sistemas de soporte a la decisión clínica · sap® – software – plataforma integrada hospital...
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Carlos CodinaServicio de Farmacia Hospital Clinic.Barcelona
Grupo Tecno. SEFH. 2010
Sistemas de Soporte a la Decisión Clínica
DefiniciónClinical Decision Support (CDS) is defined broadly as a clinical system, application or process that helps health professionals make clinical decisions to enhance patient care. Clinical knowledge of interest could range from simple facts and relationships to best practices for managing patients with specific disease states, new medical knowledge from clinical research and other types of information. (J Osheroff 2004)
Healthcare Information and Management Systems Society
HipótesisComputerized physician order entry (CPOE) & Pharmacy review & drug administration, with clinical decision support (CDS) has been promoted as an effective strategy to prevent the development of a drug injury defined as an adverse drug event (ADE).
ObjectivoDiseñar us sistema Prescripción – Validación –Administración y seguimiento, asistido que permita mejorar los resultados en salud de los pacientes
SAP® – Software – Plataforma IntegradaHospital Clinic. - Barcelona
SAP – MM – Financiero - Compras
SAP – ISH – Estación Clínica - HCE
SAP – FAR – Farmacia – PEA - ADMDATAWAREHOUSE
SAP / Enfermería / Plan de Curas y Cuidados
SAP / Urgencias; Consulta externa...
Módulos
Balanced Score Card“Cuadro de Mando”
Prescripción
Validación
Administración
SAP FAR – CPOE – PHARM - EMAR
CDS 5 RIGHTS AND MEDICATION MANAGEMENT STEPS
©2009 HIMSS
Selección de Medicamentos (Médico & Farmacéutico)Guías Clínicas; Protocolos Búsqueda libre (Criterios: formulario + dosis) Fármacos restringidos
Conciliación de tratamiento habitual (Médico; Farmacéutico; Enfermera) Recordatorios de carácter preventivo (Médico; Farmacéutico; Enfermera)Resultados de Laboratorio (Médico; Farmacéutico; Enfermera)Alertas (Médico; Farmacéutico; Enfermera)
Alergias; Interacciones; ajuste dosis por IR; Dosis Máxima; Duplicados; Embarazo…
Validación FarmacéuticaPharmacy rules; Listados cruzados; Intervenciones; condiciones; …
Información de Medicamentos (Médico; Farmacéutico; Enfermera)Medimecum ; Micromedex ;Intranet ; Bibliotecas,…
Información de Medicamentos al Paciente (Médico; Farmacéutico; Enfermera)
Iniciativas – Sistemas de Soporte a la Decisión Clínica
Diagnóstico,
Problema de Salud…
Admisión Paciente
“CPOE & CDS”
Admisión Paciente
“CPOE & CDS”
Alergias
Fármacos /indicación
Protocolos
Guías Clínicas,
Esquemas tto.
Edad
RAM
Función renal
Pruebas Laboratorio
Microbiología
- Perfil Farmacoterapeutico–
InteraccionesDuplicados,
Right MedicamentoRight DosisRight FrecuenciaRight VíaRight Duración
Conciliación Tto
CPOEPropuesta de
tratamiento con ajustes de dosis y/o justificación
de uso
Validación Tratamiento
Embarazo
Lactancia
Peso, altura
11
22
33
44
55
Fármacos /indicación
Protocolos
Guías Clínicas,
Esquemas tto
22
ConstantesPlan de curasPetición LabortDietasTratamiento
FarOtras pruebas
Protocol Xxx disease
AGE >
AllergicA
AGE <
Drug A
CL CR
Drug D
Other situat.
Drug F
Other..
Drug B
Drug C
Drug E
Drug G
Algorithm Example
Grupo Terapéutico / indicaciónFármaco A: Dosis /Pauta/VíaFármaco B: Dosis / Pauta /
VíaFármaco C: Dosis / Pauta /
Vía
Fármacos, dosis, pauta….
