Our Guests: Derek Empey, RPh, MSHI Informatics, Quality, Safety, Compliance, Leadership State University of New York Upstate Medical University; Alex Rodriguez MHIIM CPhT Lead Compliance Data Analyst, St. Jude Children’s Hospital
In the fight against medication diversion, having the right tools at your fingertips is critical. This episode features two experts with contrasting approaches. Alex leverages a third-party diversion detection software as the primary monitoring tool, supplementing with reports from Epic for additional insights. Derek relies on a system of custom-built reports he’s developed himself, conducting manual reviews to identify potential diversion. Together, they delve into the pros and cons of each approach, exploring:
- The Power of Third-Party Software: Efficiency, ease of use, and a centralized view of potential diversion red flags.
- Beyond Automation: The value of complementary reports for uncovering policy violations and other diversion risks not captured by the software.
- Homegrown Hero? The challenges of developing and maintaining in-house reporting systems for diversion detection.
- Resource Allocation: Considering the staffing requirements needed for manual review of custom reports.
This episode is a must-listen for pharmacy directors, hospital administrators, and anyone committed to safeguarding medication integrity.
Transcript:
Terri
Welcome back, listeners to diversion insights. We have a sponsor today, Midas Healthcare Solutions. They’re introducing a new product to help deter and prevent medication diversion. Midas View provides a holistic approach to medication wasting and its documentation with the ability to integrate with your ADC’s, your emrs and your diversion software. It allows for an easy to use system consistent with the nursing workflow for the first time. Their 360 degree camera provides real time and on demand visual proof that the medication was actually discarded. Any time witness technology allows the convenience and flexibility when a witness is required in the disposal of unused controlled substances. Today, my guests are a couple of it pharmacy data analysts, nerds. And don’t worry, I’m not insulting them. They’re very proud of their nerdness. Derek MP wears many hats at New York’s upstate medical University.
Terri
Those hats include drug diversion officer, clinical and quality informatics. Alex Rodriguez is a very familiar face for those of you who listen to the podcast regularly. Alex is the lead compliance data analyst and former diversion compliance program manager for St. Jude Children’s Research Hospital. Welcome to you both.
Alex
Thank you.
Derek
Thanks.
Terri
I wanted these two to share with you listeners some of the reports and ways they use technology to monitor for diversion. In the case of Derek, he is dependent on all homegrown monitoring methods, whereas Alex, he uses many things to supplement a third party surveillance software package. So I want them to kind of discuss some of the things that they use. And just a reminder to both of you know, how they say, put your prescription instructions at a third grade level language. You have to do that with me as we’re talking about it. I am not it. So keep it simple. Pretend I don’t know anything, because I probably don’t. And we’re going to start with Derek. So Derek, tell us a little bit about your monitoring program and some of the things that you put in place.
Terri
And if I recall correctly, you were actually hired to develop this program and all of these reports?
Derek
Yeah, that’s correct. So before I came around, about six ish years ago, we had the basic review, the discrepancy when it occurs, some monthly spot checks for some random audits, and that was about it. So when I was hired, we really began to start to formalize the process, determine what metrics we wanted to look at, and, you know, become more of a whole house monitoring system. But we didn’t have the luxury of having a pre built or a third party solution in place. So with my informatics background, I began to work on a series of report building queries and feeds into some homegrown databases that then funnel to dashboards either in tableau or power bi. So basically, on a monthly basis, we have some daily and weekly reporting as well.
Derek
But the big picture stuff, we run monthly reports from a series of sources that feed into a database that connects to power Bi and then tableau. Power Bi is, I use more for nursing integration. Power BI is able to produce some visuals that are very specific to individual units, users areas, and it’s able to be printed and distributed more easily, at least for my purposes that I have available to me. Tableau, I use a little bit more internally for me and my team for a little bit more deep dive analytics and things that we need to look into or requests that come across for on the floor nursing concern.
Derek
So, yeah, so we start basic raw data feeds into a homegrown database stored locally on my computer, and then connects to a series of dashboards, either in power Bi or tableau, also on my computer, but then gets distributed from there on out.
