Insourcing Roadmap

Get moving with InsourcingLet Baxter’s GPS (Guiding Pharmacy Solutions) help you get there.

The key driver for bringing back control of compounding sterile products is associated with improving quality control mechanisms.

See how two different hospitalpharmacy models illustrate the benefits of insourcing.

$3.85 million over 5 years

$550,000 over 3 years

CENTRAL FILL1 SINGLE SITE2

1 Greenville Health System, Greenville, South Carolina (Fred Bender, Director of Pharmacy Services) 2 Tufts Medical Center, Boston, Massachusetts (Melissa Ortega, Asst. Director of Pharmacy)

$3.85 million over 5 years

CENTRAL FILL MODELSHospitals are evaluating the insourcing of sterile products through two

primary approaches. One approach for insourcing is a central operation

independent of existing hospitals (such as a distribution center or home

infusion), or the creation of a new central facility. This may be more capital

intensive but it provides the opportunity for superior workflow design and

processes. The expansion of compounding operations within a large hospital

is another approach. This expansion model will be less capital intensive. It may

focus on patient-specific doses or PN preparation and is often considered

a first step to establishing a stand-alone facility.

SINGLE SITE MODELIf you create an insourcing pharmacy in a single site model, there is

opportunity to improve your operations and realize savings as well.

The investment will be less, but just as a large IDN, you’ll have more

flexibility and control with your in-house sterile IV compounding.

$550,000 over 3 years

EVALUATEEvaluating what you should insource is key to building a total cost analysis.

To analyze the benefits your primary considerations should be to look

at everything you are currently outsourcing. Analyze how much of the

outsourcing is high volume, low risk, medium risk and/or high risk. Then

assess what you are spending and what would make the most sense to

insource. Lastly, look at your facility—can you adapt it to meet your

insourcing needs or do you need to build a clean room?

What are we Outsourcing?

What should we Insource?

Do we need to build or adapt a

Clean Room? What Staff do we need?What are we

Spending?

TCO

Ask Baxter to analyze your total cost of ownership.

Rules and Regulations

Questions? Call our CCOE team

• Compounding Safety Assessment

• Baxter Product Use Review and Total Cost of Ownership

• Parenteral Nutrition Process Assessment

ASHP Insourcing

Toolkit

TCOTool

Webinar: Update on Legislation & Standards

http://www.cspinsourcing.org/



http://www.ashpadvantage.com/drugquality




Questions? Call our CCOE team

• Compounding Safety Assessment

• Baxter Product Use Review and Total Cost of Ownership

• Parenteral Nutrition Process Assessment

TPN Analysis Tool

ASSESSOnce you have decided to insource you may need a little help developing

your strategy. There are a myriad of Baxter resources you can draw upon

to help you achieve your goals. We have deep experience in compounding—

from logistics to operations to evaluating what products you need for

your particular health system, we can help you every step of the way.

Call a Baxter Nutrition Specialist

for Insourcing Solutions

Parenteral Nutrition Portfolio:

Click here

Learn from a Peer

• PA.com webinars

• ASHP Insourcing Toolkit

• Baxer PN insourcing Microsite

http://www.baxtermedicationdeliveryproducts.com/nutrition/nutrition.html




https://www.pharmacyadvisor.com/pharmacyadvisor



http://www.baxtermedicationdeliveryproducts.com/nutrition/insourcing_resources.html

http://www.baxtermedicationdeliveryproducts.com/nutrition/insourcing_resources.html

Automate and optimize sterile compounding or premix nutrition with ABACUS Software.

Hard and soft limits help prevent ordering errors.

Customizable order templates support your prescribing practices.

ABACUS Calculation Software is intended as an adjunct to and tool for pharmacy practice.

It in no way replaces the professional judgement

of a pharmacist.

Baxter’s premix PN, Multivitamins, Amino

Acids and Lipids. In the same way nutrients are an essential part of a

patient’s TPN therapy, a pharmacy’s parenteral nutrition portfolio isn’t

complete without a variety of nutrients for both adult

and pediatric needs. Additionally, having a full selection supports your

pharmacy’s efficiency and safety goals.

