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Medication Reconciliation – time to rethink informatics support ? Trillium II Workshop at Informatics for Health 2017, Manchester UK

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Medical Related information reconciliation when a patient sees many providers or transfers between health facilities is challenging. Lack of updated and correct information is a key concern for patient safety during a health and illness trajectory [1]. Errors, near misses and adverse medication events are too common, particularly whne transfers between hospitals, nursing home and home are frequent, or engagement of multiple specialties is common [2]. Lack of effective informatics support can be harmful to a person’s health, leading to suffering, increased use of health care resources and increased costs.
As a case for interactive discussion, we have chosen information exchanges related to medication, prescription-based as well as over the counter drugs. This challenging chain of activities includes: (a) prescribing on paper or electronically by several medical specialists, (b) transcribing by sending and interpreting prescriptions in the pharmacy, (c) dispensing medication by brand name or generic substitution, (d) acquiring over the counter medication, (e) administering medication as a user, and (f) observing effects and side-effects. The risk of missing information leading to mistakes in the chain of activities in medication management is likely to increase as complex medication regimes become common due to demographic developments, co-morbidities or more personalized treatment. Potentials in patient activation and relevant informatics tools for medication reconciliation need further exploration.
Anne MOEN Institute for Health and Society, Faculty of Medicine, University of Oslo, NORWAY
Catherine CHRONAKI HL7 Foundation, Brussels, BELGIUM
Christian NØHR, Aalborg University, DENMARK
Line Helen LINSTAD Norwegian Center for eHealth Research, Tromsø, NORWAY
Petter HURLEN Akershus University Hospital, NORWAY





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Medication Reconciliation – time to rethink informatics support ? Trillium II Workshop at Informatics for Health 2017, Manchester UK

  1. 1. Medication reconciliation - time to re-think informatics support ? Workshop Informatics for Health / MIE2017 Monday April 24th 2017 Anne Moen, Petter Hurlen, Line Linstad, Christian Nøhr, Catherine Chronaki
  2. 2. Objectives for the workshop • Challenging – error prone process – complex medication regimes – failure of information sharing • Current solutions’ potentials and limitations – ePrescription – (national) drug record • Informatics support ? – Socio-technical approaches – Interoperability standards – Patient summary – patient generated data
  3. 3. Chain – medication (formalized) Prescribing – (several) medical specialist(s) Transcribing; interpreting and preparing – pharmacy Dispensing; brand name - generic substitution – pharmacy – citizen - specialist Taking – administering - medication – citizen – home care – nurses - specialist Observing effects /side-effects – citizen – nurses - specialist
  4. 4. Time to rethink ? • Challenges seem to persist – Too simplistic model(s) for informatics support ? • Explore interdependencies – Organizational – Technological – Professional – citizen patient/family collaboration • Realism for informatics support – What to do and not to do ? – Workshop conclusion – moving forward ?
  5. 5. Medication reconciliation Re-thinking the concept Olav´s story (and Jon´s) Petter Hurlen Akershus University Hospital
  6. 6. One doctor One patient One cure
  7. 7. # Indication Brands 1 Dyspepsia Somac 2 Lab results NycoPlus mutlivit 3 Lab results Magnesium One doctor One patient Some cures?