Terri
Okay. Do you bring in from the ADC and the EHR?
Derek
So I bring in, yeah, primarily it’s ADC. I don’t have a great way to marry the two at this point in time, the ADC and the EHR data. So we use epic and picsis, and I know a lot of folks out there do as well. So I have epic reporting that is built within epic that helps to reconcile removals, but it’s not connected from Pixis database to epic database like I know some of the third party softwares do. Mine still remains separate.
Terri
So do you have to look at two different reports to see if things are accounted for or visit? Sometimes.
Derek
Sometimes, yes. Yeah. Because the reporting that were able to build an epic, we haven’t been able. We haven’t been able to 100% clean that up so that it’s full removal of false positives. So there still is a little bit of process there to validate.
Terri
Okay. Okay. Alex, after listening to what Derek has in place, are you doing any of these same things to supplement the third party software or. And maybe you even have some feedback for him of what he could maybe look at to get it to work. You’ve been there, but now you’ve got third party.
Alex
Yeah. So we got third party tools and that monitors the transactional oversight and monitoring, but our homegrown stuff is more like on the workflow and compliance side. So we kind of tied our institutional policies to the data and the monitoring of those things. Like, cycle counting or how quickly a discrepancy needs to be resolved. We also, as far as, like, tying in the EHR, like Derek was mentioning, the only metric we’re currently tying in is the patient population for that day. To kind of give us, like, something to compare for how many controlled substances or how many medications were dispensed that day does that, you know, so we can see if there’s any spikes that doesn’t fit with what we expect to see for how many patients are coming through our institution.
Alex
The other metric that we started pulling in, but I have not tied to our dashboard, is morphine milligram equivalents. I think that’s an untapped metric so far in drug diversion prevention. And I’d like to see more of that analytics, not just for diversion prevention, but for opioid stewardship. And that committee, they also have a lot of those metrics that, on what physicians are prescribing, how many milligrams a patient is getting, just to be really good about keeping that monitoring in place. And the other thing I have found being a new metric, not everybody counts that metric the same. So it’s also comparing with other institutions and third party vendors to see, like, does that fentanyl vial mean the same thing that you think? I think it means. Right. So that’s been pretty interesting.
Alex
Now, Derek, we had a candidate come through here yesterday, and he gave me a great idea for both of us. He works in quality and safety for a different institution right now. And they’re tying a lot of these metrics into. Back into epic using caboodle, which is their data warehouse, where you can kind of bring in external factors. And I think that could go a long way, because all these, like, homegrown solutions, and whether it’s in power, bi or tableau, like, I always want to meet the clinical staff where they can see that information. And right now, we’re relying on a lot of emails and maybe printed out reports to get that information across. But I would love to see that right there in their EHR.
Alex
Like, instead of having, you know, to wait for my email, if they open up for the day and they see that, oh, the cabinet is supposed to be cycle count today, and I haven’t done it, and it’s something where they’re already there, I think that’d be really interesting to see people adapt that more into their health record system.
Derek
I’m glad you mentioned that, because I’m actually a recent graduate of the EpIc Cogito certification, so I’m very in tune now with the Caboodle database and some of the abilities that EpIc has with regard to metrics and reporting and report building and dashboarding. And then, you know, they have this. They have another tool in their suite called Slicer Dicer. So I’ve been using that pretty heavily when it comes to looking at overrides very recently.
Derek
So we look at controlled substance overrides, if they have an order that’s been linked, if they are, if they’ve been administered as given or returned back to the ADC, and then I’ve taken a series of slicer dicer sessions and I’ve made it all into a dashboard that monitors whole house control substance override compliance, and it breaks it out based on drug department or unit, and then even down to the user level. And nurse managers have access to this dashboard. So I’m a huge proponent, like you said, of end user access and ease of usability. So being able to build that with an epic for our end users has been. Has been huge. And we’ve seen a drastic improvement in our unreconciled override compliance and order linking.
