RxInformatics.com instead

Please go to the following site for ongoing blog post and discussions.

http://rxinformatics.com/

RxInformatics is a collaborative site with Chad Hardy and John Poikonen. Rather than support his blog, I will be consolidating on this site.

I will cross post to my personal blog as well at http://rxdoc.org/ or http://pharmacyinformatics.wordpress.com/

Thank you all for your comments and interest!

John Poikonen, PharmD

ASHP Hypocrisy

I have commented on the cluelessness of Am Soc of Health System Pharmacists (ASHP) on-line publishing model in the past via their forums.

My motivation for this is to get them to wake up and realize the potential of a full scale on line presence and to get them off of their antiquated paper publishing model before they go by the way of the Rocky Mountain News and Seattle Intelligencer

A new bizarre irony and hypocritical situation has emerged. While endorsing electronic medical records they still will not allow members to opt out of getting publications on paper. Their journal is extremely valuable and of high quality that I read religiously on lne. Every two weeks a large (rather nice, but incredibly wasteful) package arrives. Every two weeks I populate my town’s landfill with more waste.

Posted via web from RxDoc.Org

Why is there not a Sermo for Pharmacists? Lets start one

See http://www.sermo.com/

The Sermo business model is based on “Information Arbitrage.” This is the opportunity that arises when breaking medical insights intersect with the demand for actionable, market-changing events in healthcare. Our clients include some of the nation’s most prestigious healthcare companies, financial services institutions and government agencies: any organization that can benefit from early insight into clinical events. These parties create a financial incentive that is used to generate, sustain, and support participation in the online physician community.

Through information arbitrage, our clients are able to:

• Help forecast potential problems or new uses for commercially significant medical products and therapies
• Gain early insight into outbreaks and other changes in disease states and conditions that can affect the public health
• Perform epidemiologic research investigations
• Perform real-time surveys of the opinion of practicing physicians on topics related to medical care
• Assess the success and adoption of best practice recommendations
• Find opportunities to improve medical practice, and protect and promote patient safety and the public health

Clients pay a subscription fee and in return can post questions to the Sermo community. If you vote on one of these postings, you may be financially rewarded for your astute observations.

Posted via web from RxDoc.Org

(NQF) has revised its list of practices that have proven effective in reducing adverse events - Pharmacy Informatics perspective

The National Quality Forum (NQF) has revised its list of practices that have proven effective in reducing adverse events.  This is a very impressive list of practices.  It also revealing what is not on the list.

From a pure pharmacy informatics perspective the following practices are good to see.  CPOE and Pharmacy leadership are, of course, welcome additions to this list.  Using technology to enhance medication reconciliation and antimicrobial stewardship will go a long way to enhancing care as well and need a full court press by pharmacy and informatic departments.

Bar Code Medication Administration (BCMA) is not on the list.  This is not a big surprise.  I have settled into a role and view of a counter balance to most of my pharmacy colleagues.  There is a wide effort to implement BCMA to decrease adverse events without much evidence that it does anything.   Spouting a negative view on this practice is not comfortable nor one that I believe will last forever.  I fully believe that this practice will eventually be proven effective.  At this time it clearly is not.  Given this list of these proven practices, spending time and effort on BCMA if all of these practices are not fully exploted, may even be harmful.  We all have limited resources and time taken away from proven practices to ones of dubious value needs to be evaluated.

What say you?

John Poikonen
john@poikonen.NET
http://twitter.com/poikonen
Blog = http://pharmacyinformatics.wordpress.com/

Posted via email from RxDoc.Org

No More NUPOR Mooing and Musings #3

The first article on NUPOR is out in the April 1^st, Am J Health System Pharmacy. It is brilliant and will change the face of pharmacy as we know it (IMHO of course).

Opportunity cost of pharmacists’ nearly universal prospective order review

Allen J. Flynn

Am J Health Syst Pharm 2009;66 668-670
http://www.ajhp.org/cgi/content/full/66/7/668

I will have a letter in response (and support) of this from an informatics point of view in the next issue, April 15^th AJHP. There already are other responses in press and will be appearing soon. This topic is also covered in my blog. Click this for more info (if you dare/care)

http://pharmacyinformatics.wordpress.com/?s=NUPOR

There is a link at the bottom of the article’s full text to submit a response the article. I encourage you to do this whether you agree, disagree or have additional points to make. This is the AJHP link to send a direct response.

http://www.ajhp.org/cgi/eletter-submit/66/7/668

I look forward to hearing and viewing the responses.

Posted via email from poikonen's posterous

Two Very Different Views of eRx and EHR benefits

E-prescribing savings will offset the $19 billion feds will spend for health IT
and
Bad Bet on Medical Records

While not exactly apples to apples, example of the diverse opinions.  Mine is somewhere in the middle.  I do not think eRx will achieve this lofty goal.  The Washington Post editorial is a bit biased.  Not sure what the authors axe to grind is?

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Health Affairs March April 2009 Issue

The latest issue of Health Affairs is packed full of content on health information technology from almost every angle.  This issue will keep me reading for some time.  There is a web site that has the entire audio, video and powerpoints from a briefing in Washington DC.  Twitter has a series of tweets done from the meeting that is insightful, especially if you read when viewing the video; you get this weird virtual feeling of being there.  One of the articles, free to all, called Social Media In Health Care is excellent.

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Getting Started on Twitter

On Twitter, for those that want to enter the twitterverse, here is a suggestion.  Following these people initially will help you put your toe in the water (to better understand) without jumping in and drowning.