Nota. Si existe mas de un problema el sistema debe ser capaz de realizar la comprobación de duplicidades
Petición de analisis
Radiología estudio,……
Plan de Curas, ….
Perfil de Paciente
Selección de medicamentos:
Guía Farmacoterapéutica.
Formularios : 1 - Pacientes Ingresados2 – Pacientes externos
Medicamentos no Guía. Programa de equivalentes terapéuticosEn caso de prescribir un medicamento fuera Guia, utilizar otro “tipo de letra”, para diferenciar
SAP – HCP 2010
Templates – Therapeutics Groups – Medical Service - Unit
Protocols – Medical Service - Unit
SAP – HCP 2010
Selección de Protocolos. Hospital Virgen de la Arrixaca. Murcia
Selección de Protocolos. Hospital Son Dureta. Palma de Mallorca
Selección de Protocolos. Hospital Ramón y Cajal. Madrid
Selección de Protocolos. Hospital Gregorio Marañón. Madrid
Selección de Protocolos. Brigham and Women’s Hospital. Boston
Selección de Protocolos. Brigham and Women’s Hospital. Boston
Selección de Protocolos. Brigham and Women’s Hospital. Boston
Selección de Protocolos. Brigham and Women’s Hospital. Boston
Selección de Protocolos. Brigham and Women’s Hospital. Boston
Selección de Protocolos. Brigham and Women’s Hospital. Boston
Selección de Protocolos. Brigham and Women’s Hospital. Boston
Anne Bobb 2010
Selección de Protocolos. Northwestern Memorial Hospital. Chicago
Anne Bobb 2010
Selección de Protocolos. Northwestern Memorial Hospital. Chicago
Posibilidad de incluir dosis en función del peso o superficie corporal
Conexión al Protocolo
SI NO
NO SI
SI NO
*En caso de EPOC o apnea del sueño se recomienda en todos los tipos de insomniozolpidem. Una alternativa es trazodona 50 mg antes de acostarse.*En pacientes geriátricos o en presencia de insuficiencia hepática se recomiendadisminuir la dosis a la mitad.*En embarazadas que no responden a higiene del sueño se recomienda utilizardoxilamina 10-20 mg/24h.
IC psiquiatría
Continuar
Zolpidem10 mg/24h
Dificultad de conciliación
Lorazepam1-2 mg/24h
Despertares nocturnos
Tipo de insomnio
¿El paciente responde?
Higiene del sueño Continuar tratamientoy revalorar al alta
Consumidor crónico de hipnóticos
Enfermedad psiquiátrica(ansiedad, depresión,...)
Intranet ProtocolosFormato PDF
BWH 2010
BWH 2010
BWH - 2010
Anne Bobb 2010
Kuperman et al.. 2007
LorazepamProblem list
Lorazepam 1 mg C/24 H N VOLorazepam 0,5 mg C/24 H N VOLorazepam 2 mg C/24 H N VOLorazepam 5 mg C/24 H N VOLorazepam …/…
Drug List
Order Set
Protocols
Therapeutic Group
ClonazepamDiazepamLorazepam LormetazepamZolpidemTrazodona…/…
Insomnio
Preop. Cirugia DigestivaQuioterapia
Medical Service
Drug; Therapeutic group; protocol; disease ; indication based…
Medical service, Unit, Department,..
Fast Drug Search (Drug name and route)
Drug dose and frequency (usual alternatives)
2
SAP – HCP 2010
Fármacos de Uso Restringido: Ej. Linezolid
Justificar su utilización
Nota:El Comité de Farmacia y Terapéutica aprobó el uso de Linezolid, en las siguientes Indicaciones. Seleccionar la que proceda o solicite la aprobación, del especialista en enfermedades infecciosas.
