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Interoperability and eMedicines Management within the Hospital Setting
Dr Kanaka Ramyasiri
Clinical Architect
HealthShare Ltd
Midland District Health Boards
NZ Hospital eMedicines Programme
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Interoperability and eMedicines Management
• A walk through of a piloted intra-hospital eMedicines
Landscape
• Benefits arising from intrahospital electronic sharing
of patient medicines information
• Standards utilised to share medication details
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But more importantly!
• Lets deconstruct our pilot implementation to expose
Wider Lessons & Observations related to
interoperability in general
Zen and the art of interoperability…
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Where are we?
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Where are we?
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Taranaki
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Programme Context
• This pilot solution is affiliated to and part funded by
the New Zealand Hospital eMedicines Programme
and the New Zealand Medication Safety Programme
in conjunction with Taranaki District Health Board.
• This solution in conjunction with 2 other pilot sites in
New Zealand is intended to generate knowledge
and learnings to enable widespread rollout of
Hospital eMedications Management in the NZ
Health Sector.
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HIMSS definition of Interoperability
“Interoperability means the ability of health information systems to work together within and across organizational boundaries in order to advance the health status of, and the effective delivery of healthcare for, individuals and communities.”
http://www.himss.org/library/interoperability-standards/what-is?navItemNumber=17333
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New Zealand Strategic Direction
• Interoperability is a strategic enabler within the NZ
Health IS Plan.
• Emphasis on best of breed interoperable systems
with national standards for interoperability.
• HL7 CDA R2, IHE XDS, SNOMED CT formally
endorsed standards in NZ context.
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NZ Pilot Hospital eMedicines Management Solution
Function Application Component
Inpatient ePrescribing CSC MedChart
Inpatient Dispensing CSC ePharmacy
Inpatient eAdministration CSC MedChart
Inpatient Electronic Drug Cabinets Carefusion Pyxis
eMedicines Reconciliation Orion SMT
eDischarge Summary Orion SMT
Single Source Allergy Management CSC MedChart
Clinical Portal Orion Clinical Portal (aka Concerto)
Patient Administration System CSC webPAS
Middleware Orion Rhapsody
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Integration Schematic
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But what is the diagram not telling us?
• How deeply each component talks to each other.
• The workflow capabilities in each component that
facilitate interoperability
• Lets examine some of the key interoperability
scenarios contained within the solution and some
related general lessons learned
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High Level Workflow – Within the Hospital
• Prescriber Charts Medication on MedChart ePrescribing System
Prescribe
• Pharmacist Processes prescribed order on ePharmacy Dispensary system
• Confirms Product to Dispense or activate on Pyxis
Dispense• Nurse can retrieve
medication on ward via Pyxis electronic drug cabinet
• Records administration in MedChart
Administer
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Ward Prescribing to Dispensary Interoperability
• Prescribing actions are messaged to the Pharmacy
Dispensary system automatically (ePharmacy).
• Workflow capability within ePharmacy enables the
management of the incoming Prescription – either
dispense the medication, or activate on Pyxis.
MedChartMedication
Order Message
ePharmacyDispense, or Message to
Pyxis
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What is Pyxis?
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Ward Prescribing to Dispensary Interoperability
Sounds simple, so where are the challenges?
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Ward Prescribing to Dispensary Interoperability
Lesson 1 – Common Code Set / Terminology
• We were lucky to have the same vendor supplying
both the Prescribing and Dispensary systems which
utilised a common medication code set. But we
cannot always count on this scenario.
• Consistent Medication terminologies still evolving or
being implemented.
• Compounded, non formulary, or otherwise non-
standard medications need to match across both
systems.
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Ward Prescribing to Dispensary Interoperability
Lesson 2 – Differing requirements across Professional boundaries need to be managed.
• Doctors and Pharmacists view a prescription at different
levels.
• Not so much of an issue when a trained pharmacist is
involved in dispensing a Doctors prescription, but when we
are trying to create an electronic workflow…
• Doctors deal in generics, or brand names, but rarely specify a
strength.
• Pharmacists deal in specific strengths and forms of
medications.