The EXACTAMIX Compounder is an

automated pumping system that compounds

multiple sterile ingredients into a finished solution in a

single patient bag.

The EXACTAMIX Compounder produces a

3-liter bag in approximately 4.5 minutes.

Use for your compounding needs: parenteral nutrition,

CRRT, cardioplegia, base solutions and epidurals.

The DoseEdge TPN system helps clinicians identify compounding errors.

Enables remote pharmacist verification from web-enabled devices on the

hospital’s network.

The DoseEdge System is not intended to replace the

knowledge, judgment or expertise of pharmacists

and pharmacy technicians in the preparation of IV

admixtures or oral liquid doses.

ORDERINGPREMIX

PN SOLUTIONS

STERILE COMPOUNDING

PHARMACY WORKFLOWMANAGER

> > >

IMPLEMENTThere are policies and procedures you’ll have to follow

and Baxter can help “translate” some of the requirements

for you. We have tools, resources, consultants, videos,

demos and inservicing that can help make the road a little

easier for you while you implement an insourcing strategy.

Technical Services• Inservice Training and

Support helps to ease the transition process

• 24/7 Technical Support

Policies & Procedure

Inservice

• Nutrition Specialists

• CCOE team

Tools/Resources

• EXACTAMIX Compounder Demo

• ABACUS Software Demo

• Premix PN Activation Video

• Premix PN Toolkit• ASHP Insourcing

Toolkit

http://www.baxtermedicationdeliveryproducts.com/ccoe/ccoe.html

http://www.baxtermedicationdeliveryproducts.com/nutrition/exactamixautomated.html

http://www.baxtermedicationdeliveryproducts.com/nutrition/exactamixautomated.html

http://www.baxtermedicationdeliveryproducts.com/nutrition/abacussoftware.html

http://www.baxtermedicationdeliveryproducts.com/nutrition/abacussoftware.html

http://www.baxtermedicationdeliveryproducts.com/nutrition/clinimix.html

http://www.baxtermedicationdeliveryproducts.com/nutrition/clinimix.html



SAFETYPatient safety is paramount.

Developing an insourcing pharmacy

under the best quality control

standards will help support your

patient safety goals.

CONTROLAn insourcing strategy puts you in

control—of inventory, quality, access,

safety and more. This ensures you

will not be left out in the cold by an

outsourcing facility that may be out

of product or not up to the quality

standards you demand and your

patients deserve.

SAVINGSIncreasing health system consolidation

and ongoing negative outsourcing

events have introduced a new paradigm

where health systems can achieve scale

to support their compounding needs.

This represents a significant opportunity

to help capture savings for your

health system.

Ask us for a Total Cost of Ownership

Analysis.

REALIZE BENEFITS

For safe and proper use of the devices referenced herein, refer to the appropriate Instructions for Use or Operator’s Manual.

Baxter, Abacus, DoseEdge and Exactamix are trademarks of Baxter International Inc., or its subsidiaries. USMP/MG1/15-0147a(1) 3/16

http://www.baxtermedicationdeliveryproducts.com/ccoe/pharmacyprograms.html

http://www.baxtermedicationdeliveryproducts.com/ccoe/pharmacyprograms.html

SUPPORT AND SERVICE

Designed to enhance productivity, minimize

waste, optimize product selection and

faciliate safe parenteral nutrition practices.

Allowing management to evaluate Lean

process improvement for purchasing,

storage, preparation, delivery, and workflow

efficiencies associated with parenteral

nutrition.

PARENTERAL NUTRITION PROCESS ASSESSMENT

Baxter Healthcare CorporationRoute 120 and Wilson RoadRound Lake, IL 60073

Baxter, Connections Portfolio and Design are trademarks of Baxter International Inc. Any other trademarks, product brands or images appearing herein are the property of their respective owners.