  8. 8. # Indication Brands 1 Dyspepsia Somac 2 Lab results NycoPlus mutlivit 3 Lab results Magnesium 4 Coronary Lipitor 5 Coronary Albyl-E 6 Coronary Plavix 7 Hypertension / angina Amlodipin 8 Hypertension Selo-zok 9 Hypertension Carduran 10 Hypertension/ uremia Burinex
  9. 9. # Indication Brands 1 Dyspepsia Somac 2 Lab results NycoPlus mutlivit 3 Lab results Magnesium 4 Coronary Lipitor 5 Coronary Albyl-E 6 Coronary Plavix 7 Hypertension / angina Amlodipin 8 Hypertension Selo-zok 9 Hypertension Carduran 10 Hypertension/ uremia Burinex 11 Gout Kolkisin 12 Gout Zyloric 13 Uremia Rocatrol (vit. D) 14 Anemia Aranesp
  10. 10. # Indication Brands 1 Dyspepsia Somac 2 Lab results NycoPlus mutlivit 3 Lab results Magnesium 4 Coronary Lipitor 5 Coronary Albyl-E 6 Coronary Plavix 7 Hypertension / angina Amlodipin 8 Hypertension Selo-zok 9 Hypertension Carduran 10 Hypertension/ uremia Burinex 11 Gout Kolkisin 12 Gout Zyloric 13 Uremia Rocatrol (vit. D) 14 Anemia Aranesp 15 Dementia TrioB One patient Eight (groups of) doctors Fifteen drugs
  11. 11. One patient Eight (groups of) doctors Fifteen drugs 41 brands 230,400 combinations # Indication Brands 1 Dyspepsia Somac / pantoprazol (3) 2 Lab results NycoPlus mutlivit 3 Lab results Magnesium 4 Coronary Lipitor (2) / Atorvastin (2) 5 Coronary Albyl-E / Acetylsalisylsyre 6 Coronary Plavix (2) / Clopidogrel (3) 7 Hypertension / angina Amlodipin (4) / Norvasc 8 Hypertension Selo-zok / Metoprolol (2) 9 Hypertension Carduran / Doxacocin / Alfadil 10 Hypertension/ uremia Burinex (4) 11 Gout Kolkisin / Colrefuz 12 Gout Zyloric (2) / Allopur / Allopurinol 13 Uremia Rocatrol (vit. D) 14 Anemia Aranesp 15 Dementia TrioB
  12. 12. # Indication Brands 1 Dyspepsia Somac / pantoprazol (3) 2 Lab results NycoPlus mutlivit 3 Lab results Magnesium 4 Coronary Lipitor (2) / Atorvastin (2) 5 Coronary Albyl-E / Acetylsalisylsyre 6 Coronary Plavix (2) / Clopidogrel (3) 7 Hypertension / angina Amlodipin (4) / Norvasc 8 Hypertension Selo-zok / Metoprolol (2) 9 Hypertension Carduran / Doxacocin / Alfadil 10 Hypertension/ uremia Burinex (4) 11 Gout Kolkisin / Colrefuz 12 Gout Zyloric (2) / Allopur / Allopurinol 13 Uremia Rocatrol (vit. D) 14 Anemia Aranesp 15 Dementia TrioB
  13. 13. Medication reconciliation Re-thinking the concept Jon Olav, and Nora
  14. 14. Thank you petter@hurlen.no Jon Olav, and Kari
  15. 15. Policies and practices Line Linstad Norwegian Centre for E-health research
  16. 16. Person-centered Individual targets Informed active patient Proactive services Self-management support Remote follow-up Integrated care Coordinated and planned care team Active ingredients - Patient Centered Teams - PACT
  17. 17. Core care process in Patient Centered Teams - PACT
  18. 18. National policy • Norway has a National E-health Strategy and Action Plan 2017 – 2022 One of the goals : • realize closed medication loop in both specialist- and primary care.
