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Medication Use Automation –Other Topics in Informatics
Jim Carpenter, RPh, MSRegional Information ServicesRegional Information Services
Providence Health SystemPortland, Oregon
My History with Automation
Downstairs lab computer – terminal to theDownstairs lab computer terminal to the mainframe – one!Pharmacist “interface” between non interfacedPharmacist interface between non-interfaced systemsI f i i di l f dInformation immediately out of date
Pharmacy Order Entry Systems
Maintenance of IV product profiles on paperI / billiInventory management / billingProduction of labels and cart fill lists
Starting to see increasing clinical capabilitiesStarting to see increasing clinical capabilities
Pharmacy Order Entry Systems
Purpose: central record-keeping system for medication data
Integration with Electronic Medical RecordIntegration with Electronic Medical RecordCPOE / Bar Coding / Allergy Messaging
+/- Alerts Engines
RisksOver-reliance: “The computer says so”Over reliance: The computer says soIsolationThe computer system becomes the job
Automated Dispensing Devices
Candy Machines?Candy Machines?Override – interface with Pharmacy system –toward closed loop medication managementtoward closed-loop medication management
Automated Dispensing Devices
PPros: convenience Narcotic controlinventor controlinventory controlCubies vs. “pockets”
Cons:nurse queuesrefill needs decentralized / chronic
Future: In-Room?
McKesson Robot Rx
Pros:Pros: Central Dispensing functionMulti facility capabilitiesMulti-facility capabilitiesRe-allocation of personnel
Techs don’t do daily fillTechs don t do daily fillPharmacists don’t check the daily fill
Waiver from Board of PharmacyyPromise: more time for clinical services
McKesson Robot Rx
Cons:Cons: Centralized Dispensing Not convenient to nurses
Snapshot in time dispensing for 24 hour periodSnapshot in time dispensing for 24 hour period
Multi-facility capabilities Downtime DisastersExpensive Multi year contractsExpensive Multi-year contractsFull circle = PRC - manual delivery to the bedside
Med Carousels
Pros:Pros: Inventory managementEfficient use of space vs rolling shelvesEfficient use of space vs. rolling shelvesBar code scan on fill and removal
CCons: Space! WeightExpense
BCMA / eMAR
Most effective patient safety intervention -Most effective patient safety intervention ISMPEliminates order transcription onto manualEliminates order transcription onto manual Medication Administration Records (MAR)A d i f d d i i dAccurate documentation of meds administered (who / when / what)Accurate billing - bill on administration instead of billing on dispense
Bar Coded Medication Administration-Drug Errors Interrupted by the Computer-
1 103J 2002
379 30
571,103
97 539
No Med Order Found
Order on Hold
No Schedule FoundJune 2002
891
379
117
97,539
120
2,911
Total # of Medications Administered
Admin too Early
Incorrect Amt.
Recently Given
Admin. too late
14
120
200Variance Messages
Site required
Drug/Order Unitmismatched
Recently Given
q5 RightsRight Patient, Right Drug, Right Dose, Right Time, Right Route
Bedside Barcoding
Unintended consequences – Emily Pattersonnurses dropping other activities to reduce workloadnurses dropping other activities to reduce workload during busy periodsincreased prioritization of monitored activities pduring goal conflictsdecreased ability to deviate from routine sequences
Workarounds – copies of armbands on a piece of paper!
Other Implications: Bedside BarcodingBarcoding
Lack of standards: barcoding symbologyLack of standards: barcoding symbologyRe-packaging
Of f i h l d b d d!Often for items that are already barcoded!Manufacturing?
RFID
How it worksHow it worksA transponder - the RFID tag - has been programmed with information. RFID tag passed through the field of the scanning transceiver
d h dDecoder interprets the dataDetects the activation signal from the antenna" akes p" the RFID chip transmits the"wakes up" the RFID chip transmits the information on its microchip picked up by the scanning antenna. g
Radio Frequency ID
Next step with Barcoding?Next step with Barcoding? Encodes much more dataU d i iUsed in inventory managementBut . . .
Can’t be done in-house . . . Slip it into a unit dose container? A small vial?p
RFID
Uses:Uses:Medication ScanningPatient location / disposition around surgery orPatient location / disposition around surgery or transport times
IssuesIssuesExpenseM f liManufacturer compliance
RFID
Use in humans!Use in humans!can incorporate personal medical information and could save lives and limit injuries from errors in medical treatments Access to secure environments
Other Uses:Passports – security and fraud prevention
IED concern! If from a certain country
Transportation tollroads and vehicle trackingTransportation – tollroads and vehicle trackingAnimal ID – passive RFID is what is used in animal “chips”Libraries – holdings trackingg g
Smart Pumps
Most common reason for administering wrong infusion g gdose was incorrect programming of the pump
AJHP 2005;62(5):917-20“key bounce” / hitting a key twiceHow do they work?
