brent i. fox, pharmd, phd harrison school of pharmacy auburn university [email protected]
TRANSCRIPT
Brent I. Fox, PharmD, PhDHarrison School of PharmacyAuburn [email protected]
The current state: focus on medication use safety
Connecting providers and patients Unavoidable patient safety technologies Portable technology The e-Society Conclusions
Safe- patient’s safety comes first
Timely- care delivered in a timely manner
Effective- based on the best science available
Efficient- avoids waste of time, money, resources
Equitable- care provided to all in an equitable manner
Patient-centered- patients participate fully in care decisions
IOM Workshop
Ordering
49%(48%)
Transcribing
11%(23%)
Dispensing
14%(37%)
Administering
26% (0%)
Bates DW et al. Incidence of adverse drug events and potential adverse drug events: Implications for prevention. JAMA 1995. 274(1):29-34
6.5% of patients experience ADE 28% of ADEs are preventable
Preventable ADEs LOS increased 4.6 days Total costs increased $5857
Bates DW et al. Incidence of adverse drug events and potential adverse drug events: Implications for prevention. JAMA 1995. 274(1):29-34
Bates DW et al. The cost of adverse drug events in hospitalized patients. JAMA 1995. 277(4):307-311
Migrating from Paper to ElectronicData
“the way I do it now”
Paper
“feels like typing or dictating”
Electronicfree text
“feels like filling in a form”
Partiallystructured
“feels like picking everything from a huge menu”
Rigidly structured
Starting Point
8
Isordil ?
Plendil?
ZestrilJury blames doctor's bad penmanship for patient death; awards
$450,000
Responsible?Responsible?
http://www.ama-assn.org/amednews/1999/pick_99/prl21122.htm
9
Copyright ©1997 BMJ Publishing Group Ltd.
Smith, R. BMJ 1997;314:1495
How "industrial age medicine" will invert to become "information age healthcare”
Inverting the Pyramid
Can be exceedingly expensive
Technology seen as “fix” for more fundamental problems
Suboptimal or poor design
Response time, downtime, crashes, viruses, and hardware failures
Deferred improvement, waiting for the new to be developed
Losses in clinician time, efficiency and redistribution of tasks
Poor interconnectivity and integration
Volatile, vendor-driven marketplace
Poor marketplace memory of failed implementations
Underdeveloped mechanism for continuous learning
CDSS often not standardized, untested, poor signal to noise ratio
Can cause errors, and these can be large scale
Tendency to over-rely on info from computer rather than the patient
Lack of integration for medication reconciliation across the continuum
Increasing information overload from sheer volume without reliable filters
1515
www.cchit.org 15
16
EHREHRPharmacyPharmacy
PBMPBMPharmacyPharmacy
PBMPBM
PayerPayerPayerPayer
ElectronicElectronicMedicalMedicalRecordRecord
ElectronicElectronicMedicalMedicalRecordRecord
PersonalPersonalHealthHealthRecordRecord
PersonalPersonalHealthHealthRecordRecord
HospitalHospitalInformationInformation
SystemSystem
HospitalHospitalInformationInformation
SystemSystem
Managed CareManaged CareInformationInformation
SystemSystem
Managed CareManaged CareInformationInformation
SystemSystem
PharmacyPharmacyPharmacyPharmacy
PhysicianPhysicianPracticePractice
PhysicianPhysicianPracticePractice
PatientPatientPatientPatient
HospitalHospitalOr IDNOr IDN
HospitalHospitalOr IDNOr IDN
PharmacyPharmacyManagementManagement
SystemSystem
PharmacyPharmacyManagementManagement
SystemSystem
LabLabLabLab
Clinical LabClinical LabInformationInformation
SystemSystem
Clinical LabClinical LabInformationInformation
SystemSystem
Inpatient EMRClinical Data Repository
Payer EMRMember Clinical SummaryRx Claims History
Patient Lab HistoryBlood Donor RepositoryGenetic Profiles
ImagingImagingImagingImaging
ImageImageManagementManagement
SystemSystem
