of others. Eventually, I became inspired by the fact that barcoding, when done properly,  prevents injury to patients, saves lives, and spares loved ones from emotional pain. It assists physicians and protects nurses in fulfilling their high callings—Lord knows, we can’t afford to lose more nurses! All of that is ministry.

Some people think I never stopped being a preacher. I’ve been called the barcode evangelist. When I have conviction about something, I have trouble holding it in.

Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, Moniz, T., et al. (2010). Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine, 362(18), 1698-1707.