Corrections departments are responsible for so many burdensome tasks that many of their everyday functions, like administering prescription drugs to inmates, are afterthoughts for the public. However, dispensing medication was so laborious and wasteful for the San Bernardino County (Calif.) Sheriff-Coroner Department that officials sought a way to streamline the process. The end product was essentially a vending machine that links to correctional facility databases and dispenses prescription medications.
San Bernardino County -- the largest county by area in the United States -- has seven correctional facilities scattered across its more than 20,000 square miles. Terry Fillman, health services supervisor of the county sheriff's West Valley Detention Center, said at one of the locations it took four nurses -- each working four hours every day -- to prep medicine for delivery to prisoners. The time-intensive process also generated medical waste because inmates might be moved between facilities or released during the time it took to prepare their medications, which left some prescriptions unused.
Pharmaceutical regulations require that if medication is prepared for a patient and he or she can't be reached, it's deemed undeliverable and must be destroyed. The leftovers are typically flushed down the toilet or incinerated. Also, many medications are packaged in 30-count blister packs that are prescribed for individual patients and must be disposed of if that person no longer needs the medicine or is released from the correctional facility.
The county corrections department needed a streamlined process to save time and decrease waste, so it teamed up with its pharmacy system to find a solution that would benefit both entities. The result was an automated system composed of software that connects directly to the pharmacy and dispenses medications on a per-patient basis.
"One of the corrections-specific things that was pretty much eluding everybody was if the patient moves in the time period from when you prepare the medications to the time period you deliver them, then you have an enormous percentage that are undeliverable -- waste," Fillman said. He estimated that the county delivers 1.5 million pills to inmates annually. Although the corrections department didn't track the amount of medicine that had to be disposed of, Fillman said it was an enormous amount.
To reduce the amount of medical waste the sheriff's department was creating, in 2006 it teamed up with the Arrowhead Regional Medical Center (ARMC), which houses the pharmacy that serves the county's correctional facilities.
"We needed a better solution. We needed something corrections-specific that would address the issues we had -- eliminating the waste of time and money, while providing accuracy and efficiency for the delivery of health care," Fillman said.
Apurva Patel, pharmacist director of inpatient services at ARMC, said they contacted vendors in search of a new pharmaceutical system. After researching the different available offerings and the processes used by other corrections departments, they started working with vendor Talyst. "We presented to them what kind of system we were looking for and what they could do for us," Patel said.
The ARMC had its own reasons for wanting an automated system. "What we were looking to get out of the system was mainly accuracy, so we're decreasing the medication errors and having an accurate account from the time the doctors write the orders to the time the nurses enter them [in the system]," Patel said.
The sheriff's department, ARMC, Talyst and multiple IT departments collaborated on the project. Eventually the InSite Remote Dispensing System was created. The machine is a medication management system that produces individually sealed packets containing patient-specific pharmaceutical drugs, and it interfaces with software that connects the pharmacy and corrections systems.
Patel said this new idea for a medications dispenser was something that no other corrections department in the United States was using. Although Talyst met the project's demands, barriers had to be broken down and obstacles overcome by all the involved entities before implementation.
According to Cindie Watkins, director of information services for the ARMC, the center's IT department didn't want to replace the systems already being used by each stakeholder. "We took the systems that were already in place and used those to give correct information to the newer systems coming on," she said, "and then made sure all those systems could talk across the entire county because it included multiple entities."
This was a unique deployment, she said, because usually there's one pharmacist stationed at each facility within many corrections systems. For San Bernardino's setup, Watkins said, one pharmacist essentially is teleconnected to all of the locations. "We allowed the pharmacist to dispense the drugs from one location," she said. "Instead of having to drive 150 miles to the farthest jail, he was able to connect by computer and tell another computer system to unlock and allow these drugs to be dispensed."
The medication dispensing system is linked to the pharmacy and correctional facilities through Kalos Inc.'s CIPS -- a.k.a. Correctional Institutional Pharmacy Software. CIPS interfaces with the jail information management system that tracks inmate movement, intake and release, which helps eliminate waste due to undeliverable medications.
After the system was created, the West Valley Detention Center tested it before it was deployed to the six other correctional facilities more than a year ago. The seven medicine dispensers are interfaced to ensure that the system at the correct location packages the medications for each patient.
"It's a computer system that will update in real time if a patient moves," Fillman said. "So in the 30 seconds prior to me running the medication, if that patient gets moved, it won't come from my packager machine. It will go to the packager that does have the guy at its location."
When it's time to prepare the medications, the nurse selects the per-dose medications for the proper time. It usually takes the machine 45 minutes to package 1,500 prescriptions, Fillman said. The nurses still prepare liquids and creams, and medicine that must be injected, but those only represent approximately 5 percent of the medications, according to Fillman.
To ensure accuracy, the machine creates a dispensation record after each session that logs all of the medications that were packaged. On each package, the machine prints the medications enclosed, a bar code, and the patient's name and location, among other identifiers. The nurse has a medication administration record that describes the color and shape of the pills to verify that the package is correct upon delivery to the inmate.
Improved accuracy has been a major benefit to the ARMC, Patel said. Before using the system, a doctor wrote a prescription for an inmate, then a nurse faxed the prescription to the pharmacy -- where its staff manually entered the information into its computer system. A pharmacist would review the order, and it usually took 24 to 48 hours for the medication to be made available to the patient. Now after the doctor writes the prescription, a nurse enters it into the system and it goes into a queue for review by a pharmacist. The information
never has to be entered into another system.
"We're decreasing the medication errors and getting an accurate account from the starting point -- from the time the doctors write the orders to the time the nurses enter them," Patel said. "We can track an order starting with the doctor writing it to the time the nurses actually delivered medications to the patients."
Fillman said they are developing an electronic medication administration record that will utilize the medication package's bar codes. This will enable the bar codes to be scanned so the facility can keep real-time records. He said one of the barriers to implementing this in correctional facilities is the lack of wireless connectivity available in the block walls. A test model is being developed that will run in disconnect mode -- which means it will work offline and later be synced to the system -- to enable the nurses to use it throughout the facilities.
The San Bernardino County Board of Supervisors approved $3.8 million for the project, which includes development, implementation and system costs. However, Fillman said the sheriff's department completed the task $500,000 under budget.