ImageImageManagementManagement
SystemSystem
PACS ArchiveDiagnostic Image Repository
Prescription History
PHRClipboardPMR: Current Meds
Ambulatory EMR
Digital scale
Sphygmomanometer
Glucometer
Pulse oximeter
Electrocardiogram/ Respiration
Thermometer
The PHR contains an “ongoing, longitudinal and life-long record of information that bridges both wellness and illness” [Markle Personal Health Working Group]
Each person controls their own PHR: individuals decide which parts of their PHR can be accessed, by whom and for how long
Slightly different than allowing a patient view of an EHR (it which case ‘the system’ owns and controls the record)PHR requires more initiative from the consumerEHR may have stronger advantage with respect to patient
observing errors (or verifying a lack of errors for ‘buy in’)
iMetrikus MediCompass: Biometric Device Interfaces
Blood Glucose Monitors:•Accu-Chek ™ Active •Accu-Chek™ Advantage•Accu-Chek ™ Compact •Accu-Chek ™ Complete•Ascensia® Breeze™•Ascensia® Contour™•Ascensia Elite XL®•Bayer Glucometer ® DEX•Bayer Glucometer ® DEX2•Bayer Glucometer ® Elite XL•BD Logic ™•BD Paradigm Link ™•In Duo ™•One Touch® Basic•One Touch ® II•One Touch ® Profile•One Touch ® Ultra•One Touch ® UltraSmart•One Touch ® Sure Step•Precision Q-I-D ®•Precision XTRA™•Prestige Smart System™•TrueTrack Smart System ™•TheraSense FreeStyle ®
Diabetes Management
Cardiac Management
Respiratory Management
Insulin Pumps:
D-TRON PlusBlood Pressure Cuffs:A&D LifeSource UA-767PC (Arm)OMRON HEM-637 (Wrist)OMRON HEM-705CP (Arm)
Digital Scales:A&D LifeSource UC-321PL*
Digital Spirometry:
AirWatch Lipid Testing:
CardioChek PA*(cholesterol, triglycerides, glucose, & ketones)
Reminds patients of their
scheduled activities, such as taking medications and physiologic measurements.
Provides patients with health education tailored to their clinical situation based on orders.
Collects information from patients about compliance with the orders, their comprehension of the educational information, and their clinical status.
Contains a system of "clinical alerts" allowing the agency to identify specific events that need to be brought to a clinician's attention.
Pharmacy/medication mistakes due to negative drug interactions, misread handwriting, and dosage misinterpretation
Repeat laboratory procedures Increase defensive medicine costs Repeat imaging Increased capacity for fraud Paperwork costs of faxing records Increased capacity for medical overuse Increased number of medical visits Increased cost of chronic disease management
Pricing/PerformancePricing/PerformanceTransparencyTransparency
Providers (By Specialty/Service)Providers (By Specialty/Service)
Payers (By Health Plan Class)Payers (By Health Plan Class)
Drugs, Devices, Equipment, SuppliesDrugs, Devices, Equipment, Supplies
Treatments/InterventionsTreatments/Interventions
Pricing/performance transparencywill clarify the value propositions acrossproviders, payers, drugs, etc.
ID Patients at Risk
ID Best Practice
A Broad Vision of Web/Health 2.0A Broad Vision of Web/Health 2.0Reformulating Data for Transparency, Decision Support Reformulating Data for Transparency, Decision Support
& Revitalized Health Care Markets& Revitalized Health Care Markets
Brian Klepper andBrian Klepper andJane Sarasohn-Kahn, Jane Sarasohn-Kahn, October, 2007October, 2007
EMREMREMREMR
PHRPHRPHRPHR
Data sources Data sources mapped to a mapped to a common common format format (e.g., CCR).(e.g., CCR).
ClaimsClaims
ClinicalClinical
DrugDrug
LabLab
ImageImage
Health MgmtHealth MgmtHealth MgmtHealth Mgmt
Expert-Expert-GeneratedGenerated
ContentContent& Search& Search
AnalyticsAnalyticsAlgorithms for achieving transparency (e.g., ETGs, DxCGs, CRGs, APR-DRGs) should be well-accepted and their approaches transparent.