Terri
It’s interesting. I mean, I guess some of these metrics are obviously, we’re looking for diversion, but as you mentioned, Alex, and then Derek, you touched on that following policies and procedures. So, I mean, we can see in third party software if somebody has an override that matches the order that’s there. But I guess if they’re not supposed to be doing that on the unit. Right. We’re not necessarily going to focus on that.
Derek
Sure. I think it’s, you know, I think it’s hugely. It’s about mitigation of risk points. Right. You know, it’s. It’s not just doing what you’re supposed to do, but it’s. It’s also, you know, limiting. Limiting some of those more risky areas.
Terri
Right.
Alex
Yes. You mentioned the false positives and, like, that also goes in hand with policies and procedures. Like, if you have that feedback, your data is going to be cleaner and you’ll get less of those false positives, which, honestly, I think that’s like 50% of building these dashboards and doing the data collection is fixing those false positives so that you can minimize and get actionable data more often.
Terri
Yeah, absolutely. Do you guys think. I mean, I’m gonna. Well, I’ll wait to hear what you have to say. But do you think that. And it’s just. It’s epic. Both of you guys are using epic, that it’s possible to do everything you need with all of these reports and be quite robust? Or do you think that a third party software really elevates what you can do.
Derek
As long as everything is mapped appropriately? And what I mean by mapping is, you know, are we taking a. A data point in PCs and through HL seven messaging? Sorry to get technical, but are we making sure that message for that removal gets sent over to Epic so that it’s read in either the patient’s chart or under that order history? Because then under that order history, that’s where you’re going to have subsequent administration records or returns or wastes and that sort of thing. So if everything is mapped appropriately and going back to data quality, to answer your question, Epic has the potential to build a very robust program when it comes to diversion monitoring and overall control substance. I mean, it honestly, it doesn’t have to be controlled substance. It could be anything, sure. But yeah, the potential is there. The tools are there.
Derek
I haven’t really explored procedural areas yet when it comes to the Cogito caboodle suite of epic tools. Depending on what you have on the procedural side, for drug storage, we have pixis, anesthesia machines, and removals are handled a little differently and it’s a little bit more a la carte, item by item and case by case type removal, and then you reconcile in one big swoop at the end. I haven’t really explored how that may look from a reconciling perspective on the epic side, but I imagine it’s certainly going to be more challenging.
Alex
I think the oversight goes in two phases. It’s always like standardized workflows and then next is, okay, now let’s mess around with the messy one. The procedural side? Yeah, it always takes more time and more resources. And I think your question about can epic look at everything versus a third party, to me that really is a resource question. I think you can make everything homegrown and build it out. But a lot of these third parties have one, the resources to get you up and going. They can connect you to all these other systems that aren’t just ABC and EHR. So maybe you’re looking at time clock. Are people dispensing things outside the hours that they’re even working? Do you know, do you want to oversight into what’s coming into your institution?
Alex
Like then you want to connect to the wholesalers and make sure that there’s no diversion on the buying side, which, you know, those big cases are usually before it even hits the safe. Somebody’s already taken a few balls of something, right, and then reverse distribution, that’s another area. And then also, you know, like that crosswalks of all these, like I just mentioned, like five systems. So now you have to make them all translate into the same amount, usually the ADC or EHR. So now you’re, like, having to create all these crosswalks. And I just don’t see that a lot of healthcare institutions today have the resources for that. And you definitely, at least today, not getting those from epic, maybe be in the future. I could see something like that being just part of that suite.
Alex
But to actually get something like that stood up without, like, me or Derek on the scene building it all homegrown, like, it’s a big ask of a lot of healthcare institutions.
Terri
Derek, you must be exhausted after what Alex just said. I’m tired.
Derek
It’s so exhausting. Yeah, I mean, yeah, it’s like you said, many hats, right?
Terri
I. Yeah, it’s only part of your job.
Derek
It’s funny, it’s, you know, I have all these. I have all these dreams and aspirations, but, you know, at the end of the day, it’s, what do you have time for and what are your priorities? And, you know, what are the priorities of the people who are, you know, employing you? But I do know. I do know that epic also has a pretty robust list of things they can connect to when it comes to crosswalking, like you mentioned. I know. I believe it’s their caboodle database setup. They can actually connect to wholesaler data now and accept imports as well as a slew of other things. Reverse distribution, probably nothing. And then time and attendance data. Not sure about that, but I have heard rumblings of being able to connect to wholesale data.
