What Pharmacists Should Know About Drug Diversion

Ninety-two percent of hospital executives and providers surveyed by the BD Institute for Medication Management Excellence are optimistic that drug diversion can be controlled with adequate resources and attention. Yet it is no secret that drug diversion remains a multi-faceted, pervasive challenge that can endanger patients and clinicians, and even lead to financial penalties and reputational damage to health care systems.

What will it take for hospitals to curb drug diversion, which has been referred to as a hidden epidemic within health care? During a recent roundtable discussion, industry leaders shared frontline insights on the biggest drug diversion challenges and the most promising opportunities for better detecting and mitigating risk.

Risks and Ramifications

During the discussion, roundtable panelist Janice Ahlstrom, FHIMMS, CHIMS, CCSFP, RN, BSN, director of risk advisory at Baker Tilly, emphasized that drug diversion can result in compromised care and substantial harm to patients, including inadequate pain control or exposure to infectious diseases.

Ahlstrom specficially pointed to 20 years of CDC research investigating nine drug diversion incidents, which found that 163 patients were impacted by either a gram-negative bacteria or hepatitis C infections.

In her practice as a consultant, Ahlstrom has seen diversion occur everywhere from drug procurement, receipt and prescribing, to administration and wasting and removal of expired or recalled medication.

“Across the entire lifecycle, there are opportunities for diversion and the need for investigation. I see it’s a large burden on members of the healthcare team and hospital system to undertake proper diversion programming,” Ahlstrom said during the discussion.

Zeroing in on the Hurdles

At Hospital Sisters Health System’s (HSHS) St. Elizabeth’s Hospital, one of 15 hospitals that make up HSHS, the COVID-19 pandemic has magnified this burden on the pharmacy team, which was already stretched thin, explained panelist Julia Schimmelpfennig, PharmD, MS, BCPS, the hospital’s pharmacy director.

“We wear many hats on a daily basis,” Schimmelpfennig said during the discussion. “A lot of things have changed over the past year, and the time we would have liked to invest looking at diversion has decreased.”

Schimmelpfennig’s staff is not alone in this struggle, according to an online poll of the more than 300 roundtable attendees. In the poll, more than 70% explained limited staff time and other priorities often compete for attention as their biggest challenges in identifying drug diversion.

Panelist Andy Schuelke, PharmD, the regional informatics pharmacist at St. Vincent Healthcare, SCL Health-Montana, echoed this concern.

“I’m the only one who does proactive investigation at this time,” Schuelke said during the discussion. “The biggest thing for me is the time commitment.”

Rethinking Responsibilities

While pharmacists have typically handled drug diversion management, cross-disciplinary drug diversion investigation and review teams are becoming more common. For example, Schuelke’s team includes nursing, risk management, and human resources, which bolsters efforts to approach drug diversion proactively rather than reactively.

“Gone are the days when it’s pharmacy’s responsibility…I can’t say enough about the strength of multidisciplinary teams,” Ahlstrom explained during the discussion.

She added that much of the responsibility for targeting drug discrepancies has now shifted to nurse managers and charge nurses as a result of the widespread implementation of electronic health records (EHRs), automated dispensing systems (ADS) and other technologies.

Changes to the health care landscape and patient care model, driven by health care technology adoption and accelerated by COVID-19, are also prompting a need to rethink drug diversion management.

“With a lot of responsibilities offsite at this time, those issues have occurred in different patterns, so trying to identify diversion has become a little bit different,” Schimmelpfennig said. “Just trying to figure out what’s best in the current environment is a role we have been trying to work through.”

Capitalizing on Technology

Across the board, panelists and attendees noted that technology was a game changer for combating drug diversion. When asked what they saw as the greatest opportunity to improve diversion identification, approximately 48% of attendees named technology such as automation, machine learning and artificial intelligence, while two-thirds reported that they currently use technology to identify and manage drug diversion.

Optimizing technology begins with implementing EHR and ADS technology in high-risk areas such as intensive care units, emergency rooms, and operating rooms, as well as obstetrics, orthopedics, gastroenterology, and other specialty units, according to Ahlstrom.

“We’re seeing more diversion in all those areas. Using these systems is key to taking you to the next step to be able to do reporting and leverage analytic tools,” Ahlstrom said.

Most importantly, hospitals need the tools and staff to analyze the data they gather. Ahlstrom noted that too often they “lack the resources and analytics engine to take information from multiple sources, crunch it, apply rules to it and have machine learning look for patterns and learn from the data.”

Furthermore, data from disparate systems can be disconnected and messy, making it challenging for hospitals to generate meaningful insights. Software tools that integrate multiple data sources from various technology platforms in near real time are vital to highlighting potential risks, problem areas, and documentation anomalies.

“I’m a big believer in bringing in as much data as one can,” Ahlstrom said. “I’ve worked with clients who have found diversion because they decided to take their Kronos system data and cross-reference it with their EHR documentation of controlled substances.”

Strategies that Work

The panelists explained during the discussion that they see plenty of return on investment in drug diversion technology. Schimmelpfennig noted specifically a reduction in staff hours was necessary to reconcile data, and Schuelke credited technology’s increased efficiency with eliminating the need to hire an additional investigator.

Schimmelpfennig also explained that he appreciates the ability to generate weekly reports and identify standard deviation differences, as well as drill down quickly to red flags at the individual level.

“Time is definitely of the essence for helping that individual,” Schimmelpfennig said during the discussion. “To break it down simply—software does the grunt work for you so you can really focus on the issues that software finds.”

ABOUT THE AUTHOR

Patrick Yoder, PharmD, is the chief executive officer at LogicStream Health. He started his career in medical research, then as a clinical pharmacist and an informatician. He also led the informatics team at Hennepin County Medical Center before co-founding LogicStream Health.