User-GeneratedContent
Patients and caregivers advising others, sharing family histories, and more.
Vendor MgmtVendor MgmtVendor MgmtVendor MgmtTools
DecisionDecisionSupportSupport
Expert content, data-based evidence and artificial intelligence algorithms can drive better decision making for patients, clinicians, health managers and purchasers.
CentralizedCentralizedDataData
RepositoryRepository
If open about their analytical approaches, public & private groups can credibly report comparative pricing and performance information.
PublicPublicReportingReporting
Count only White Shirt to White Shirt Direct Passes that are Flat or Arched
Bounced passes do NOT count.
Black Shirt passes do NOT count.
Nurse barcode scans name tag
Nurse barcode scans patient identification bracelet
Patient MAR appears on bedside laptop
Scheduled and prn meds are scanned
Warnings/alerts are issued when indicated
Barcode Technology
Manufacturer bar codes
Repackaging
Adding barcodes to existing package
Quality control
How will this be managed? Resource requirements (FTE’s)Chris Fortier & Mike Sura
Dispensing Errors Alert fatigue
Intentional System Bypass Process resistance → easier workaround Medication Held/Discontinued Medication not bar-coded Emergency situation Patient’s own medication
Unintentional System Bypass Alert fatigue Workflow Hardware issues
Chris Fortier & Mike Sura
Often a low therapeutic index All patient populations Responsible for >50% of all serious and
potentially life threatening ADEs
Misuse of infusion pumps & other parenteral systems proximal cause of 13% of administration errors
Williams & Maddox. Implementation of an IV medication safety system. AJHP. 2005;62:530-536.
Leape LL et al. Systems analysis of adverse drug events. JAMA. 1995;274:35-43.
Assess impact of smart pumps on rate of serious medication errors
Four 8-week data collection periods 1st & 3rd: control 2nd & 4th: intervention (real time DS)
DS – drug library, dose & rate limit alerts
Hard limits were not used Nonspecific generic infusions
Rothschild JM et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med. 2005;33:533-540.
4276 patient pump days control; 3869 patient pump days intervention 5364 & 5295 IV meds ordered, respectively
ControControll
InterventioInterventionn
p-valuep-value
Preventable ADEsPreventable ADEs 1414 1111 0.80.8
Nonintercepted Nonintercepted potential ADEspotential ADEs
7373 8282 0.0860.086
Serious med errorsSerious med errors 8787 9393 0.1240.124Rothschild JM et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med. 2005;33:533-540.
Robotic IV automation removes the largest source of contamination from the compounding environment: the human operator
Robots provide consistent operational support
Improved accuracy and documentation
Mike Culligan and Luci Power
44Mike Culligan and Luci Power
Mike Culligan and Luci Power
ISO 5 compounding area Contained air handling system –
designed for hazardous drugs No human access to compounding area
during compounding process Flexible selection of syringes, IV bags,
elastomeric infusers and bottles
Mike Culligan and Luci Power
ISO 5 compounding area ISO 5 vestibules for loading inventory into
the storage carousels Contained air handling system – designed
for standard sterile compounding but may be used for hazardous drugs
No human access to compounding area during compounding process
Mike Culligan and Luci Power
IntelliFill IV automates the preparation of small-volume IV medications in 12 ml syringes for doses as small as 0.5mls to as large as 11.5mls.
Can hold up to ~40 different medications in drug cabinet
First Introduced in 2002
Mike Culligan and Luci Power
52
RFID’s Impact on Pharmacy Settings
The advantage of RFID is that it does not require direct contact or line-of-sight scanning.
RF signals communicate through many materials including clothing
RFID can store much more data than a typical barcode.
Some RFID tags can both transmit and record data.
Sackett and his colleagues define evidence-based medicine as, "The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients."