• http://twitter.com/Berci Fascinating medical student in Hungary, quickly becoming the first Web 2.0 Medical superstar.
• http://twitter.com/kevinmd Kevin Pho, MD from Nashua NH in primary care and winner of the best medical blog of 2008.
•  And if you can stand it:http://twitter.com/poikonen

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50 Successful Open Source Projects That Are Changing Medicine

I have a new appreciation for Open Source projects, primarily through this book (currently free download). It seems to me that an Open Source project focused on medication clinical decision support is needed.  There will be more on this later as I am working with some others to develop this idea.  In the mean time this is a fantastic list of projects, fyi.  Found at http://nursingassistantguides.com/2009/50-successful-open-source-projects-that-are-changing-medicine/

 

50 Successful Open Source Projects That Are Changing Medicine

February 19, 2009

Open source healthcare is forging forward quickly on the Internet. But, fast developments often produce many failures. But, many medicinal open source projects that have gained success development. This success shows that open source alone is not the solitary factor in development. Instead, look to great management, public relations, marketing and a sound program that stands up under the scrutiny of a growing number of peer users and, often, patients.

To limit this list to 50 projects means that we’ve tapped only the tip of the mountain of open source projects available to the healthcare industry. The following list is categorized alphabetically, and each link under every category is arranged alphabetically as well. We use this methodology to show that we do not favor one resource over another.

Ambulatory Care

1. ClearHealth: Medical software designed by clinics and hospitals and powered by Open Source software. ClearHealth includes modules for document storage, customizable reporting/forms, lab results and prescription management.
2. EGADSS: EGADSS is an open source tool that is designed to work in conjunction with primary care Electronic Medical Record (EMR) systems to provide patient specific point of care reminders in order to aid physicians provide high quality care.
3. GNUmed: Use this free/open source software, released under the GNU Public license to andle your patient’s records.
4. IndivoHealth: Indivo is a personally controlled health record system that enables patients to own complete, secure copies of their medical records.
5. OpenEHR: In the clinical space, it is about creating high-quality, re-usable clinical models of content and process - known as archetypes - along with formal interfaces to terminology. OpenEHR could take you there.
6. OpenEMR: OpenEMR is a free medical practice management, electronic medical records, prescription writing, and medical billing application.
7. OpenMRS: OpenMRS is a community-developed, open-source, enterprise electronic medical record system framework.
8. Tolven: An opportunity to use electronic Clinician Health Record (eCHR) and electronic Personal Health Record (ePHR) systems.
9. Ultimate EMR: Ultimate EMR was designed as a Commercial Open Source application rich in features and that can be combined with many other products and tools.
10. WorldVista EHR: WorldVistA EHR is an open source electronic health record based on the highly acclaimed VistA system of the United States Department of Veterans Affairs (VA).

Collaboration

1. GNU Projects: The Free Software Foundation provides a variety of free and open source software and publishes a list of various open source licenses and comparative features.
2. Medsphere: Medsphere.org is a community gathering place where healthcare administrators, clinicians, developers and enthusiasts can interact, share, and collaborate.
3. Open Health: This Yahoo! Group focuses on discussion of FOSS health I.T.-related topics.
4. Open Source Health Informatics Working Group: IMIA OSWG brings together experts and interested individuals from a wide range of health professions and with a range of interests in the potential application of free/libre and open source solutions within their domains of expertise.
5. OS-WG: The mission of the OS-WG (Open Source Working Group) is to act as the primary conduit between the broader open source community and AMIA (American Medical Informatics Association).
6. OSHCA: OSHCA’s membership comprises a community of people, civil societies and professional bodies in health care and informatics industries that promotes the Free/Open Source Software Concepts in Health Care.

Integration

1. Gello: ANSI-accredited HL7 standard for creating computable, unambiguous clinical queries.
2. i2b2: i2b2 (Informatics for Integrating Biology and the Bedside) is an NIH-funded National Center for Biomedical Computing based at Partners HealthCare System. Their work is designed to facilitate the design of targeted therapies for individual patients with diseases having genetic origins.
3. IHE Open Source: This project holds an implementation of the Cross-Enterprise Document Sharing (XDS) profile as defined by IHE (ihe.net).
4. Mirth: Mirth is an open source cross-platform HL7 interface engine that has established itself as the baseline for healthcare information exchange. Mirth allows messages to be filtered, transformed, and routed based on user-defined rules.
5. Records for Living: OpenHealth services allow for a wide variety of safe, secure reports and services to be delivered to consumers, leveraging the power of their electronic medical records.

Imaging/Visualization

1. BrainStorm: BrainStorm is an integrated free Matlab toolkit dedicated to Magnetoencephalography (MEG) and Electroencephalography (EEG) data visualization and processing.
2. Medical Exploration Toolkit: Advanced two- and three-dimensional visualizations with easy application building and efficient case management.
3. MicroDicom: MicroDicom is application for primary processing and preservation of medical images in DICOM format.
4. O3-RWS: O3-RWS is the Radiology Workstation of the Open Three (O3) Consortium. O3-RWS is an Open Source, IHE based, Internationalized, Modular and Portable Image Display.
5. SMIViewer: A free (soon to be open source) DICOM volume analyzer for research/teaching on Windows.

Medical Practice Management Software

1. CARE2X: Care2x integrates data, functions and workflows in a healthcare environment.
2. iHRIS Suite: Open source HRIS solutions, distributed under the GPL, to supply health sector leaders and managers with the information they need to assess HR problems, plan effective interventions and evaluate those interventions.
3. MirrorMed: MirrorMed is a free and open source EHR and practice management system written in PHP. This is a Web-based application that is capable of running a healthcare practice.
4. OpenDental: Previously known as Free Dental, OpenDental is an open source Practice Management Software licensed under the GNU General Public License.
5. OpenTAPAS: Technology Assisted Practice Application Suite (TAPAS) is a model to assist primary care physicians use technology in a targeted manner in their practices. It is an open source (GPL 2.0) collection of tools.

