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One-on-One with David Troiano, R.Ph., Principal, CSC Corporation

May 15, 2009
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Troiano discusses how progress toward medication safety is still not fast-tracked.

It’s almost universally acknowledged — and backed up by statistics — that medication errors remain the largest category of medical errors overall. Yet moving the healthcare system forward toward the next level of medication safety is a step beset with challenges, as Julie Morrison, David Troiano, R.Ph., Jane Metzger, and David Classen, M.D., the authors of a new report from the Falls Church, Va.-based CSC Corporation found this spring. In their introduction to Moving Medication Safety to the Next Plateau, the CSC researchers found that, “Much of the progress so far has been achieved by reacting to external direction concerning safe practices and focusing on gaps that become apparent in the investigation of incidents.” Further, the authors say, “Getting to the next plateau will require continuing this work, but with a focus on the entire medication use process, rather than on piecemeal projects. Building upon the work so far, it will also involve extending standardization, incorporating safe practices to all key processes and patient care areas, and optimizing reliable workflows, reinforced by carefully-designed safeguards.” The intelligently applied use of clinical IT will obviously be critical to that effort.

David Troiano, R.Ph., who leads CSC’s medication safety practice, spoke recently with Senior Contributing Editor Mark Hagland regarding the findings of the report, and what needs to happen next. Below are excerpts from that interview.

Mark Hagland: It’s becoming clear that medication management really is an incredibly complex process, isn’t it?

David Troiano, R.Ph.: It certainly is, yes.

MH: Did you and your colleagues feel discouraged in completing this report?

DT: It was almost a reaction of surprise, really. It’s not that a lot of people aren’t making progress and working hard on this; but though there’s a lot of effort going on, there’s still a long way to go. For example, I started working recently with a hospital client; they’re a very sophisticated hospital. But they’ve made some mistakes—they decided they wanted to go with barcoded meds administration, but they neglected to understand how that process was integrated with dispensing, so they made some fairly unwise choices around how dispensing should take place, choices that introduced added inefficiencies into the system. They hadn’t understood this, but fortunately, someone from the organization called us before they had gone live. And hopefully, we’ll be able to work things out for them.

MH: It makes me think of the visual image of trying to organize a football stadium filled with people to hold up flash cards in just the right way for television cameras. It feels that complex.

DT: Yes, exactly, that’s a good metaphor. You start out saying, we’ll do this one thing in this one area, and then you realize that everything bumps into everything else. So, for example, you and your colleagues decide to work on ensuring that all medication use is safe; but to do so, you find you need to look into such diverse areas as med/surg floors, the ED, the OR, and so on. They’re all such different clinical environments, and yet your goal is trying to achieve standardization and compatibility of solutions, so that the people in the pharmacy can manage the overall process in some way that makes sense.

MH: And it seems that the medication order-set issue seems to be a complex and challenging one that is so often overlooked.

DT: Yes. And in many organizations, it really requires a multi-year initiative to achieve success in that area. The first step is simply coming up with that content, and getting the diverse physicians to agree that that’s the right content, and covering enough of the bases and giving them enough flexibility to deal with the outlier situations; that part of the work alone is a huge task that can take years to put in place. And second, there’s the transition from paper to electronic; that ends up requiring a whole different process. We’ve often had to go through two rounds of work with clients, in that regard. And how do we model choices, in terms of what is acceptable and not? And translating that into a system is a huge task unto itself.

MH: It has to be a multidisciplinary process involving medicine, nursing, pharmacy, and IS from the very beginning working together, don’t you agree?

DT: Yes, absolutely. And people tend to think far too narrowly; they’ll say, well, I just want to change this one little thing in pharmacy, but it ripples out. And whether you’re doing process redesign or system redesign, you have to have a multidisciplinary focus, or you’ll end up with something unsatisfactory for everyone.

MH: What are the pioneering organizations doing in this whole area, and what have been their critical success factors?

