Anyone who has been exposed to electronic order entry has experienced the dreaded "alert fatigue". If the goal of electronic prescribing is to improve patient safety and outcomes, alerting clinicians to potential drug interactions or other dosing precautions is necessary. In our current information age, there is a plethora of information available regarding medication safety and potential safety issues with the use of medications. In an attempt to help clinicians sift through all this information, the FDA has established the use of a "Black Box Warning" to call attention to the most important safety issues. A recent
study published in the Archives of Internal Medicine reviewed several drug information providers comparing their ability to identify black box warnings and confirmed that Lexicomp is the leader in this area.
In an effort to incorporate this valuable information into the clinician's busy workflow, Lexcomp has recently enhanced their Lexi-Data product to include Black Box Warnings. The Black Box Warnings table allows system vendors to present critical medication safety information from these warnings within a health information system. The data is also structured in a way that will allow the system vendors to filter which alerts are presented, allowing for instance a prescriber to see warning specific to the ordering process and a pharmacist seeing warnings more relevant to the dispensing process.
Improving patient safety requires the use of "intelligent alerting",
Lexi-Data has given system vendors the ability to present critical safety information in a meaningful way.
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/.
There have been thousands of articles written discussing why EMR adoption rates have been so low and why physicians especially have been resistant to moving into the electronic age. Little return on the initial investment, lack of efficiency in the system and no improvements in patient outcomes have been listed as reasons for reduced adoption rates.
One key element to the lack of efficiency and little improvement in patient care is due to the number of alerts that are generated when trying to use these systems. As a pharmacist, I enter in hundreds of medication orders in a shift and it is rare that I do so without receiving an alert from my HIS telling me about a drug interaction or duplicate therapy. These alerts although technically accurate, often involve medicine interactions that are so minor or irrelevant to hospital medicine.
If an HIS truly wants to improve patient care and become an indispensable part of medicine, it must provide clinical decision support that can accurately and appropriately give clinicians therapeutic alerts that are relevant and can help improve patient care. That is the goal of Lexi-Data. For more information about Lexi-Data, check out www.lexi.com.
As we attempt to incorporate more technology into medicine through the use of HIS, it brings to light the need for more than just a simple medication list. Health information systems are now being asked to help improve patient outcomes by performing other clinical decision support functions that go beyond a pick list. If we truly want to improve patient outcomes, it is important that our HIS provide relevant clinical guidance especially in a critical population such as pediatrics. Calculating pediatric doses is not always an easy task and having data in your HIS that can perform pediatric dosing calculations can be an invaluable tool in improving patient outcomes.
Lexicomp has a long standing reputation of providing this valuable and often difficult dosing information in the Pediatric Dosage Handbook. For over 20 years, we have been providing neonatal and pediatric dosing based on available literature and current clinical practice. More recently this information has been transformed into Lexi-Data's Pediatric Dosage Range Checking application. This content can be used within an HIS to provide guidance to your clinicians on appropriate dosing for this difficult and vulnerable population.
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.
As hospitals and EMR vendors scramble to prepare for Stage I Meaningful Use criteria, the Stage II criteria are already being prepared. The Stage II requirements will require hospitals to continue with and advance the use of CPOE, and the use of clinical decision support elements including drug interaction and drug allergy screening. Additionally, patient education materials must be offered to at least 80% of patients at discharge.
Although most of these requirements are simply advancing a requirement from Stage I, the ultimate goal of requiring the use of clinical decision support tools is to improve patient care, especially as it relates to high priority health conditions. In order to accomplish this, CDS should have specific attributes: authenticated, credible, evidenced-based and patient-context sensitive. This can only be accomplished by using a drug reference database that can provide information that meets this criteria.
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.
Once again, meaningful use and clinical decision support will be at the forefront of the
HIMSS11 Annual Conference and Exposition. Both vendors and clinicians have a vested interest in achieving meaningful use and providing patients with improved outcomes which will be the focus of this year's meeting.
Lexicomp will again be exhibiting at this year's meeting and will be providing information on how our transactional drug information, Lexi-Data, can be integrated into new and existing health information systems. This will be an opportunity for vendors and clinicians to learn more about how using Lexi-Data for Pediatric Dosage Range Checking, drug allergy assessment, drug interaction analysis and duplicate therapy alerting can help improve patient care and medication safety.
