EHR Vendors Struggle with Meaningful Use

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 it's Lexi-Data product 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 product that is easy to integrate and provides meaningful alerts will ultimately lead to product you can be proud of.

One of the most common comments I hear from users of Electronic Medical Records (EMR) systems is associated with “alert fatigue” from unwelcome drug interaction notifications. Many users tell me that they are flooded with unavoidable but unnecessary alerts that interrupt their workflow, decrease productivity, and make the important alerts harder to see. Clinicians find themselves clicking through the alerts as quickly as possible which defeats the purpose of clinical decision support. 

In today's fast-paced healthcare industry, electronic health record (EHR) and other healthcare information system vendors need smart, current drug data that will enable their systems to drive patient safety and improve healthcare -- without generating a flood of annoying alerts that will only be ignored. Lexicomp has recently included new functionality that can alert users with the appropriate Black Box Warning where appropriate in the current workflow. 

In the most simple terms, an FDA Black Box Warning is the strongest warning that the US Food and Drug Administration (FDA) puts on a drug. It means that you should pay close attention to the drug's usage because there are some potentially extremely harmful or dangerous threats to your health that the already FDA approved drugs could pose.

The other side of the coin, however, is that an FDA Black Box Warning means that despite the FDA's knowledge of these harmful, serious and sometimes deadly side effects that they are still leaving the FDA approved drug on the market for you to be able to take and potentially experience these harmful side effects. In theory, these FDA Black Box Warnings are designed for both the doctor who is prescribing the drug to be aware of the problems and for you as the consumer to be more aware.

The warning is placed in a prominent 'black box' on the package insert of an FDA approved drug so that people and their doctors can be more aware of it, but few doctors ever see the pill bottles and the vast majority of consumers realistically aren't going to go through the amazingly large amount of technical and medically detailed information on a package insert. This can lead to doctors note being aware of a serious alert which can have serious consequences. With Lexicomp’s inclusions of Black Box Warnings within their medication database, the warnings can be provided to the physician during the prescription process where they are most needed.

Over the past decade, the number of reports of adverse drug events has been on a dramatic rise.   The FDA currently uses an Adverse Event Reporting System (AERS) which has seen a large increase on the number of reports coming in.  In fact, researchers at the University of Maryland School of Pharmacy revealed in a new study of adverse events linked to medications─compiled by the FDA since 1969─that 55 percent have been reported to the agency in the past decade.


Drug makers are required by federal regulations to report possible health problems possibly linked to their products, but reporting by doctors, patients, and others is voluntary.  New safety warnings and technology making reporting easier could play a part in this increase in reports, but there may be other contributing factors.  With the current US populations aging, more and more people are taking multiple medications to treat multiple medical conditions.  This has been most apparent when I have spoken with a few nursing home and assisted living facilities who have relayed that a number of their patients currently have a medicine list of over 10 medications and some are as high as 20.  With all of these medication being taken together, it stands to reason that additional adverse drug events are reported.


There is drug information software available to help with checking medication lists for things like drug food interactions, drug-drug interactions, drug-allergy interactions, and drug-condition interactions that could potentially help reduce these adverse drug event reports.  In fact, software like Lexi-Data from Lexicomp has been included in a number of applications including EMRs, EHRs, analytic tools, and ePrescribing  solutions with the intent of screening in real time for adverse events while medication are being prescribed.  Also, new patient education materials that are easily understood by the patient can help reduce things like drug-food interactions by informing the patient of the potential.


While software systems generally rely on case studies or published information to screen for adverse drugs events, the increase in the number of reports to the FDA will hopefully help to identify additional adverse drug events that have yet to be identified, leading to better outcomes for patients in the future.

With HIMSS 11 rapidly approaching, a number of vendors will be arriving in Orlando.  With the number of booths at this years event, it will be hard to see everything there is to offer during the three days the exhibit hall is open.  To cut down on time spent reviewing vendors, look for specific product features that will address specific Meaningful Use criteria.

Lexicomp can help by providing a medication list that includes both generic, brand name, and over-the-counter drugs. By providing drug interaction screening including drug-drug, drug-allergy, drug-condition, dose range checking, and duplicate therapy screening, Lexicomp can help EHR vendors meet a number of Meaningful use requirements.  The Lexi-Data product delivered by Lexicomp is also mapped to RXNORM and contains patient education which is another check box on the Meaningful Use requirements list.   

Although there are a number of vendors providing drug nomenclatures,  not many can provide all of these features, and could lead to issues down the road with achieving Meaningful Use certification.  Use your time wisely while at HIMSS and visit Lexicomp at booth #6653.

I read an article from msnbc.com on Friday that discussed a problem that has been affecting the healthcare industry for a number of years. In drug nomenclature there are a few different names a drug can have. Many times these names are similar and can create confusion and ultimately lead to serious patient harm including, in some cases, death. There are instances where a drug brand name and a drug generic name sound or look similar and are easily confused. In fact, the article provides a link to The Institute for Safe Medication Practices list of over 1500 drugs having sound-alike or look-alike issues that have been reported to the ISMP’s Medication Errors Reporting Program.

The article goes on to list that almost 4 billion prescriptions were filled in 2009 and the overall error rate is around 1.7%, leading to 66 million drug errors each year. Of those, 325,000 are the wrong-drug errors that were serious enough to cause potential harm, including long-lasting injury or death, to patients. Although this is a small number compared to the 4 billion prescriptions that were filled last year, these mistakes could happen to anyone and sometimes have severe consequences. With the push to be more efficient, doctors, pharmacy technicians, and pharmacists are usually rushed and, in the end, are human. Given time, errors are likely to occur at some point.

So what is the answer? Is there a way to correct the problem? I am not sure is it can ever be eliminated completely, but computers may be one avenue to address some of the issues. ePrescribing may eliminate some of the issues related to look-alike drug names as well as poor hand writing by having an electronic drug listing to pick from tied in with a clinical decision support system. This can help to reduce errors during the prescribing and order filling workflow.  Another avenue might be to get the patient involved. A number of consumer websites have been emerging that provide drug interaction databases free to the public and present results in consumer friendly text. 

Even with these solutions in place the chance for error still exists, but I believe the number of errors would be far less than what we see today.