Medication Use Automation Other Topics in Informatics

Transcription

1 Medication Use Automation Other Topics in Informatics Jim Carpenter, RPh, MS Regional Information Services Providence Health System Portland, Oregon

2 My History with Automation Downstairs lab computer terminal to the mainframe one! Pharmacist interface between non-interfaced systems Information immediately out of date

3 Pharmacy Order Entry Systems Maintenance of IV product profiles on paper Inventory management / billing Production of labels and cart fill lists Starting to see increasing clinical capabilities

4 Pharmacy Order Entry Systems Purpose: central record-keeping system for medication data Integration with Electronic Medical Record CPOE / Bar Coding / Allergy Messaging +/- Alerts Engines Risks Over-reliance: The computer says so Over reliance: The computer says so Isolation The computer system becomes the job

5 Automated Dispensing Devices Candy Machines? Override interface with Pharmacy system toward closed-loop loop medication management

6 Automated Dispensing Devices Pros: convenience Narcotic control inventory control Cubies vs. pockets Cons: nurse queues refill needs decentralized / chronic Future: In-Room?

7 Dispensing Robots

8 McKesson Robot Rx Pros: Central Dispensing function Multi-facility capabilities Re-allocation of personnel Techs don t do daily fill Pharmacists don t check the daily fill Waiver from Board of Pharmacy Promise: more time for clinical services

9 McKesson Robot Rx Cons: Centralized Dispensing Not convenient to nurses Snapshot in time dispensing for 24 hour period Multi-facility capabilities Downtime Disasters Expensive Multi-year yearcontracts Full circle = PRC - manual delivery to the bedside

10 Med Carousels Pros: Inventory management Efficient use of space vs. rolling shelves Bar code scan on fill and removal Cons: Space! Weight Expense

11 Barcode Med Administration (BCMA)

12 BCMA / emar Most effective patient safety intervention - ISMP Eliminates order transcription onto manual Medication Administration Records (MAR) Accurate documentation of meds administered (who / when / what) Accurate billing - bill on administration instead of billing on dispense

13 Bar Coded Medication Administration -Drug Errors Interrupted by the Computer- 97,539 June 2002 Total # of Medications Administered 2,911 1, No Med Order Found 379 Incorrect Amt. 891 Admin too Early No Schedule Found Order on Hold Admin. too late Recently Given Variance Messages 5 Rights Right Patient, Right Drug, Right Dose, Right Time, Right Route Drug/Order Unit mismatched Site required

14 Bedside Barcoding Unintended consequences Emily Patterson nurses dropping other activities to reduce workload during busy periods increased prioritization of monitored activities during goal conflicts decreased ability to deviate from routine sequences Workarounds copies of armbands on a piece of paper!

15 Other Implications: Bedside Barcoding Lack of standards: barcoding symbology Re-packaging Often for items that are already barcoded! d! Manufacturing?

16 Radio Frequency ID (RFID)

17 RFID How it works A transponder - the RFID tag - has been programmed with information. RFID tag passed through the field of the scanning transceiver Decoder interprets the data Detects the activation signal from the antenna "wakes up" p"therfidchip transmits the information on its microchip picked up by the scanning antenna.

18 Radio Frequency ID Next step with Barcoding? Encodes much more data Used in inventory management But... Can t be done in-house... Slip it into a unit dose container? A small vial?

19 RFID Uses: Medication Scanning Patient location / disposition around surgery or transport times Issues Expense Manufacturer compliance

20 RFID 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 tracking Animal ID passive RFID is what is used in animal chips Libraries holdings tracking

21 Smart Pumps Most common reason for administering wrong infusion dose was incorrect programming of the pump AJHP 2005;62(5): key bounce / hitting a key twice How do they work? Assistance with hdose calculations l Dosing / drug libraries: Decision Support Communication with orders Settings for drip rates in critical care Bedside nurses must refrain from bypassing this feature

22 Smart Pumps More organizations interested in investing in smart pumps in the next 12 months than BCMA and CPOE

23 Smart Pumps Issues: Maintainance of knowledge base Training Agreeing on standard concentrations Setting dose limits

24 Closed Loop Medication Management Physician Pharmacy Verify Pharmacy dispense nurse administration flowsheet documentation Closed loop Allergy integration But humans can subvert the system Bar code warning overrides This thing isn t scanning! Pharmacy order modifications for CPOE orders Communication deficits clinicians need to communicate!

25 Mobile Computing PDA s Palms epocrates Mobile MicroMedex Calculators CDS conference

26 Mobile Computing Tablet PCs Ruggedized Washable / submersible Imbedded camera Imbedded bar code scanner Bio-ID Paving the cowpath Simplifying Intel tablet Cleanliness infection risk Isolation Rooms iphone not quite there Can t run Citrix Hacks are forthcoming but primarily this is a closed system

27 TV invented 1929! Telemedicine

28 Telemedicine / Telehealth Telemedicine: focus on discipline / technology Teleradiology Telepathology Teledermatology Telepsychiatry Telehealth: focus on the patient Patient Records Disease Management Remote Monitoring Patient Compliance Home Care / Hospice Wound d/ Burn Rehab

29 Telehealth Chronic disease management consumes more resources than acute care events + staff shortages!! Travel # of patients treated / caseload $$ Response time ehealth use of interactive technologies to enable health care improvement and services

30 Goals of Telehealth Remote monitoring of ECG, CBG s, Maintain independent living Patient empowerment Individually tailored interventions Reach underserved populations Scalability

