Medication Use Automation –Other Topics in Informatics

Jim Carpenter, RPh, MSRegional Information ServicesRegional Information Services

Providence Health SystemPortland, Oregon

My History with Automation

Downstairs lab computer – terminal to theDownstairs lab computer terminal to the mainframe – one!Pharmacist “interface” between non interfacedPharmacist interface between non-interfaced systemsI f i i di l f dInformation immediately out of date

Pharmacy Order Entry Systems

Maintenance of IV product profiles on paperI / billiInventory management / billingProduction of labels and cart fill lists

Starting to see increasing clinical capabilitiesStarting to see increasing clinical capabilities

Pharmacy Order Entry Systems

Purpose: central record-keeping system for medication data

Integration with Electronic Medical RecordIntegration with Electronic Medical RecordCPOE / Bar Coding / Allergy Messaging

+/- Alerts Engines

RisksOver-reliance: “The computer says so”Over reliance: The computer says soIsolationThe computer system becomes the job

Automated Dispensing Devices

Candy Machines?Candy Machines?Override – interface with Pharmacy system –toward closed loop medication managementtoward closed-loop medication management

Automated Dispensing Devices

PPros: convenience Narcotic controlinventor controlinventory controlCubies vs. “pockets”

Cons:nurse queuesrefill needs decentralized / chronic

Future: In-Room?

Dispensing Robots

McKesson Robot Rx

Pros:Pros: Central Dispensing functionMulti facility capabilitiesMulti-facility capabilitiesRe-allocation of personnel

Techs don’t do daily fillTechs don t do daily fillPharmacists don’t check the daily fill

Waiver from Board of PharmacyyPromise: more time for clinical services

McKesson Robot Rx

Cons:Cons: Centralized Dispensing Not convenient to nurses

Snapshot in time dispensing for 24 hour periodSnapshot in time dispensing for 24 hour period

Multi-facility capabilities Downtime DisastersExpensive Multi year contractsExpensive Multi-year contractsFull circle = PRC - manual delivery to the bedside

Med Carousels

Pros:Pros: Inventory managementEfficient use of space vs rolling shelvesEfficient use of space vs. rolling shelvesBar code scan on fill and removal

CCons: Space! WeightExpense

Barcode Med Administration (BCMA)(BCMA)

BCMA / eMAR

Most effective patient safety intervention -Most effective patient safety intervention ISMPEliminates order transcription onto manualEliminates order transcription onto manual Medication Administration Records (MAR)A d i f d d i i dAccurate documentation of meds administered (who / when / what)Accurate billing - bill on administration instead of billing on dispense

Bar Coded Medication Administration-Drug Errors Interrupted by the Computer-

1 103J 2002

379 30

571,103

97 539

No Med Order Found

Order on Hold

No Schedule FoundJune 2002

891

379

117

97,539

120

2,911

Total # of Medications Administered

Admin too Early

Incorrect Amt.

Recently Given

Admin. too late

14

120

200Variance Messages

Site required

Drug/Order Unitmismatched

Recently Given

q5 RightsRight Patient, Right Drug, Right Dose, Right Time, Right Route

Bedside Barcoding

Unintended consequences – Emily Pattersonnurses dropping other activities to reduce workloadnurses dropping other activities to reduce workload during busy periodsincreased prioritization of monitored activities pduring goal conflictsdecreased ability to deviate from routine sequences

Workarounds – copies of armbands on a piece of paper!

Other Implications: Bedside BarcodingBarcoding

Lack of standards: barcoding symbologyLack of standards: barcoding symbologyRe-packaging

Of f i h l d b d d!Often for items that are already barcoded!Manufacturing?

Radio Frequency ID (RFID)

RFID

How it worksHow it worksA transponder - the RFID tag - has been programmed with information. RFID tag passed through the field of the scanning transceiver

d h dDecoder interprets the dataDetects the activation signal from the antenna" akes p" the RFID chip transmits the"wakes up" the RFID chip transmits the information on its microchip picked up by the scanning antenna. g

Radio Frequency ID

Next step with Barcoding?Next step with Barcoding? Encodes much more dataU d i iUsed in inventory managementBut . . .

Can’t be done in-house . . . Slip it into a unit dose container? A small vial?p

RFID

Uses:Uses:Medication ScanningPatient location / disposition around surgery orPatient location / disposition around surgery or transport times

IssuesIssuesExpenseM f liManufacturer compliance

RFID

Use in humans!Use in humans!can incorporate personal medical information and could save lives and limit injuries from errors in medical treatments Access to secure environments

Other Uses:Passports – security and fraud prevention

IED concern! If from a certain country

Transportation tollroads and vehicle trackingTransportation – tollroads and vehicle trackingAnimal ID – passive RFID is what is used in animal “chips”Libraries – holdings trackingg g

Smart Pumps

Most common reason for administering wrong infusion g gdose was incorrect programming of the pump

AJHP 2005;62(5):917-20“key bounce” / hitting a key twiceHow do they work?