  19. 19. Action points: • Create one medication list • Include home-care and primary care (nursing homes) • Reduce number of prescription which are not relevant based on medical arguments • Increase better functionalities in existing EHR’s in cooperation with the vendors • Regional implementation of “closed loop medication”. • Increase use and implementation of decision-support • Develop three scenarios on how to realize closed loop medication in the whole sector
  20. 20. Medication reconciliation An ST approach Christian Nøhr, Professor, PhD Department of Planning Director, Danish Centre for Health Informatics Aalborg University Denmark
  21. 21. © Christian Nøhr The Danish healthcare sector  Population 5.6 million  HC expenditures:  9.8% of GNP  Funded by taxes  Private GPs:  Gatekeepers  Fee for service (public)  Hospitals:  27 hospitals (72 locations)  15,000 beds  Almost all public (97%)  Owned & run by 5 regions  Long term & home care:  Run by 98 municipalities  Unique Personal Identifiers since 1967
  22. 22. 23 Shared Medication Record Attempt to solve significant problems: 1. Many medication errors 2. Medicine reconciliation difficult 3. Patients have no overview of medication Implementation started 2010
  23. 23. © Christian Nøhr Danish Health and Medicines Authority Pharmacy General Practice Citizen Hospital Homecare Nursing home
  24. 24. © Christian Nøhr Central database Danish Health and Medicines Authority Pharmacy General Practice Citizen Health Portal Shared Medication Record Hospital Homecare Nursing home
  25. 25. © Christian Nøhr Shared Medication Record 1. One central server holds ALL prescriptions 2. Everybody (including patients/citizens – GP – hospitals – Home care) can access this database 3. Data are handled within “own” system (GPs) 4. All preconditions in place – by 2010
  26. 26. © Christian Nøhr Experience: • Before SMR it was the nurses' job to obtain medication information - which they spent heaps of time - Now I do it myself with SMR • …. • Does it (SMR) mean that everybody can see which drug I prescribe to my patients? • ….
  27. 27. © Christian Nøhr
  28. 28. © Christian Nøhr A SMR-consultation consist of one or more actions: - Make a new prescription - Prescription on hold - Prescription off hold - Update a prescription - Discontinue a prescription - Continue a prescription
  29. 29. © Christian Nøhr Percentage of updates in relation to SMR consultations in general practice per region, all patients in January 2015 - February 2017
  30. 30. © Christian Nøhr 31 Success: Technical Implementation Failure: Organizational implementation  Contradiction of stakeholder’s interests are exposed when data has to be shared  Technical interoperability achieved
  31. 31. © Christian Nøhr How can organisational implementation be improved? Implementation science is the methods to promote the systematic uptake of clinical research findings and other evidence based practices into routine practice and hence improve the quality and effectiveness of health care Eccles M. Mittman BS. Welcome to Implementation Science. Implement Sci.2006;1:1. Normally clinicians can be motivated by clinical evidence  75 RCT’s and 11 systematic reviews published every day • Often read by fellow researchers • Less by policymakers, managers or clinicians  Most studies in patient safety produce “soft” data
  32. 32. © Christian Nøhr How can implementation science support improving the quality and safety of patient care? Jeffry Braithwaite et.al. – Systematic (PRISMA) review of 57 out of 466 references and found eight dominating success factors of implementation. Jeffry Braithwaite, Danielle Marks and Natalie Taylor: Harnessing implementation science to improve care quality and patient safety: a systematic review of targeted literature. International journal for Quality in Health Care 2014; Vol 26,3. pp 321-329.  Preparing for change  Capacity for implementation • People • Setting  Types of implementation  Resources  Leverage  Desirable implementation features  Sustainability
  33. 33. © Christian Nøhr Types of implementation Leverage and resources Capacity for implementation People - Setting Sustainability Jeffry Braithwaite, Danielle Marks and Natalie Taylor: Harnessing implementation science to improve care quality and patient safety: a systematic review of targeted literature. International journal for Quality in Health Care 2014; Vol 26,3. pp 321-329. Preparing for change Phases of implementation
  34. 34. Citizens; patients & family can help ! • Involved every step in the chain – Actually taking (and benefiting) the medication • overview – medication - includes – Prescribed drugs – ‘Over the counter’ / non prescribed drugs • Require access to information – Oversight – by user for self selected support – Empowerment – understanding / literacy