For years, healthcare providers have been using Lexicomp's clinical information to help guide therapy decisions on drug dosing and drug interaction management. As we head toward this era of meaningful use and electronic health systems, we have taken this trusted clinical content and created a transactional drug database that can be leveraged to help achieve meaningful use. Stop by the booth to see this product in action.
A recent survey of members of the College of Health Information Executives reported that fewer CIOs are expecting to be qualified for meaningful use dollars by April of 2011 (
http://www.ihealthbeat.org/articles/2010/12/9/cios-lower-expectations-for-early-meaningful-use-compliance.aspx). Having an EMR that is capable of screening for drug interactions, allergy issues, duplicate therapy and dosage range checking are key elements in meeting the meaningful use criteria. Now is the time to make sure your clinical decision support systems are powered by the best available data.
Recent research from Chilmark (mHealth in the Enterprise: Trends, Opportunities and Challenges.) is predicting that the mHealth market will see exponential growth over the next several years. The research is predicting that mobile applications that can connect physicians to other hospital HIS such as CPOE and EMR will be the fastest growing group. This leads us to consider how this trend will impact patient safety and workflows. As more mHealth technology is developed, there will be a focus on clinical decision support tools within these applications. Physicians will be looking for guidance on drug-drug interactions, allergy screening and therapeutic dosing recommendations within these mHealth apps. Making sure that the information behind these systems is founded on current clinical guidelines and expert dosing recommendations will be the key to realizing an actual improvement in patient care.
As the push for meaningful use continues, more and more clinicians of different backgrounds (physicians, nurse practitioners, pharmacists, etc.) will be using electronic systems to document patient care, write medication orders and make critical therapy decisions. Using electronic systems can hopefully improve patient care and outcomes through highly relevant clinical decision support tools such as drug interaction screening, dosage range checking, allergy screening and other safety alerts. The reality is that these tools must be able to not only provide meaningful and relevant alerts, but should also provide clinicians with the ability to further research the area of concern with trusted reference content. Too many times a clinical warning message that is displayed in an HIS system does not provide enough context to the user to make better therapeutic decisions.
As HIS system vendors navigate their way through the certification maze, it will be important to not settle for inferior clinical reference data to augment these systems. Those millions of clinical alerts that fire everyday are only as good as the information behind them.
The Office of the National Coordinator for Health Information Technology (ONC) has selected three ONC-Authorized Testing and Certification Bodies (ATCBs) that will be certifying electronic medical record systems that are capable of achieving meaningful use. The three groups that have received this initial authorization are: Certification Commission for Health Information Technology (CCHIT); Drummond Group; and InfoGard Laboratories. These ATCBs will be using the previously announced meaningful use criteria to perform testing and certification. This certification will announce to eligible providers that electronic health record technology has the capabilities necessary to meet the meaningful use Stage 1 criteria.
As vendors begin to apply for these certification programs it will be extremely important to have the mandatory clinical decision support functions in place to pass these certification tests. This means that all EMRs will have to be able to demonstrate dosage range checking, drug interaction screening, duplicate therapy screening and drug allergy screening. Given the fact that this mandatory clinical decision support functionality will be part of every system, the key to having an impact on clinical outcomes will depend on the drug information used within each system. Clinicians have been relying on Lexi-Comp's drug dosing, drug interaction and drug therapy information for over 30 years to make drug therapy decisions and improve patient outcomes. When it comes to selecting the content for your clinical decision support tools, why not choose the information that clinicians use every day?
Summer means hot dogs, fireworks, swimming and for hospitals it means a new batch of residents. Although working with new residents can be challenging at times, new practitioners offer a wonderful opportunity to test our clinical decision support systems that are in place to help improve patient care. By definition, new practitioners have little practice experience and rely on decision support alerts to avoid drug interactions and medication dosing mistakes. Additionally, residents often embrace new technology and can be a driving force as we strive to achieve meaningful use of our health information systems.
Rather than the usual, "here we go again" attitude toward working with new residents, this is the time to ensure that the clinical information systems we have in place are based on clinical practice guidelines and can improve patient care. Ultimately, these new practitioners can be the strongest advocates for adopting this new technology provided the drug interaction, dosage range checking and duplicate therapy alerts that we bombard them with help improve patient care.
On July 14 the final
Meaningful Use rules were released and gave some specific requirements for clinical decision alerting. This ruling means that clinical decision support and the drug nomenclature that is incorporated into these systems will be evaluated with a more critical eye than ever. With these new meaningful use requirements, clinicians that write more than 100 e-prescriptions during the reporting period must have drug-drug interaction, drug-allergy, duplicate therapy and formulary screening alerts enabled within their systems and have a way to track user response to these alerts.