Derek
So I think they’re exploring their outreach of connectivity, but certainly not as robust as a third party solution would offer. For sure.
Alex
The gap on the inventory side. Right now, I heavily lean on outpatient being, and I’m talking like, outpatient pharmacies. And on some of these institutions being a big gap, you know, you got epic. Willow keeps an inventory, your ADC keeps an inventory. You need to make sure that those are aligned for controlled substances. You know, you have DEA come in and they’re like, okay, show us how many tablets of morphine you have. And somebody hands over the epic sheet, and then later they get the ADC sheet and they’re like, this doesn’t look right. Right. So you would be constantly chasing that. And I think there’s a lot of improvement for that to flow in one direction and make sure that those counts are correct.
Terri
Okay. Yeah, I was going to ask you about that if you’re using it for outpatient settings and because the third party software is little week there too, depending on what you’ve got. Right. What system you have.
Alex
Yep.
Derek
Yeah. I use, I’ve used Epic for some of our outpatient monitoring. And I think earlier you touched on some opioid stewardship ideas. I also dabble in that. And I help the enterprise with some very high level prescribing practice and monitoring and on the outpatient side for all of our epic satellites and outpatient clinics. So they, as long as they’re using epic, you know, we can monitor what they’re prescribing, convert those into morphemeal equivalents and see, you know, those morphemeal equivalents don’t work for amphetamines and things like that. So you have to, you know, it gets a little tricky with some of the buckets that you’re creating with what you’re monitoring. But the conversion of morphine mill equivalents is built in as well. So when it comes to opioid prescribing practice, it’s very easily handled by the tools that are built in already.
Terri
Yeah, let’s talk about morphine mill equivalents. Alex, from your perspective, I know your third party has introduced mmes to their. What are you finding? Are you, I mean, at first when I looked at it, I thought, well, this doesn’t look right, but I didn’t dig in. I thought, I’ll leave that to other users. Let them dig in. What are you finding compared to how you interpreted?
Alex
So to us, right off the bat, it brings value when it comes to legislative side, when we have to say, hey, we need a higher threshold of how many mmes we’re allowed to dispense because we treat patients who have cancer and we’re dealing with a lot more opioids than some other institutions. Having that data is very valuable for driving that story and trying to make sure that we’re not outside the range of what should be expected for us. And that’s been kind of valuable. The other part is the mmes can be used not just for prescribing what the patients are receiving, but also who’s handling most of it in the institution. Like, is there one person that is, always has a high amount of mmes? Doesn’t matter which opioid it is that person, should they be handling that much of it?
Alex
Is there a reason they’re always handling that much of it. I think those are some of the alerts that are missing today, and we can probably start to build some of that out with some of this data.
Terri
Okay. When you say build some of that out, meaning separate reports or, like, create.
Alex
Some flags, like, hey, you should look into this. This is outside the norm. You know, this is definitely outside the norm for even this month. Right. This person doesn’t normally handle that much. Why is so much in their possession this month?
Terri
Right. Which the third party software should be able to do. But can you do that with a homegrown report as well?
Alex
Yes. Yeah, I think. I think that’s the road I’m probably going to go to show proof of concept to supplement that, which helps drive the third party vendors to create that.
Derek
Yeah.
Terri
You’re like, look, I can do this. Why can’t you? Do you use anything with Mmes, Derek, with any of your reports?
Derek
Yeah, I have some. I have some reporting built out within the. Within the cogito dashboarding slicer dicer realm.
Terri
That helps not just opioid stewardship, but.
Derek
Not really for diversion. No. I mean, at least from my perspective, I don’t. You know, I’m focusing on narcotics in general. So whether you’re stealing or diverting tramadol, which is a 10th of 1 morphine, if you take ten tramadol, that’s one morphine mill equivalent, right?
Terri
Yeah, sure. Wouldn’t add up to most.