A i i h d l l iAssistance with dose calculationsDosing / drug libraries: Decision SupportCommunication with ordersSettings for drip rates in critical careBedside nurses must refrain from bypassing this feature
Smart Pumps
More organizations interested in investing inMore organizations interested in investing in smart pumps in the next 12 months than BCMA and CPOEand CPOE
Smart Pumps
Issues:Issues:Maintainance of knowledge baseT i iTrainingAgreeing on standard concentrationsSetting dose limits
Closed Loop Medication ManagementManagement
Physician Pharmacy Verify Pharmacy dispensePhysician Pharmacy Verify Pharmacy dispense nurse administration flowsheet documentation
Closed loop Allergy integrationp gy g
But humans can subvert the systemBut humans can subvert the systemBar code warning overrides
“This thing isn’t scanning!” Pharmacy order modifications for CPOE orders
Communication deficits – clinicians need to communicate!
Mobile Computing
Tablet PCsRuggedizedWashable / submersibleImbedded camera
b dd d b dImbedded bar code scannerBio-ID
“Paving the cowpath”Simplifying – Intel tablet
Cleanliness – infection riskIsolation Rooms
iPhone – not quite thereCan’t run CitrixHacks are forthcoming but primarily this is a closed system
Telemedicine / Telehealth
Telemedicine: focus on Telehealth: focus on theTelemedicine: focus on discipline / technology
Teleradiology
Telehealth: focus on the patient
Patient RecordsTelepathologyTeledermatology
Disease ManagementRemote Monitoring
Telepsychiatry Patient ComplianceHome Care / HospiceW d / B R h bWound / Burn Rehab
Telehealth
Chronic disease management consumes more resourcesChronic disease management consumes more resources than acute care events
+ staff shortages!!
Travel# of patients treated / caseloadp$$Response timepeHealth – use of interactive technologies to enable health care improvement and servicesp
Goals of Telehealth
Remote monitoring of ECG CBG’sRemote monitoring of ECG, CBG s, Maintain independent livingP iPatient empowermentIndividually tailored interventionsReach underserved populationsScalabilityScalability
Telehealth Applications
Demonstrated positive outcomes inDemonstrated positive outcomes in ElderlyHeart FailureDiabetesWound Care / DermatologyHome HealthPediatric AsthmaDi bDiabetesSpecialty ConsultationsMedication ComplianceMedication Compliance
Telehealth Challenges
Physical barriersPhysical barriersLack of rural infrastructurefundingfundingAccessU biliUsabilityHealth and Technology literacyPrivacy and securityPhysician and patient acceptance
Knowledge Management Systems
17 year innovation adoption curve to get new17 year innovation adoption curve to get new knowledge into practiceMore than 150,000 medical articles are publishedMore than 150,000 medical articles are published each month and there are more than 20,000 biomedical journalsjMedical Literature doubles every 19 years2 million facts needed to practice medicine2 million facts needed to practice medicineGenomics and “Personalized Medicine” will increase the problem exponentiallyincrease the problem exponentially
Knowledge Management Systems
Standardizing caregShort-circuits the long series of meetings required to reach consensus on order setsWeekends at home developing own
Regulatory and Reimbursement pressures / fPerformance measures
Evidence-based carel l d l l d l kclinical recommendations also include links to
specific references to ensure clinicians have the latest findingsthe latest findings.
Knowledge Management Goals
Order Set ManagementgContinually adapt content to incorporate the latest clinical research, performance measures, and best practices.
Clinician AdoptionSurprise! Clinicians want to practice good clinical care!Healthcare professionals may resist technology initiatives, because of concerns about the quality of clinical information, the reliability of information technology solutionsy gy
KM at Prov
Productivity / Clinical Interventions TrackingTracking
Purpose:pMonitor clinical workloadDocument ongoing follow-up needsDocument costs avoidedJustify clinical resourcesBenchmark against other facilitiesBenchmark against other facilities
Paper tracking of interventionsp gCosts assigned to interventions are sometimes debatable
Pharmacy Surveillance Systems
coalesce store and monitor data residing incoalesce, store, and monitor data residing in disparate hospital information systems notify clinicians of intervention opportunitiesnotify clinicians of intervention opportunities triggered by datad i b li i l ldriven by clinical rules. every staff member can create user-defined rules and reports
Few actually do.
Pharmacy Surveillance Systems
Examples:pErythropoetin: received epo + Hgb >/= 12 Renal dosing: scr >1.5 + age > 65 years + on your selected
ll li i t d drenally-eliminated drugs Potassium: diuretic + no k+ supplement + k < 3.5 Digoxin: digoxin + digoxin level g g gMetformin: metformin + scr > 1.4 female IV/PO: on IV med listed on target IV/PO list
d k dCMS Indicator: troponin > 0.2 or ckMB positive and not on a B-blocker, ACE/ARB/ASA/statin Warfarin: warfarin + INR > 4.0
Pharmacy Surveillance Systems
Other applications:Other applications:Other disciplinesQuality Management OfficeQuality Management Office
Antibiotic and Anticoagulation stewardshipWeb-based – use their servers.
