Rob Brenninkmeijer, pharmacist

Digitalis Rx bv, Amsterdam

Medicines Management

Guideline Management

Two systems, one approach

Digitalis started 20 years ago in the Netherlands as an enterprise

for digital pharmaceutical care and medicines management by ways of:• Publishing, content management & distribution of

electronic prescription guidelines• Implementation of electronic guidelines and

integration in GP prescribing practice (Electronic Prescribing System, Prescriptor)

• Production, content management, desk editing & publication of interactive web & workshoptools for the rational and transparent selection of medicines

Prescriptor

e-Prescribing system (EPS) for applying therapy guidelines

Software component bolt on to electronic patient record (ePR) systems

First module ready 1988 Rudimentary techniques and systems Not ‘the end’ Not even the ‘beginning of the end’ Getting doctors to agree (motto: when two

doctor’s agree, one is not a doctor….)

Prescriptor

e-Prescribing system (EPS) for applying therapy guidelines

Software component bolt on to electronic patient record (ePR) systems

First module ready 1988 Rudimentary techniques and systems Not ‘the end’……. Not even the ‘beginning of the end’ Getting doctors to agree (motto: when two

doctor’s agree, one is not a doctor….)

Prescriptor-EPS: why?

Development of a road atlas versus a navigation system:• Therapeutic network has vastly expanded in the last 20 years.• Printed guidelines: not effective, and hard to manage• Digital guidelines: flexible and easy to maintain; higher level of

integration in the care process• Autonomy prescriber as the “driving force” is guaranteed

Regional and/or national implementation of electronic medication record of the patient:• Facilitating exchange of medication history of the patient between

care providers • GP and pharmacist share a higher level of mutual responsibility to

prevent medication-conflicts and adverse reactions• GP can process online notifications of ‘traffic incidents’ more

efficiently with an EPS!

First NL article published in 1988

Prescriptor: UK publications

First introduction in the UK 1993: Prodigy

Prescriptor revisited

First phase sponsored by the NHS, however not much direct involvement

Therapy decision tree linked to READ diagnostic codes

Based on translated Dutch Guidelines (Nijmegen regional formulary)

Reasonable balance between technical brilliance and daily practice

NHS takes over…..

Renames Prescriptor UK to Prodigy Prescribing RatiOnally with Decision

support In General practice studY Rolled out 1996 – 1997 Prescriptor was used as a reference

model and integrated in three GP-systems Pilot worked in a way

BMJ 1996

Prodigy Phase II Rebuild from scratch in 1997 Launched around 2000 Bad, reasonable and good implementations in many

different GP systems Part success - part failure: too much top down Too little effort in making it work in the field: not enough

bottum up Phase III never left the drawing board! NHS kept on developing Prodigy guidelines until 2007 NHS should have focused on a more bottum up

implementation instead

In the meantime….Prescriptor NL

National sponsored project on national Electronic Prescribing System started in 1998

Prescriptor initially left out of it Eventually part of EPS project thanks to active lobby of

GP user groups Connected to 6 major GP-systems and installed base of

70% of all GP practices in NL Also implemented in combination with all 3 out of hours

call management systems; In use in all medical departments of penitentiary

institutions and within the military services Some implementations in large nursing homes

Demo:

Anatomy of a Prescriptor Guideline

The tree

The IndicationClinical Recommendation

Connected to a classificatione.g. Read, ICPC, ICD, SNOMED: the trunk

Therapy SchemeClinical Scenario’s: the branches

Therapy Cluster

Prescription

FiltersSelection criteria

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Local

Regional / Transmural formularies

STEPSelect

National formulary

(e.g. derived from national guidelines)

Formulary Management

Local adjustments

Reference formularies

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EPS-Pyramid

Summary Prescriptor

Supports goal oriented therapeutic navigation within prescribing process: from complaint or disease to treatment.

