Informatics Primer

Pharmacy Informatics:From Bytes to Bedside

Objectives
Describe what pharmacy informatics encompasses
Describe components necessary to implement key healthcare technologies
Identify current technology used in the medication use cycle
Discuss future potential applications of healthcare technology
Implement methods to analyze how human interactions with technology may lead to failures

Translational research, Translational IT Bytes to Bedside

What does an informatics RPh do?
Writes drug information papers
Improves patient outcomes using technology
I don’t know
Fixes the department’s printer

What does aninformatics RPhdo?
Writes drug information papers
Improves patient outcomes using technology
I don’t know
Fixes the department’s printer

PPMI Summit Recommendations
http://www.ashp.org/DocLibrary/PPMI/Summit-Recommendations.aspx

What is pharmacy informatics
Encompasses IT-enabled medication-related quality, efficacy, and safety initiatives
Should be part of a single accountable process entity that makes decisions regarding the latter
Traditional organizational structures for paper based systems did not account for the collaboration required for decisions to implement medicine within an electronic environment

What is pharmacy informatics?
...[informatic] pharmacists must use their knowledge of information systems and the medication-use process to improve patient care by ensuring that new technologies lead to safer and more effective medication use."
http://www.ashp.org/DocLibrary/BestPractices/AutoITStInformatics.aspx
Flynn, A. The Current State of Pharmacy Informatics Education in Professional
Programs at US Colleges of Pharmacy. American Journal of Pharmaceutical Education 2005; 69 (4) 66.

To Err is Human: Building a Safer Health System
Institute of Medicine (IOM) published a report in 2000
7,000 Americans die each year due to medication use errors
IOM recommends:
to “implement proven medication safety practices”
reduce reliance on memory
standardize terminology
utilize constraints, force functions, protocols, and checklists
minimize data handoffs and entering data more than once by hand
Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. 1st ed. A report of the Institute of Medicine. Washington, DC: National Academy Press; 2000.

Who is a informatics pharmacist
Dual specialization
Pharmacotherapy
Technology to facilitate the latter
Pharmacy advocate to manage enterprise-wide deployment of systems that integrate medicine in an electronic environment

Role
Medication safety
Provide leadership and guidance with all technology initiatives that involve medication use
Customize and maintain systems to the changing needs of professional pharmacy practice

Current Technology Overview
Computerized Provider Order Entry (CPOE)
Clinical Decision Support Systems (CDSS)
Bar Coded Medication Administration (BCMA)
Smart pumps
Automated dispensing cabinets (ADC)
Carousels

Remote IV telepharmacy
High fidelity cameras for particulate
Bar coded verification of ingred.
Think of “snapshots” in current
workflow
Strive for standardized formulations
Work with the
board of
pharmacy
USP 797
compliant
O'Neal B., et. al. Telepharmacy and bar-code technology in an i.v.
chemotherapy admixture area. Am J Health-Syst Pharm. 2009; 66:1211-17

The President’s First Weekly Address
“To lower health care cost, cut medical errors, and improve care, we’ll computerize the nation’s health records in five years, saving billions of dollars in health care costs and countless lives.”
Saturday, January 24th, 2009

Question
According an ASHP's survey, what percentage of hospitals in 2007 were fully electronic?
1. <10% 2. 10-50% 3. >50% 4. >80%

Question
According an ASHP's survey, what percentage of hospitals in 2007 were fully electronic?
1. <10% 2. 10-50% 3. >50% 4. >80%
Pedersen CA, Gumpper KF. ASHP national survey on informatics: Assessment of the adoption and
use of pharmacy informatics in U.S. hospitals. American Journal of Health-System Pharmacy. 2008; 65 (23): 2244-2264.

Meaningful Use
The use of a certified EHR in a meaningful manner, such as e-prescribing.
The use of certified EHR technology for electronic exchange of health information to improve quality of health care.
The use of certified EHR technology to submit clinical quality and other measures.