USMP/MG1/15-0098 7/15

PROGRAM ALLOWS MANAGEMENT TO:

• Identify ways to streamline workflow, improve efficiencies, reduce waste, help improve safety and/or enhance overall utilization of compounded, outsourced and/or premixed parenteral nutrition solutions

• Help optimize the parenteral nutrition dispensing systems currently used

• Help improve workflow processes involving parenteral nutrition therapies

METHODOLOGY

• Current operations for the use of parenteral nutrition solutions are analyzed including procurement, storage, compounder setup and verification, ordering, checking, and dispensing of parenteral nutrition therapy with pharmacy and patient care area observations

• Data is collected through observation of practices and product utilization. Interviews with pharmacy staff will include 2–3 patient care areas and will require one day on-site.

DELIVERABLES

• A report with detailed findings based on an analysis of the entire parenteral nutrition use process

• Review of strengths and potential opportunities for improvement

• Actionable recommendations aligned with nationally recognized standards and guidelines for safer processing of parenteral nutrition, as well as Lean priniciples for efficiency

BENEFITS

• A report detailing IV medication use processes based on ASHP, ISMP, A.S.P.E.N. and USP 797 guidelines

• Provide strategies for improving efficiency, reducing potential waste, and enhance overall understanding of Lean processes surrounding parenteral nutrition preparation and dispensing

• Identify practices and product use gaps which can be used for targeted educational initiatives

• Decrease variability to help achieve consistent and optimal practice

www.baxtermedicationdeliveryproducts.com

PARENTERAL NUTRITION PROCESS ASSESSMENT

A fee is associated with the administration of this program. Please see your Baxter representative for details.

SUPPORT AND SERVICE

Designed to review a healthcare facility's

current practices for preparing compounded

sterile products (CSPs)

Allowing Pharmacy management to assess

the level of safety that is associated with

CSP preparation

COMPOUNDING SAFETY ASSESSMENT

USMP/MG1/13-0054a(2) 07/15

COMPOUNDING SAFETY ASSESSMENT


Baxter, Connections Portfolio and Design are trademrks of Baxter International Inc. Any other trademarks, product brands or images appearing herein are the property of their respective owners.


PROGRAM ALLOWS PHARMACY MANAGEMENT TO:

• Assess the level of safety that is associated with CSP (compounded sterile product) preparation

• Understand gaps in CSP preparation practices

• Prioritize potential needs by area

METHODOLOGY

• On-site data collection that includes: - A review of relevant policies and procedures - Direct observations of the compounding activities

within the IV Room

• Interviews with pharmacy staff and management

DELIVERABLES

• A detailed report of the findings to identify areas for process and practice improvements

BENEFITS

• Perform a detailed gap analysis comparing CSP practices to the following guidelines:

- ISMP Sterile Preparation Compounding Safety Summit: Guidelines for SAFE Preparation of Sterile Compounds

- ASHP Guidelines on the Safe Use of Automated Compounding Devices for the preparation of Parenteral Nutrition Admixtures

- The Second Consensus Development Conference on the Safety of Intravenous Drug Delivery Systems – 2008

• Perform a high level assessment of adherence to USP Chapter <797> guidelines: Pharmaceutical Compounding Sterile Preparations

• Perform a high level assessment of adherence to USP Chapter <1066> guidelines: Physical Environments That Promote Safe Medication Use

A fee is associated with the administration of this program. Please see your Baxter representative for details.

The TPN (Total Parenteral Nutrition) Order Analysis Tool is a tool the Nutrition Specialists can use to identify potential opportunities to incorporate Baxter’s CLINIMIX and CLINIMIX E Injections into a patient’s total parenteral nutrition program.

The tool also provides a printable PDF of the analysis results:

SUPPORT AND SERVICE

Designed to evaluate the use of Baxter

products employed in the pharmacy and

nursing units to help improve the customers’

experience with drug delivery, parenteral

nutrition and infusion therapy.

Provides valuable insights that help a

facility target and educate staff on specific

practices to help increase standardization,

safety, and decrease waste.

BAXTER PRODUCT USE REVIEW


Baxter, Connections Portfolio and Design are trademarks of Baxter International Inc. Any other trademarks, product brands or images appearing herein are the property of their respective owners.