Online Publications

1. PLos Medicine: A peer-reviewed open-access journal published by the Public Library of Science.
2. LinuxMedNews: This is your site for Linux, Free and Open Source medical software news, and has been since March 2000.

Programs

1. Debian Med: The goal of Debian Med is a complete system for all tasks in medical care which is built completely on free software.
2. Eclipse Open Healthcare Framework (OHF) Project: The project is composed of extensible frameworks and tools which emphasize the use of existing and emerging standards in order to encourage interoperable open source infrastructure, thereby lowering integration barriers in healthcare informatics technology.
3. NHS: A UK NHS Interface (CUI), program guidance and product library available to NHS users and service providers using N3.
4. ODIN: ODIN is a C++ software framework to develop, simulate and run magnetic resonance sequences on different platforms.
5. Open Three (O3) Consortium: An innovative open-source project dealing with the multi-centric integration of hospitals, RHIOs and citizen (care at home and on the move, and ambient assisted living), based on the about 60 HECE bilateral cooperation Agreements with healthcare facilities. Use their imaging, collaboration and other software.
6. OpenGalen: Their goal is to promote healthcare through stimulating the use and development of GALEN experience and technology as a basis for teaching, training and services in the area of medical terminology, language, knowledge and information and in anything directly or indirectly related in the widest sense.

Public Health and Biosurvellance

1. EpiSPIDER: This experimental map is generated from news reports from both expert-curated and general news sources on epidemics.
2. Influism: To be used for pandemic preparedness planning by health care offices, this download computes the effect of interventions like antiviral treatment of cases and social distancing.
3. OpenEMed: Biosurveillance and clinical data repository based on Web services and modules. Offers solid interoperability and federation of clinical data.
4. RODS: “Real-time Outbreak and Disease Surveillance” (RODS) is an open-source public health surveillance software.
5. Sispread: This open source tool was created to help people concerned by public health to easily perform epidemic simulations and to analyze their results.

Software

1. ATP III Cholesterol Management: This interactive guideline tool will assist the clinician in implementing the ATP III Cholesterol Guidelines at the point of care on a Palm OS.
2. BMI Calculator : This calculator runs on any device running the Palm Operating System (Palm OS) and PocketPC 2003.
3. Heart Attack Signs: This Palm OS program provides physicians and other health care providers talking points for discussing heart attack warning signs and survival steps with patients.
4. IPath : iPath is an open source platform for telemedicine applications such as consultations, case discussions, virtual staff meetings and more.
5. MedMapper: Medical decision making algorithm tool. Visual design tool generates Tcl/Tk code. Non-programmers can design interactive algorithms. Generates notes for inclusion in medical record.
6. Zephyropen : Open source SDK for health monitoring devices and downloads for OSX, PC and cell phones.

 

John Poikonen

john@poikonen.net

On Line Presence 

http://twitter.com/poikonen

http://pharmacyinformatics.wordpress.com

http://www.evernote.com/pub/poikonen/PublicPharmacoinformatics

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Hospitals try ATM for drugs

 

Hospitals try ATM for drugs   3/16/2009 11:46 AM  from  http://www.nationalpost.com/story-printer.html?id=1393577
Hospitals try ATM for drugs Machine connects to call centre to dispense pills Tom Blackwell,  National Post  Peter J. Thompson/National Post Hundreds of Toronto patients have been picking up their prescription drugs in recent months much as they might withdraw cash or buy a can of soda -- from special vending machines that some observers believe could transform the pharmacy business. Customers using the PharmaTrust kiosks insert their prescription into a slot and, a few minutes later, the device spits out their medication. Skeptics question whether the machines will ever duplicate the benefits of meeting in person with a druggist. Proponents, though, say the Canadian-made invention, which allows users to communicate with a real pharmacist by video link, offers real convenience when there is no pharmacy open, or close by. "I think it could be the next BlackBerry," says Dr. Sharon Domb, medical director of family medicine at Toronto's Sunnybrook Health Sciences Centre, which has been testing the technology since last June. "The feedback has been positive: 'It's great, it's fast, I don't have to go anywhere else.' " Another hospital -- Cam-bridge Memorial in southwest Ontario -- plans to install the machines in its emergency department next month, while more are to be rolled out in a large, east-end Toronto doctor's office at about the same time. Some pharmacists will undoubtedly feel threatened by the technology, says Jeff Poston, executive director of the Canadian Pharmacists' Association. But he predicts the machines will have only a niche role, likely in remote communities that have limited pharmacy services, since the devices offer patients a "lesser" form of communication with the druggist. "I tend to think the face-to-face encounter with the pharmacist would win hands down," he said. Yet the notion of purchasing prescription medicine somewhat as one would buy a bag of chips does not seem as jarring to many patients as it sounds. Shelly Dev, a long-time patient of Dr. Domb's at Sunnybrook, even suggests the machine's built-in telephone allows for a more private conversation with the pharmacist, while the whole transaction is far quicker than visiting a drugstore. She used one of the dispensers for the first time on Friday to fill a prescription for antibiotics, and was done in less than five minutes. "It's very easy to use," said Dr. Dev, who is an intensive-care physician at Sunnybrook. "Usually, for most folks, you go see your physician ... you leave, you go to another place to drop off your prescription, you have to go back to pick it up. It's monotonous." When customers insert their prescription, the ATMlike machine -- made by PCA Services Inc. -- snaps high-resolution photographs of both sides and transmits them to a pharmacist waiting in the firm's Oakville, Ont., call centre. He or she reads the information, directs the machine to start dispensing and waits while robotic technology finds the prescribed medicine from among 340 different drugs stored inside. Once the pharmacist has verified the kiosk has picked the right product, the machine pops out the order. During the transaction, the customer speaks to the pharmacist via a telephone and video screen built into the kiosk. Just over 800 patients used the machines at Sunnybrook to obtain 1,200 prescriptions between June and September. A survey of 108 of them indicated that more than 95% received their drug in less than five minutes and would use PharmaTrust again, said Peter Suma, president of PCA. None of the prescriptions was incorrectly filled, he said. Not everyone, however, was able to take advantage of the pharmaceutical ATMs. About a third of patients who tried discovered that their medicine was not available, said Dr. Domb, though PCA offers to deliver those orders to the patient's home the next day. Despite such limitations, Mr. Suma predicts his kiosks will be embraced by consumers accustomed to instant, technologically aided service, especially when the devices are "deployed ubiquitously." "Although this seems controversial now, I bet the telephone seemed controversial to the guys who were delivering messages back then," he said. And steps are being taken in one province, at least, to allow much wider distribution of the machines, which in Ontario can be set up now only in hospitals and clinics. The Ontario College of Pharmacists recommended last week the province change the law to allow all "remote" dispensing-- whether it involves a machine or a technician based in an isolated locale -- as long as a licensed pharmacist oversees the transaction. "It could be a very good thing, provided the safeguards for the public and accountability are in place," said Deanna Williams, the college's registrar. The financially strapped Cambridge hospital will earn some revenue from the machines, but contracted with PCA chiefly to offer convenience to emergency patients who show up 24 hours a day, said Julia Dumanian, the hospital's CEO. Relatively few pharmacies in the community are open late, let alone all night, she said. Meanwhile, PCA is on the verge of striking deals with major clients in the United States and the United Kingdom. In those cases, the company plans to partner with another organization, which would run the call centre, much as RIM works with cellphone networks to provide Blackberry service, said Mr. Suma. © 2009 The National Post Company. All rights reserved. Unauthorized distribution, transmission or republication strictly prohibited.  Click here to download: Evernote.enex (16 KB)