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Ward Prescribing to Dispensary Interoperability
Doctors Prescription:
• “Paracetamol, 1g, four times daily, as needed”
Pharmacist Dispensing:
• “Panadol 500mg tablets, 2 tablets, four times daily, as needed”
Solution – a workflow and business rules within the dispensing
system to map a Doctors medication order into an actual
Dispensing.
• Some human interaction required for the matching process if
there are multiple possible dispensing possibilities for a given
Prescription.
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Ward Prescribing to Dispensary Interoperability
Lesson 3 – Additional Contextual Information that isn’t immediately apparent may be required to complete or exploit an integration.
• Informing the Pharmacy regarding the Priority of a
given order – e.g. workflow to indicate item that
requires urgent dispensing.
• Informing the ward of what stock actually exists on
their shelves currently – e.g. display of pharmacy
dispensary inventory information via the prescribing
system.
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Ward Prescribing to Dispensary Interoperability
Lesson 4 - Further business rules and automation need to be built into the interface.
• Automatically process data in a receiving system
rather than just present to user.
• If full automation not possible, at least attempt to
usefully constrain the options presented to a user –
e.g. filter a list of options etc. Make the UI useful.
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eMedicines Reconciliation to Primary Care Discharge
• The final Medicines reconciliation report is sent to
the Primary Care Physician at the point of discharge
electronically, within a greater discharge summary
message.
• External messaging broker utilised (HealthLink) to
store and forward message to Primary Care IS.
• HL7 2.x Referral Message used, but with base64
PDF embedded to give greater pagination.
• Obviously a candidate for a CDA document and this
is in progress at the national level.
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Old Discharge Summary to Primary Care
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eMedicines Reconciliation to Primary Care
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eMedicines Reconciliation to Primary Care
Lesson 5 – Progressive Interoperability will get you there
• Method of interfacing is “shock horror,” a PDF.
• No coded machine interpretable data for the Primary
Care physician apart from the patient identifier.
• But, very positive feedback from Primary Care.
• CDA with structured medications section on the way
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Allergy Data Interoperability
• Key feature of the solution is the creation of a single
source of truth for patient allergy and adverse drug
reaction data.
• Crucial that a patients allergy status is clearly
known.
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Allergy Data Interoperability
NHI Medical Warning System
PAS
SMT
Discharge Summary
& eMR
MedChart Prescribing
Decision Support
ePharmacy Dispensing
Decision Support
MedChart
Allergies Service
Concerto Portal
Patient Summary
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Allergy Data Interoperability – Source Entry
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Allergy Data Interoperability – ePrescribing View
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Allergy Data Interoperability – Dispensing / ePharmacy
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Allergy Data Interoperability – Portal Patient Summary
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Allergy Data Interoperability – eMedicines Rec
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Allergy Data Interoperability
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Key Standards utilised (or to be utilised)
HL7 2.x Medication Order Messaging
HL7 2.x Referral Messaging
NZULM (New Zealand Universal List of Medicines)
and NZMT (New Zealand Medicines Terminology)
Web Services transport
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Observations about medication interoperability
• Interoperability isn’t a technical exercise. Its
primarily a professional and cultural exercise.
• Organisational issues regarding professional
disciplines and identities abound and are amplified
when different departments are brought together via
newly interoperable systems.
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Observations about medication interoperability
• Do not maintain a view that “we are just here to
provide some technology and the clinical change
manager will do the rest” - we are all doomed to
failure and frustration with that approach.
• Expect that workflow requirements may not have
been fully appreciated yet, in spite of prior analysis.
• Employ genuine subject matter expertise and strong
Clinical Leadership asap in conjunction with
technical work…
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Observations about medication interoperability
• Consuming external data is likely to involve a whole
new set of electronic workflows within the
consuming system.
• It is easy to not appreciate the importance of data
context when importing from one system to another.
• Don’t structure everything for the sake of it. Think of
the envisioned follow on workflow / task or report
that would utilise that structured element.
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Kanaka’s Wishlist
• All application components expose their key
datasets via standards based interfaces, out of the
box.
• Key application functions are exposed via APIs to
allow more than just “document transfer”
interoperability.
• Local “connectathon” events or labs to accelerate
progression of interoperability. Don’t leave it up to
implementation projects.