• Save
Himss 10 Myths Of Pharmacy interoperability
Upcoming SlideShare
Loading in...5
×
 

Himss 10 Myths Of Pharmacy interoperability

on

  • 15,336 views

 

Statistics

Views

Total Views
15,336
Views on SlideShare
15,308
Embed Views
28

Actions

Likes
12
Downloads
0
Comments
0

4 Embeds 28

http://www.slideshare.net 12
http://simonletellier.blogspot.com 11
http://static.slideshare.net 4
http://feeds.feedburner.com 1

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • The top ten myths on pharmacy interoperability will be presented to demonstrate the complex nature of integrating medications into the health care system. Recognize the two main differences between an medication orderable from a dispensable Understand the pros and cons of RxNorm Assess the workload impact of less than optimal interoperability in areas of order entry, verification and dispensing.

Himss 10 Myths Of Pharmacy interoperability Himss 10 Myths Of Pharmacy interoperability Presentation Transcript

  • Top 10 Myths of Pharmacy Interoperability John Poikonen, Pharm.D. Office of Patient Safety Partners HealthCare System Boston, MA
  • Outline
    • Credibility
    • Definitions
    • Top ten myths
  •  
  • What is Interoperability?
    • In Healthcare, Interoperability is the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively, and consistently, and to use the information that has been exchanged*
    • *NAHIT
  • Upon this gifted age, in its dark hour, Rains from the sky a meteoric shower Of facts . . . They lie unquestioned, uncombined. Wisdom enough to leech us of our ill is daily spun, but there exists no loom to weave it into fabric. Edna St. Vincent Millay
  • Interoperability Scenarios
    • CPOE order is used to dispense, administer and monitor medication
    • The outpatient medication list can be used as a starting point for the inpatient medication list
    • Mom sending kid to school – wants cumulative immunization record
    • Moving from San Diego to Boston – wants to transfer electronic medical record data
    • Comparing management of asthmatics in 2 hospitals
    • Is Boston seeing an increased rate of rare bleeding syndrome with new antibiotic?
  • Myth #10
    • Interoperability is a community and national effort
  • Formulary, purchasing decisions Inventory management Dispense/ distribute medication The Inpatient Medication Management Process FCG/VHA Obtain Medication-related History Document Medication History Diagnostic/ Therapeutic Decisions Made Medication Ordered Evaluate order Select medication Educate patient regarding medication Order verified and submitted Prepare medication Educate staff regarding medications History-Taking Ordering Pharmacy Management Education Select the correct drug for the correct patient Administer according to order and standards for drug Document administration and associated information Assess and document patient response to medication according to defined parameters Intervene as indicated for adverse reaction/error Administer Medication Monitor/Evaluate Response Document Medication Inventory Management Administration Management Incident/adverse event surveillance and reporting Surveillance
  • Formulary, purchasing decisions Inventory management Dispense/ distribute medication Inpatient Medication Management Process Obtain Medication-related History Document Medication History Diagnostic/ Therapeutic Decisions Made Medication Ordered Evaluate order Select medication Educate patient regarding medication Order verified and submitted Prepare medication Educate staff regarding medications History-Taking Ordering Pharmacy Management Education Select the correct drug for the correct patient Administer according to order and standards for drug Document administration and associated information Assess and document patient response to medication according to defined parameters Intervene as indicated for adverse reaction/error Administer Medication Monitor/Evaluate Response Document Medication Inventory Management Administration Management Incident/adverse event surveillance and reporting Surveillance
    • Wireless devices for medication history capture, etc.
    • Physician Order Entry
    • Pharmacy Information Systems
    • Robotic dispensing systems
    • eMAR, Bar coding administration, smart infusion pumps