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(NQF) has revised its list of practices that have proven effective in reducing adverse events - Pharmacy Informatics perspective

The National Quality Forum (NQF) has revised its list of practices that have proven effective in reducing adverse events.  This is a very impressive list of practices.  It also revealing what is not on the list.

From a pure pharmacy informatics perspective the following practices are good to see.  CPOE and Pharmacy leadership are, of course, welcome additions to this list.  Using technology to enhance medication reconciliation and antimicrobial stewardship will go a long way to enhancing care as well and need a full court press by pharmacy and informatic departments.

Bar Code Medication Administration (BCMA) is not on the list.  This is not a big surprise.  I have settled into a role and view of a counter balance to most of my pharmacy colleagues.  There is a wide effort to implement BCMA to decrease adverse events without much evidence that it does anything.   Spouting a negative view on this practice is not comfortable nor one that I believe will last forever.  I fully believe that this practice will eventually be proven effective.  At this time it clearly is not.  Given this list of these proven practices, spending time and effort on BCMA if all of these practices are not fully exploted, may even be harmful.  We all have limited resources and time taken away from proven practices to ones of dubious value needs to be evaluated.

What say you?

John Poikonen
john@poikonen.NET
http://twitter.com/poikonen
Blog = http://pharmacyinformatics.wordpress.com/

Posted via email from poikonen's posterous

No more NUPOR Mooing and Musings #1

From the Executive Summary on the Global Conference for Hospital Pharmacy Practice (August 2008):

“Optimally, all medicine orders should be reviewed by a pharmacist , but many countries do not have adequate resources to support this practice. Hospital pharmacists should assess which patients or patient care areas are in the greatest need of this service and then focus their order-review efforts on those patients or patient-care areas.”

The information transmitted is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. Any review, transmission, re-transmission, dissemination or other use of, or taking of any action in reliance upon this information by persons or entities other than the intended recipient is prohibited. If you received this in error, please contact the sender and delete the material from any computer.

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No More NUPOR - Near Universal Pharmacist Order Review

The concept of studing the possibility to eliminate NUPOR with better computerized clinical decision support originated with Allen Flynn, pharmacist informatics guru at Univ of Michigan Medical Center.  He will have a brilliant commentary in the Am Journal of Health System Pharmacy in the April 1, 2009 issue.  I will have a follow up in the April 15th issue and Dennis Tribble, CTO/CPO, ForHealth Technologies will have a subsequent letter on the subject in the May or June time frame.

The basic premise is that we need to study the impact of mandating near universal pharmacist order review on patient care and the profession.  If computerized clinical decision support can do some part or segment of order review as good or better than pharmacists, then that will free pharmacists to do more beneficial services for patients.  The AJHP commentaries will explore this in some depth.   I encourage all to read and comment on this revolutionary topic.  Please comment directly in the new AJHP response system on the AJHP.org site that is below the articles.  Of course I welcome comments to this blog, but that will have wider exposure (for now, at least).

At a speech by Robert Wachter of the great blog Wacher’s World he indicated that when you gore sacred cows, expect a lot of Mooing.  NUPOR is a pharmacy sacred cow.  From time to time I will be posting the various Mooing and Musings on this topic.  I welcome your comments as this plays out, which I suspect might be a number of years.

John Poikonen, PharmD

Posted via web from poikonen's posterous

Checking out the amazing service Posterous.com

This service will post via emails or SMS text to Twitter and Blogs automatically.
See this for more info.  http://www.posterous.com/faq/
Very intriguing.  Single email will post to everything.

Posted via email from poikonen's posterous

Nancy-Ann DeParle

Here is one ray of hope for transformative change in healthcare. Nancy-Ann DeParle has been tapped to head the White House Health Care transition plan. She has been on some company boards that provide some insight that is positive. Presumably she 'gets' pharmacy (Medco), Health IT (Cerner) and Boston (Boston Scientific). Ok, that last one is a stretch.

