Interoperability and eMedicines Management within the Hospital Setting

Dr Kanaka Ramyasiri

Clinical Architect

HealthShare Ltd

Midland District Health Boards

NZ Hospital eMedicines Programme

Interoperability and eMedicines Management

• A walk through of a piloted intra-hospital eMedicines

Landscape

• Benefits arising from intrahospital electronic sharing

of patient medicines information

• Standards utilised to share medication details

But more importantly!

• Lets deconstruct our pilot implementation to expose

Wider Lessons & Observations related to

interoperability in general

Zen and the art of interoperability…

Where are we?

Where are we?

Taranaki

Programme Context

• This pilot solution is affiliated to and part funded by

the New Zealand Hospital eMedicines Programme

and the New Zealand Medication Safety Programme

in conjunction with Taranaki District Health Board.

• This solution in conjunction with 2 other pilot sites in

New Zealand is intended to generate knowledge

and learnings to enable widespread rollout of

Hospital eMedications Management in the NZ

Health Sector.

HIMSS definition of Interoperability

“Interoperability means the ability of health information systems to work together within and across organizational boundaries in order to advance the health status of, and the effective delivery of healthcare for, individuals and communities.”

http://www.himss.org/library/interoperability-standards/what-is?navItemNumber=17333

New Zealand Strategic Direction

• Interoperability is a strategic enabler within the NZ

Health IS Plan.

• Emphasis on best of breed interoperable systems

with national standards for interoperability.

• HL7 CDA R2, IHE XDS, SNOMED CT formally

endorsed standards in NZ context.

NZ Pilot Hospital eMedicines Management Solution

Function Application Component

Inpatient ePrescribing CSC MedChart

Inpatient Dispensing CSC ePharmacy

Inpatient eAdministration CSC MedChart

Inpatient Electronic Drug Cabinets Carefusion Pyxis

eMedicines Reconciliation Orion SMT

eDischarge Summary Orion SMT

Single Source Allergy Management CSC MedChart

Clinical Portal Orion Clinical Portal (aka Concerto)

Patient Administration System CSC webPAS

Middleware Orion Rhapsody

Integration Schematic

But what is the diagram not telling us?

• How deeply each component talks to each other.

• The workflow capabilities in each component that

facilitate interoperability

• Lets examine some of the key interoperability

scenarios contained within the solution and some

related general lessons learned

High Level Workflow – Within the Hospital

• Prescriber Charts Medication on MedChart ePrescribing System

Prescribe

• Pharmacist Processes prescribed order on ePharmacy Dispensary system

• Confirms Product to Dispense or activate on Pyxis

Dispense• Nurse can retrieve

medication on ward via Pyxis electronic drug cabinet

• Records administration in MedChart

Administer

Ward Prescribing to Dispensary Interoperability

• Prescribing actions are messaged to the Pharmacy

Dispensary system automatically (ePharmacy).

• Workflow capability within ePharmacy enables the

management of the incoming Prescription – either

dispense the medication, or activate on Pyxis.

MedChartMedication

Order Message

ePharmacyDispense, or Message to

Pyxis

What is Pyxis?

Ward Prescribing to Dispensary Interoperability

Sounds simple, so where are the challenges?

Ward Prescribing to Dispensary Interoperability

Lesson 1 – Common Code Set / Terminology

• We were lucky to have the same vendor supplying

both the Prescribing and Dispensary systems which

utilised a common medication code set. But we

cannot always count on this scenario.

• Consistent Medication terminologies still evolving or

being implemented.

• Compounded, non formulary, or otherwise non-

standard medications need to match across both

systems.

Ward Prescribing to Dispensary Interoperability

Lesson 2 – Differing requirements across Professional boundaries need to be managed.

• Doctors and Pharmacists view a prescription at different

levels.

• Not so much of an issue when a trained pharmacist is

involved in dispensing a Doctors prescription, but when we

are trying to create an electronic workflow…

• Doctors deal in generics, or brand names, but rarely specify a

strength.

• Pharmacists deal in specific strengths and forms of

medications.

