Design of Decision Support Interventions

Medication safety screening, as I have written about at length previously, has the potential to reduce prescribing errors and therefore to improve patient safety. I have also previously described alert fatigue, which occurs when the signal:noise ratio is so low that providers start to ignore the alerts. Design of clinical decision support (CDS) systems is therefore a critical factor in order to optimize the impact of these systems on patient care.

In a recent article in the International Journal of Medical Informatics, Horsky et al reviewed the literature in this area and formulated some recommmendations. Below are some highlights of their recommendations, from my point of view.

Use severity levels
In the category of reducing excessive alerting, the authors state the importance of tiering alerts by severity level, which is an important attribute of drug interaction databases, such as Wolters Kluwer’s Medi-Span® database. How the severity level is used varies by implementation, but in general, more severe alerts are generally configured as interruptive, whereas less severe alerts may be configured as informative. Interruptive alerts require acknowledgment by the user, whereas informative alerts provide information on the screen but do not require explicit acknowledgment. When a user acknowledgment is required, some systems require the user to provide a reason for overriding the alert. The authors suggest presenting a short list of reasons in a dropdown list.

Ensure correct underlying patient data
Still in the category of reducing excessive alerting, the authors emphasize the importance of having correct patient data in the electronic medical record (EMR). For example, if a patient is listed as having an allergy to penicillin, then allergy alerts will be triggered whenever penicillin or a similar drug is prescribed. If the patient is in fact not allergic to penicillin, the authors state that this allergy should be removed from the patient’s profile.

Use patient context
The authors also talk about using additional patient context as the basis to filter alerts. I previously summarized another paper looking at ways to develop these contextual models. In addition, the authors suggest distinguishing between new orders and renewals of existing orders, since in the latter case, the patient may already be tolerating the drug combination without any problems, so displaying the same alerts every time the medication is renewed contributes to alert fatigue.

Design of alert boxes
The authors provide a detailed table of optimal design attributes for alerts, making recommendations in areas such as color (e.g. reserve red for severe situations), size (e.g. variable), layout (e.g. simple geometry), font (e.g. draw attention to the drug names) and language (e.g. clear and concise). For the content, they recommend providing a link to a detailed explanation. For example, Medi-Span® contains a detailed monograph for each drug-drug interaction.

User control
The authors indicate that physicians may be allowed to turn off individual alerts with certain caveats related to their knowledge and comfort level. For example, Wolters Kluwer’s Medi-Span® Clinical software provides this capability.

Summary
In summary, the authors provide a practical set of design recommendations to reduce alert fatigue. The health information technology (HIT) community would be wise to adopt their excellent advice.

 

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5 Benefits to using Medi-Span for Developers

Medi-Span continues to be ranked as one of the top drug databases for EMR/EHR software vendors. So what benefits does it offer to developers?

  1. Meaningful Use support: Including drug-drug and drug-allergy interaction checking
  2. Superior customer service:  Every customer has a dedicated implementation specialist assigned to assist them
  3. Advanced filtering options: A unique system of filters helps to decrease alert fatigue for users
  4. Trusted content and name: Thousands of healthcare professionals rely on Medi-Span drug information every day
  5. Modular design - With our modular approach to APIs, you can select the APIs you need now for clinical screening and add on others at a later date
These are just five of the many benefits that Medi-Span customers enjoy. To find out more, request a demonstration today!

 

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Meaningful Use, Patient Portals and other thoughts

I just re-read a posting by my colleague Matt Bennardo about how Meaningful Use is now addressing patient portals.  A very informative posting.  Although I posted this before,  I am re-posting again and am pulling out an excerpt below:

"Recently, Physicians Practice reported on the challenges facing both providers and EHR vendors when it comes to new Stage 2 Meaningful Use rules. One item noted in the article is that patient portals are now mandatory functionality for EHRs, which was not true under Stage 1.

Though healthcare providers are challenged with setting up and maintaining patient portals for their patients, EHR vendors have the even bigger task of ensuring their software is compatible with a patient portal. For many vendors, this will mean developing their own patient portal as an extension of the EHR system.

Patients are different from clinicians
As this work begins, developers will need to remember that patients are very different from clinical users like doctors, pharmacists, and nurses. Information on medication and conditions that is appropriate for clinicians will often leave patients scratching their heads -- or in a panic.