    • Automated Surveillance
    EHR, Claims and Ambulatory Pharmacy data
    • Inventory Managment JIT systems
  • Example: Medication Reconciliation Source 1 Med List Problem list Allergy List* Source 2 Med List Problem list Allergy List*
    • Information from multiple sources displayed on one screen
    • Information is not integrated
    • Difficult to “transform” into orders
  • Myth #9
    • An Orderable is a dispensable is a administrable
  • Barriers to CPOE Captain, let me make something clear to you: I’m a doctor!... not a !&#$%! computer programmer!
  • Order = Dispense = Administer Orderable Item Dispensable Item Administrable Item Amox. 500mg Q6H Amox. Susp. 250mg/5ml 80ml Bottle Amox. Susp. 500mg (10ml) PO 12-6-12-6
  • Order = Dispense = Administer Orderable Item Dispensable Item Administrable Item Dopamine 1-3mcg/kg/min Dopamine 400mg in 100ml D5W Dopamine 0.9ml/hr
  • Ordering Medications Medication Name Routed Med Routed Doseform Med Strength / Units Routed Med Strength / Units
  • Myth #8
    • Tylenol (acetaminophen) or Brand (generic) is the best way to display orders.
  • Myth #8
    • ISMP Recommendations
      • generic [BRAND]
      • list the generic name first, followed by brand name, strength, dose (if different than strength) and dosage form
      • timolol [TIMOPTIC] 0.5% ophthalmic solution
      • diazepam [VALIUM] 5 mg tablet
      • propranolol [INDERAL] 5 mg [1/2 x 10 mg] tablet
      • http://www.ismp.org/Newsletters/acutecare/articles/20030220.asp
  • Myth #7
    • Interfacing pharmacy systems is good enough
  • Systemic Interoperability Taxonomy* No PC/information technology Fax/Email Structured messages, non-standard content/data Structured messages, standardized content/data *CITL Report on Healthcare Information Exchange and Interoperability Secure e-mail of free text and incompatible/proprietary structured messages, HL-7 msgs Machine-organizable data 3 PC-based and manual fax, e-mail, or scanned documents Machine-transportable data 2 Mail, phone Non-electronic data 1 EDI of structured messages with controlled terminology Machine-interpretable data 4 Examples Description Level
  • 10-Year Cumulative Net Return by HIEI Level Level 4 (standardized content/data) in billions $(200) $(100) $- 0 $100 $200 $300 $400 1 2 3 4 5 6 7 8 9 10 Years Level 1 (paper) Level 2 (fax, email) Level 3 (structured message/HL7)
  • Barriers to interoperability
    • No common approach to:
    • Structure and grammar of data
    • Meaning of data
    1/27/01/10:35 John W. Jones Tylenol 325MG 2 tabs BID John Jones 1/27/2001 APAP 650MG twice daily
  • Aligning systems….
    • Application/DB 1
    • Name -- Penicillin
    • Route -- PO
    • Dose – 500 mg
    • Frequency -- QID
    • Instructions – {}
    • PRN – {}
    • Application / DB 2
    • Name – Pen Oral Tab
    • Dose -- 500
    • Dose unit -- mg
    • Frequency – 4x/day
    • Comments – {}
  • Current Case: How is Interoperability Achieved Moving data between Applications – Level 3 Messages may be structured, e.g. HL7 ver2, but all data must be mapped (if possible) ~Map! DB Application 1 Meds Problems Allergies Labs Meds’ Problems’ Allergies’ Labs’ DB Application 2
  • Future Case: How is Interoperability Achieved Moving data between Applications – Level 4 Messages are structured AND data meaning is explicit (based upon standard) = DB Application 1 Meds Problems Allergies Labs DB Application 2 Meds Problems Allergies Labs
  • Activity around Medications
    • HL7 – traditional exchange protocol for inpatient settings (order, order fulfillment, Rx)
    • NCPDP – standards for Prescriber/Rx interface
      • SCRIPT for electronic prescription transmission
      • Common SIG (extension to Script) (NCVHS 12/05)
    • RxNorm – emerging standard for interoperability: “clinical drug” identification
    • Standards for Allergens/reactions being added to SNOMED
    • Caution warranted around mapping precision for true semantic interoperability use cases; e.g.; dosing or medication reconciliation
  • Myth #6
    • All CIS vendors have integrated pharmacy systems
  • Myth #6
    • CPOE
    • CPOE with eMAR/BPOC
      • Less than 10% of CPOE hospitals
    • Redundant Medication ordering
  •  
  •  
  • Myth #5
    • Receiving claims data will determine what the patient is really taking