31 Telehealth Applications Demonstrated positive outcomes in Elderly Heart Failure Diabetes Wound Care / Dermatology Home Health Pediatric Asthma Diabetes Specialty Consultations Medication Compliance

32 Telehealth Challenges Physical barriers Lack of rural infrastructure funding Access Usability Health and Technology literacy Privacy and security Physician and patient acceptance

33 Health Buddy

34 Knowledge Management Systems 17 year innovation adoption curve to get new knowledge into practice More than 150,000 medical articles are published each month and there are more than 20,000 biomedical journals Medical Literature doubles every 19 years 2 million facts needed to practice medicine Genomics and Personalized Medicine will increase the problem exponentially

35 Knowledge Management Systems Standardizing care Short-circuits the long series of meetings required to reach consensus on order sets Weekends at home developing own Regulatory and Reimbursement pressures / Performance measures Evidence-based care clinical recommendations also include links to specific references to ensure clinicians have the latest findings.

36 Knowledge Management Goals Order Set Management Continually adapt content to incorporate the latest clinical research, performance measures, and best practices. Clinician Adoption Surprise! 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 solutions KM at Prov

37 Productivity / Clinical Interventions Purpose: Tracking Monitor clinical workload Document ongoing follow-up needs Document costs avoided Justify clinical resources Benchmark against other facilities Paper tracking of interventions Costs assigned to interventions are sometimes debatable

38 Pharmacy Surveillance Systems coalesce, store, and monitor data residing in disparate hospital information systems notify clinicians of intervention opportunities triggered by data driven by clinical rules. every staff member can create user-defined rules and reports Few actually do.

39 Pharmacy Surveillance Systems Examples: Erythropoetin: received epo + Hgb >/= 12 Renal dosing: scr >1.5 + age > 65 years + on your selected renally-eliminated li i drugs Potassium: diuretic + no k+ supplement + k < 3.5 Digoxin: digoxin + digoxin level Metformin: metformin + scr > 1.4 female IV/PO: on IV med listed on target IV/PO list CMS Indicator: troponin > 0.2 or ckmb positive and not on a B-blocker, ACE/ARB/ASA/statin Warfarin: warfarin + INR > 4.0

40 Pharmacy Surveillance Systems Other applications: Other disciplines Quality Management Office Antibiotic and Anticoagulation stewardship Web-based use their servers.

41 Dashboard Presentation

42 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 evaluations a 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 pti patientst reduced to 15 to 30 minutes per day pay for itself and beyond in saved pharmacist hours

43 E-prescribing Why? 3-4 billion prescriptions written annually Pharmacists make 900 million calls to physicians each year to clarify prescriptions 65% of the public receives at least one Rx / year Drug decisions are made with limited information Most prescriptions are still handwritten

44 E-prescribing Access to clinical decision support at the point of prescribing Benefit eligibility / Copay information Formulary compliance Med History information Route prescriptions to the patient s pharmacy Brick and mortar Mail order

45 E-prescribing What s required? Connectivity to Payers: RxHub Master Patient Index Eligibility information Medication History Connectivity to Pharmacies: SureScripts, Per-Se, erx, Medavent ~90% of Pharmacies are certified to receive electronic prescriptions Hospitals connections: comprehensive med use history

46 From:

47 The Real Future of Medicine

48 Pharmacogenetics The study of how genetic variation leads to variation in responses to drugs One of the promises of the genome project Genesis of Personalized Medicine

49 Pharmacogenetics Bevacizumab [Avastin] only blocks VEGF (Vascular Endothelial Growth Factor) VEGF governs angiongenesis important in tumor growth very effective against VEGF-dependent colorectal tumors

50 From: ppt#312,56,Slide 56

51 Bioinformatics vs. Applied Clinical Bioinformatics: Informatics intersection between computer science and biological research Although researchers from both areas have occasionally collaborated, their training, objectives and interests have been quite different Once unique genetic markers are teased out these can be made actionable within clinical systems Only computerized tools will be capable of maintaining this y p p g inventory of patient-specific genetic markers.

52 Collaboration / Patient Advocacy Sites / Online Communities Criticisms: Sympathy and Stories little practical information Hyper-informed patients Googlers Threat to physician i omniscience? i Changing the practice of medicine? Consumers as practitioners? HIPAA 2002 electronic medical records streamline adoption and inter-operability; saddled with patient privacy issues 18 categories of PHI Patients on these sites voluntarily share this information Short-circuits the evidence into practice waiting game?

53 Online Communities PatientsLikeMe.com 7000 members Data! Bar Graphs List symptoms and treatment dials into other patients with similar profiles / conditions. MySpace for the afflicted? MS / Parkinsons / AIDS / ALS Heart Dz / Diabetes / Mental Health (subjective) communities planned Baclofen QD increase to 40 QD no longer stuck Sells anonymized patient data; trial recruiting tool

54 Online Communities

55 Informatics Training Sites

56 Pharmacy Informatics Residencies Topics: Foundational technology competency Medication safety Data warehousing and mining Capital budgeting Project management Vendor relations Physician order entry Decision support Integration of systems Research and Publication Teaching

57 Pharmacy Informatics Residencies InformaticsTrainingProgs.II.pdf UMass Memorial Medical Center Brigham and Women s University of Michigan Nebraska Methodist Sentara Norfolk, VA McKesson Medication Management Executive Traineeship in Medication Use Automation and Pharmacy Informatics Johns Hopkins Theradoc Auburn University