Dosing in Pediatrics

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.

Great drug reference databases do not grow on trees.  If you are in the midst of developing or redesigning an EMR or EHR, then you already know this.  There are lots of key questions to keep in mind throughout the decision process:

1. How much will they help in setting up the API's? 
2. Do they have a specific pediatric dose range checking product?  
3. Do they have patient education leaflets?
4. Are they available in foreign languages? 

Take a look at the marketplace and see who can meet all your needs--check out Lexicomp early in the searching process and you will be pleasantly surprised.

• Our Web API solution empowers integration of all Lexicomp content. Consistent API programming calls save time and allow clinicians to launch from their internal applications into our clinical databases, utilizing whatever delivery platform they choose.

• Our Web Services platform is written for compatibility with Microsoft® .NET™ and Java™ programs. XML data can be obtained via standardized calls and is then processed and returned in real-time. Your application will retrieve and parse the content into your display, making complete customization a reality.

• If live Internet calls are not preferred, XML datasets are available for download from an FTP site and incorporated directly into the database.

What do these words have in common?  "Pediatric dosing information; Medicine lists; Medicine brand names;  Drug-drug interaction;  Drug-allergy interactions; Drug interaction database; ePrescribing;  Patient education."  

There are many EMR products under development, many targeting smaller hospitals and ambulatory facilities.  There are also a number of other EMR and Practice Management products that are going through major product re-design.  Many of these development groups need to confront the decision about what drug information supplier to use.  As the title of this posting says "EMR developers are now searching for drug and disease information providers that are easy to work with" (Note: most are not).   This might not sound like a tall order, but as it turns out, it is much more difficult than they think.   It's about the data as much as it about the quality of the relationship as well as the flexibility and helpfulness of the vendor. 

How much will they help in setting up the API's?  Do they have a specific pediatric dose range checking product?  Do they have patient education leaflets? Are they available in foreign languages? 

                         One drug data provider stands out above else....Lexicomp.  If your serious, check them out.

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.

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

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.