It will be crucial for developers to leverage "consumer level" content -- that is, information on clinical topics that is written with non-technical consumers or patients in mind. One provider of such information is  Lexicomp.    Not only do they have patient education leaflets for drugs and diseases, but they have consumer-level interaction monographs that can be used in conjunction with some clinical decision support functions.

Contact Lexicomp today to learn more about this consumer-level data to help you build out your patient portal."

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Meaningful Use Now Addressing Patient Portals

I just read a posting by my colleague Matt Bennardo  about how Meaningful Use is now addressing patient portals.  A very informative posting.   In case you missed it,  I am pulling out an excerpt below:

 

"Recently, Physicians Practice reported on the challenges facing both providers and EHR vendors when it comes to new Stage 2 Meaningful Use rules. One item noted in the article is that patient portals are now mandatory functionality for EHRs, which was not true under Stage 1.

Though healthcare providers are challenged with setting up and maintaining patient portals for their patients, EHR vendors have the even bigger task of ensuring their software is compatible with a patient portal. For many vendors, this will mean developing their own patient portal as an extension of the EHR system.

Patients are different from clinicians
As this work begins, developers will need to remember that patients are very different from clinical users like doctors, pharmacists, and nurses. Information on medication and conditions that is appropriate for clinicians will often leave patients scratching their heads -- or in a panic.

It will be crucial for developers to leverage "consumer level" content -- that is, information on clinical topics that is written with non-technical consumers or patients in mind. One provider of such information is Lexicomp (Note: The Lexicomp solution Lexi-Data referenced in this post has been replaced by newer Medi-Span solutions as of January 2013.). Not only do they have patient education leaflets for drugs and diseases, but they have consumer-level interaction monographs that can be used in conjunction with some clinical decision support functions.

Contact Lexicomp today to learn more about this consumer-level data to help you build out your patient portal."

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Patient portals now required by Meaningful Use

Patient Education

Recently, Physicians Practice reported on the challenges facing both providers and EHR vendors when it comes to new Stage 2 Meaningful Use rules. One item noted in the article is that patient portals are now mandatory functionality for EHRs, which was not true under Stage 1.

Though healthcare providers are challenged with setting up and maintaining patient portals for their patients, EHR vendors have the even bigger task of ensuring their software is compatible with a patient portal. For many vendors, this will mean developing their own patient portal as an extension of the EHR system.

Patients are different from clinicians
As this work begins, developers will need to remember that patients are very different from clinical users like doctors, pharmacists, and nurses. Information on medication and conditions that is appropriate for clinicians will often leave patients scratching their heads -- or in a panic.

It will be crucial for developers to leverage "consumer level" content -- that is, information on clinical topics that is written with non-technical consumers or patients in mind. One provider of such information is Lexicomp. Not only do they have patient education leaflets for drugs and diseases, but they have consumer-level interaction monographs that can be used in conjunction with some clinical decision support functions.

Contact Lexicomp (Note: The Lexicomp solution Lexi-Data referenced in this post has been replaced by newer Medi-Span solutions as of January 2013.) today to learn more about this consumer-level data to help you build out your patient portal.

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A Growing Trend In Medicine: A Focus on Pharmacogenomics

Recently I have had several conversations with developers who are building software systems that require not only the standard drug interaction checking, but also a focus on pharmacogenomics.  Pharmacogenomics presents information concerning key genetic variations that may influence drug disposition and/or sensitivity.  Whether the timing of these conversations are coincidence or there is a more clinician focus on more personalized medicine, I'm not sure, but it is exciting. 

We know that pharmacists have always been advocates of individualized pharmacotherapy.  They employ efforts such as therapeutic drug monitoring programs to identify appropriate therapeutic dosage selection. Diagnostic genetic information will help predict not only an individual patient's response to some medications, but also the likelihood of drug interactions and adverse effects- truly enabling the individualization of drug and dosage selection.  

If you are in search of a Pharmacogenomics database, please contact us and we'd be happy to talk to you about our offering.  Our database provides rapidly-expanding genomic knowledge into the management of drug therapy as well as a concise reference on key polymorphisms known to influence drug response.