I had the pleasure to shadow the CEO of Cerner a while ago. If he is anything, he is passionate on the impact technology can and should have on health care. She would not be on the board unless she was totally committed to the use of technology to improve health.

As an aside, the Cerner CEO is a rapid Republican. His wife even ran for Congress but lost b/c she was way to the right of most rational mortals. So I love it that a (soon to be former) board member will be part of the Obama Administration.

http://www.nytimes.com/2009/03.../03health.html?_r=2&hp

Ms. DeParle has extensive experience in the business world that has prompted questions from some liberals and from some of the people who vet appointments for Mr. Obama. Ms DeParle is now or has been a director of huge health care companies including Medco Health Solutions, a pharmacy benefit manager; Cerner, a supplier of health information technology; Boston Scientific, a medical device company; DaVita, which runs kidney dialysis centers; and Triad Hospitals.

http://medpedia.com/

YIPPEE. worth checking out.

Your credentials have been verified and you have been granted Editor privileges on Medpedia. You may now directly edit the Article pages of the collaborative encyclopedia.

The goal of the Medpedia project is to create a new model of how the world will assemble, maintain, critique and access medical knowledge. The repository of up-to-date, unbiased medical information will be written and maintained by health experts like you, and will be freely available to everyone.

As an Editor, you will receive permanent, public recognition for your contributions to this transformational project.

Please click the link below to begin developing your presence in Medpedia by adding to and editing the Articles in your areas of expertise

http://medpedia.com/

Welcome,

The Medpedia Project

-------

Medpedia - a new model for sharing and advancing knowledge about health, medicine and the body.

Penicillin Allergies

Here is a really interesting study, per Jim Carpenter in Portland, on a very high documented true allergy rate of self reported Penicillin allergies in a ED.  91% of people that stated a PCN allergy did not have a IgE mediated response.  Wow, that sounds high to me. 

As Jim points out in his Twitter post, this may have significant implications for CDS alerting.  Some logic based on the patients condition and infection where a PCN or Cephalosporin may be the best choice might invoke a suggestion to do a skin test to determine if a true allergy exists.   The article has a table of potential cost savings.

http://www.annemergmed.com/webfiles/images/journals/ymem/asraja.pdf

How Twitter Changed by Life

Ok, this might be a stretch, my life has not changed all that much, but Twitter is fascinating. This slide show posted by Berci, famous for all things Medicine 2.0 is useful to introduce you to Twitter. btw my name on Twitter is "poikonen" -jp

http://scienceroll.com/2009/02/14/how-twitter-changed-my-life-slideshow/

How Twitter Changed My Life

View more presentations from Minxuan Lee. (tags: micro twitter)

Clinicians Ignore most eRx Alerts

What in medicine do we tolerance 90%+ false positive rates, without getting rid of it?
We have a long way to go in CDS.  Below is from a ASHP press release on a new Archives of IM study, recommended read.
-jp


Clinicians Ignore Most e-Prescribing Alerts
Kate Traynor

BETHESDA, MD 09 February 2009—A large study of electronic prescribing in the outpatient setting suggests that prescribers override most warnings that indicate a medication allergy or drug interaction, according to a report in the February 9 Archives of Internal Medicine.

The analysis of data for 2872 prescribers in Massachusetts, New Jersey, and Pennsylvania over a nine-month period in 2006 found that the clinicians accepted 23% of alerts for medication allergies and 9.2% of drug interaction alerts. Alerts were almost always ignored for medications that had been previously prescribed for the patient.

The study examined more than 3 million electronic prescriptions generated using Zix Corporation's PocketScript program. Of these, about 6.6% resulted in an interaction alert to the prescriber. Less than 2% of the alerts were for medication allergies; the rest informed the clinician that the selected medication potentially interacts with another drug currently taken by the patient.

Drug interactions were classified in the prescribing program as low, medium, or high severity, and the severity level was displayed on the prescribing device's screen. About 62% of the alerts in the study were classified as high severity, and 29% were of medium severity. High-severity alerts were overridden about 90% of the time, and lower-level alerts were disregarded about 93% of the time.

According to the report, PocketScript's severity classifications are produced by pharmacists at a health information technology company. The report's authors suggested that reexamining and reclassifying some of the high-severity alerts, particularly those that are most often overridden, may increase prescribers' acceptance of drug-interaction warnings.

Prescribers took some high-severity drug–drug interactions more seriously than others. For example, warnings not to use noncardioselective beta-blockers and macrolides together were accepted 43.1% of the time.

The next-most-commonl...

View Original Article

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More on the BCMA AHRQ Report

I commented on a report by AHRQ on BCMA already in this post.  It does nothing to bolster the BCMA evidence.

Now on further examination the references are even more embarrassing than first thought.  Thanks to Brent Fox at Auburn that noticed this.  Check these sets of references in the report:

• 2, 16, 26
• 6 and 27
• 8 and 18
• 9 and 19
• 10 and 20
• 11 and 21
• 12 and 22
• 13, 14, 23, 24

Must be getting paid by the references.  More references = more credibility? Not.  Very disappointing from AHRQ, whose publications are usually first rate.

Patient Safety and a Tale of Two Pilots: US Airway’s Sullenberger and KLM’s Van Zanten

When a New York policeman commandeered a chopper after receiving a “plane down” distress call, he expected to find a Cessna or a Piper in the river. “I never, in a million years, expected to see US Airways in the Hudson,” said Sgt. Michael Hendrix when...(read more)

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AJHP versus NEJM

The Efficient MD - Life Hacks for Healthcare: Twitter Dispatches from the New England Journal of Medicine's Horizons Conference

I happened on this blog that is very interesting.  This post on what the NEJM is doing, struck me as something AJHP might consider. 

 

This initiative by NEJM is outstanding.  Clearly they are skating to where the puck is being shot, not to where it is now.