□ Indicación A
□ Indicación B
□ Indicación C
□ Otras _____________________________
Medication Use Guidelines
BWH 2010
Specialist Approval
BWH 2010
Pharmacy review
55 Medical Drug Prescription
New: patient status, or condition, or treatment?
Drug alerts, rules behind, or modification
is needed
Medical justificationis needed
JustificationReasonable
yes
no
yes
Pharmacist verificationapproval
noPharmacy proposal Intervention is open
automatically
no
Patient Drug Profile
yes
Pharmacy Intervention is open
Conciliación Tratamiento
Asistencia Primaria
• Perfil de medicación
Hospital
Paciente Ingresado
• Drug profile
Paciente externo, alta
• Hospital de Día• Consulta externa• Urgencias• Alta Hospitalaria•…/…
Drug List Inpatient Discharge
Nombre Genérico – Especialidad Farmacéutica - Dosis - Frecuencia – Vía – Fecha de inicio - Duración
□ Continue □ Modify □ Stop□ Discharge□ Continue □ Modify □ Stop□ Discharge□ Continue □ Modify □ Stop□ Discharge□ Continue □ Modify □ Stop□ Discharge
□ Continue □ Modify □ Stop□ Discharge□ Continue □ Modify □ Stop□ Discharge□ Continue □ Modify □ Stop□ Discharge
Conciliación al ingreso y al alta
Furosemida 40 mg c/24h VODigoxina 0,25 mg c/24h –SyD VOAtenolol 50 mg c/24h VO
Paracetamol 500 mg c/8h VO
Metformina 850 mg c/12h
Digoxina 0,25 mg c/24h – SyD VO
Amoxicilina 500 mg c/8h VOGentamicina 240 mg c/24h IV
Insulina NPH 10 UI C/12h SC
Medicación habitual domiciliaria Medicación paciente ingresado
Continuar… Continuar…
Conciliación al ingreso y al alta
Furosemida 40 mg c/24h VODigoxina 0,25 mg c/24h –SyD VOAtenolol 50 mg c/24h VOAmoxicilina 500 mg c/8h VO
Paracetamol 500 mg c/8h VO
Metformina 850 mg c/12h
Digoxina 0,25 mg c/24h – SyD VO
Amoxicilina 500 mg c/8h VOGentamicina 240 mg c/24h IV
Insulina NPH 10 UI C/12h SC
Medicación habitual domiciliaria Medicación paciente ingresado
Continuar… Continuar…
PAML Builder: Action on Admission
BWH
Lab results; Microbiology; Medical records,….
SAP – HCP 2010
Creatinin
SAP – HCP 2010
Electronic Health Record (EHR)
SAP – HCP 2010
Allergies
Age
ADR
Renal Function
Lab results
Microbiology
- Drug Profile –Drug InteractionsDrug Duplicates
Drug Class Duplicate
Drug reconciliation
Pregnant
Lactation
Weight - Tall
33 Age. Contraindications / Beers criteria
Drug dosing depending on weight / tall / Body surface..
Pregnant (contraindications) Lactation (contraindications)
Allergies (contraindications)
Adverse Drug Reactions (information)
Dose adjust depending on Clearance (Cockroft –Gault)
Lab results contraindication / adjustment proposal
Microbiology antibiogram sensitivity (information)
Patient Drug profile and drug reconciliation
Drug interaction level 1 (contrain); Drug Duplicates (info)
Aviso de Interacción. Hospital Son Dureta. Palma de Mallorca
Aviso de Interacción. Hospital Ramón y Cajal. Madrid
Aviso de Interacción. Hospital Gregorio Marañón. Madrid
Aviso de Interacción. Hospital Virgen de la Arrixaca. Murcia
Alerts: Allergies; Drug-Drug Interactions; Duplicates; Drug adjust RI; Age >65; Max. Dose (daily & doses); Pregnant.External Drug Data Base located at Hospital Intranet -
SAP – HCP 2010
SAP – HCP 2010
Condiciones del sistema idealProducto externoUbicado en la Intranet del HospitalActualización automática por internetPosibilidad de adecuación de los niveles de alerta según centro y usuarioDisparo de la consulta según el tipo y nivel de la alertaEn alertas graves, proponer cambio de tto, (proactivo)Posibilidad de solicitar un motivo al sobrepasar una alertaSistema de registro de alertas sobrepasadasAlergias y RAM deberían registrarse en la Historia
Clínica
Alergias. Historia Clínica
SAP – HCP 2010
i
Pharmacy Intervention, is waiting for you (proposal)
Pharmacist InterventionsMedication ErrorsAdverse Drug ReactionsAllergies- EMR
Allergies RAM
SAP – HCP 2010
Medical Drug Prescription
New: patient status, or condition, or treatment?