A i i h d l l iAssistance with dose calculationsDosing / drug libraries: Decision SupportCommunication with ordersSettings for drip rates in critical careBedside nurses must refrain from bypassing this feature

Smart Pumps

More organizations interested in investing inMore organizations interested in investing in smart pumps in the next 12 months than BCMA and CPOEand CPOE

Smart Pumps

Issues:Issues:Maintainance of knowledge baseT i iTrainingAgreeing on standard concentrationsSetting dose limits

Closed Loop Medication ManagementManagement

Physician Pharmacy Verify Pharmacy dispensePhysician Pharmacy Verify Pharmacy dispense nurse administration flowsheet documentation

Closed loop Allergy integrationp gy g

But humans can subvert the systemBut humans can subvert the systemBar code warning overrides

“This thing isn’t scanning!” Pharmacy order modifications for CPOE orders

Communication deficits – clinicians need to communicate!

Mobile Computing

PDA’sPDA sPalms

PePocratesMobile MicroMedexCalculatorsCDS conference

Mobile Computing

Tablet PCsRuggedizedWashable / submersibleImbedded camera

b dd d b dImbedded bar code scannerBio-ID

“Paving the cowpath”Simplifying – Intel tablet

Cleanliness – infection riskIsolation Rooms

iPhone – not quite thereCan’t run CitrixHacks are forthcoming but primarily this is a closed system

Telemedicine

TV invented 1929!TV invented 1929!

Telemedicine / Telehealth

Telemedicine: focus on Telehealth: focus on theTelemedicine: focus on discipline / technology

Teleradiology

Telehealth: focus on the patient

Patient RecordsTelepathologyTeledermatology

Disease ManagementRemote Monitoring

Telepsychiatry Patient ComplianceHome Care / HospiceW d / B R h bWound / Burn Rehab

Telehealth

Chronic disease management consumes more resourcesChronic disease management consumes more resources than acute care events

+ staff shortages!!

Travel# of patients treated / caseloadp$$Response timepeHealth – use of interactive technologies to enable health care improvement and servicesp

Goals of Telehealth

Remote monitoring of ECG CBG’sRemote monitoring of ECG, CBG s, Maintain independent livingP iPatient empowermentIndividually tailored interventionsReach underserved populationsScalabilityScalability

Telehealth Applications

Demonstrated positive outcomes inDemonstrated positive outcomes in ElderlyHeart FailureDiabetesWound Care / DermatologyHome HealthPediatric AsthmaDi bDiabetesSpecialty ConsultationsMedication ComplianceMedication Compliance

Telehealth Challenges

Physical barriersPhysical barriersLack of rural infrastructurefundingfundingAccessU biliUsabilityHealth and Technology literacyPrivacy and securityPhysician and patient acceptance

“Health Buddy”

https://www.healthhero.com/hb2_demo_v2.swf

Knowledge Management Systems

17 year innovation adoption curve to get new17 year innovation adoption curve to get new knowledge into practiceMore than 150,000 medical articles are publishedMore than 150,000 medical articles are published each month and there are more than 20,000 biomedical journalsjMedical Literature doubles every 19 years2 million facts needed to practice medicine2 million facts needed to practice medicineGenomics and “Personalized Medicine” will increase the problem exponentiallyincrease the problem exponentially

Knowledge Management Systems

Standardizing caregShort-circuits the long series of meetings required to reach consensus on order setsWeekends at home developing own

Regulatory and Reimbursement pressures / fPerformance measures

Evidence-based carel l d l l d l kclinical recommendations also include links to

specific references to ensure clinicians have the latest findingsthe latest findings.

Knowledge Management Goals

Order Set ManagementgContinually adapt content to incorporate the latest clinical research, performance measures, and best practices.

Clinician AdoptionSurprise! Clinicians want to practice good clinical care!Healthcare professionals may resist technology initiatives, because of concerns about the quality of clinical information, the reliability of information technology solutionsy gy

KM at Prov

Productivity / Clinical Interventions TrackingTracking

Purpose:pMonitor clinical workloadDocument ongoing follow-up needsDocument costs avoidedJustify clinical resourcesBenchmark against other facilitiesBenchmark against other facilities

Paper tracking of interventionsp gCosts assigned to interventions are sometimes debatable

Pharmacy Surveillance Systems

coalesce store and monitor data residing incoalesce, store, and monitor data residing in disparate hospital information systems notify clinicians of intervention opportunitiesnotify clinicians of intervention opportunities triggered by datad i b li i l ldriven by clinical rules. every staff member can create user-defined rules and reports

Few actually do.