Other types of Decision Support Systems are: Algorithms Guidelines Order sets/standing orders Trend monitors Co-sign enforcers
Patricia L. Hale, Ph.D., M.D. Patricia L. Hale, Ph.D., M.D. Medical Informatics Subcommittee ACP-ASIM
Results - Frequency Recommendations (Ondansetron)
020406080
100120
-4 -3 -2 -1 0 1 2 3 4 5 6 7 8
Week
% o
f O
rders
TIDQID
p value <0.001 at –4 and 4 weeks
(Teich, 2000)
1. Speed is everything
2. Anticipate needs and deliver in real time
3. Fit into the user’s workflow
4. Little things can make a big difference.
5. Physicians resist stopping
6. Changing direction is fine
7. Simple interventions work best
8. Asking for information is OK--but be sure you really need it
9. Monitor impact, get feedback, and respond
10.Knowledge-based systems must be managed and maintained
Bates DW Kuperman GJ et al J Am Med Inform Assoc 2003; 10:523
Evanston Northwestern Healthcare implemented an EMR (Epic) with CPOE capability at three hospitals and 50 outpatient clinics and medical offices. The number of system users is 6,200. Number of delays in administering medication has fallen
by 70% Omitted administration of drugs has dropped 20% Test results for mammograms now take one day, down
from as long as three weeks Cardiographics reports also take one day, down from as
many as 10 days Spent $7.5 million on training and $35 million capital on
hardware, software, and implementation Won the Davies Award for 2004
Source: HIMSS 2007 HIMSS AnalyticsSource: Gregory S. Walton, FHIMSS, Oct 2007
► Perspective► Rate of prescriber order entry► Reduction in medication errors► Legibility► Efficiencies► The Leapfrog Group hospital quality ratings Leap 1 = CPOE
In order to fully meet Leapfrog’s CPOE Standard, hospitalsmust:1. Assure that physicians enter at least 75% of medication orders via a computer system
that includes prescribing-error prevention software;2. Demonstrate that their inpatient CPOE system can alert physicians of at least 50% of
common, serious prescribing errors, using a testing protocol now under development by First Consulting Group and the Institute for Safe Medication Practices (this criterion for the Leap will not count towards the hospital’s publicly reported status on this Leap until the test is available); and,
3. Require that physicians electronically document a reason for overriding an interception prior to doing so. (www.leapfroggroup.org accessed 3/11/08)
Anne Bobb & Lynn Boecler
“If I had one thing to ‘do over’ in our CPOE implementation, it would be to
have devoted more resources to track errors and problems that were created---it is just impossible to ‘get
it all right’ at the outset, because the processes involved are so
complex.”
David Bates, June 2005
Anne Bobb & Lynn Boecler
5. Expert Opinion
4. Case Series*
3. Case Control
2. Cohort*
1b. Single RCT
1a. Multiple RCTs
Centre for Evidence-based Medicine. Levels of evidence and grades of recommendation. November 1998; Available at: http://www.cebm.net/levels_of_evidence.asp. Accessed October 1, 2006.
Error Rate in %
Hospital Before After Installation
1mo. 2mo. 3mo. 2 Yrs
X - Unit A 14 10 12 8 7
Unit B 17 6 20 12 5
Y - Unit A 14 12 21 13 9
Unit B 4 6 12 12 5
Source: Barker, Flynn and Bunnell, 2000
85.5
93.494.6
93.194.9
89.3
95
89.2
97
91
96.897.8
9191.7 92.6
9795.7
84
86
88
90
92
94
96
98
100
Jul F
Y01
Au
g
Sep
t
Oct
Nov
Dec
Jan
Feb
Mar
Ap
r
May
-Ju
n
Jul F
Y02
Au
g
Sep
t
Oct
Nov
Dec
#6. Cubie Installation Complete
#5. New Units Added/ TS Drug List Revised
#4. Pharmacy Nursg Reviewed Video
#3. Education per Video
#2. Connect Complete
#1. LPN Role Change
CONFIDENTIAL QUALITY ASSURANCE INFORMATION PROTECTED FROM DISCOVERY BY ALABAMA CODE 22-21-8
Effect of Interventions on Accuracy, Hospital X, FY 01-02
456
341
050
100150200250300350400450500
Errors detected on 2557 doses
Observation(RPh)
Chart review(RPh)
Incident reports
Observer selection and training program Manual Interactive video Training Practice observations Tests
Software for data analysis, PowerPoint slide generation
Observer certification Service and Support
86.7
89.4
91.5 91.2
94.495.2
81.9
86
91.792.9 93
94.4
747678808284868890929496
Y X
BaselineFY 97FY 98FY 99FY 2000FY2001
Palm OS, Pocket PC, Blackberry, iPhone Color Quality (Monochrome - RIP) At least 32 (>200 to 4000) MB RAM Expandable Memory (8+ GB) Wireless (IR – Bluetooth – Cellular WAN –
WiFi) Telephone Combination (SmartPhone) Peripherals Multimedia
• Mini-Laptop• PDA• WiFi• Bluetooth• WAN• Camera• Speech
Emano Tec Inc., has designed a wafer-thin, wireless hand-held computer that can be washed thousands of times.