Pharmacy Surveillance Systems
Sentri 7 Results:Holy Family saw a 90% increase in the number of weekly changes in recommended therapy by pharmacy related to lab evaluationsa 43% increase in the number of weekly changes in therapy related to appropriate indication for medication.
Clinical staff pharmacists were spending one to two hours a day performing med-lab profile reviews on p ti tpatients
reduced to 15 to 30 minutes per daypay for itself and beyond in saved pharmacist hours
E-prescribing
Why?Why?3-4 billion prescriptions written annuallyPharmacists make 900 million calls to physiciansPharmacists make 900 million calls to physicians each year to clarify prescriptions65% of the public receives at least one Rx / year65% of the public receives at least one Rx / yearDrug decisions are made with limited informationMost prescriptions are still handwrittenMost prescriptions are still handwritten
E-prescribing
Access to clinical decision support at the pointAccess to clinical decision support at the point of prescribing
Benefit eligibility / Copay informationBenefit eligibility / Copay informationFormulary complianceMed Histor informationMed History information
Route prescriptions to the patient’s pharmacyBrick and mortarMail order
E-prescribing
What’s required?What s required?Connectivity to Payers: RxHub
Master Patient IndexEligibility informationMedication History
Connectivity to Pharmacies: SureScripts Per-Se eRxConnectivity to Pharmacies: SureScripts, Per Se, eRx, Medavent~90% of Pharmacies are certified to receive electronic prescriptionsHospitals connections: comprehensive med use history
Pharmacogenetics
The study of how genetic variation leads toThe study of how genetic variation leads to variation in responses to drugs
One of the promises of the genome project
Genesis of Personalized Medicine
Pharmacogenetics
Bevacizumab [Avastin]Bevacizumab [Avastin] only blocks VEGF (Vascular Endothelial Growth Factor)Factor)
VEGF governs angiongenesis – important in tumor growth
very effective against VEGF-dependent colorectal tumors
From: http://biocc.kobic.re.kr/Teach/kim_tae_hyoung/course/altman/genetics-11-12.ppt#312,56,Slide 56
Bioinformatics vs. Applied Clinical InformaticsInformatics
Bioinformatics: intersection between computer science and biological research
Although researchers from both areas have occasionally collaborated their training objectives and interests have beencollaborated, their training, objectives and interests have been quite differentOnce unique genetic markers are teased out these can be made actionable within clinical systemsactionable within clinical systems
Only computerized tools will be capable of maintaining this y p p ginventory of patient-specific genetic markers.
Collaboration / Patient Advocacy Sites / Online CommunitiesSites / Online Communities
Criticisms:Sympathy and Stories – little practical information
Hyper-informed patients – “Googlers”Th t t h i i i i ?Threat to physician omniscience?Changing the practice of medicine? Consumers as practitioners?
AA l d l d lHIPAA – 2002 – electronic medical records streamline adoption and inter-operability; saddled with patient privacy issuesp y
18 categories of PHIPatients on these sites voluntarily share this information
Short circuits the evidence into practice waiting game?Short-circuits the evidence into practice waiting game?
Online Communities
PatientsLikeMe.com7000 membersData! Bar Graphs
List symptoms and treatment – dials into other patients with similar profiles / conditions.
MySpace for the afflicted?MySpace for the afflicted?MS / Parkinsons / AIDS / ALSHeart Dz / Diabetes / Mental Health (subjective) communities plannedplannedBaclofen QD – increase to 40 QD no longer stuck
Sells anonymized patient data; trial recruiting tool
Informatics Training Sites
http://www.nlm.nih.gov/ep/GrantTrainInstitute.htmlhttp://www.nlm.nih.gov/ep/GrantTrainInstitute.html
Pharmacy Informatics Residencies
Topics:pFoundational technology competencyMedication safetyData warehousing and miningData warehousing and miningCapital budgetingProject management
d l iVendor relationsPhysician order entryDecision supportppIntegration of systems Research and PublicationTeachingTeaching
Pharmacy Informatics Residencies
http://www.ashp.org/s_ashp/docs/files/R-dInformaticsTrainingProgs.II.pdf
UMass Memorial Medical CenterBrigham and Women’sgUniversity of MichiganNebraska MethodistSentara Norfolk VASentara – Norfolk, VAMcKesson Medication Management Executive Traineeship in Medication Use Automation and Pharmacy InformaticsJohns HopkinsJohns HopkinsTheradocAuburn University