USMP/MG14-0210b(1) 06/15

PROGRAM ALLOWS PHARMACY AND NURSING MANAGERS TO:

• Assess their clinicians' understanding of proper Baxter product use that is consistent with product labeling

• Identify gaps in proper use of Baxter products and implement changes to help increase standardization, safety and reduce potential waste

• Provide opportunities for targeted educational initiatives on the use of Baxter products

METHODOLOGY

• Review of the facility’s Nursing and/or Pharmacy product usage

• Data is collected through observation of practices and product use, as well as clinician-to-clinician interviews

DELIVERABLES

• A report with detailed findings and results relative to the proper use of Baxter products

• Identify strengths and gaps in product use

• Actionable recommendations aligned with nationally recognized standards, regulations and guidelines

BENEFITS

• Observe current practices with the use of Baxter products and identify practice and product use gaps

• Assess care provider’s understanding of the proper use of Baxter products

• Provide targeted recommendations to help improve product use and customer experience

• Decrease variability in the product use process


PRODUCT USE REVIEW

Customer NameCustomer Number

Average Parenteral Nutrition Bags Produced Daily AverageCustom adult and youth patient bagsCustom neonate patient bagsCLINIMIX 1 liter bagsCLINIMIX 2 liter bagsGravity Bags

Compounder Product Information Number of CompoundersAverage days per week for compounder

setup Average days per week dosing lipids Lipid Dosing % Preferred Amino Acid Concentration Adult

EM 1200 CompounderEM 2400 Compounder

Annual Cost Current Proposal 1 Proposal 2 Baxter -$

EXACTAMIX Compounder*Clinimix -$ -$ -$

Outsourced -$ -$ -$ *Compounding includes Software, Hardware and Labor if entered

Cost Savings when using Baxter Current Yr 1 Proposal 1 Proposal 2 vs Outsourced/Competitive Compounder -$ -$ -$

% Variance vs Competitor

Cost/PNAdult Neonate Adult Neonate Adult Neonate

Baxter -$ -$ -$ EXACTAMIX Compounder*

Clinimix** -$ -$ -$ Outsourced -$ -$ -$ -$ *Compounding includes Software, Hardware and Labor if entered**Includes Lipids and Vitamins

Customer Information

Current Proposal 1 Proposal 2

Cost of PN Preparation through Single Vendor

0% 0%

PN Cost Analysis for AAMC

TPN Order Analysis Tool

Guide

The TPN (Total Parenteral Nutrition) Order Analysis Tool is a tool for clinicians to identify potential opportunities to incorporate Baxter’s CLINIMIX and CLINIMIX E

injections into a patients total parenteral nutrition program.

Baxter Healthcare Confidential – Internal Use Only

© 2014 Baxter Healthcare. All rights reserved.

Table of Contents

Introduction ..................................................................................................................................... 1 Overview ...................................................................................................................................... 1 Benefits ........................................................................................................................................ 2 User Types.................................................................................................................................... 2 Hardware ..................................................................................................................................... 3

Access TPN Order Analysis Tool ...................................................................................................... 4 Login ............................................................................................................................................. 4 Logoff ........................................................................................................................................... 5

Home Screen Overview ................................................................................................................... 6 Create New Analysis ........................................................................................................................ 7

Choose Case Entry Format ........................................................................................................... 9 Entering The Numbers ............................................................................................................... 11

Analysis Results ............................................................................................................................. 16

Created: 10/06/2014 Updated: 00/00/2014 Page 1 of 17


Introduction

OVERVIEW

The TPN (Total Parenteral Nutrition) Order Analysis Tool is a tool for clinicians to identify potential opportunities to incorporate Baxter’s CLINIMIX and CLINIMIX E into a patients total parenteral nutrition program.

The tool also provides a printable PDF of the analysis results:

CLINIMIX and CLINIMIX E Injections are contraindicated in patients having intracranial or intraspinal hemorrhage, in patients who are severely dehydrated, in patients hypersensitive to one or more amino acids and in patients with severe liver disease or hepatic coma. Solutions containing corn-derived dextrose may be contraindicated in patients with known allergy to corn or corn products. The TPN Order Analysis Tool is not intended to provide or replace good clinical practice regarding the proper treatment of individual patients. It is intended as a tool for clinicians to identify potential opportunities to incorporate manufacturer prepared remix parenteral nutrition into a patients total parenteral nutrition program. It is solely within the clinician's professional judgment as to what protocol should be prescribed for a patient. Baxter encourages you to read and follow all prescribing information for CLINIMIX Injections. It is essential that a carefully prepared protocol based on current medical practice be followed, preferably by an experienced nutrition support team.