GP is driving force and is responsible for minor adjustments

Supports multisource national, regional and/or local prescription formularies

National guidelines and Patient information leaflets Integration of a national “Drug Dictionary” Prospective Medication Surveillance is integrated

Consequences of decision support e-Prescribing

Prescribing less experience/intuition driven• Prescribing less “spinal” driven, adhoc, soloistic, but is

more conditioned, based on mutual professional agreements

Consensus on therapy guidelines and selection procedures of medicines become more rational group processes • The dynamics to issue, maintain, distribute and

implement guidelines AND to enhance appropriate prescribing will increase

• Improved infrastructure / communication chain within the domain of pharmacotherapy

Guidelines and medicines

root: clinical evidence & experience

trunk, branches: guideline

leaves: precriptions, medicines

Medicines Management

“Encompassing the entire way that medicines are selected, procured, delivered, prescribed, administered and reviewed to optimise the contribution that medicines make to producing informed and desired outcomes of patient care”

Medicines Management and Guideline Management are complimentary!

Medicines management: why

The present healthcare system faces great challenges:• increasing numbers of adverse events• poor adherence• increasing numbers of medication incidents • inadequate communication across the

primary/secondary care interface.

• Furthermore, expenditure on medicines is one of the major cost elements in healthcare.

Lack of integrated Product Use

This is identified as a significant element in inefficiency of the current medicines management system.• fragmented and dispersed application and use of

agents within a therapeutic class• different generics being used• discontinuity between primary and secondary care• use of parallel imports in primary care• confusion for patients, particularly the elderly• avoidable drug-related hospital admissions

STEPSelect: Northern Irish–Dutch collaboration

Incorporated in several approaches:• Medicines governance

(policy)• Integrated Medicines

management (prescribing, dispensing, procurement)

• Guideline Management

STEPSelect: 4 stages STEP I – clinical evaluation:

Evaluation and continuous updating of all available evidence relating to efficacy, evidence, safety, tolerability, ease of use, medical interactions and experience is carried out. This pre-selection of medicines within a therapeutic class is purely based on clinical criteria.

STEP II – risk assessment: This phase focuses on factors that impact upon the safe use of the various products during routine use by patients. This assessment is carried out on both the packaging and instructions, to minimise difficulties for patients and help them safely and optimally use their medicines.

STEPSelect: 4 stages STEP III – budgetary impact analysis:

This phase entails looking at the impact of the use of the agents in a therapeutic class on the complete healthcare economy, in both primary and secondary care.

STEP IV – final procurement: The procurement model also allows for a radical redesign of the medicine tariff based upon safety, efficacy and economy. Flexibility is built into the process as it does not demand 100% compliance with the product selections, but rather, only requires a reasonable percentage compliance (70 – 80% depending on the group)..

www.stepselect.com

Facilitates clinical fase I of STEPSelect

Online matrix modules by which rational considerations are made using review criteria to select preferred medicines.

Process: • collection of literature data• production of matrix, article and

scores• review by experts, industry and

patient groups• (virtual) workshops with prescribers

STEPSelect in N-I: outcomes quality(Q) and safety(S) result in both health

improvement(I) and better efficiency(E): Q+S=I+E • effectively linking clinical evidence with the procurement

process resulting in a much more integrated, less fragmented approach to medicines management that exists in the field of communication and decision-making within primary and secondary care chains of prescribers, suppliers and procurers of pharmaceutical care (Q and E).

• evidence based reduction in the incidence of hospitalisation due to the inappropriate use of medicines (S and I)

• Cost reduction by efficiency improvement that can (also) make room for innovative new drugs: all in all….investments outweighted the costs involved (E but….Q, S and I first!!!

The guideline is patient but the doctor is not....*)

Lessons learned….• Allow multisource national and/or regional FLEXIBLE

implementation of guidelines • Minimize distance between guideline management and

medicines management: ownership practitioners• Correct focus, less technique, more implementation• Teaching doctors how to improved use of electronic medical

records and better ways to share information• Shift from professional-centric – towards a more

interdisciplinary approach • See the little picture, don’t create ONE BIG UNIVERSE or

pursue a BIG BANG

*) free after Joseph Joubert (1754-1824): the paper is patient but the reader is not.