Drug alerts, rules behind, or modification
is needed
Medical justificationis needed
JustificationReasonable
yes
no
yes
Pharmacist verificationapproval
noPharmacy proposal Intervention is open
automatically
no
Patient Drug Profile
yes
Pharmacy Intervention is open
Antibiotics Prescription
Indication correct?
Renal function Correct?
Lab Res & Micro labsCorrect?
Is drug dose adjusted?
Is it modified?
Is it justified?
yes
yes
Pharmacy approval pending
yes
DDI, Allergies,.Correct?
Dose, route, Frequency..
Correct?
Is it modified?
Is it modified?
Pharmacy interventionIt’s opened
yes
no
no
no
no
no
no
no
no
no
no
yes
iPharmacy Intervention, is waiting for you (proposal)
Pharmacy Intervention (closed)
Pharmacy Interventions
Med Errors ADR
SAP – HCP 2010
Pharmacy Screen
SAP – HCP 2010
Pharmacy System
SAP – HCP 2010Prioritize PI
Información de medicamentos1 – Catalogo de especialidades2 – Micromedex
(Médico – Farmacéutico- Enfermera)SAP – HCP 2010
PEA – Mismo procedimiento que en paciente ingresado
Alta Hospitalaria
SAP – HCP 2010
SAP – HCP 2010
SAP – HCP 2010
Validación del FarmacéuticoSAP – HCP 2010
Patient discharge. Proposal (I)
Drug reconciliation SAP – HCP 2010
Perico de los Palotes
Perico de los Palotes
SAP- Lloc de treball- Sol·licituds- Consulta d’altres episodis: Patient Organizer
HCO: IPA Obstetricia- Registres assistencials- Consulta d’informes (IA, IR)- Generació d’iformes
Projecte Pilot IPA - Servei MaternofetalModel Funcional Fase I
Hospital ClinicMedical Informatics 2010
Projecte Pilot IPA - Servei MaternofetalNivell de presentació
Hospital ClinicMedical Informatics 2010
Clinical Pharmacy tool
Plan estratégicoPresentar y consensuar proyecto en el Servicio de FarmaciaPresentar proyecto a la Dirección del HospitalCrear un Grupo multidisciplinar de Trabajo
Médico; Farmacéutico, enfermera, informático, …Seguir las recomendaciones del ISMP en la creación de Guías Clínicas o peticiones agrupadasDiseñar los esquemas de las Guías Clínicas en formato excelEstablecer la lista de medicamentos de uso restringido y crear los diálogos asociadosDiseñar los diálogos y o condiciones de apertura de Intervenciones FarmacéuticasPresentar propuestas al Comité de FarmaciaPilotar en una Unidad de HospitalizaciónEvaluar y/o continuar
Degrees of computerization(1) The computer offers no assistance; humans must do it all. (2) The computer offers a complete set of action alternatives, and (3) narrows the selection down to a few, (4) suggests one, and (5)executes that selection if the human approves, or (6) allows the human a restricted time to veto before automatic execution, or (7) executes automatically, then necessarily informs the human, or (8) informs him or her after execution only if he or she asks, or (9) informs him or her after execution only if it, the computer, decides to. (10) The computer decides everything and acts autonomously, ignoring the human.