BENEFITS

Here are the added benefits of this new tool versus the old tool:

• Improved user experience • Progressive loading to improve the application startup time • Sales Representatives can now login with their Baxter NT User name / Password • When a Sales Representative logs into the tool, the search feature is now limited to the

hospitals that are assigned to that Sales Representative • Assign analysis between Sales Representatives • Ability to enter current patient solution details into the tool via an Excel upload • Ability to change the tolerance levels between 10% and 15% • Sales Representatives can see and print other Sales Representatives analysis • The PDF Analysis report has a better look and feel

USER TYPES

This guide is created for the following users:

• Baxter Administrators (Business staff) • Nutrition Sales Representatives



HARDWARE

The TPN Order Analysis Tool is compatible with both your laptop and iPad. For the purpose of this guide, we’ll be demonstrating the use of this tool using the laptop.



Access TPN Order Analysis Tool

LOGIN

1. From Outlook, open the TPN Order Analysis email.

2. Click the TPN Order Analysis Tool link. (https://webapphosting.inbaxter.com/tpnoa)

3. In the login box, type your Passport ID (6+1) and your network password. Click the LOGIN button.

4. The tool requires that you read a pop-up statement regarding the tool’s intent. Check the box in the lower, left corner to designate you read the statement and then click the CONTINUE button.

Baxter Healthcare Confidential Baxter Healthcare Confidential – Internal Use OnlyBaxter Healthcare Confidential Internal Use Only

https://webapphosting.inbaxter.com/tpnoa





The TPN Order Analysis Tool’s home screen displays. From this screen, you can monitor all the analyses you’ve created.

LOGOFF

1. From the home screen, or any analysis screen, click the LOGOUT link in the upper, right corner of the screen.

You’re taken back to the Login screen.




Home Screen Overview

The home screen enables you to:

• View and edit your active analyses • View only your archived analyses • View only all the analyses you’ve created as well as those of your colleagues • Create a new analysis • Edit your profile • Logout of tool

Other abilities are described below.

Once created, you cannot delete an analysis.


Takes you back to this

home screen

Edit your personal profile

Exits the tool taking you back to the login screen

Designates a help screen is

available

Click triangle to sort column

Creates a new analysis

Click triangle to

Expand and Collapse section

Navigates you to additional

pages

Opens the analysis for

editing

Opens the analysis,

yet cannot edit the analysis

because these are also

analyses of your colleagues



Create New Analysis

An analysis enables the Sales Rep to enter current patient solution details into the tool to see if CLINIMIX injection can be substituted.

1. From the home screen, click the CREATE NEW ANALYSIS button. The Search field that appears enables you to find the hospital or organization for which you are conducting the analysis. You can search by hospital’s zip code, name, state, or account number. Since the tool knows you are logged in, the search is directed towards hospitals/organizations in your area. 2. Type in the search criteria and click the SEARCH button.

3. From the search results, click the SELECT link from the appropriate option.

The Search field that enables you to find the hospital for which you are



The Hospital Analysis Information page displays with the contact’s information fields auto-populated. 4. If needed and known, type information into the blank Contact fields.

5. Type a name for this analysis in the Analysis Name field.

6. If needed, type notes pertinent to this analysis in the Analysis Notes field.

The name you choose will be the name used in the Project column of the overall analysis.

Contact is a one-time entry

time entry

The Analysis Nameappears here



CHOOSE CASE ENTRY FORMAT

1. Select the appropriate format to enter the total daily Dextrose and Amino Acid amounts for each case.

2. For assistance on choosing, click the question mark icon beside each choice to review the format options along with completed examples.

For the purpose of this guide, we’ll choose the Final Concentration case entry - the other options require similar steps.



One or more pop-up dialog boxes display asking for answers to information pertinent to the case entry you selected. 3. Answer the pop-up dialog boxes as appropriate. (The other case entry options will ask different

questions in their pop-up dialog boxes.) The appropriate Analysis case entry screen displays.



