MEDICATION RECONCILIATIONMEDICATION RECONCILIATION

Using PH-DocUsing PH-Doc

June 12, 2012June 12, 2012

Presented byPresented by

Daniel Jensen, Associate Director of Public Health, Olmsted CountyDaniel Jensen, Associate Director of Public Health, Olmsted County

Deb Castellanos, Technical Manager/Project Manager, Xerox CorporationDeb Castellanos, Technical Manager/Project Manager, Xerox Corporation

Powerpoint and Demo of the “PH-Doc” software

Intellectual property of MCCC, powered by Xerox Corp.

Software installed in 28local public health agencies

in South East Minnesota

What is local public health

in MINNESOTA?

Public Health Documentation System

Software applicationowned and managed by the users

long-standing relationship with the developers

First program written in 1984“Re-engineered” several times over 28 years

Electronic Chartand

Practice Management System

Years 2008 - 2012“re-engineering for interoperability” when along came the

SE Minnesota Beacon Project

Community of hospitals, clinics, counties and schools sharing clinical health information

Mayo Clinic – GE’s EMRMayo Health Systems – Cerner’s EMROlmsted Medical Center – Med3000’s EMRWinona Health – Cerner’s EMRAllina Health – Epic’s EMR11 counties in SE MN – PH-Doc Health Record46 school districts in SE MN - PH-Doc Portal

These clinics, hospitals and counties are exchanging clinical data using the National Health Information “NwHIN” specifications and open source software; GATEWAY at each site with the ability to perform peer-to-peer communications

• Uses SOAP webservices over HTTPS• Wraps payload in SAML assertions• Includes auditing and logging• Enables the exchange of CDA Documents

SE Minnesota Beacon ProjectApril 2010 – April 2013

What is a CDA Document?

Structured XML document based on the HL7 V3 RIMactivities, entities, participants, roles, moods

Standard HEADER sectionpatient information, title, date, author, custodian, authenticator

Sections of clinical content – preferably structured and codedmedications, allergies, problems, immunizations, vital signs,procedures, advance directives, payers, results, plan of care,family history, social history, pregnancy, visit notes, comments

Under the Beacon project …several enhancements were made to PH-Doc

o  structured medications and allergiesRXNORM, UNI, NUI, Snomed

o  structured CDA documents Summary of Care, Laboratory Studies, Asthma Action PlansPublic Health CDA (environmental, social factors, behavioral factors)

o  live feeds to Regenstrief Institutepatient visits and quality of life indicators

Under the Beacon project …infrastructure was added to each county

to host its gateway

An appliance (from Mirth corporation) was ordered for each of the 11 counties

Mirth Appliance

The appliance hosts communication services; SFTP, HTTP, WebServices, LLP …

… and includes the Aurion Gateway… ‘open source’ with support

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Public Health Nurse

Firewall

DMZPH-DocApplicationServer

Internet

ConnectGateway

•Patient Correlation•Security and Authentication•Audits and Logs

MIRTH

Mayo Clinic

Mayo Health

Olmsted Medical

Winona Health

Allina Health

Outgoing REQUEST – one per patient

• Patient Demographics – used to match at destination site

• Requestor – name and Role

• Purpose for request

• Destination Gateway(s) – based on Release of Information

• Type of document(s)

Each request becomes a thread

Don’t want to tie up the nurse.

Depending on number of documents and gateways, could take a few minutes

ALERT when the request has finished processingStatus of documents that have been pulledEach document stored as XML with stylesheetEach document rendered/stored as PDFEach document parsed for structured data

Parsing the Coded Data

.NET shopUsed C# and XPATHSpecifications from HITSP

C32C83C80C154

Parsing the CCDParsing the CCD

Details from

HITSP C80/C83

Structured data elements &

code tables

To develop our parsing rules

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MayoMayo

Parsing the CCDParsing the CCD

Details from

HITSP C80/C83

Structured data elements &

code tables

To develop our parsing rules

22

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Now that we have parsed data…

able to tackle “reconciliation”

As defined by the JACHO, medication reconciliation is "the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner or level of care. “

… we’ve done it before …

Designed as an INTERACTIVE process• nurses working with the patient in the home/school/jail

Our first reconciliation screen dealt with IMMUNIZATION data coming from the state of Minnesota’s IMMUNIZATION registry

Used a secure webservice to request data. We used the codeswe received from the state and mapped to CPT/CVX codes.

Design Standards

Side by side presentation of two lists

Pink coding identifies information missing from PH-Doc

Easy drag and drop (or click multiples and press ARROW)

LEFT – incoming data RIGHT – PH-Doc Chart

Medication Reconciliation

Even better ….

• RXNORM codes• Multiple sources• More data – dosing, physician, reaction, text• Current and History

Medication Reconciliation

Nurse works with the patient to reconcile the two lists

•Sometime multiple sources - pull most recent and show others

•Pull to current vs pull to history

•“History” – requires REASON – only text today. Hope to make this more robust, able to share these reasons with clinicians

• “Too expensive”• “Upsets my stomach”• “Heard rumors about possible side effects”

Once an accurate medication list has been documented

… hopefully all associated with RXNORM codes

Time for DRUG-TO-DRUG interactions check

Allergy Reconciliation

Same concept for reconciling allergies

•Request external documents•Parse data and store in ‘auxiliary tables’•Present side-by-side•Allow external data to be merged with existing data