Drug Reference Book

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

Several institutions, as well as drug data vendors, have constructed dose range checking content. In many cases, the institutions have learned that this can be a difficult process to complete and maintain. Reliance on a drug reference book such as the Pediatric Dosage Handbook to create these data technically is outside of the terms of use, and leaves open the issue of maintenance and timely modification as new information appears in the literature.

Without a valid model to identify, acquire, evaluate, and publish. Dosage precautions which are not actively supported by this type of surveillance typically fall out of date rather rapidly. Pediatric dose calculations can be limited, and therapeutic dosages which are supported in the literature may be identified as outside the range. This type of over-alerting is a source of frustration. Lexicomp has worked with its partners to transform the content of the Handbook into a database with associated APIs to execute dose range checking for pediatrics. In addition, these data are actively modified in conjunction with the normal process of maintaining this publication. In this way, the user can integrate dose range checking simply, with the assurance that the data are continuously updated and expanded.

As clinical decision support systems become more common in more places, the fragmentation of the drug information market is becoming more apparent -- and more of a problem. At HIMSS this year, I spoke with several clinicians who told me that the drug information they access in hand-held references is not the same as that which they see in  their EHR, EMR, or HIS. They all asked the same thing, "Can't everything come from the same vendor?"

With Lexicomp, the answer is a resounding "Yes!" but it's not so easy with other providers. The reason is that Lexicomp is one of the few providers of both "reference" drug information (designed to be used by clinicians) and "transactional" drug information (designed to be used by computer systems). By contrast, those who use other "transactional" vendors are forced to go elsewhere for reference information on hand-held devices -- often to Lexicomp.

It seems that "consistency of information" will increasingly be a competitive advantage for EHRs and EMRs. That's not just internal consistency within the system, but also consistency with other sources used by the clinicians. And it makes sense -- sorting through conflicting drug and interaction information is frustrating in a time-crunched environment like a hospital or doctor's office. But a partnership with Lexicomp means that users can get all their information from a single vendor -- and one that's already trusted by pharmacists, doctors, dentists, and nurses.

Looking through the meaningful use requirements, there's no mention of integrated drug reference information being needed in EHR systems.  So why should you care if your drug data provider can give your users access to reference information in addition to transactional data?

The answer is in who is using your EHR: humans.  Although computers need rigidly structured tables to perform clinical decision support tasks like dosage calculation and drug interaction checking, that's not the best format for doctors and other (non-computer) clinicians.

For decades, clinicians have thumbed through well-worn copies of drug reference books, looking for answers to questions.  The human urge to know more isn't going to change simply because a computer is helping clinicians with some tasks now!  Doctors, nurses, and pharmacists are still going to want reference resources, and will find value in an EHR system that links directly to a resource like Lexicomp's Lexi-Comp Online.  Lexicomp is the only transactional data provider that has been publishing industry-leading drug reference material for the past 30 years, and it is now a convenient single stop for both human-readable and computer-readable drug information that can be integrated into EHR systems.

Try telling a doctor that she's just like a pharmacist, or a nurse practitioner that he's just like a physician's assistant, and you'll soon find out that the differences between healthcare professionals run wide and deep.  Companies that sell drug reference books and drug reference software directly to doctors, pharmacists, nurses, and dentists have long known this -- but do EHR vendors and the suppliers of transactional drug data know it?

In the reference market, you'll find there are different solutions with similar drug interaction and drug reference information marketed to each type of healthcare professional.  The underlying information is often the same, but a doctor's first choice would never be a resource designed for a pharmacist, and vice versa.

When spending their own money, healthcare professionals seek out specific resources
The reason for this is simple: Healthcare professionals adamantly will not accept "one-size-fits-all" reference resources!  They actively seek out those that have the right level of detail, the right formatting, and the right focus on relevant topics to help them do their jobs quickly, efficiently, and safely.

For example, doctors like to have diagnostic information alongside drug information, but have less need for the in-depth pharmacokinetics and pharmacodynamics that pharmacists often require.  Nurses, meanwhile, are most interested in information about proper administration of a drug and patient education.  These different needs have driven the evolution of the drug reference market over the past several decades -- don't fool yourself into thinking they won't be important to EHRs as well!

Clinicians are also going to have a huge amount of input into which EHR vendor their hospital or practice partners with.  And if they won't accept a generic approach in a drug reference book (retail: $150), you can be sure they won't accept it in a clinical decision support system (retail: $15,000)!

Does your drug information data provider understand this?
Lexi-Comp is the only drug data provider that operates across the entire spectrum of healthcare professionals.  Lexi-Comp sells reference resources directly to pharmacists, physicians, nurses, dentists, and specialists -- and they choose Lexi-Comp because of the value they find in resources that are specially tailored to their needs.

Moreover, Lexi-Comp is the only transactional data provider that has such a wide reference user base of pharmacists and clinicians.  Imagine the power of partnering with a clinical decision support data provider who already understands what each of your different end users may want!  After thirty two years of delighting clinicians with superior reference solutionss, Lexi-Comp knows how to keep delighting them with data.  That's something that the "one-size-fits-all" providers can't say.

Pediatric dose calculations represent a particular challenge to some healthcare professionals. A drug reference book can help, but there are additional considerations which are not part of the text. Considerations such as the maturation of the child and nutritional status are not easily factored. In addition, drug interactions may play a role in the adjustment of dose. When using a pediatric dosage calculator, it is important that the medicine list be reviewed, as a calculator typically focuses on only a single medication. Augmenting the decision-making process with drug interaction software can help assess these influences on dosing. Both processes are essential in arriving at an appropriate therapeutic dosage.
 

