optimizing pharmaceutical care via health information ... rounds... · optimizing pharmaceutical...
TRANSCRIPT
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©2011 MFMER | slide-1
Optimizing pharmaceutical care via Health Information Technology:The Epic Challenge
Rilwan Badamas, PharmD, CAHIMS
Pharmacy Grand Rounds01/03/2017
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The medication management team requests you do not share this document with anyone outside
of Mayo Clinic.
Note that screenshots included are still under development and may change.
©2011 MFMER | slide-2
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©2011 MFMER | slide-3
Objectives• State the current gaps in pharmaceutical care
• Identify tools within electronic health record that can assist pharmacists in improving care
• List challenges in optimizing pharmaceutical care with Health Information Technology (HIT)
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Which of the following is the greatest limitation in providing optimal pharmaceutical care?
A. Limited pharmacist resources
B. Difficulty identifying high risk patients
C. Obtaining a complete patient home medication list
D. Numerous applications for patient care
©2011 MFMER | slide-4
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Patient Scenario
Photo Credit: Mayo Media Support Services
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US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014
©2011 MFMER | slide-6
Shehab N, et al. JAMA. 2016;316(20):2115-2125
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US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014
©2011 MFMER | slide-7
• Public surveillance in 58 EDs located in the US
• Objective was to describe characteristics of ED visits for adverse events in the US
Background
• Data from 42,585 cases an estimated 4.0 (95% CI, 3.1-5.0) ED visits for adverse drug events occurred per 1000 individuals annually in 2013 and 2014
• 27.3% (95% CI, 22.2%-32.4%) of ED visits for adverse drug events resulted in hospitalization
• Anticoagulants, antibiotics, and diabetes agents were implicated in an estimated 46.9%
Results
• The prevalence of ED visits for adverse drug events estimated to be 4 per 1000 individuals in 2013 and 2014
• The most common drug classes implicated were anticoagulants, antibiotics, diabetes agents and opioid analgesics
Conclusions
Shehab N, et al. JAMA. 2016;316(20):2115-2125
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US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014
©2011 MFMER | slide-8
• Public surveillance in 58 EDs located in the US
• Objective was to describe characteristics of ED visits for adverse events in the US
Background
• Data from 42,585 Adverse Drug Events were reviewed
• 27.3% (95% CI, 22.2%-32.4%) of ED visits for adverse drug events resulted in hospitalization
Results
• The prevalence of ED visits for adverse drug events estimated to be 4 per 1000 individuals in 2013 and 2014
• The most common drug classes implicated were anticoagulants, antibiotics, diabetes agents and opioid analgesics
Conclusions
Shehab N, et al. JAMA. 2016;316(20):2115-2125
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US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014
©2011 MFMER | slide-9
• Public surveillance in 58 EDs located in the US
• Objective was to describe characteristics of ED visits for adverse events in the US
Background
• Data from 42,585 Adverse Drug Events were reviewed
• 27.3% (95% CI, 22.2%-32.4%) of ED visits for adverse drug events resulted in hospitalization
Results
• The prevalence of ED visits for adverse drug events is estimated to be 4 per 1000 individuals in 2013 and 2014
• Anticoagulants, antibiotics, diabetes agents and opioid analgesics
Conclusions
Shehab N, et al. JAMA. 2016;316(20):2115-2125
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Transitions of Care
©2011 MFMER | slide-10
of all medication errors occur during times of care transition
60%60%
Journal of the American Geriatrics Society. 2003; 52(4): 556-557
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Medication Discrepancies in Transitions of Care
Kripalani et al. J Hosp Med 2008;3:12-19
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Transitional Care Model
“A set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the
same location”
©2011 MFMER | slide-12
•The American Geriatrics Society (2003)
•www.transitionalcare.info
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Pharmacist Impact Potential in Transitional Care
50%Reduction in preventable 30-day readmission
due to pharmacist intervention
©2011 MFMER | slide-13
•Source: FPA/UCare Fairview Transition Pilot
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Areas of Pharmacist Intervention
• Admission medication reconciliation
• Daily patient medication review
• Participation on rounds
• Medication education for patients
• Discharge coordination
©2011 MFMER | slide-14
Chisholom-Burns, et al. Med Care. 2010; 48:923-33
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Gaps in Pharmacist Medication Reconciliation
• Access to patient home medication list
• Identifying high-risk patients
• Limited pharmacy resources
©2011 MFMER | slide-15
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How can HIT optimize pharmaceutical care?