 

 

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Drug Interaction Software, Meaningful Use and other relevant issues

My colleague  posed the following question earlier this week:

Does your drug interaction software comply with Meaningful Use?

He posed the question of  what EMR and EHR developers  need to consider when they make  decisions of which drug data vendor they should select for their product.  With the final fule for State 2 Meaningful Use imminnent,  this question of selecting the right drug database and drug information takes on an even more important role.   I am quoting Matt B's comment.  It is worth reading:

 

"As we await word from CMS and OMC on what criteria will be included in the final rule for Stage 2 of Meaningful Use, it's hard not to reflect on how interdependent many parts of healthcare have become. Doctors and hospitals now rely on their EMR or EHR vendors to ensure that they have the needed functionality to avoid penalties. And those vendors themselves rely on data providers to keep ahead of new criteria.

 

I sometimes wonder if EMR and EHR vendors know how much is riding on their decision to choose one medical reference database over another. The drug interaction software powered by that database will become an important part of many users' medical practices for the next several years. The readiness of that database provider to deal with changing regulations could make the difference between a clinician receiving an incentive payment, or a penalty.

A forward-thinking database provider is crucial to keeping your users happy. At Lexicomp (Note: The Lexicomp solution Lexi-Data referenced in this post has been replaced by newer Medi-Span solutions as of January 2013.), we are already preparing for future Meaningful Use criteria that may affect your users. For instance, we offer patient education leaflets in up to 19 different languages -- anticipating the day when CMS and OMC require that patients be informed of conditions and medications in the language they speak.

Contact Lexicomp now to find out more."

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Does your drug interaction software comply with Meaningful Use?

As we await word from CMS and OMC on what criteria will be included in the final rule for Stage 2 of Meaningful Use, it's hard not to reflect on how interdependent many parts of healthcare have become. Doctors and hospitals now rely on their EMR or EHR vendors to ensure that they have the needed functionality to avoid penalties. And those vendors themselves rely on data providers to keep ahead of new criteria.

I sometimes wonder if EMR and EHR vendors know how much is riding on their decision to choose one medical reference database over another. The drug interaction software powered by that database will become an important part of many users' medical practices for the next several years. The readiness of that database provider to deal with changing regulations could make the difference between a clinician receiving an incentive payment, or a penalty.

A forward-thinking database provider is crucial to keeping your users happy. At Lexicomp, (Note: The Lexicomp solution Lexi-Data referenced in this post has been replaced by newer Medi-Span solutions as of January 2013.) we are already preparing for future Meaningful Use criteria that may affect your users. For instance, we offer patient education leaflets in up to 19 different languages -- anticipating the day when CMS and OMC require that patients be informed of conditions and medications in the language they speak.

Contact Lexicomp now to find out more.

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How to Integrate a Drug Interaction Database -- For EMR and EHR vendors

I was re-reading a  posting  my colleague Dave White wrote several years ago  (like "counting sheep" during the daytime  -- very  therapuetic and reduces side-effects of too much multi-tasking.  Which of course helps my medium term memory,  as oppposed to eating my daily walnuts,  which aids  my critial thinking ability.).   Anyway, back to my point.

Even though Dave wrote this several years ago,  I think it is as meaningful today as it was then  -- despite the dynamic fluidity of the healthcare marketplace.   He wrote:

"With the recent changes regarding meaningful use of EHR, system vendors are faced with many clinical decision support challenges when developing new software applications.  One such challenge is how to easily integrate a drug interaction database into an existing EHR framework.  

To quickly overcome this obstacle, many EHR vendors are turning to Lexi-Comp (Note: The Lexicomp solution Lexi-Data referenced in this post has been replaced by newer Medi-Span solutions as of January 2013.) for a drug interaction software solution.  Lexi-Comp has a comprehensive drug interaction database concerning drug-drug and drug-food interactions available through our integrated solution, Lexi-Data.  Lexi-Data's drug-drug interaction API accepts as an input one or more drugs.  Drugs can be single ingredient agents or multi-ingredient agents and requests for drug interaction checking can be made for either generic drug names or brand names.


To get the drug interaction data that you need with an uncompromising level of customer service, trust Lexi-Comp to deliver.  Contact Lexi-Comp today to learn how you can quickly and easily integrate a drug interaction database into your EHR system."