 

 

The New England Journal of Medicine is seeking to bring together a group of visionary medical students and trainees to help NEJM push the boundaries of traditional medical publishing. We are looking for creative minds to join the editors for a weekend to explore what's possible. We anticipate a vigorous dialogue around the ideas that invited participants and other speakers share with the group.

 

Twitter feed of the conference

http://search.twitter.com/search?max_id=1172796326&page=1&q=%23NEJM

 

My bias and unfounded perception is that AJHP is stuck in the mud a bit.  Part of this bias is the (weird) push back I have gotten on the Green Initiative passed by the HoD; right or wrong. 

Medication Errors Occurring with the Use of Bar-Code Administration Technology

Below is a very nice article on how to overcome workarounds and process improvement.

My 'beef' with this and many other bar code studies is that it assumes that BCMA is a good thing. This is a false assumption.

The studies and references in this paper do not support the benefit statements.

"Studies have shown that BCMA can reduce medication errors by 65% to 86%. 5,6,7 "

• *Reference 5 is a HIMSS presentation (no peer review)
• *Reference 6 is pure speculation piece in AJHP (no science)
• *Reference 7 is based on reportable errors. What if folks where so busy or ticked off that they did not report errors, post implementations. The author of this reference even has communicated to me that this study was never intended to be used as evidence for showing decrease errors.

Also: "one hospital in Pennsylvania showed that the direct-observation accuracy rate before BCMA was 86.5%; after BCMA, the rate rose to 97%.8"

• *This reference is a post study from complete manual to full eMAR and BCMA. What if 99% of the benefit was with eMAR and not bar coding?

Medication Errors Occurring with the Use of Bar-Code Administration Technology -

Medication Errors Occurring with the Use of Bar-Code Administration Technology

Pa Patient Saf Advis 2008 Dec;5(4):122-6.

Abstract

Bar-code medication administration (BCMA) systems can improve medication safety by verifying that the right drug is being administered to the right patient. Studies have shown that BCMA technology can reduce medication errors by 65% to 86%. But BCMA technology alone does not ensure a safe medication-use system. A number of reports submitted through PA-PSRS describe medication errors that occurred in organizations that used a bar-code system for administration. Some of these errors result from failures to use this technology appropriately, employing workarounds or overriding alerts, disruptions in the medication administration process, and dispensing errors that arise in the pharmacy. Strategies to address problems with this technology include reviewing BCMA logs to evaluate overrides and identify system weaknesses and monitoring and measuring compliance with the technology to identify and remove any barriers to its appropriate use.

A prospective cohort study of medication errors by Leape et al.1 determined that 39% of errors occurred during the prescribing phase, 12% during transcription, 11% during dispensing, and 38% during administration. Close to half of the errors that occurred during the prescribing phase were intercepted before they reached the patient; in contrast, only 2% of errors that occurred during the administration phase were intercepted. Another study using direct observation in 36 healthcare facilities found that medication administration errors occurred in almost 20% of doses administered.2 Data from U.S. Pharmacopeia’s (USP’s) medication error reporting database, MEDMARX®, indicates that an error at the point of administration is least likely to be intercepted before reaching the patient, compared to other phases of the medication-use process.3

One form of technology that may address administration errors is a bar-code medication administration (BCMA) system. BCMA c...

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Study: Health IT Use Can Lower Hospital Mortality Rates, Costs

Landmark study in Archives of Internal Medicine with nice editorial by David Bates.   I have some thoughts on what the pharmacy department might be doing in these hospitals where there was a difference in mortality; will post later.  Would like to see similar study on outcomes with and without BCMA (Hey – a guy can dream).

Study: Health IT Use Can Lower Hospital Mortality Rates, Costs - iHealthBeat -

Study: Health IT Use Can Lower Hospital Mortality Rates, Costs

Hospitals' use of health IT is associated with lower mortality rates, complications and costs, according to a new study published in the Archives of Internal Medicine, Reuters/Washington Post reports (Steenhuysen, Reuters/Washington Post, 1/26).

Study Details

The researchers divided clinical IT systems into four categories:

• Clinical decision support;
• Medical notes and records;
• Order Entry; and
• Test Results.

The researchers surveyed physicians at 41 urban hospitals in Texas about their use of IT systems in each of the four categories. The researchers then looked at the relationship between IT usage and the rates of inpatient death, complications, costs and lengths of stay for 167,233 patients ages 50 and older who were admitted to the participating hospitals in 2005 and 2006.

The study was funded by the Commonwealth Fund (Conn, Modern Healthcare, 1/26).

Study Findings

The study found that patients at hospitals that ranked highest in health IT use by physicians were 16% less likely to develop complications than patients treated at hospitals where physicians used IT less.

The study also found that patient mortality rates were 15% lower at hospitals that ranked highest in the use of software to automate patient records and notes.

In addition, heart attack patients had a 9% lower risk of dying and bypass patients had a 55% lower risk of dying at hospitals with high scores in use of software to track physicians' orders, according to the study.

"If these results were to hold for all hospitals in the United States, computerizing notes and records might have the potential to save 100,000 lives annually," Neil Poe of Johns Hopkins University School of Medicine, who worked on the study, said (Reuters/Washington Post, 1/26).