Ward Prescribing to Dispensary Interoperability

Doctors Prescription:

• “Paracetamol, 1g, four times daily, as needed”

Pharmacist Dispensing:

• “Panadol 500mg tablets, 2 tablets, four times daily, as needed”

Solution – a workflow and business rules within the dispensing

system to map a Doctors medication order into an actual

Dispensing.

• Some human interaction required for the matching process if

there are multiple possible dispensing possibilities for a given

Prescription.

Ward Prescribing to Dispensary Interoperability

Lesson 3 – Additional Contextual Information that isn’t immediately apparent may be required to complete or exploit an integration.

• Informing the Pharmacy regarding the Priority of a

given order – e.g. workflow to indicate item that

requires urgent dispensing.

• Informing the ward of what stock actually exists on

their shelves currently – e.g. display of pharmacy

dispensary inventory information via the prescribing

system.

Ward Prescribing to Dispensary Interoperability

Lesson 4 - Further business rules and automation need to be built into the interface.

• Automatically process data in a receiving system

rather than just present to user.

• If full automation not possible, at least attempt to

usefully constrain the options presented to a user –

e.g. filter a list of options etc. Make the UI useful.

eMedicines Reconciliation to Primary Care Discharge

• The final Medicines reconciliation report is sent to

the Primary Care Physician at the point of discharge

electronically, within a greater discharge summary

message.

• External messaging broker utilised (HealthLink) to

store and forward message to Primary Care IS.

• HL7 2.x Referral Message used, but with base64

PDF embedded to give greater pagination.

• Obviously a candidate for a CDA document and this

is in progress at the national level.

Old Discharge Summary to Primary Care

eMedicines Reconciliation to Primary Care

eMedicines Reconciliation to Primary Care

Lesson 5 – Progressive Interoperability will get you there

• Method of interfacing is “shock horror,” a PDF.

• No coded machine interpretable data for the Primary

Care physician apart from the patient identifier.

• But, very positive feedback from Primary Care.

• CDA with structured medications section on the way

Allergy Data Interoperability

• Key feature of the solution is the creation of a single

source of truth for patient allergy and adverse drug

reaction data.

• Crucial that a patients allergy status is clearly

known.

Allergy Data Interoperability

NHI Medical Warning System

PAS

SMT

Discharge Summary

& eMR

MedChart Prescribing

Decision Support

ePharmacy Dispensing

Decision Support

MedChart

Allergies Service

Concerto Portal

Patient Summary

Allergy Data Interoperability – Source Entry

Allergy Data Interoperability – ePrescribing View

Allergy Data Interoperability – Dispensing / ePharmacy

Allergy Data Interoperability – Portal Patient Summary

Allergy Data Interoperability – eMedicines Rec

Allergy Data Interoperability

Key Standards utilised (or to be utilised)

HL7 2.x Medication Order Messaging

HL7 2.x Referral Messaging

NZULM (New Zealand Universal List of Medicines)

and NZMT (New Zealand Medicines Terminology)

Web Services transport

Observations about medication interoperability

• Interoperability isn’t a technical exercise. Its

primarily a professional and cultural exercise.

• Organisational issues regarding professional

disciplines and identities abound and are amplified

when different departments are brought together via

newly interoperable systems.

Observations about medication interoperability

• Do not maintain a view that “we are just here to

provide some technology and the clinical change

manager will do the rest” - we are all doomed to

failure and frustration with that approach.

• Expect that workflow requirements may not have

been fully appreciated yet, in spite of prior analysis.

• Employ genuine subject matter expertise and strong

Clinical Leadership asap in conjunction with

technical work…

Observations about medication interoperability

• Consuming external data is likely to involve a whole

new set of electronic workflows within the

consuming system.

• It is easy to not appreciate the importance of data

context when importing from one system to another.

• Don’t structure everything for the sake of it. Think of

the envisioned follow on workflow / task or report

that would utilise that structured element.

Kanaka’s Wishlist

• All application components expose their key

datasets via standards based interfaces, out of the

box.

• Key application functions are exposed via APIs to

allow more than just “document transfer”

interoperability.

• Local “connectathon” events or labs to accelerate

progression of interoperability. Don’t leave it up to

implementation projects.

Thank you for your attention

kanaka.ramyasiri@healthshare.co.nz

+64 21 368 047