With this paradigm shift in the way healthcare is being delivered, it will be paramount that these systems provide accurate, meaningful clinical decision support and avoid the pitfalls of alert fatigue. Now is the time clinicians should demand that the clinical systems that are implemented have quality alerting and drug reference information based on current clinical guidelines.
We often complain that the clinical information systems that we use provide too many alerts for meaningless drug interactions, duplicate therapy alerts that are therapeutically justified or a dosing alert that doesn't truly understand how dosing in pediatrics actually works. These are the challenges that we face everyday in working with these systems, however what is the alternative?
A recent
report published by the Leapfrog group analyzed how well a CPOE system performed when providing clinical decision alerts for common medication orders. The survey tested 10,447 medication orders known to contain a medical error and found that 52% of the adult orders passed through the system without providing any alert and 42% of the pediatric orders passed without any alerting. Additionally, the report showed that approximately 33% of the errors could be fatal errors.
I guess before we complain that our systems are providing "too many" alerts, we better make sure that they're providing enough...
As we move forward in the era of ARRA, new requirements for clinical information systems will begin to force specialty vendors of ER systems and anesthesiology systems to go beyond the traditional medication lists and begin to incorporate clinical decision support alerts within their applications. Traditionally, these systems have been self-contained and have not provided alerts such as drug interaction warnings, duplicate therapy notifications and dosage range checking when orders are processed. As new meaningful use criteria is developed, these systems are now being required to incorporate this type of functionality and soon the ER physicians will experience the wonderful frustration of "alert fatigue".
In these settings where time is of the essence and patients typically receive single doses that may be life-saving or recommended by current clinical practice guidelines, it is paramount to provide alerts that are truly useful and can/should impact therapy. I only hope that these systems evaluate carefully the data they use to meet these needs and provide useful alerts for these physicians, as they make critical medication decisions in a very stressful and time-sensitive situation.
When it comes to designing a new product, how intuitive or easy the product is to use has a huge impact on its success. The same concept holds true for clinical information systems. In order to achieve meaningful use of an EHR, it must be something that is first and foremost, "usable". A usable system should not just provide clinical decision alerts, but rather meaningful drug interaction or duplicate therapy alerts and clinically appropriate dosage range screening. The onus of creating a usable system ultimately falls on the shoulders of the EHR vendors, however they are at the mercy of the data available for use.
For example, if you are designing a system that is designed to accommodate pediatric patient care, you must have reliable, valid pediatric dosing information powering that system. If your system is using data that does not understand the nuances of pediatric dosing, how can it be expected to provide meaningful screening that will ultimately improve patient safety? That is the question that EHR vendors should be asking when selecting the data source for their systems.
A recently published
article in Healthcare IT News predicts that the global market for EHR vendors will grow at a rate of 15.3 percent over the next seven years. This growth will mean that clinical decision support and the drug nomenclature that is incorporated into these systems will be evaluated with a more critical eye than ever. With the new meaningful use requirements that are soon to be implemented, more clinicians will be exposed to drug interaction, duplicate therapy, drug allergy, and dosage range alerts than at any other time.
With this paradigm shift in the way healthcare is being delivered, it will be paramount that these systems provide accurate, meaningful clinical decision support and avoid the pitfalls of alert fatigue. Now is the time clinicians should demand that the clinical systems that are implemented have quality alerting and drug reference information based on current clinical guidelines.
As a staff pharmacist, we are constantly bombarded with warnings about drug interactions, duplicate therapy and therapeutic dosage. If the average hospital pharmacist inputs 500 or more medication orders in a typical shift, how many warnings must he/she override when entering those orders? 50? 100? 200 or more? In many instances a duplicate therapy alert will fire for using two different medications in the same base fluid. In most instances, a pharmacist can easily decide when to override an unnecesary duplicate therapy alert or can use his clinical knowledge to correctly override a therapeutic dosage alert.
But if the point of having a clinical decision support system is to improve patient safety, shouldn't our alerting systems be smarter? The key to smarter alerts is using smarter data and building a pharmacy system that can utilize this data.
Hopefully with the advances in technology and our new focus on using electronic systems, we can begin to have medication databases that work to improve patient outcomes and not continue to be "noise" that is often overlooked.
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