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EMRs, EHRs looking for novel ways to reduce alert fatigue

 

http://blog.lexi.com/blog/drug-information

 

How to reduce "alert fatigue' and at the same provide the system  framework to improve outcomes?  That is the question that most system developers have been struggling with for over a decade.  It is difficult enough for a large hospital wide EMR to achieve this goal.  How much more difficult for ambulatory EMRs?

In the last few years,  Lexicomp has become a major provider of drug information used by ambulatory and smaller hospital EMRs.  As part of Lexi's entry into this market,  they have now included a unique aspect of their drug-drug interaction rating system,  which defnitely could help in improving "alert fatigue."  My colleage,  Mark Dachille recently said the following about "alert fatigue:" (Note: The Lexicomp solution Lexi-Data referenced in this post has been replaced by newer Medi-Span solutions as of January 2013.)

"Another aspect that can prove beneficial is what types of alerts you choose to show users.  Lexicomp has recently rolled out another aspect of drug-drug interaction within Lexi-Data called risk rating.  By utilizing risk rating along with the more commonly known drug interaction severity, more impactful and actionable alerts can be provided to clinicians which will ultimately improve patient care and reduce alert fatigue for clinicians. 

Whether you are building a complete EMR, ePrescribing application, or mobile medical app utilizing drug interaction software, proper integration of the data is the key.  Taking the time and utilizing the right database that is easy to integrate and provides meaningful alerts will ultimately lead to an offering you can be proud of."

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Drug Database Integration You Can Be Proud Of

Drug Database Integration

 

 

 

 

 

 

 

 

 

In speaking with a number of EMR developers and in reviewing many products which integrate clinical decision support utilizing commercial drug database, a few things have become apparent.  One of the the biggest challenges is to integrating clinical decision support for functions like drug-drug, drug-allergy, drug condition interaction checking  in a meaningful way that is not disruptive to a clinicians workflow. Many times just throwing alerts at clinicians can lead to alert fatigue and eventually alerts will be ignored.  In my experience, having a clinical resource to help with development will pay big dividends in the end.

Another aspect that can prove beneficial is what types of alerts you choose to show users.  Lexicomp has recently rolled out another aspect of drug-drug interaction within Lexi-Data called risk rating.  By utilizing risk rating along with the more commonly known drug interaction severity, more impactful and actionable alerts can be provided to clinicians which will ultimately improve patient care and reduce alert fatigue for clinicians.  (Note: The Lexicomp solution Lexi-Data referenced in this post has been replaced by newer Medi-Span solutions as of January 2013.)

Whether you are building a complete EMR, ePrescribing application, or mobile medical app utilizing drug interaction software, proper integration of the data is the key.  Taking the time and utilizing the right database that is easy to integrate and provides meaningful alerts will ultimately lead to a product you can be proud of.

 

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Clinical Decision Support for Dental Practice Management Systems

As more and more healthcare professionals are adopting EMR technology to meet Meaningful Use requirements, we are receiving more and more interest from dentists about adding clincial decision support technology into their dental practice management system.  They are quickly realizing that Lexicomp is the preferred vendor of choice to work with, because we provide the very best dental specific drug database to integrate into their EMRs as well as personalized customer support during development.   Another important piece to consider in a dental EMR is an ePrescribing tool.  Lexicomp has a close partnership with DoseSpot to deliver this solution.  By selecting DoseSpot for ePrescribing, our clients are able to get to the market faster and reduce their headaches in developing the tool on their own. (Note: The Lexicomp solution Lexi-Data referenced in this post has been replaced by newer Medi-Span solutions as of January 2013.)

Lexi-Data provides the drug information for  dose range checking,  pediatric dosing, drug calculators, medicine interactions, dosage precautions, clinical guidelines, drug interaction software, duplicate therapy, drug classifications, generic drug names, drug nomenclature and more.  These are critical paths for a dental EMR build. 

To learn more about Lexicomp's dental solutions, please visit our website at http://www.lexi.com/individuals/dentistry/

If you are interested in learning more about our integration capabilities, we'd love to talk with you.  Please contact us at 1-877-819-6883.