Sheridan TB, Thompson JM. People versus computers in medicine. In: Bogner MS, (ed). Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, 1994, pp 141–59.
10 commandments
Speed is everythingAnticipate needs and deliver in real timeFit into the user’s workflowLittle things can make a big differenceRecognize that physicians will strongly resist stoppingChanging direction is easier than stoppingSimple interventions work bestAsk for additional information only when you really need itMonitor impact, get feedback, and respondManage and maintain your knowledge base systems
Bates D. J Am Med Inform Assoc. 2003; 10:523-530
CDS – Five Rights1 Right Information2 Right Person3 Right CDS intervention format4 Right Channel5 Right Time in workflow
Applying CDS to Medication Management
1 - Medication Selection / Reconciliation2 - Ordering3 - Verification / Dispensing4 - Administration5 - Education6 - Monitoring
Osheroff et al. Improving Medication Use and Outcomes with Clinical Decision Support: A Step by Step Guide. 2009
1 - Medication Selection/Reconciliation
Select, for a clinical condition, a medication that is safe and effective. Based on clinical evidence, patient characteristics and cost effectiveness.The selection requires access to patient information, clinical history, weight, height and ageAccess to disease management knowledge and drug information Support medication reconciliation with an accurate list of the patient’s medication.
2 - OrderingCreate a medication order/prescription (ideally linked to the indication)Provide dosing recommendations, ideally specific to patient and clinical conditionConduct automatic check for contraindications, duplications, DDIs, drug –lab interactions, allergies, right dose/route/frequency.
3 – Verification/Dispensing
Double check for interactions, appropriateness / contraindications, right dose / route / frequency / timing.Math prescription/ order to correct dose and dose formCheck for proper concentration and volume to minimize pump programming errors, incompatibilities.
4 - AdministrationMake positive medication and patient identificationAsses patient and document pertinent parameters (such as blood pressure, heart rate, blood glucose, pain level) prior to administrationCheck for incompatibilities/interactions, such as between parenteral medications, between medications and foods, etc.Recheck right dose/route/frequency, administration technique and timing, monitoring guidelinesProvide reminder/guidance when medications are not administered at the appropriate time or are delayed or missed
Future dosing decision support research should focus on:
1. Determining the most effective way to deliver dosing decisionsupport (e.g., when are default suggestions or post-hoc critiques more effective).2. Developing robust dosing knowledge for the general population as well as special populations (pediatrics, geriatrics, oncology, renal impairment).3. Determining how best to increase compliance with dosing suggestions.4. Identifying medications that are most likely to be incorrectly dosed and/or have narrow therapeutic windows that could be the target of high-priority, advanced efforts.5. Determining how best to disseminate dosing knowledge broadly so that each institution does not have to “reinvent the wheel.”6. Determining the best ways to reconcile when multiple factors are present that may impact on optimal dose (e.g., more than one of advanced age, impaired renal function, and impaired liver function).
Kuperman et al. J Am Med Assoc. 2007; 14:29-40
Recommendations to Research Community
The area of clinical decision support is replete with opportunities for further research. Examples of CDS-related areas where research is needed include:To what extent does alerting impact on clinician behavior and patient outcomes?What is the optimal way to present alerts to prescribers?How can clinicians’ sense of satisfaction with alerts and other kinds of decision support be increased, i.e., so clinicians find decision support useful and not annoying?When does “alert fatigue” happen?What is the best way for organizations to share alert knowledge?How can commercial medication knowledge bases be edited to yieldclinically valuable knowledge bases?Where there are multiple presentation modes, which mode is most appropriate for any given alert?Which member of the health care team—for example, physician, nurse, pharmacist, other—is the best recipient of any kind of alert?Should physicians and pharmacists see the same drug related alerts?
Kuperman et al. J Am Med Assoc. 2007; 14:29-40