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(AHRQ) Medical Errors & Patient Safety Update

Great idea to standardize evidence of interventions

(AHRQ) Medical Errors & Patient Safety Update -

Agency for Healthcare Research and Quality (AHRQ) Medical Errors & Patient Safety Update

AHRQ Awards Contract to Develop Criteria to Assess the Evidence Base for Patient Safety Practices On January 8, AHRQ awarded a contract to develop a set of criteria to be used for assessing the evidence base for the effectiveness and safety of patient safety practices (PSPs) in future evidence reviews and for use by implementers of PSPs. The $1 million contract, Assessing the Evidence for Context-Sensitive Effectiveness and Safety of Patient Safety Practices: Developing Criteria was awarded to RAND, Johns Hopkins University, and the University of California-San Francisco, working in partnership with the Karolinska Institute (Sweden) and a technical expert panel. AHRQ recognizes that there is a need for a suitable set of criteria by which to assess which patient safety practices will work and are safe in specific settings. All across the country, providers, hospitals, health systems and policymakers are attempting to improve the safety of patient care, and are looking for guidance on what works. This 1-year initiative will be the first to take into account the complexity of patent safety interventions in the real world and tie those components to research and evaluation considerations. Those considerations include assessment of theoretical models for designing PSPs and the usefulness of innovative methods for evaluating intervention results. For more information, please contact the AHRQ Project Officer, Denise Dougherty, at Denise.Dougherty@ahrq.hhs.gov or 301.427-1868.

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Drug Induced QT Prolongation

Here is a series of articles on medication QT Prolongation. My sense is it is a under recognized problem, although I have no basis for this view, just a feeling.  This would make for an interesting CDSS to incorporate wave form analysis. 

Drug Induced QT Prolongation -

Editors' view

Drug-induced long QT syndrome and drug development

J. M. Ritter,

Department of Clinical Pharmacology, School of Medicine at Guy's, King's College & St Thomas' Hospitals, St Thomas' Hospital, Lambeth Palace Road, London SE1 7EH UK

Copyright Journal compilation © 2008 Blackwell Publishing Ltd

ABSTRACT

No Abstract

DIGITAL OBJECT IDENTIFIER (DOI)

10.1111/j.1365-2125.2008.03275.x About DOI

 

 

  Introduction

September's issue is themed around cardiovascular clinical pharmacology. It includes articles on a range of topics, spanning a review of the role of the renin-angiotensin system in atrial fibrillation [1], through the effect of atorvastatin on high-sensitivity CRP in acute coronary syndrome [2], and the pharmacokinetics and pharmacodynamics of nicorandil in healthy and acute heart failure subjects [3] to the influence of paraoxonase-1 (PON-1) phenotype on the response of paraoxonase activity to statins [4]. Several papers [5–7] relate directly or indirectly to effects of drugs on the electrocardiographic QT interval, and it is on this subject that this Editors' View is focused.

 

  The vulnerable period and the long QT syndrome

George Ralph Mines identified the 'vulnerable period' within the cycle of the cardiac action potential/pacemaker (or resting) potential [8]. (Mines [9], a contemporary at Cambridge of AV Hill, also described cardiac re-entry and identified the active principle of munchi arrow poison as strophanthin. He was appointed professor of physiology at McGill University in Canada aged 28, but died tragically soon thereafter – of which more later).

A ventricular extra beat falling early in the cardiac cycle, so that it coincides with ventricular repolarisation (the 'R on T' phenomenon), can provoke ventricular tachycardia (VT), and/or ventricular fibrillation (VF). The QT interval is measured from the beginning of the QRS complex (whether Q or R wave) to the end of the T wave. The latter may be difficult to define, especially when a U wave succeeds the T; however, the U wave tends to b...

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RxNorm and CMS in eRx 2009 Call Letter

It seem clear from this CMS correspondence that RxNorm will be replacing NDC codes (finally). It is time to contact your pharmacy system vendor to insure that they put the RxNorm code in their data structure. All of the major drug database vendors support the RxNorm CUI codes.
RxNorm and CMS in eRx 2009

Call Letter -

H. RxNorm CMS will continue to utilize a Formulary Reference File (FRF) and proxy National Drug Codes (NDCs) for HPMS submission of Part D formularies. For CY2009, CMS also will introduce the RxNorm nomenclature for the FRF drugs because we are exploring RxNorm as a potential alternative to proxy NDCs for formulary submissions in future years. RxNorm is a standardized nomenclature for clinical drugs produced by the National Library of Medicine (http://www.nlm.nih.gov/research/umls/rxnorm/index.html). CMS is working with the Page 60 60 National Library of Medicine to evaluate whether RxNorm would provide a more effective means of drug product identification for the FRF. CMS recognizes the value of a standardized nomenclature system for the purpose of Part D formulary submission and review and for its potential application as electronic prescribing evolves. For each CY2009 FRF proxy code, the RxNorm semantic names and RxNorm concept unique identifier (RXCUI) code (when available) will be included. Part D sponsors should be aware that FRF format changes will be forthcoming. CMS wishes to clarify again that the submission process for CY 2009 formularies will not involve the use of RxNorm concept unique identifiers. We will continue to investigate the benefits of using these codes for subsequent plan years. Should CMS determine that the utilization of RxNorm would be a beneficial means for indicating drug coverage during the formulary submission and review process for CY 2010, we will notify plans in the fall of 2008 of such changes.

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Rock and Roll Health IT Funding

The source of this report is interesting.  Time to turn up the amps to “11”

Economist's Letter to Obama Calls for Health Care IT Investment

In an open letter to President Obama published in the February issue of Rolling Stone, Nobel Prize-winning economist Paul Krugman calls for spending federal money "on things of lasting value," such as health IT, Healthcare IT News reports.

Krugman -- a professor of economics and international affairs at Princeton University and columnist for the New York Times -- writes that health care IT, "like similar infrastructure investments, would help create jobs," which then would address the economic crisis.

Krugman writes that Obama should "improve information technology in the health care sector, a crucial part of any health care reform."

Obama has said he wants to spend $50 billion over five years to support the adoption and use of health care IT (Monegain, Healthcare IT News, 1/19).

More Opinion and still lack of science on BCMA

This is getting downright weird.  I am starting to feel like Henry Fonda in 12 Angry Men, calling for real proof of decrease med errors rather than jumping on the BCMA bandwagon. 