 

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EMR's now have a web services option to access drug data

ePrescribing

Lexicomp has now released the second phase of a comprehensive web services solution to EMR developers to access drug information.  (Note: The Lexicomp solution Lexi-Data referenced in this post has been replaced by newer Medi-Span solutions as of January 2013.) For those EMR and Practice Management systems that do not want to store drug information in their product,  they now have an option.  In the second phase,  Lexicomp has released web services to include a proprietary Black Box warning decision tool to reduce alert overload.  Phase II also include dose range checking (DRC) and 12 new searching tools.


For EMR developers that have need for any of the following drug nformation or tools in their product, Pediatric Dose Range Checking (Lexicomp is the leader in this area); Patient Education Materials;  Drug Interaction Software;  RxNorm Mapping;  Medicine Lists,  Generic Drugs;  Dose Information; ePrescribing,  and more--- they should call Lexicomp.
 

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Eliminate Alert Fatigue with Customized Drug Database

Alert fatigue is related to the barrage of messages provided clinical decision support systems which can overwhelm a provider and cause them to ignore messages. The alerts, while found to be helpful in some cases, can result in a type of "fatigue" whereby the provider, after receiving too many alerts, begins to ignore and/or override the alerts. Receiving too many alerts can result in slowing the provider down rendering the alert useless.

One of the key reasons that clinicians are frustrated with decision support related to drug interaction software is the potential for this alert fatigue. Clinicans do not want to be messaged regarding dosage precautions related to an interaction which has already been recognized and addressed. It is particularly important in the era of electronic prescribing to engineer systems which can present the appropriate information to the appropriate person. Systems need to recognize whether an individual has previously addressed the issue, rather than simply blindly alerting to the presence of two medications within the medicine list. A collaborative effort between drug database providers and application vendors is needed, and discussions to improve the quality of alerts, while decreasing the quantity, are moving forward. These will greatly improve satisfaction with these tools. 

Not all clinical information is structured the same!
The more detail that your medication and clinical information vendor provides about crucial alerts, the easier it is for you to implement customization for your users. If every alert looks the same (which is true of what many vendors provide!), then that means that your users will have to go through them all one by one, setting their preferences on warnings and dosage precautions by hand. Then they have to keep their settings up to date as new alerts are added. That's not user friendly design!

By contrast, Lexicomp's implementation of Black Box Warnings (also called Black Boxed Warnings) gives a great deal of flexibility to developers to allow for multi-dimensional customization. Each warning contains information about which clinician the alert is intended for, how severe the alert is, and whether the alert applies only to patients with specific conditions (e.g., pregnancy). (Note: The Lexicomp solution Lexi-Data referenced in this post has been replaced by newer Medi-Span solutions as of January 2013.)

Win customer loyalty by automating alert customization! 
This way, you can automate much of the customization without having to ask for input from every individual user. You can simply have the system hide alerts intended for nurses from pharmacists, and vice-versa. Likewise, you can make your system intelligent enough to hide alerts related to pregnancy from male patients. This is the kind of smart implementation that users are looking for to help them aviod alert fatigue and become more efficient and effective clinicians. Talk to Lexicomp today to learn more!
 

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All in the presentation?

A recent JAMIA study by Bates et al. noted that the strongest factor influencing acceptance of alerts from drug interaction software is the presentation. This was found to have a stronger association than factors such as the setting or level of the alert. In an electronic prescribing environment, there is much concern about alert fatigue. Drug data vendors are often the targets of frustration of clinicians, and there is a reasonable criticism regarding the ability to have more consistency in alerting, the ability to filter to the user, and suppression of "truthful but not useful" alerts. Considering the role these alerts play in preventing adverse drug events, it would seem that at least as much attention should be paid to the way the alerts are delivered.

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Black Boxed Warning, EMR, Alert Fatigue -- a new answer

In the last two years Lexicomp has quickly become  a major provider of drug information  to EMR companies for clinical decision support.  Many of the new EMRs hitting the market are using Lexicomp medicine information for drug interactions,  dose range checking,  therapeutic dosages,  adverse drug advents,  electonic eprescring,  and more.   Lexi-Data has become the popular choice based on top quality information,  unparalleled customer service,  state-of-the-art data structure and top-notch APIs.  Now something new!! (Note: The Lexicomp solution Lexi-Data referenced in this post has been replaced by newer Medi-Span solutions as of January 2013.)
 
