Comprehensive Drug Database Use

As it is part of Meaningful Use Stage 1, drug interaction checking is a critical piece.  Not only is it required for reimbursement, but it is also important for improving patient safety.  The difference between content and the quality and depth of the interaction information that you choose to integrate is important to understand.  Many common drug references have an interaction checker where you can manually enter the medications a patient is taking and check for the significance of any interactions.  For clinicians and patient safety this is important; however, when it resides outside of the workflow it can become time consuming.  

A drug interaction list within your system can increase the likelihood that interactions will be checked as it puts these alerts directly into the workflow.  Some of the most important aspects are not the common drug interactions, but the uncommon interactions that are not widely known. Keep in mind that users of your system will most likely want to customize or localize alerts to cut down on the number of insignificant alerts to reduce alert fatigue.  Lexi-Data can help with this as the database is structured to allow for customization, turning off of certain alerts, and is an overall robust interaction checker covering common and less common drug interactions. Lexi-data also allows for drug interaction checking via a web service so there is less IT development time and maintenance.  Contact Lexicomp to request more information on drug interaction lists. 

Here are definitions from the NLM site for RX Norm.

What is RxNorm?

RxNorm, a standardized nomenclature for clinical drugs and drug delivery devices, is produced by the National Library of Medicine (NLM). In this context, a clinical drug is a pharmaceutical product given to (or taken by) a patient with a therapeutic or diagnostic intent. A drug delivery device is a pack that contains multiple clinical drugs or clinical drugs designed to be administered in a specified sequence. In RxNorm, the name of a clinical drug combines its ingredients, strengths, and/or form.

While ingredient and strength have straightforward meanings, clarification of what is meant by form may be needed. In RxNorm, the form is the physical form in which the drug is administered or is specified to be administered in a prescription or order. The RxNorm clinical drug name does not refer to the size of the package, the form in which the product was manufactured, its form when it arrived at the dispensary or the intended route.

RxNorm’s standard names for clinical drugs and drug delivery devices are connected to the varying names of drugs present in many different controlled vocabularies within the Unified Medical Language System (UMLS) Metathesaurus, including those in commercially available drug information sources. These connections are intended to facilitate interoperability among the computerized systems that record or process data dealing with clinical drugs.

Purpose of RxNorm

Because every drug information system that is commercially available today follows somewhat different naming conventions, a standardized nomenclature is needed for the smooth exchange of information, not only between organizations, but even within the same organization. For example, a hospital may use one system for ordering and another for inventory management. Still another system might be used to record dose adjustments or to check drug interactions. Several cooperating hospitals might have different systems, and find their data incompatible.

A standardized nomenclature that relates itself to terms from other sources can serve as a means for determining when names from different source vocabularies are synonymous (at an appropriate level of abstraction). The goal of RxNorm is to allow various systems using different drug nomenclatures to share data efficiently at the appropriate level of abstraction.

1.  No supported API and substantial learning curve on how the data is organized

2.  At this time SureScripts does not allow RxNorm for the Benefits and Med History Certification

3.  RxNorm is still changing quite a bit.   NDF-RT had been added/new terminology types (MIN [multi ingredient concept])

4.  Distribution model for RxNorm is still a bit convoluted (does not seem to be a publication service to know when there is a new version to pull down)

5.  RxNorm does not provided Duplicate Therapy, Drug-Drug interactions and  Drug-Allergy warning information  (CCHIT must)

170.207 (d) Vocabulary Standards for Representing Electronic Health Information

·         Lexi-Data uses RXCUI codes from RXNorm on medications

170.302 (m) Patient Specific Education Resources

·         Lexi-Comp Online can provide patient tailored educational information pertaining to their medications, conditions or procedures.

170.302 General Certification Criteria for Complete EHRs or EHR modules

·         Lexi-Data provides medication lists for provider order entry

·         Lexi-Data supports drug-drug and drug-allergy interaction checking

·         Lexi-Data facilitates the maintenance of the active medication list as well as the allergy list

·         Lexi-Comp Online provides numerous calculators, including one to calculate the Body Mass Index based on a patient’s height and weight

·         Lexi-Data can be integral to customized clinical decision support rules designed around medications

170.304 Specific Certification Criteria for Complete EHRs or EHR Modules Designed for an Ambulatory Setting

·         Lexi-Data supports the requirement to generate an electronic copy of health information pertaining to the patient’s medication and allergy lists.

·         Lexi-Data facilitates the selection of medications for e-prescribing activities

One of the concepts we have been trying to shed some more light on is the importance of having drug data and clinical decision support data that can be easily customized to the needs of the end user location.  In last year's Agency for Healthcare Research and Quality (AHRQ) Annual Meeting there were Guidelines Into Decision support that were presented.  These are also know as the acronym GLIDES.  These guidelines are actually a pretty interesting take on the advancement of Clinical Decision Support.

In order to account for users in various types of settings and locations, as well as different dosage precautions, this report specifically calls out the need for better customization.  This may seem a lofty goal but is, nonetheless, worthwhile.  The need to customize clinical decision support to the end user makes complete sense in the fact that being able to deliver appropriate alerts through an EMR geared toward a certain specialty is critical. For example, pediatric dosage calculations and alerts would really be most appropriate within a pediatric practice and, for this reason, these end users may want to see something different.  In an EMR for an oncology practice it would make sense that an alert specific to a chemo regimen appear.  Just something else to think about when building your drug data.

Drug interactions, duplicate therapy, allergy checking, and other clinical decision alerts are an important part of clinical decision support systems.  There has been much emphasis in the past few years on implementation of these clinical alert systems.  With the federal government driving mandates for use of electronic medical records, the challenge of changing current workflows and getting physicians up to speed with CPOE has become much more apparent.  With physician adoption still low there is great opportunity for an EMR company to make their product stand out when it comes to clinical decision support. 

Lexi-Data, Lexi-Comp's comprehensive drug database, offers decision support content that can easily be integrated into various healthcare applications, including EMRs.  With a part of certification focusing on decision support and meaningful use criteria driving how these systems are used, EMRs can differentiate themselves by allowing their users to optimize how clinical decision support is used within their workflow. 

Lexi-Data allows for customization so end users can possess the flexibility to alleviate alert fatigue, provide more meaningful alerts, and overall, influence more relevant decision alerts within the workflow.  Lexi-Data has a flexible API that allows this customization. 

As important as clinical decision support systems are, that is only one part of the entire use for a drug database within an EMR application.  Lexi-Data also provides medication brand names, medication generic names, NDCs, drug lists, etc., and can serve as a comprehensive drug database.