Clinical Information Systems

There have been thousands of articles written discussing why EMR adoption rates have been so low and why physicians especially have been resistant to moving into the electronic age.  Little return on the initial investment, lack of efficiency in the system and no improvements in patient outcomes have been listed as reasons for reduced adoption rates.

One key element to the lack of efficiency and little improvement in patient care is due to the number of alerts that are generated when trying to use these systems.  As a pharmacist, I enter in hundreds of medication orders in a shift and it is rare that I do so without receiving an alert from my HIS telling me about a drug interaction or duplicate therapy.  These alerts although technically accurate, often involve medicine interactions that are so minor or irrelevant to hospital medicine.  

If an HIS truly wants to improve patient care and become an indispensable part of medicine, it must provide clinical decision support that can accurately and appropriately give clinicians therapeutic alerts that are relevant and can help improve patient care.  That is the goal of Lexi-Data.  For more information about Lexi-Data, check out www.lexi.com.

Matt Bennardo had a great blog post last week where he wrote about the positive benefits of Meaningful Use on the development of EHRs and their impact on patient safety.  He cites a study by Practice Fusion,  where it has been shown that EHR's are having a real impact on the decrease in infant mortality.  This is great news!

As Matt wrote, "Of course, to get these kinds of results, the information in the EHR needs to be accurate, timely, complete, actionable, and specific to the patient. With respect to pediatric and neonatal patients, that last point is especially important. An EHR that is only set up to perform dose range checking and interaction checking on adults won't be nearly as helpful when it comes to children."

All pediatric dosage calculators are not created equally.   As Matt goes on to say, "But luckily there are drug information vendors like Lexicomp that understand there is a vast world of difference between adults and children -- and often between older children and neonates. Lexicomp's drug information is trusted by dozens of EHR vendors to guide clinicians in prescribing, fulfilling, and administering drugs to patients of all types -- including children.

Lexicomp provides both "machine readable" transactional information (geared towards specific populations) for use in clinical decision support, as well as "human readable" reference materials for clinicians and patients. Even Lexicomp's patient education leaflets are written with either adult or pediatric patients in mind.

If you are developing an EMR or looking to improve an EHR or HIS system, I would suggest reaching out to Lexicomp for some suggestions.

• anesthesia and critical care concerns, use, dosage, and monitoring parameters
• anesthetic drug interactions

• Pediatric Dosage Calculations in both transactional information for the clinical decision support systems and reference materials designed for clinicians.
• Pediatric focused patient education materials

The goal of policy makers in requiring the use of e-prescribing is to improve medication safety.  Many systems have the ability to screen a new prescription for safety using clinical decision support tools such as drug interaction, drug allergy, duplicate therapy and dosage range checking.  A recently published study by the Center for Studying Health System Change (HSC) analyzed the use of e-prescribing in physician practices and the impact on patient care.  The study included 24 practices and found that while most e-prescribing systems used had access to patient medication information and clinical decision support tools built-in, only slightly more than half of the physicians reported accessing this information.  Several reasons were cited for this low usage including the fact that it is difficult to import medication histories into the patient records and that physicians found little value in reviewing this information when making prescribing decisions.

The results of this study raise some interesting questions.  The challenge of incorporating patient specific medication histories from multiple sources certainly is a real barrier and one that is pivotal to making CDS useful.  Maybe more alarming is the perception that the alerts and checks that the system can provide are not useful in influencing prescribing decisions.  This point can be challenging when e-prescribing systems are not built with reliable and clinically relevant data to power the CDS processes.  

Lexicomp provides clinical information that can be used to perform key CDS functions such as drug interaction, drug allergy, duplicate therapy and dosage range screening.  This content is derived from our well-established drug reference information that is evidenced-based, peer-reviewed and up-to-date.  If you are a clinician working in health care, you most likely have relied on this content to help you make patient care decisions for many years.  If CDS is going to accomplish its goal of improving patient care, it is going to require a strong, evidenced based library of clinical information.  Something Lexicomp has been doing for over 30 years.      

Let’s face it: your customers need to prove Meaningful Use of their certified EMR in order to qualify to receive government incentive money. And if you don’t clearly communicate to users how your system will help them achieve Meaningful Use, you may get left behind.

So rest assured that when you implement Lexicomp's drug data and reference information, your EMR will be one step closer to complying with Meaningful Use! Lexicomp provides:

• Data for drug-drug, drug-allergy and drug-disease interaction screening
• Data to support duplicate therapy and dose range checking for pediatric and adult patients
• Data that allows users to generate patient-specific education handouts

Hospitals are complex organizations with many different systems used by different departments, and often not well integrated. All kinds of errors can occur -- human errors, data-entry errors, labeling errors. And unfortunately, sometimes those errors have fatal consequences, such as this case of a premature infant that received a lethal dose of sodium due to a parenteral nutrition compounding error.

In this particular case, the death was reported to have led from incorrect data entry into the compounder, insufficient oversight by the pharmacist, incorrect labeling, and an unfulfilled physician request for investigation into abnormally high sodium levels in the infant. Though neither the EMR nor the CPOE were directly implicated in the error this time, it's always worth thinking about whether your system would have been capable of preventing this mistake -- and if not, what you may need to change.

Needed: Dose range checking -- and then some
In order for any system to have detected this error, some form of dose range checking would need to have been in place. This wasn't a result of an adverse drug event or an improperly prescribed medication, so Meaningful Use interaction and allergy checking are of no use. Only knowledge of the correct dosage for this specific patient would help.

In fact, not even all dose range checking would be helpful. This patient belonged to a special class -- a neonate. So the dose checking would need to be differentiated between adult and pediatric (or, in this case, neonatal). Otherwise, a dose that would be appropriate for an adult but fatal to an infant could easily be prescribed.

IV compatibility also an issue
This case also dealt with a solution administered intravenously. In this particular case, there was no adverse reaction between the ingredients being compounded, but with IV administration that's always a possible danger. Therefore, to be 100% safe, your EHR or HIS would also need to contain information about IV Y-site compatibility.
 
And of course, all of this would need to be checked and double-checked at every stage of the process by every clinician: the physician entering the order into the CPOE, the pharmacist compounding the solution, and the nurse administering it to the patient. The systems that each clinician uses should be able to check for each of these factors (and more!), and also should be able to provide the clinicians with more "human readable" information in case something doesn't seem right.

With the state of healthcare IT today, most of us are still a long way off from being able to implement a perfectly integrated system that can eliminate this kind of error entirely. But taking a few steps with the systems we have control over can reduce tragic outcomes like this one. One place to start is to contact a clinical and drug information vendor like Lexicomp to find out what information is available to be integrated into your systems -- both transactionally for automatic clinical decision support and as reference material for clinicians to make use of.