DT: First, they’re choosing integrated systems. They’re integrating EMR, CPOE, pharmacy, and barcoded meds administration. They’re going for a core clinical IS, one that integrates med/surg, the OR and the ER, all together. Second, they’re really starting to look at the impact, and prioritize their efforts, based on the medication safety impact. Because the question, assuming the funding is available, is ‘what is our goal?’ And the pioneers are saying, ‘our goal is medication safety,’ and they’re prioritizing choices based on that. In many places, organizations are asking, ‘should we do CPOE? Should we do barcoded meds administration? And what will have the biggest bang for the buck?’ And medication safety becomes the organizing principle, if you will, that helps them to drive and determine how they’re moving forward, and what compromises they’re willing to make and not make.

Third, they’re becoming much more holistically focused as well, viewing things more broadly, not doing things just for the pharmacy department or for nursing, or whatever; they’re focused on broad goals like medication safety. Fourth, organizations are becoming much more data-driven, continuing to measure their adverse drug events and medication errors, and continuously improving processes. Because putting the systems in, in the first place, is really just the first step. So they’re constantly working to get better at med safety.

MH: What are the smart CIOs doing?

DT: I think that they’re stepping back in some ways and saying, these are performance improvement initiatives, and they must be driven by clinicians. So whereas in the past, IS might have done something like this by itself, they’re standing behind the clinician leaders, saying, OK, you’re the driver, and you, the director of pharmacy and the chief of the medical staff, will drive this. So IT is providing support and the mechanism and the means, but they’re not driving it.

MH: The organizations making the most progress on this are already ones driven by performance improvement and a quest for quality, and have a culture of multidisciplinary collaboration already, don’t you find?

DT: Yes, exactly. Because you won’t be successful in doing things like this, otherwise.

MH: When will we get to a critical mass of a majority of hospitals putting most of these elements in place?

DT: That’s a hard question to answer, because of the current economic environment; but what is happening is that organizations are saying that these investments, these projects, are reasonable, not only because they’re the right thing to do in terms of medication safety, but because they actually have a significant financial payback. So I think it’s still a five-year horizon in terms of most organizations really having moved forward. As of late 2007, you had about 25 percent of hospital organizations that had implemented barcoded meds administration, according to ASHP [the Bethesda, Md.-based American Society of Health-System Pharmacists]. Now, some of the organizations involved are like the VA, which was a pilot organization for that. And if you look at some of the other data we see, somewhere in the neighborhood of 10 or 20 percent of hospitals plan to do so every year. So you’ll be seeing over 50 percent of hospitals doing barcoded meds administration in the next three years. Now, some of the supporting technologies, such as CPOE, are more challenging. But, given some governmental incentives, perhaps you might cross that 50 percent threshold in the next five years or so; it’s around 15 or 20 percent of hospitals now. If the government gives them a little bit more motivation, both in terms of funding and de-funding, we might then get to 50 percent.

MH: CPOE is a critical element of this, to get it right, correct?

DT: Oh, it absolutely is. And if you look at the studies of where medication errors and adverse drug events emanate from, you still see that a little under half of those are coming out of the order entry process, so that’s something you can’t ignore. But where we’re seeing the most effort is not so much in CPOE, which really requires the goodwill of the physicians; instead, we’re seeing progress in areas that they can control internally, especially in terms of medication dispensing, in terms of the use of robots, and of cabinets and carousels. There are lots of things that are becoming more automated and typically make use of barcoding.

MH: Would you agree that public interest and awareness are beginning to accelerate in this area?

DT: Yes, absolutely. Five years ago, you’d almost never come across articles in the mainstream press on medication errors. But about a year or so ago, I started tracking articles on medication errors and safety, and you can’t go a day without a major article on the topic in a major newspaper; and I think that’s only for the good. And I love working on this. I go from hospital to hospital, and I help them improve medication safety; for me, it’s a dream job.

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