Derek
Does that make it okay? You know, like. So I usually won’t. I don’t focus on that too much. From a diversion perspective, it all matters.
Terri
Yeah. Yeah. No, that makes sense. That makes sense. Okay. Well, Derek, you’re doing some great things. I’m sure you have more things on your list that you would like to get to. Or maybe not. Maybe you just want time to use what you already have and actually look at it. Gonna have time to digest it as well. I mean, is it. Is it set up to where you then have to sit down, literally, and look at it? Or do you have it flagging you with alerts to tell you, hey, there’s a problem here?
Derek
No, I have to look at it. Yeah, yeah. So that. That. That portion, you know, the. The AI portion is. Is still 100% humanity for me at this point in time. So I have to look at it. And, you know, it’s relatively. The way I have it built and the visuals that are presented, it’s relatively easy to see an issue as you go through, but you still have to go through it manually. And it’s. We have between my two hospitals, we have 800 beds and 40 units, so it’s a lot to scan through.
Terri
Yeah.
Derek
Back to your resources. Comments. If we all had unlimited resources then we would be really good at what we do. So.
Terri
Yeah, well, I mean if it makes you feel any better, and I don’t know, I’ll be interested to hear what Alex has to say. But even with the third party software it might be bundled a little bit, you know, more condensed, but it still requires a look. I mean it may flag you that there’s a problem, but lots of times I go to look and it’s like, no, there’s not really a problem here. There’s another explanation. Do you agree with that, Alex?
Alex
I agree. I think the one other like big benefit of those third party tools is that you have one source of truth for all this information. And so, I mean you’re always looking at it because of the validation side. And once you feel good about that then you can point to one place where you believe that data is correct, whether it’s any of the systems we talked about, the wholesaler, ADC, ehr, I think that’s where the big value comes in. And I think we talked a little bit about like moving, like is the source of truth. Can it be epic one day? I think that’s a maybe. I don’t think that’s the case today, at least for us.
Alex
I think that third party tool is a good place to have all that information and not send the person that’s investigating this information to have to go so many places. You know, you have 800 beds and that’s a lot of data to have to go get from many places. Right. So I want to make that as streamlined as possible for anybody doing that investigation.
Derek
Yeah, for sure. And I think one of the other big pieces for me that’s missing and I try to supplement with, you know, some of the Microsoft tools is that collaboration piece. You know, when you need, when you have been alerted you do a little bit of recon and then you realize you need to at least involve somebody else to continue a conversation or start a formal investigation. You know, when you have a third party solution, as I believe most of them do now, that’s, it’s further centralized for that collaboration piece and then all of that documentation and the conversation gets in there as well into one place. I have all this data in one area and then I share, but then the collaboration piece is within our Microsoft suite.
Derek
You know, I have a series of, you know, lists and things like that I can pull other people in and then conversations start and are stored there, but it still is separate.
Terri
Yeah, it’s very Derek. Yeah. Nice to have one place very Derek dependent. Right. If you’re not there one day, then nobody can access what? Yeah, correct. Oof.
Derek
Yeah.
Terri
Okay. All right.
Alex
Are you also trying to cure.
Derek
Just kidding.
Alex
You also try to plug the Microsoft epic relationship coming up because I’m like, maybe one day that, that all is under one umbrella.
Derek
So is that a real thing?
Alex
Is that. Well, fabric? Yeah, Microsoft fabrics coming to epic. Somebody else nudged me this week. They had announced that Microsoft building like some AI facility in Wisconsin. And I’m like, that’s awfully close to epic. So I was like, okay, I’m keep an eye on this and see what develops. I think it’ll be really interesting.
Terri
How do you see them? It’s probably obvious to you guys, but yeah. How do you see them collaborating?
Alex
When were talking about like the Caboodle database stuff, a lot of that I believe will be moving over to more Microsoft data structures or like Azure or Lakehouse, all Microsoft driven. And maybe some of, from that we’ll be able to merge some of this homegrown work more easily with the epic EHR. At least that’s my blue sky. That’s where I like to go. But all of that takes time.