Lexi-Data has introduced a new structure which allows for the customization of Black Boxed Warning to reduce alert fatigue,  yet at the same time delivers the warning to the person who needs it most.  This information structure is new and as far as we know not available elsewhere.  
 

API and Database Features:
 
  • 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
 
This is terrific stuff.   So for anyone  developing  drug interaction software or eprescribing modules, this is something you will want to look into.   
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Dentistry Practice Management Systems Need Clinical Decision Support

EMR vendors are not the only ones rapidly deploying clinical decision support systems to healthcare providers. Dental professionals are demanding that their practice management systems overcome massive development hurdles in order to comply with Meaningful Use standards.

There is a buzz in the dental technology community about Meaningful Use and incorporating more clinical decision support into the practice management system workflow. If you are searching for the best dental specific drug database to integrate into your dental EMR, turn to Lexicomp. There are very few suppliers of drug data within the dental market and even fewer still that are easy to work with.  And if you are looking for an easy-to-use, out-of-the-box ePrescribing tool, trust our partner DoseSpot to deliver the solution.  What do all of these companies have in common?  They are easy to work with and provide you with the ability to get to the market fast! (Note: The Lexicomp solution Lexi-Data referenced in this post has been replaced by newer Medi-Span solutions as of January 2013.)

Don't wait to the end of your development process to worry about:  dose range checking,  pediatric dosing, drug calculators, medicine interactions, dosage precautions, clinical guidelines, drug interaction software, duplicate therapy, drug classifications, generic drug names, drug nomenclature and more.  These are critical paths for a dental EMR build.  But it's not just about the information.  It's about who you select as your partner and who has seamless API's which makes your development easier.   

You owe it to your product and your customer to make the right choice.  

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Clinical Decision Support and Alert Fatigue

One of the key reasons that clinicians are frustrated with decision support related to drug interaction software is the potential for alert fatigue. Clinicans do not want to be messaged regarding dosage precautions related to an interaction which has already been recognized and addressed. It is particularly important in the era of electronic prescribing to engineer systems which can present the appropriate information to the appropriate person. Systems need to recognize whether an individual has previously addressed the issue, rather than simply blindly alerting to the presence of two medications within the medicine list. A collaborative effort between drug database providers and application vendors is needed, and discussions to improve the quality of alerts, while decreasing the quantity, are moving forward. These will greatly improve satisfaction with these tools. 

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Even more EHR growth than expected!!

Back in January of this year, I wrote about the steady increase of Electronic Health Records/Electronic Medical Records with the market projected to be at $3.8 billion in 2015.  Now, according to this report, "The U.S. EMR market is expected to grow from $2,177 million in 2009 to $6,054 million in 2015."  This number is almost double!! 

 
 

What I said back in January continues to apply today, as it is still not too late to get your software certified with trusted drug data.  Don't wait until the end of your development process to worry about: medicine interactions, a drug reference database, pediatric dosing, dose ranges and more.  But it's not just about the information.  It's about who you select as your partner and who has seamless APIs to make your job easier.  


So leave the drug content to us and know you have made the right decision.
 

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Re-evaluating EMR design in a changing market

In the past few years, new developments on many fronts have created innovation and changes among EMR vendors. Regulations like Meaningful Use have caused particular features and functions to gain sudden prominence. New technologies have given us buzzwords like "software as a service" (SaaS) and "the cloud" -- along with new ways to deliver information. New business models have some EMR companies giving away their product to users. And new hardware like tablets and smartphones are suggesting new ways that clinicians can interact with their EMR systems.

As EMR vendors plan to release new products or new versions of software to take advantage of some of these new opportunities (or to comply with government mandates), it's also the perfect time to evaluate the drug information that forms the basis of any EMRs clinical decision support.

When many EMRs were first designed several years ago, there weren't many choices for drug information. Now there are new vendors in the market with competitive offerings, like Lexicomp. Many new EMRs are finding it to their advantage to sign up with Lexicomp for their drug reference and clinical decision support information. If you've been using the same drug information vendor for years because you thought you had no other choice, it's time to find out why! (Note: The Lexicomp solution Lexi-Data referenced in this post has been replaced by newer Medi-Span solutions as of January 2013.)

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