Dosage Range

• Implementing dose range checking: From a clinical point of view, this is one of the big gaps in what we've seen so far in the first two stages of Meaningful Use. Many of the news stories we read about adverse drug events aren't about interactions or allergies at all -- they're about mistakes in dosing. This is especially true with pediatric dosing, which can be extremely complicated. If dosage precautions were more widely implemented, patient safety would be positively affected.
• Addressing alert fatigue: Many EMR systems are likely to live or die based on this issue alone. Whoever can figure it out will have an undeniable benefit over the competition. As with many Meaningful Use issues, it starts with drug information vendors -- does yours provide the detail needed to make alerts intelligent?
• Improving patient education: The new recommendations for Stage 2 Meaningful Use are all about provider-patient communication. And transcripts of workgroups show that CMS and ONC are very interested in improving not just the method of communication, but the quality of information that flows through it. It seems likely that this will eventually include things like specific patient education materials for pediatric and adult patients, delivered in the language they primarily speak.

• Incorporates not only the BBW as published within the package insert, but also pulls contextual or supporting information as written by Lexicomp clinical experts 
• Each summary is broken down and tagged as separate messages / instructions 
• Each message is paired to a recipient user category – this allow for differentiating where in the workflow of an EMR the message may be displayed 
• Can be filtered for a more specific and targeted set of messages to clinician/recipient groups, as defined for their site

Don't get discourgaged when looking for a drug data partner. Whether you have a laundry list of items or a small budget, Lexicomp has an intuitive database design that will help you seamlessly integrate complex drug reference databases into your system, allowing for easy implementation.

Other items that Lexicomp can help check off your list:

• Consumer-facing patient education materials in 19 languages
• Compliance with the RxNorm 
• Dosage range checking, for both adult and pediatric

And many more!  

Having a sick child can be a challenging and stressful time for any parent.  A sick child also presents challenges for health care professionals as well as health information systems as it relates to prescribing medications.  For a number of medications, pediatric dosage calculations are based on weight.  Having a weight available in the community pharmacy setting is often challenging, however this is only the first step in being able to validate the correct dosage range.  The second piece necessary to accurately check the validity of a pediatric prescription is having the correct information in your pharmacy system. 

All too often, community pharmacy systems are not equipped with the necessary drug reference database to accurately evaluate a pediatric dose.  For over 15 years, pediatric practitioners have been using Lexicomp's Pediatric Dosage Handbook and more recently, our electronic versions to prescribe and validate pediatric dosing.  Now, this information has been transformed into a data set that can be integrated into pharmacy systems to allow your HIS to help you validate these critical doses.  For more information about this product, visit http://www.lexi.com/businesses/ehr-vendors/. 

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.

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.      

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.

• 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