Terri
Yeah. So get your stock now before everybody else does. Interesting. Okay. All right. Any other parting words that either one of you have for the listeners in terms of reports? Alex, it sounds like to a certain extent, you use your reports when you find there’s a missing gap in your third party software and so then you develop something to find it. And then I imagine you go back to your vendor and say, hey, man, can we do something like this?
Alex
I love to keep that one source of truth going. So, you know, whatever I need to do to make sure that stays. And then just one thing, like all this data is fantastic, but I really lean on education and talking to those providers because the data can’t tell you everything and usually need someone to speak up. So to me, that’s also a big part of this.
Terri
Yeah, yeah.
Derek
Great. Education. We stress very heavily. And then probably our other number one risk point that we stress is the waste practice. We as a whole house have jumped in about two to three years. When we began the waste practice effort, were probably 75% integrated waste, maybe even close to 80%, but now we’re over 90.
Terri
Wow.
Derek
Yeah. Yeah. We’ve really been able to move the needle and, you know, through a lot of education effort and great support from leadership and a lot of our nursing directors and managers. So, you know, we’ve, that’s awesome. We’ve actually, you know, I mean, not that I like to carry this heavy, heavy cloud of, you know, compliance concern, but, you know, when it comes to control substance compliance, when it seems that we’ve instilled this sense of almost fear that when something goes wrong and the nurse isn’t sure what to do or they can’t fix it even sometimes it’s just, it’s a little thing and it’s okay. They’re literally distraught about it and, you know, so there we’ve instilled a super heightened sense of respect across the enterprise when it comes to control substance.
Derek
So, you know, it probably doesn’t need to be as severe as some of the examples I’ve seen, but I’d rather. I’d rather have it that way than, you know, the other way.
Terri
So, you know, I mean, that’s a good point, Derek, because I think that most hospitals when they do start monitoring, especially if they have a third party product and they’re starting to see every single unaccounted for Med, it’s a little alarming how careless staff is with closing that loop. And so if you’ve instilled that accountability piece, that is a large piece of it. So kudos to you.
Derek
Yeah, it gets a little diluted recently because of our percentage of travelers and that’s increased a little bit as of late, but still, I think our resident nurses and some of our more senior staff do a great job at relaying that tone.
Terri
Yeah. And I talked to a facility recently that they have turned on mandatory integrated wasteland. They can’t even proceed if they’re not going to do the waste at that moment.
Derek
Interesting.
Terri
Curious. Yeah. To see how that, and obviously there’s exceptions, you know, procedural areas back to the more complicated areas. You know, that’s impossible. But we have that spelled out in.
Derek
Policy pretty clearly is, you know, your only option to waste later is a, if it’s an override or if b, 100% cannot waste now or, you know, you can’t find a witness or, you know, but there’s very, a very limited list of reasons, so.
Terri
But they’re complying because you’re holding them accountable, which isn’t always the case.
Derek
Absolutely. Yeah.
Alex
I’d love to see more of this data being used by, it doesn’t matter EHR or third party solutions to help give us feedback on what our policy should say. I mean, you’re capturing how long it takes somebody to waste, how long it takes somebody to administer. We should be getting that feedback from these tools to let us know, hey, this would be a good time interval for your institution. It doesn’t fit everyone, but they have the information to help calculate that.
Terri
Yeah. Yeah, because there are variables. Certainly. Okay, great discussion. Thank you. Thank you both, gentlemen and listeners. Please hit that subscribe button because it lets me know that you are listening. It’s a lot of work to do these podcasts and take our guests away from their work, so let us know that you get value out of it. And as a reminder for those of you attending the ASHP future meeting in Portland in June, visit the Midas Healthcare solution exhibit, where they will be conducting demonstrations of its capability and learn about its unique approach to controlled substance wasting. The current process detracts from patient care, can result in lengthy investigations, and is proofless, but minus few is an intelligent, technology rich wasting system that can help deter and prevent drug diversion. Thank you, both of you, Derek and Alex, for your time today.
Derek
Thank you.
Alex
Thank you. Have a great day.
Terri
You too.