Pharmacy Surveillance Systems

Examples:pErythropoetin: received epo + Hgb >/= 12 Renal dosing: scr >1.5 + age > 65 years + on your selected

ll li i t d drenally-eliminated drugs Potassium: diuretic + no k+ supplement + k < 3.5 Digoxin: digoxin + digoxin level g g gMetformin: metformin + scr > 1.4 female IV/PO: on IV med listed on target IV/PO list

d k dCMS Indicator: troponin > 0.2 or ckMB positive and not on a B-blocker, ACE/ARB/ASA/statin Warfarin: warfarin + INR > 4.0

Pharmacy Surveillance Systems

Other applications:Other applications:Other disciplinesQuality Management OfficeQuality Management Office

Antibiotic and Anticoagulation stewardshipWeb-based – use their servers.

Dashboard Presentation

Pharmacy Surveillance Systems

Sentri 7 Results:Holy Family saw a 90% increase in the number of weekly changes in recommended therapy by pharmacy related to lab evaluationsa 43% increase in the number of weekly changes in therapy related to appropriate indication for medication.

Clinical staff pharmacists were spending one to two hours a day performing med-lab profile reviews on p ti tpatients

reduced to 15 to 30 minutes per daypay for itself and beyond in saved pharmacist hours

E-prescribing

Why?Why?3-4 billion prescriptions written annuallyPharmacists make 900 million calls to physiciansPharmacists make 900 million calls to physicians each year to clarify prescriptions65% of the public receives at least one Rx / year65% of the public receives at least one Rx / yearDrug decisions are made with limited informationMost prescriptions are still handwrittenMost prescriptions are still handwritten

E-prescribing

Access to clinical decision support at the pointAccess to clinical decision support at the point of prescribing

Benefit eligibility / Copay informationBenefit eligibility / Copay informationFormulary complianceMed Histor informationMed History information

Route prescriptions to the patient’s pharmacyBrick and mortarMail order

E-prescribing

What’s required?What s required?Connectivity to Payers: RxHub

Master Patient IndexEligibility informationMedication History

Connectivity to Pharmacies: SureScripts Per-Se eRxConnectivity to Pharmacies: SureScripts, Per Se, eRx, Medavent~90% of Pharmacies are certified to receive electronic prescriptionsHospitals connections: comprehensive med use history

From: http://www.ncvhs.hhs.gov/050921p3.pdf

The Real Future of Medicine

Pharmacogenetics

The study of how genetic variation leads toThe study of how genetic variation leads to variation in responses to drugs

One of the promises of the genome project

Genesis of Personalized Medicine

Pharmacogenetics

Bevacizumab [Avastin]Bevacizumab [Avastin] only blocks VEGF (Vascular Endothelial Growth Factor)Factor)

VEGF governs angiongenesis – important in tumor growth

very effective against VEGF-dependent colorectal tumors

From: http://biocc.kobic.re.kr/Teach/kim_tae_hyoung/course/altman/genetics-11-12.ppt#312,56,Slide 56

Bioinformatics vs. Applied Clinical InformaticsInformatics

Bioinformatics: intersection between computer science and biological research

Although researchers from both areas have occasionally collaborated their training objectives and interests have beencollaborated, their training, objectives and interests have been quite differentOnce unique genetic markers are teased out these can be made actionable within clinical systemsactionable within clinical systems

Only computerized tools will be capable of maintaining this y p p ginventory of patient-specific genetic markers.

Collaboration / Patient Advocacy Sites / Online CommunitiesSites / Online Communities

Criticisms:Sympathy and Stories – little practical information

Hyper-informed patients – “Googlers”Th t t h i i i i ?Threat to physician omniscience?Changing the practice of medicine? Consumers as practitioners?

AA l d l d lHIPAA – 2002 – electronic medical records streamline adoption and inter-operability; saddled with patient privacy issuesp y

18 categories of PHIPatients on these sites voluntarily share this information

Short circuits the evidence into practice waiting game?Short-circuits the evidence into practice waiting game?

Online Communities

PatientsLikeMe.com7000 membersData! Bar Graphs

List symptoms and treatment – dials into other patients with similar profiles / conditions.

MySpace for the afflicted?MySpace for the afflicted?MS / Parkinsons / AIDS / ALSHeart Dz / Diabetes / Mental Health (subjective) communities plannedplannedBaclofen QD – increase to 40 QD no longer stuck

Sells anonymized patient data; trial recruiting tool

Online Communities

Informatics Training Sites

http://www.nlm.nih.gov/ep/GrantTrainInstitute.htmlhttp://www.nlm.nih.gov/ep/GrantTrainInstitute.html

Pharmacy Informatics Residencies

Topics:pFoundational technology competencyMedication safetyData warehousing and miningData warehousing and miningCapital budgetingProject management

d l iVendor relationsPhysician order entryDecision supportppIntegration of systems Research and PublicationTeachingTeaching

Pharmacy Informatics Residencies

http://www.ashp.org/s_ashp/docs/files/R-dInformaticsTrainingProgs.II.pdf

UMass Memorial Medical CenterBrigham and Women’sgUniversity of MichiganNebraska MethodistSentara Norfolk VASentara – Norfolk, VAMcKesson Medication Management Executive Traineeship in Medication Use Automation and Pharmacy InformaticsJohns HopkinsJohns HopkinsTheradocAuburn University