ENTERING THE NUMBERS

Before you enter your numbers, you have a choice on how to enter them. You can type the entries on the screen shown below, or download a spreadsheet, type your entries there, and then upload those numbers into the tool. Important Note: For the results to be calculated and printed onto a report, you need to enter numbers for at least 25 patients. If you cannot complete all 25 at once, you can click the EDIT link from the home screen and complete additional entries. Choose how you want to enter the patient’s numbers: 1. Type the patient’s numbers into the blank entry fields.

2. Click the ADD button.

3. Repeat Steps 1 and 2 until you have entered at least 25 patients.

Or…

1. Click the DOWNLOAD link to put all your entries into a spreadsheet.

The entry fields are intelligent enough to know if your entry is outside of allowable parameters and will generate an error message if outside.

The columns without entry fields are auto-calculated based on your entries.

Continue to the next section entitled Analysis Results.

Your entries are saved once the Add button is

clicked



2. Click the OPEN button.

The Initial Concentration spreadsheet opens.

3. In the yellow bar, click the ENABLE CONTENT button.

The spreadsheet may take approximately 15 seconds to open.



4. Type the patient’s numbers into the blank entry fields.

When done with all entries, save the spreadsheet to your laptop to upload in the next step.

5. Back in the tool, click the CHOOSE FILE button.

6. Locate your previously saved spreadsheet.

7. Click the spreadsheet file and then click the OPEN button.

The entry fields are intelligent enough to know if your entry is outside of allowable parameters and will generate an error message if outside. A range of allowable entries are shown in yellow text above each column.

The columns containing pre-filled zeroes will auto-calculate based on your entries.

It is recommended to change the spreadsheet’s name to something related to this particular analysis.

Created: 10/06/2014 Updated: 00/00/2014



8. Click the UPLOAD button.

The upload begins processing.

Once done, you should see the phrase Uploaded Successfully. Also notice that the screen’s title changes from New Analysis to Manage Analysis.



The entries from your spreadsheet auto-populate into the tool and are displayed as shown:

This EDIT link enables you to switch all your entered numbers into a different Case Entry type



Analysis Results

The TPN Order Analysis Tool enables you to view a report (in real-time) of all the numbers you just entered. 1. Click the VIEW RESULTS button at the bottom, right of the Manage Analysis screen. The Sales Representative Results Preview displays. The tool also provides a printable PDF of the analysis results. 2. Click the VIEW PRINTABLE VERSION button.

Toggle between 10% and 15%

Tolerance



3. Click the OPEN button. A printable PDF version of your analysis results displays. You can now to choose to save this report and/or print it.

Baxter Healthcare Confidential Baxter Healthcare Confidential – Internal Use OnlyBaxter Healthcare Confidential

Here is a summary of what you can expect to see in

the report

CLINIMIX and CLINIMIX E Injections Implementation Tool Kit

ABOUT Tab:

CLINIMIX and CLINIMIX E Injections One page summary CLINIMIX and CLINIMIX E Injections Portfolio Brochure

IMPLEMENTATION Tab:

CLINIMIX and CLINIMIX E Injections Checklist CLINIMIX and CLINIMIX E Injections How to Use CLINIMIX and CLINIMIX E Injection Package Inserts CLINIMIX and CLINIMIX E Injections TPN Sample order forms CLINIMIX and CLINIMIX E Injections Electrolyte Profile Brochure CLINIMIX and CLINIMIX E Injections Micro/Macronutrient booklet CLINIMIX and CLINIMIX E Injections Nutrient Profile CLINIMIX and CLINIMIX E Injections Activitation Video CD

SUPPORT Tab:

CLINIMIX and CLINIMIX E Injections Reimbursement & Billing Guide Dual System White Paper Nutrition in Clinical Practice Guidelines

The tool kit is designed to provide practitioners with educational resources, tools, and support documents to assist with the implementation of Clinimix and

Clinimix E Injections within their institutions.

TOOL KIT CONTENTS:

herrink

Rectangle

Documents

Insourcing Roadmap