    • Retail Pharmacies are ready and willing to share data electronically
    • Together they are accelerating ePrescribing adoption
  • Graduated Levels of Electronic Prescribing eHealth Initiative. Electronic Prescribing: Toward Maximum Value and Rapid Adoption, April 2004 1. Basic electronic reference only. Drug information, dosing calculators, and formulary information are available, but are not automatically shown while prescribing. 2. Standalone Prescription Writer: search by drug name and create prescription; no long-term data about patient is accessible 3. Supporting patient data is included (Demographics, Allergy, Formulary, and/or Payer Information) 4. Medication Management: Prior medications are available for renewal, interaction checks, etc. 5. Connectivity: MDs Office, Pharmacy, PBM and Intermediaries 6. Integration with EMR
  • Myth #5
    • MedsInfo-ED
      • Pilot project for web based medication profile access by ED’s in MA.
      • Functional Level 2 Interoperability
      • screened-out “sensitive” classes of medications for treatment of HIV/AIDs, Mental Health, Substance Abuse
  • Medsinfo-ED Health Affairs 2005;24:1197-1204
  • Myth #5
    • Claims data good but
      • Only what has been paid for by insurer
      • Some valuble data being left out
        • HIPAA issues
    • Retail Pharmacies will be an partner in solving medication reconciliation
      • Very helpful with Level 1 interoperability
      • Need level 4 b/c of PBM data may not be complete
      • History segment in SCRIPT 8.x Standard
      • Need to demand this of pharmacies
    • While not all rowing in the same direction, optimistic for the near future
  • Myth #4
    • CPOE decision support eliminates the need for pharmacist verification
    • and related CPOE myth
    • Physician will love clinical decision support
  • The Impact of Computerized Physician Order Entry on Medication Error Prevention JAMIA 6:313, 1999 Pharmacist Participation on Physician Rounds and Adverse Drug Events JAMA, 282:267,1999
    • POE with Decision support
      • Medication error rate reduction 81% (Bates)
      • 142 per 1,000 patient days to 26.6
      • ICU rate - 248 to 35.2
      • 64 per 1,000 identification rate (Rashke)
          • $3 Millon/year savings
    • Pharmacist in the ICU
      • ADE decreased by 66%
      • 10.4 per 1,000 patient days to 3.5
  • Types of Improvement
    • POE/CDS
      • Dose (47%)
      • Frequency (25%)
      • Route (14%)
      • Substitution (7%)
      • Allergy (5.9%)
      • Wrong drug (4.1%)
    • Pharmacist in ICU
      • Correction of order (45%)
      • Provision of drug information (25%)
      • Alternative Therapy recommendation (12%)
    86%
  • How Much CDS is Too Much?
    • Alert fatigue
      • 88% interaction override (Payne, AMIA 2002)
      • ~90% allergy, high sev interaction (Weingart, Arch IM ’03)
    • Signal-to-noise
      • Commercial kb emphasize breadth (highly inclusive)
    • Expected response rates
      • ~ 60% cancel / modify
    • Hard stops, redirection
    • Override capture
  • Myth #3
    • NDC numbers are great identifiers
  • Myth #3
    • The Scope
      • 260,581 total NDCs to track (91,522 active)
      • 200-250 NDCs added weekly
      • 2-4/month actually represent a new drug
    • The Problem
      • Assigned by Manufacturer or Repackager
      • No central source or listing
      • Synchronization, Maintenance and more
    • Example
      • Primarily a billing, purchasing issue
      • POE has Orange Book NDC
      • Pharmacy has Red Book NDC
      • Wholesaler has own NDC process
  • Myth #2
    • Since the FDA mandate, bar coded medications are widely available to implement bar coding at the point of care (BPOC)
  • Myth #2
    • Loop hole in FDA mandate
      • March, 2003: FDA publishes proposed rules in Federal Register to require bar code on pharmaceutical packaging.
      • All unit of use packaging not required
  • Myth #2
    • Tight link needed from dispensing system
    • Hidden cost to BPOC
      • Repackaging (4 to 16 cents per dose )
      • Labels on every thing
        • Topicals, vials, ampules, OTCs
      • Order entry time to insure accuracy of dispensed to administer.
      • After hours Order entry by pharmacists
