Medication Reconciliation in Electronic Health Information Exchange

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Presented at Midwest HIMSS Fall Technology Conference - November 12, 2013 http://www.falltechnologyconference.org/

Presented at Midwest HIMSS Fall Technology Conference - November 12, 2013 http://www.falltechnologyconference.org/

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  • 1. Medication Reconciliation in electronic health information exchange Presented by: Tomasz Adamusiak MD PhD ( Mary Shimoyama PhD November 2013 Technology Innovations 1 @7omasz)
  • 2. Conflict of Interest Disclosure Tomasz Adamusiak Mary Shimoyama Have no real or apparent conflicts of interest to report. Slide 1
  • 3. Using medication reconciliation to prevent errors The Joint Commission. Medication reconciliation. Sentinel event alert. Issue 35. 2006 The process of comparing a patient's medication orders to all of the medications that the patient has been taking. Slide 2
  • 4. Aim: avoid polypharmacy Excessive or unnecessary medications acquired at interfaces of care—when a patient is admitted to, transferred within, or discharged from a health care facility Slide 3
  • 5. Aim: avoid adverse drug events Slide 4
  • 6. More complex than it seems ~ 800 000 drug form names • • • • • • • • • • • • • • • • Acetaminophen with HYDROcodone • acetaminophen with HYDROcodone Acetaminophen (Tylenol) • acetaminophen (Tylenol Albuterol orders • Al hydroxide/Mg hydroxide/ simethicone Azithromycin (Zithromax) 250 mg IVPB daily X 4 (Mylanta) days • albuterol orders List 1 List 2 Azithromycin (Zithromax) 500 mg IVPB once • azithromycin (Zithromax) 250 mg daily X4 days CefTRIAXone (Rocephin) • azithromycin (Zithromax) 500mg once Codeine • cefTRIAXone (Rocephin) Echinacea • codeine Furosemide (Lasix) • echinacea Ipratropium (Atrovent Neb) • furosemide (Lasix) Lisinopril • ipratropium (Atrovent Neb) MetFORMIN • levofloxacin (Levaquin) Oseltamivir (Tamiflu) • lisinopril Ranitidine (Zantac) 150mg • metFORMIN Reconcile Sodium chloride • oseltamivir (Tamiflu) Zolpidem (Ambien 5 mg) • famotadine (Ranitidine /Zantac 150mg) Slide 5
  • 7. Meaningful Use Stage 2 Context § 170.314 2014 Edition electronic health record certification criteria 45 CFR Part 170, Federal Register/ Vol. 77, No. 171 / Tuesday, September 4, 2012 http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-20982.pdf 4. Clinical information reconciliation. Enable a user to electronically reconcile the data that represent a patient’s active medication, problem, and medication allergy list as follows. For each list type: (i) Electronically and simultaneously display (i.e., in a single view) the data from at least two list sources in a manner that allows a user to view the data and their attributes, which must include, at a minimum, the source and last modification date. (ii) Enable a user to create a single reconciled list of medications, medication allergies, or problems. (iii) Enable a user to review and validate the accuracy of a final set of data and, upon a user’s confirmation, automatically update the list. Slide 6
  • 8. Improve care coordination STAGE 2 OBJECTIVES AND MEASURES 42 CFR Parts 412, 413, and 495, Federal Register/ Vol. 77, No. 171 http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-21050.pdf Stage 2 Measure The EP, eligible hospital or CAH performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the EP or admitted to the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23). Slide 7
  • 9. Medications will be encoded in a standard uniform way across all certifed EHRs § 170.207 Vocabulary standards for representing electronic health information. 45 CFR Part 170, Federal Register/ Vol. 77, No. 171 / Tuesday, September 4, 2012 http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-20982.pdf d) Medications. (1)Standard. Any source vocabulary that is included in RxNorm, a standardized nomenclature for clinical drugs produced by the United States National Library of Medicine. (2)Standard. RxNorm, a standardized nomenclature for clinical drugs produced by the United States National Library of Medicine, August 6, 2012 Release (incorporated by reference in § 170.299). Slide 8
  • 10. Only structured information allowed in MU 2 Transition of Care Consolidated CDA HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 <manufacturedProduct classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.23"/> <manufacturedMaterial> <code code="310965" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Ibuprofen 200 MG Oral Tablet"> </code> </manufacturedMaterial> </manufacturedProduct> Slide 9
  • 11. Only structured information allowed in MU 2 Transition of Care Consolidated CDA HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 <manufacturedProduct classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.23"/> <manufacturedMaterial> Medication RXCUI Information <code code="310965" Template codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Ibuprofen 200 MG Oral Tablet"> </code> </manufacturedMaterial> Normalized </manufacturedProduct> Drug Name Slide 10