5.5” X 7.5” X 0.5”
1. Lexi-Drugs 2. Lexi-Interact3. Lexi-Natural Products4. Pediatric Lexi-Drugs5. Lexi Poisoning and
Toxicology6. Lexi-Lab and
Diagnostic Procedures7. Lexi-Infectious
Diseases8. Lexi-
Pharmacogenomics9. Lexi-Calc10. Dental Lexi-Drugs
11. Nursing Lexi-Drugs12. Lexi-PALS 13. Nuclear, Biological, and
Chemical Agent Exposures14. Lexi-Companion Guides15. Perioperative Nursing Lexi-
Drugs16. Lexi-I.V. Compatibility17. Medical Abbreviations18. Griffith’s 5 Minute Clinical
Consult19. Stedman’s Medical Dictionary20. Pharmacotherapy Handbook
(from McGraw Hill)21. Harrison’s Practice
E-mail E-commerce E-learning E-government
And now e-health, e-patientsAnd now e-health, e-patients
Terms first came into use in 2000
Blogs Wikis RSS Podcast CE Twitters Jaiku Pownce Widgets Del.icio.us/Connotea
YouTube Flickr Second Life Mobile Apps Skype/VOIP Twine Semantic Web Facebook/MySpace Mashups Ingenta
13 Main Communities, 23 Bloggers, Ratings
Isn’t this Just eMail?
Not HIPAA compliant– Not secure– Limited audit trail
Free-form
Non-chargeable
One-to-one exchange without workflow support
Limited feature set
HIPAA ready– Secure servers, 2 firewalls, 128-bit, SSL
encryption– Full audit trail
Clinically structured
Reimbursable
Advanced workflow support– Message routing by type– Distinct roles/proxy rights
Comprehensive feature set– e-Prescribing, e-Referrals– Clinical content and forms
How do webVisits Work?Patients select from 140+ Common Symptoms or Chronic Conditions
How do webVisits Work?Patient Completes an MD-Authored Interactive Online Interview
How do webVisits Work?Physician Receives Concise, Structured Message with Summary Health Record
How do webVisits Work?Physician Replies using Customizable Templates and Time-saving Attachments
Results: Reduced Absenteeism
Patients who messaged their doctor using RelayHealth were…
50% less likely to report missing work# due to illness
40% less likely to report having limited work capacity† due to illness
#p < .01†p < .05
IPv4 = 4.3 billion 2/3rd usedIPv6 = 3.4 X 1038
6.5B = 5 X 1028
Google video sites reach over 37% of all internet users!
Health Information Exchange (HIE) Federal NHIN/EHR efforts Health Information Technology
Electronic Medical/Health Record (EMR vs EHR) CPOE/eRx Bar Codes and RFID Automated dispensing machines, robots, smart pumps Electronic Medication Administration Record (eMAR) Medication Reconciliation Automation
Transparency to consumers PHRs and connectivity with patients and other
providers
Brent I. Fox, PharmD, PhDHarrison School of PharmacyAuburn [email protected]