        • Telepharmacy (off site O/E)
  • Myth #1
    • Standards in pharmacy such as RxNorm will replace your need for a drug knowledge vendor and solve the drug terminology problems in the near future.
  • Perfect Standards live in a Perfect World
  • Clinical Data, Information and Knowledge Standards Data Information Knowledge
  • Information Knowledge Active Ingredient = FDA Unique Ingredient Identifier (UNII) code Dosage form and package = FDA/CDER data standard Drug Product = National Drug Code(NDC) Clinical Drug = RxNorm Drug Classification = VA NDF-RT Reference Data
  • RxNorm
    • RxNorm is a set of drug concepts created and managed by the National Library of Medicine (NLM) and available through the UMLS’s (Unified Medical Language System) Metathesaurus
    • RxNorm initially created as a means to map generic concepts between the drug compendia
    • RxNorm has since expanded to incorporate brand name concepts and different levels of drug concepts
    • Commonly referred to as “one thing” but is actually an umbrella term for multiple drug concepts
  • RxNorm
    • RxNorm is being included in the 2006 pilot tests to determine how well the RxNorm clinical drug, strength, and dosage information can be translated from the prescriber’s system into an NDC at the dispenser’s system that represents the prescriber’s intent. This translation will require the participation of intermediary drug knowledge base vendors until the RxNorm is fully mapped.
  •  
  • Qualities of Good Terminologies
    • Content coverage
    • Concept orientation
    • Concept permanence
    • Non-semantic (meaningless) concept identifiers
    • Polyhierarchy
    • Formal definitions
    • Rejection of "not elsewhere classified"
    • Multiple granularities
    • Multiple consistent views
    • Context representation
    • Graceful evolution
    • Recognized redundancy
    Desiderata for Controlled Medical Vocabularies in the Twenty-first Century. Cimino JJ, Methods Inf Med 1998 Nov;37(4-5):394-403
  • Requirements for Drug Terminology
    • Should be maintained by a primary code-assigning authority
    • Should be available for use at little or no cost
    • Content must be updated and made available quickly as drugs enter the market
    • Should be "backwards compatible" with the NDC system
    • Designed for compatibility with evolving international standards
    • Should adhere to an accepted, common information model
      • Concepts and relationships organized in formal classes for query and presentation
    • Must support abstraction at multiple levels of detail (granularity)
      • Multiple user views and settings
    • Will define how statements are composed and recorded
      • Build from “atomic” concepts
    • Should support synonyms and lexical variants
  • Information Knowledge Wisdom Active Ingredient = FDA Unique Ingredient Identifier (UNII) code Dosage form and package = FDA/CDER data standard Drug Product = National Drug Code(NDC) Clinical Drug = RxNorm Drug Classification = VA NDF-RT Reference NCPDP Claims NCPDP Script 8.x NCPDP SIG NCPDP History Segment IT Certification Standards AMCP DDI Standards? P4P / CMS driven? Data CDS Standard?
  • Ingredient : a chemical or biological component of a drug. USP/NF representation Generic ingredient set : the set of one or more therapeutically active ingredients present in a drug. RxNorm Clinical drug : a set of strength-specific therapeutically active ingredients intended in any single clinical circumstance for concurrent administration by one of a set of appropriate potential routes in a specific dose form. RxNorm Manufactured drug : one or more components which together are intended for concurrent administration. Each component is a specific clinical drug produced by a specific manufacturer. A Manufactured Drug may also optionally include an associated drug device. Most Manufactured Drugs are single-component. RxNorm Packaged drug product : a marketed drug product as it is packaged by a specific manufacturer and sold in a specific country; contains one or more manufactured drugs. NDC Representation Ingredient Generic Ingredient Set Clinical Drug Manufactured Drug Packaged Drug Product
  • Thank You
    • “ I don’t want to make the wrong mistake.” Yogi Berra
    John Poikonen, Pharm.D. [email_address]