  • 12. RxNorm http://www.nlm.nih.gov/research/umls/rxnorm/overview.html • Normalized naming system for generic and branded drugs • Semantic integration of 12 drug vocabularies • Strength + Ingredient + Dose Form + Brand name • FDA Unique Ingredient Identifiers (UNIIs) • 11-digit HIPAA format National Drug Codes (NDCs) © 2013 Medical College of Wisconsin Slide 11
  • 13. 12+1 RxNorm sources http://www.nlm.nih.gov/research/umls/rxnorm/overview.html 1. Anatomical Therapeutic Chemical Classification System Since 8/13 2. Gold Standard Drug Database 3. Medi-Span Master Drug Data Base 4. Medical Subject Headings (MeSH) 5. Multum MediSource Lexicon 6. Micromedex RED BOOK 7. FDA National Drug Code Directory 8. FDA Structured Product Labels 9. FDB MedKnowledge (formerly NDDF Plus) 10.Veterans Health Administration National Drug File - Reference Terminology 11.US Edition of SNOMED CT (drug information) 12.Veterans Health Administration National Drug File Slide 12
  • 14. RxNorm as its own source SAB=RXNORM Normalized drug names, e.g., Warfarin Sodium 1 MG Oral Tablet • Generic drugs  Ingredient Strength Dose Form • Branded drugs  Ingredient Strength Dose Form [Brand Name] • Generic drug packs  {# (Ingredient Strength Dose Form) / # (Ingredient Strength Dose Form)} Pack • Branded drug packs  {# (Ingredient Strength Dose Form) / # (Ingredient Strength Dose Form)} Pack [Brand Name] Slide 13
  • 15. RxNorm relations Link concepts that contain the same ingredient or dose form. You can navigate between an ingredient and a fully-specified drug. String Relationship Attribute String Acetaminophen 325 MG Oral Tablet has_tradename Acetaminophen 325 MG Oral Tablet [Tylenol] part_of Acetaminophen / Diphenhydramine Acetaminophen Acetaminophen 325 MG Oral Tablet [Tylenol] Oral Tablet has_dose_form dose_form_of Oral Tablet Acetaminophen 325 MG Oral Tablet [Tylenol] Slide 14
  • 16. The Anatomical Therapeutic Chemical Classification System with Defined Daily Doses (ATC/DDD) http://www.whocc.no/atc/structure_and_principles/ Furosemide RXCUI: 4603 ATC: C03CA01 Slide 15
  • 17. RxNorm translation between American and European standards Winnenburg R, Bodenreider O. Stud Health Technol Inform. 2013;192:827-31. Exploring pharmacoepidemiologic groupings of drugs from a clinical perspective. • Not all drugs in ATC available in US • Only about half of the ATC drugs can be associated with drug properties in NDF-RT • Many drugs not associated with therapeutic intent, mechanism of action or physiologic effect properties in NDF-RT • Not a complete mapping Slide 16
  • 18. RxNorm and UMLS release cycles RxNorm 1+3 weeks UMLS 6 months Slide 17
  • 19. RxNorm reconciliation scenario: patient on multiple painkillers 200 mg ibuprofen q.d.s. 550 mg naproxen sodium b.i.d. Slide 18
  • 20. RxNorm reconciliation scenario: patient on multiple painkillers Anti-Inflammatory Agents, Non-Steroidal N0000175722 200 mg ibuprofen q.d.s. Ibuprofen 200 MG Oral Tablet RxCUI: 310965 1036 NDCs 34 branded drugs, e.g., Advil 6 contraindications, e.g., asthma 550 mg naproxen sodium b.i.d. Naproxen sodium 550 MG Oral Tablet RxCUI: 849431 225 NDCs 2 branded drugs, e.g., Alfaxen 2 contraindications, e.g., Pregnancy Third Trimester Slide 19
  • 21. Twinlist Human-Computer Interaction Lab, University of Maryland User Interface and Visualization for Medication Reconciliation http://www.cs.umd.edu/hcil/sharp/twinlist/ Slide 20
  • 22. RxNorm support provided by NLM Slide 21
  • 23. MyMedicationList beta http://mml.nlm.nih.gov/ Slide 22
  • 24. RxNav – visualizing RxNorm http://rxnav.nlm.nih.gov/ Slide 23
  • 25. The Computational Photography Project for Pill Identification C3PI http://rximage.nlm.nih.gov/ Slide 24
  • 26. Our experience at MCW https://clinminer.hmgc.mcw.edu user: himssdemo password: himssdemo Pilot: 1300 patients 31% codes unable to map 4% unmapped observations 120k codes total (Epic/MediSpan) 600k Rx entries total Slide 25
  • 27. 4% FDA-supplied NDCs not in RxNorm scope (July 2013) Slide 26
  • 28. Practical reconciliation via RxNorm Part 1 – NDC search https://clinminer.hmgc.mcw.edu/clinminer#ontology/search/0573-0150-48 user: himssdemo password: himssdemo NDC: 0573-0150-48 325 TABLET, COATED in 1 BOTTLE Pfizer Consumer Healthcare Slide 27
  • 29. Practical reconciliation via RxNorm Part 2 – Exploration https://clinminer.hmgc.mcw.edu/clinminer#ontology/term/C0593505 user: himssdemo password: himssdemo Slide 28
  • 30. Thank you This project was funded in part by the Advancing a Healthier Wisconsin endowment at the Medical College of Wisconsin and the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through grant UL1 RR031973. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. We thank Stacy Zacher, Glenn Bushee, and Bradley Taylor for their help. Slide 29