Lexi-Comp is most likely the newest player in the drug data arena.  Lexi-Comp has established itself as the leading provider of drug reference information for pharmacists, physicians, and nurses and has now taken that same expertise and built the tools required to provide clinical decision support information for EMRs.  As the newest provider of this content, Lexi-Comp has built an intuitive API and an internal team of experts to provide a startup EMR with the content they need to implement drug data or for an existing EMR system to swap out a new or ancillary data source.  Lexi-Comp has successfully been used for certification and is currently being implemented across many EMRs and institutions.

As a leader in pediatric dose range checking, Lexi-Comp has published the Pediatric Dosage Handbook for over 15 years.  This book is recognized as the authority in pediatric drug information.  This content has been implemented into Lexi-Comp's drug data and can provide the backbone to the best pediatric specific information dosing, calculators, etc. for an EMR.

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Pediatric dosing is a complicated affair. With the increasing trend of childhood obesity in the United States, the risks of ordering and administering improper doses also increases. Additionally there are the complicating factors of physiological development - pediatric patients cannot be dosed as "little adults."  There are a number of well regarded pediatric drug reference books available, however when choosing one of these resources it is important to understand the publisher's editorial model.  Do they have pediatric specialists as authors and editors? How frequently is the information reviewed and updated?  Does it contain easy to read pediatric dosing charts that can be highly useful in reviewing medications across a drug class?

Additionally, there is an emerging approach to pediatric dosing through the use of drug content, both referential and transactional data.   Pediatric dose range checking functionality can be associated with content used to support electronic medical records. The advantage to this publishing model is the frequency with which updates can be made - rather than waiting for the next edition of a reference to be printed,  the on-line information can be updated at any time. However the same questions should be considered with an electronic format of information: who are the authors and how frequently is the body of content reviewed? Special care should be taken when choosing any source of information for pediatric dosing.

As e-prescribing standards go into effect, the interest in this technology appears to be on the radar of all electronic medical record providers due to the push of government incentives, health IT provisions of the American Recovery and Reinvestment Act (ARRA), the impact of Meaningful Use, and much more.  The DEA has recently issued an interim ruling that would allow electronic transmission of prescriptions of controlled substances. Up until now, the DEA has been concerned that the lack of security controls for e-prescribing of controlled substances would lead to higher levels of illegal use. The good news with this ruling is that this opens up opportunities for healthcare professionals in the dental space because the majority of the medications that they prescribe are schedule II drugs.  Ultimately, this interim ruling should help reduce the number of prescription errors caused by illegible handwriting, as well as the number of misunderstood verbally ordered prescriptions. 

In addition to our strategic partnerships with e-prescribing vendors that utilize Lexi-Comp’s decision support information such as drug interaction software checking (drug-drug and drug-food), drug allergy checking, therapeutic duplication checking, dose range checking (adult and pediatric) and more, Lexi-Comp also offers drug reference book information that is written by dentists for dental professionals.

 

Alteration of dose should be approached with an appreciation for several key factors. Other factors should be considered related to dosage administration. A drug reference book is only a starting point. One should not be so cautious about drug dosing that the therapeutic benefit of the drug is lost. Inadequate dosing may lead to treatment failure. Accumulation related to impaired elimination requires repeated dosing. In evaluating possible risks of accumulation, it is also important to balance the timing of drug accumulation, and the relationship of elevated concentrations to specific adverse effects. Drugs which are dosed for a very limited period of time, or drugs which have wide therapeutic “windows”, may not warrant much in the way of dosage adjustment.

 

The initial dose of a regimen is often not adjusted, serving as a “loading” dose to achieve therapeutic response. Subsequent dosage may be adjusted by lengthening the interval or reducing the size of an individual dose. Different drug classifications may require different dosing adjustment strategies. It is important to employ a strategy which does not compromise the efficacy of the drug – so drugs which need high “peaks” for efficacy should generally be adjusted by interval, while drugs which need a continuous presence in the serum should be adjusted by the size of the individual dose.

 

Selection of an alternative which is hepatically metabolized may be an option, but one must consider metabolites as a part of evaluation. For example, Morphine and meperidine are hepatically metabolized, but each has a metabolite which accumulates in renal impairment. In the case of morphine, additional sedation/respiratory depression may result. Meperidine’s metabolite results in neuroexcitation, potentially leading to seizures with repeated dosing. However, a single dose of either agent is not likely to result in harm. Other metabolites which may be of concern include NAPA, and desmethyldiaepam.

 

The implementation of electronic health records (EHR) claims to help reduce medical errors by providing healthcare professionals with clinical decision support. Some of the existing EHR providers in the hospital setting have the software architecture that allows the hospital to choose the drug data knowledge base that the hospital prefers to use however, there are other EHR providers in the hospital setting that force the hospital to use the drug data knowledge source without any choice.  Drug data is a critical component that has an impact on healthcare costs and the overall quality of patient care, so having the ability to select which knowledge base should be a consideration of the EHR vendor.

I have had discussions with various hospitals that are not satisfied with their current EHR provider's drug knowledge base and have expressed an interested in evaluating other drug data resources such as Lexi-Data.

Lexi-Comp offers a solution called Lexi-Data that contains decision support information such as drug interaction software (drug-drug and drug-food), drug allergy checking, therapeutic duplication checking, dose range checking (adult and pediatric) and more. Lexi-Data also contains drug reference book information, dose administrations, dosage precautions, dosing in pediatrics, and much more.  Delivery options include database tables that are compatible with Oracle, SQL Server, and MySQL and an easily implemented Software Development Kit (SDK) powered by Jav or .NET APIs.