Dosage Administration

Pediatric dosing continues to be a major concern among clinicians in almost all practice settings. In fact, those who do not regularly treat children often have the most questions about proper dosing and treatment. One area where EMR, EHR, and HIS systems can meaningfully differentiate themselves is in providing this information.

Physicians, pharmacists and nurses know that children are not simply "little adults". Besides different dosage precautions, children may require different administration or routes -- and for some cases may receive completely different medications. Different patient education leaflets are also needed when treating children.

For these reasons, it's important to partner with a drug information vendor that is well regarded in pediatrics. Lexicomp is the drug reference vendor of choice among U.S. pediatric hospitals, and has specialized in this area for decades. Most clinicians will see children as patients at some point in their work, and they know that this vulnerable population requires special care. Using Lexicomp as a drug vendor can help put their concerns to rest and add value to their EMR, EHR, or HIS system.

My colleague,  Matt Bennardo,  wrote a wonderful blog posting about the potential upcoming changes in stage two Meaningful Use guidelines as it relates to Patient Education.  This could be a very big deal.

My colleague,  Matt Bennardo,  wrote a wonderful blog posting about the potential upcoming changes in stage two Meaningful Use guidelines as it relates to Patient Education.  This could be a very big deal.

 Patient education will become more and more important over time,  because there is a strong belief that better patient outcomes will result if patients know  more about their condition, treatment program,  and drug regimen.   On the drug side,  this could mean  dose administration regimen,  dosage precautions, drug interactions,  drug-allergy interactions, adverse drug events and more.

What EMR vendors (and institutions)  need to start thinking about today,  are the implications that requirements to supply Patient Education Leaflets,  likely will not just mean English. 

In his posting,   Matt,  states:  "The workgroups are additionally talking about  better and more relevant patient education. One point of discussion has  been providing the materials in "common primary languages" for every  metropolitan statistical area. This would require providers to have  patient education available in any language that is spoken by 5% of the  population they serve, or at least 1000 people in the same population --  whichever is lower. This is a big deal, and not every information  vendor is in a position to deliver on this!

He goes on to say:

Lexicomp can help bridge the gap
Luckily, some vendors are. Lexicomp has long had patient education materials in many languages. At last count, they could provide up to 19 different languages commonly spoken in the United States and Canada. This is just one example of how a forward-thinking drug information vendor was able to anticipate and meet advanced requirements before they were even formulated. So when evaluating vendor partnerships for your EMR or HIS system, it's not enough to find one who can check off boxes. Instead, you need to find a vendor with the same commitment to improving patient care that ONC and CMS are seeking."

Please take note now,  early in the integration of your drug module into your EMR system.

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.

The consumer groups and unions expressed support for several issues, including:

• Transitioning all "optional" criteria in Stage 1 to "required" criteria in Stage 2;
• Advancing key criteria that have an impact on quality and safety, such as electronic prescribing and medication reconciliation;
• Improving collection of advance directives (CMIO, 2/28); and
• Providing patients with online access to their health data, as well as secure messaging capabilities."

• Better quality information with faster updates and fewer mistakes
• A more clinically relevant focus that their end users valued
• Easier implementation and more powerful functionality
• Superior customer service
• Unique content not available elsewhere, like Lexicomp’s industry-leading Pediatric Dose Range Checking

Recently,   I posted the blog below and since then,  it seems the scramble to gain Meaningful Use dollars through ePrescribing is on.  The first reimbursements for this MU compliance occurred this week for medicaid reimbursement.  EMR companies  that are quickly trying to get certified by early 2011.    ePrescribing and Meaningful Use are the mantras of the day, and one area that should not be overlooked is the inclusion of selecting the right drug data and working with the right drug information supplier.

"Quoting a colleague of mine:  'A recent article by HealthData Management summarizes that, 'The new law mandates use of electronic prescribing by Jan. 1, 2011. Prescribers and dispensers must use either the Health Level Seven messaging standards or the National Council for Prescription Drug Programs’ SCRIPT standard to transmit prescriptions and prescription-related information.  The law does not mandate use of electronic health records.  But to ensure EHR systems are interoperable, they must be CCHIT-certified.  Further, the EHRs must meet the e-prescribing provisions of the law.'

Looks like ePrescribing will become a widespread reality within 2 years.  There will likely  be some business opportunities for some small companies to fill in the gap between ePrescribing as part of robust EMR systems and those that just need a tool to facilitate ePrescribing,  without integration into their system.

As more companies look for opportunity in the business "seams,"  they will need to work with a drug database company to close the loop.   And if they want to do it quickly and work with a vendor who serves as a partner,  and not just a supplier,  more and more are turning to Lexicomp.  

Not only will Lexicomp  provide all the basic drug data information such as:  drug interactions;  drug-allergy interactions,  therapeutic dosages,  drug classifications, dosage administration,  pediatric drug information,  and more;  but Lexicomp will also provide the service and support to allow the vendor to move quickly.  With this quickly changing marketplace,  working with a drug interaction software company to facilitate the product launch  is imperative.    If you are looking for a stand alone online ePrescribing application,  I would strongly suggest taking a look at DoseSpot.  They have a great product."

Recent reports on research from the December 2010 issue of the Archives of Pediatric & Adolescent Medicine (abstract here) have pointed out that less than 3% of pediatric hospitals have what the researchers considered a "comprehensive EHR".  Those with "basic EHRs" amounted to just 18% more.

According to the researchers, this means that an overwhelming majority of pediatric hospitals lack standard EHR functionality like ePrescribing.  Clinical decision support functions are also not widely available.

Is the reason money... or value?
The survey cites lack of financing as the main reason for the low adoption.  But we all know that questions of money are really questions of value -- if pediatric hospitals found EHR systems highly valuable, they would be more likely to find financing for them.

When you think about the data that drives most of the common functions of EHRs (functions like drug interaction checking, duplicate therapy, dosage range checking, dosage administration, and even patient education), it's no wonder that pediatric hospitals aren't seeing the value.  Most of that data -- and, by extension, EHR functionality -- is designed for adults!

Lexicomp -- the industry leader in pediatric drug information
At the very least, pediatric hospitals need an EHR that they can customize with their own clinical guidelines on pediatric dosing and interactions.  But better than that would be a system that already takes into account their specific needs.  Lexicomp has been the undisputed market leader for reference information for pediatric hospitals for decades -- and now Lexicomp is offering transactional data as well.

The medication generic name is only one way to specify a therapeutic dosage. If a compound is available in multiple dosage forms a particular generic name may have a number of specific dosage ranges. For example, an extended release product which is dosed once daily may have a very different dosage range than its immediate-release counterpart. At the very least the acceptable frequency of administration is very different. Differences in bioavailability between products as well as salt forms may need to be addressed through separate dosage ranges. The drug brand name unfortunately is also not a simple relationship to the generic drug. For example, a brand name can be applied to an ophthalmic product and a systemic tablet. Additional differentiators (such as route) would need to be included in any review prior to dose administration.