New Report on Lessons from AHRQ-Funded Barcode Medication Administration Projects

The AHRQ National Resource Center for Health Information Technology has released a new report that summarizes key findings from grantees who have examined how applications such as barcode medication administration can improve the quality, safety, efficiency, and effectiveness of health care. The report focuses on lessons learned, challenges, and opportunities associated with introducing these applications into real-world clinical settings so that others who wish to implement and use barcode medication administration and electronic medication administration record technologies can learn from the experiences of these AHRQ projects. Select to access the report.

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Would like to hear reactions to the just released report.

My spin: It is my view that the statement below from the report does NOT support BCMA.

“Research has demonstrated successful reductions in the rate of medication administration and dispensing errors after the implementation of barcoding systems,8-16”

Reference 8 and 9 are on the dispensing process that are elegant and very convincing for the dispensing process not BCMA.

Reference 10-16 are not research studies showing reduction in errors but opinion pieces. They assume that BCMA will decrease errors and give commentary from that perspective. None of the references are research to show decrease medication errors. Something as important as this needs science not opinion.

8. Poon EG, Cina JL Churchill W, Patel N, et al. Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy. Ann Intern Med 2006 Sep 19;145(6):426-34.

9. Poon EG, Cina JL, Churchill WW, et al. Effect of bar-code technology on the incidence of medication dispensing errors and potential adverse drug events in a hospital pharmacy. AMIA Annu Symp Proc 2005:1085.

10. Patterson ES, Rogers ML, Render ML. Fifteen best practice recommendations for bar-code medication administration in the veterans health administration. Jt Comm J Qual Saf 2004 Jul;30(7):355-65.

11. Wright AA, Katz IT. Bar coding for patient safety. N Engl J Med 2005;353:329-31.

12. Patchett JA. Bar coding: A practical approach to improving medication safety. ASHP Advantage; North Shore LIJ; Hospira; 2004:1-11.

13. Department of Health and Human Services: Food and Drug Administration. Bar code label requirements for human drug products and biological products; final rule. Federal Register 2004;69(38):201-601.

14. Department of Health and Human Services: Food and Drug Administration. Bar code label requirements for human drug products and biological products; final rule. Federal Register 2004;69(38):201-601.

15. The Joint Commission. http://www.jointcommission.org/. Accessed August 30, 2008.

16. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.

If BCMA was a drug

So would you take a drug that had zero studies on its safety and efficacy?  Would labeling claims such as “over 24 million doses administered with zero serious side effects” have the wrath of the FDA down on them.

In light Coca-Cola being served with a class-action lawsuit, charging the Atlanta beverage giant with deceptive and unsubstantiated claims on its Vitaminwater beverages, consider Intellidot’s claim in a recent advertising.

“Our barcode point-of-care system has allowed our clients to deliver over 24 million medication administrations with zero serious five rights med errors.”

Intellidot is asking for and just might get into some deep do do over unsubstantiated statements such as this.  The studies to which they refer are internal, not peer reviewed and of a relative small sample size as admitted by the company in a ASHP list serv post.  Desperate times call for desperate marketing is my guess.

Nursing Informatics Conferences in 2009

Am Nursing Informatics Assoc. speaker proposals due January 25, for Las Vegas conference April 23-25, 2009.  They do not pay for anything but a registration, fyi.

http://www.ania.org/Speaker&Poster%2009.htm

Also found this http://www.ni2009.org/ The 10th International Congress on Nursing Informatics welcomes you to Helsinki Finland on 28 June – 1 July 2009.   Paper submission date has passed (bummer).

Helsinki is a wonderful place to visit, both as a historic, majestic city and summer solstice in Finland is quite a celebration.  Let’s have the 1st International Pharmacy Informatics Congress there in 2010.

Pharmacology in Second Life

Pass this on to your pharmacology profs (and watch them weep)

Pharmacology in Second Life

http://scienceroll.com/2009/01/15/pharmatopia-pharmacology-in-second-life/



I may have mentioned this before: This Medical Students blog is fantastic. Following him on Twitter is fascinating.

Pharmacoinformatics or Pharmacy Informatics Working Group

It has been kicked around in the AMIA working group that perhaps we should change the name of the working group. Currently it is the Pharmacoinformatics Working Group. Here are some some items for your thought and considerations. First is our mission statement:

Mission

To promote interaction among AMIA members who are interested in the intersection of technology and medication management. This includes all aspects of the process from prescribing, dispensing, administration, monitoring, and educating about medication use within health care delivery systems.

• Prescribing – clinical decision support to facilitate rational prescribing
• Verifying/Dispensing – interpretation, translation and perfection of medication orders, including informatics and technology in dispensing
• Administration – the information flow and decision support with electronic medication administration, 5 right checking and documentation
• Monitoring – relating to the use of ADE surveillance/prevention, pharmaco-epidemiology, pharmaco-vigilance and pharmacoeconomics to enhance patient outcomes
• Education – promoting professional and patient education

Here are some graphical representations. First is informatics defined by Ted Shortliffe.

This is an adaptation for pharmacy

Note that Pharmacy informatics does touch patients, society and then moves to professional pharmacy practice.

The next few diagrams are adaption from Terry Seaton's work. We discussed the exact location of each circle and could not exactly get it right. Both are submitted for your view.

and this one, that is a little bit different.

So the question remains. Pharmacoinformatics or Pharmacy Informatics.

The Best Medical Blogs for 2008

The polls are open to vote on the best Medical Blogs.

http://www.medgadget.com/archives/2009/01/the_2008_medical_weblog_awards_the_polls_are_open.html

Twitter List

http://www.medicalstudentblog.co.uk/twitter-doctors-medical-students-and-medicine-related/

If you are on Twitter, lets get the pharmacist list longer1