  35. 35. PHC-34 643796 36 Medication Reconciliation at an age of Disruption Pharmacovigilance legislation patients report directly adverse events e-Pharmacies you too can buy prescription online a world of apps thousands of medication apps European Union: Cross-Border Directive panEuropean medicines database cross-border ePrescription patient summaries standardization – equivocal identification of medicines openMedicine Univocal identification of medicines
  36. 36. Where are we now? Connected Europe Facility/eHealth Digital Services Infrastructure (eHDSI)? eHDSI funded Member States PS eP Austria Croatia Cyprus Czech Republic Estonia Finland France Germany Greece Hungary Ireland Italy Luxembourg Malta Portugal Sweden Switzerland • Tools and services using ICTs that can improve cross border Healthcare services. • Use Cases: – Patient Summary, provides access for health professionals to verified key health data of a patient during an unplanned care encounter while abroad – ePrescription, enables patients to receive equivalent medication treatment while abroad to what they would receive in their home country
  37. 37. What is a patient summary Consider the patient summary as: – active window to a person's health data across locations and jurisdictions, – entry point to navigate from summary context specific data to more detailed information Select and elaborate – resources to accelerate implementation and sharing of experience – new use cases using patient summaries from unplanned emergency care 25 April 2017 Informatics for Health 2017 38 Immunizations Medications Problems Identification Allergies Implantable devices Problems Health team Security preferences Security & privacy Surgical procedures
  38. 38. Medication part of the patient summary Medication Summary section List of current medicines Active ingredient Exemption: brand name Active ingredient id code (All prescribed medicines whose period of time indicated Strength for the treatment has not yet expired whether it has been dispensed or not) Pharmaceutical dose form Number of units per intake Frequency of intakes Duration of treatment Date of onset of treatment 25 April 2017 Informatics for Health 2017 39 PhP MP Package • ... • PCID (GTIN) • ... • Substances • Strength • Dose Form • ... • Country • MAH • MPCode • ... Identifier = PhPID Identifier= MPID Identifier=PCID PhP MP Package • ... • PCID (GTIN) • ... • Substances • Strength • Dose Form • ... • Country • MAH • MPCode • ... Identifier = PhPID Identifier= MPID Identifier=PCID “Is packaged as” “Is produced as”
  39. 39. PHC-34 643796 B 25 April 2017 Informatics for Health 2017 40 Source: ISO TC 215, Working Group 6 (Pharmacy and Medicines Business), December 2014 ID ... ... ... ... ... ... ... ... Prescribing App Patient App European Medicines Database Treatment data Product data Personal Product data
  40. 40. © EMA 2016 Product Lifecycle Management Clinical Trials GMP/ Inspections PhV ePrescription PSUR CESSP/eAF eHealth ISO IDMP through SPOR (Substance, Product, Organisation, Referentials) Falsified Medicines SPOR master data will deliver the foundation for business processes through the provision of timely, accurate and re-usable master data Foundation Business Cases Benefits: • Efficiency • Transparency SPOR within the regulatory context 41
  41. 41. Vision of eStandards eHealth Standards and Profiles in Action for Europe and Beyond Vision of the global eHealth ecosystem  people need navigation tools for safe and informed health care  interoperability assets fuel creativity, entrepreneurship, and innovation eStandards will:  nurture digital health innovation  strengthen Europe’s voice & impact  enable co-creation and trusted provider- user relationships 25 April 2017 Informatics for Health 2017 42
  42. 42. Advancing Standards and Profiles Today: • Massive health data accumulated in silo EHR systems serving documentation. • We need to move from passive documentation to active use of information and knowledge creation: activation! • Patient summaries defined at the macro level: cross-border exchange for emergency or unplanned care at government level. • Move to meso and micro level to address communities and individuals. Shaping the future: Focus on the top level: systems of innovation. 25 April 2017 Informatics for Health 2017 43
  43. 43. Cooperative use of standards: co-creation, governance, alignment • Co-create – to make it real using standards • Governance – to make it scale to large-scale deployment • Alignment – to make it stay in a sustainable way 25 April 2017 Informatics for Health 2017 44 ePrescri ption eDispens ation Adverse Events Reporting Patient Summar y unplanne d care Clinical Research Patient summar y chronic disease Rare Disease s Registr ies Bio surveillance Patient Summar y planned care
  44. 44. Let’s co-create the new digital culture for eStandards Come join us to debate eStandards Brussels 26-27 June, 2017 www.estandards-project.eu eHealth DSI
  45. 45. DISCUSSION • Critical transitions in the chain • Services – tools for overview & reconciliation • Citizens can help – Empowering, activating resources ?

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