Meaningful Use
Starts in 2011…
19/24 objectives must be met
14 required core objectives
5 objectives may be chosen from the list of 10 menu set objectives

Question
You are the person in charge of implementing the foundations of an EHR at your hospital. Which do you implement first?
CPOE
BCMA
CDS
eMAR

Computerized Provider Order Entry (CPOE)
Physicians and other providers input orders directly into a computer, thereby eliminating problems with handwriting legibility and order transcription
Guide the ordering provider to make good clinical decisions and appropriate choices based on an individual patient’s data in an electronic health record combined scientific medical evidence

Clinical Decision Support
Basic
drug-allergy checks
basic dosing guidance, formulary decision support
duplicate therapy checking
drug–drug interactions
Advance
dosing support for renal insufficiency and specific populations (eg., geriatric patients)
guidance for medication-related laboratory testing
drug–disease contraindication checking
drug–pregnancy checking

RxNorm
Standardized nomenclature for clinical drugs and drug delivery devices
Produced by the National Library of Medicine (NLM)
Key to interoperability between two or more systems that do not “speak the same language”
Why interoperability?
Data mapping
NDI vs. RxNorm

RxNorm
Before: DoD could understand 45 percent of VA’s mapped terms and VA could understand 26 percent of DoD’s mapped terms
After implementation: DoD understood 74 percent of VA terms and VA understood 58 percent of DoD terms

Clinical Relationships

Applications of RxNorm
Drug Allergies
Medication Reconciliation
“Bupropion continued at
same dose.”
RxNORM

Case Study
Urology service administers medications to clinic patients via a text order to nurses 
Nurses grab drugs out of the Pyxis
There is usually no pharmacist involvement, allergy check, or documentation of drugs given
How can we mitigate this issue?

Guidance on CDS
What is the optimal method to present alerts to providers?
How can you balance usefulness vs. annoyance
When does “alert fatigue” happen?
Where there are multiple presentation modes, whichmode is most appropriate for any given alert?
Which member of the health care team the best recipientof any kind of alert?
Should physicians and pharmacists see the same drug related alerts

Nearly Universal Prospective Order Review
Originated from an era absent of technology
Mandated and strongly recommended by JCAHO and ASHP, respectively
Can systems automate the review of some medication orders without pharmacist review and still safely ensure effective outcomes?
Medication Order Review vs. Medication interventions
American Society of Health-System Pharmacists. ASHP guidelines: minimum standards for pharmacies in hospitals. Am J Health-Syst Pharm. 1995; 52:2711-7.
Mahoney CD, Berard-Collins CM, Coleman R et al. Effects of an integrated clinical information system on medication
safety in a multi-hospital setting. Am J Health-Syst Pharm. 2007; 64:1969-77.

Nearly Universal Prospective Order Review
“Most data onmost patients is mostly normal most ofthe time.”
- Korpman R. The need for a computerized medical record, a sales seminar presentation on ULTICARE. 1986 Aug.

Opportunity Cost of NUPOR
Study by Mahoney showed 0.07% of CPOE orders needed renal dosage adjustments and 0.019% of orders needed dosage adjustments for [serum drug] out of therapeutic range
Risk based stratification
Flynn., Opportunity cost of pharmacists’ nearly universal prospective order review. Am J Health-Syst Pharm. 2009; 66:668-70

State of Informatics Education
Limited
New pharmacists entering practice will need to understand EHR systems and how to utilize, query, and report data
Much like the advent of the Pharm.D. degree and residency training, the use of potentially complex, technically sophisticated software tools will be the next milestone in the training of a contemporary clinical pharmacist

Resources and Training
Residency Training
Vanderbilt University Medical Center
University of Utah Hospitals and Clinics
University of Michigan Hospitals and Health Centers
Oregon Health and Science University Hospitals and Clinics
Clarian Health Partners
James A. Haley Veterans Hospital
University of Louisville Health Care
VA San Diego and Tampa Healthcare System
The Johns Hopkins Hospital
University of California San Francisco
Ohio State Medical Center

Resources and Training
http://healthit.hhs.gov
http://www.nlm.nih.gov/
http://www.himss.org
https://www.amia.org/
http://www.ashp.org/menu/MemberCenter/SectionsForums/SOPIT.aspx
@HHSGov
@HIMSS
@NPRHealth
@ASHPOfficial
@pharmacists
@AMIAinformatix

The Five Rights
Distributive Rx: right drug, right patient, right dose, right frequency, and right time
Information systems: right information, in the right format, at the right time, in the right hands
With pharmacists being as entrenched in the medication use process as they are…
They have two options:
1) Sit back and complain how unintuitive their workflow and IT systems are or…
2) Get involved with the implementation process
Tribble et. al. Whither Pharmacy Informatics. Am J Health-Syst Pharm. 2009; 66: 813-815.

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Informatics Primer

by rxinformatica on Jun 10, 2011

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Informatics Primer — Presentation Transcript