©2011 MFMER | slide-16Photo Credit: Microsoft Office
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©2011 MFMER | slide-17
Objectives• State the current gaps in pharmaceutical care
• Identify tools within electronic health record that can assist pharmacists in improving care
• List challenges in optimizing pharmaceutical care with Health Information Technology (HIT)
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History - HIT
• American Recovery and Reinvestment Act (ARRA)
• HIT infrastructure
• $150 billion total for healthcare reform
• $34 billion focused on HIT
Webster L, et al. J Am Pharm Assoc. 2010;50:e20–e34
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HIT Tools
Pharmaceutical Care
Clinical Decision Support
Patient Scoring
CPOE
Automation
Reporting/ Analytics
HIE
©2011 MFMER | slide-19
HIE = Health Information ExchangeCPOE = Computerized Prescriber Order Entry
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HIT Tools
Pharmaceutical Care
Clinical Decision Support
Patient Scoring
CPOE
Automation
Reporting/ Analytics
HIE
©2011 MFMER | slide-20
HIE = Health Information ExchangeCPOE = Computerized Prescriber Order Entry
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©2011 MFMER | slide-21Photo Source: Microsoft Office
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Medication History Data
EHREHR SureScriptsSureScripts
PBMsPBMs
PharmaciesPharmacies
PBM = Pharmacy Benefits Manager
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Medication History Elements
Included
• Medication name
• Medication strength
• Medication route
• Medication form
• Dispense date
• Days supplied
• Quantity dispensed
Not Included
• Dose per administration
• Frequency of administration
©2011 MFMER | slide-23
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Benefit of Medication History Data to Prevent Medication Errors
• Objective• Assess the potential of
Surescripts claims data to reduce medication history errors at hospital admission
• Interconnectivity between the EHR and Surescripts Electronic Pharmacy Claims Data
©2011 MFMER | slide-24
Cedars-Sinai Medical Center
Pevnick JM, et al. J Am Med Inform Assoc 2016;0:1–9Photo source: Cedars-sinai.edu
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Retrospective Study Within a Randomized Study
• Randomized Study• 3 Arms
• Admission Medication History (AMH)• Usual Care (RNs/MD)• Pharmacy Technician• Pharmacist
• Within 1 day of admission• Research pharmacist conducts a medication
history to identify errors on the initial AMH
©2011 MFMER | slide-25
Pevnick JM, et al. J Am Med Inform Assoc 2016;0:1–9.
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Retrospective Study Within a Randomized Study
• Randomized Study• Inclusion Criteria
• > 10 chronic prescription medications• AMI or CHF• Admission from SNF• History of transplant• Active anticoagulant, insulin or narrow therapeutic index
medications• Exclusion Criteria
• Admission to pediatric or trauma services• Admission to a transplant service that already used
pharmacist to obtain AMH
©2011 MFMER | slide-26
Pevnick JM, et al. J Am Med Inform Assoc 2016;0:1–9.
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Pevnick JM, et al. J Am Med Inform Assoc 2016;0:1–9.
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Outcomes
• SureScripts Medication History• Unrelated to the error• Probably would have not prevented the error• Might have prevented the error• Probably would have prevented the error
©2011 MFMER | slide-28
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Example of Error Prevention Potential CategoriesExample of SureScripts Data
Definition Error preventionpotential
Several fills for amlodipine only
Unrelated to error None
One fill for warfarin 6 months ago
Probably would not have prevented error
Low
Several refills for warfarin
Might have prevented error Medium
Several recent fills for dabigatran
Probably would have prevented error
High
©2011 MFMER | slide-29
Pevnick JM, et al. J Am Med Inform Assoc 2016;0:1–9.
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ResultsWould SureScripts have prevented the error?
N (%)
No. Unrelated to AMH error 94 (30)
Probably would NOT have prevented the AMH error
83 (26)
Might have prevented the AMH error 24 (9)
Yes, probably would have prevented the AMH error
110 (35)
©2011 MFMER | slide-30
Pevnick JM, et al. J Am Med Inform Assoc 2016;0:1–9.
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ResultsWould SureScripts have prevented the error?
N (%)
No. Unrelated to AMH error 94 (30)
Probably would NOT have prevented the AMH error
83 (26)
Might have prevented the AMH error 24 (9)
Yes, probably would have prevented the AMH error
110 (35)
©2011 MFMER | slide-31
Pevnick JM, et al. J Am Med Inform Assoc 2016;0:1–9.
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Conclusion
• Electronic pharmacy claims data had a substantial potential to prevent admission errors
• Greater potential to prevent more severe errors
©2011 MFMER | slide-32
Pevnick JM, et al. J Am Med Inform Assoc 2016;0:1–9.
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Epic medication history
©2011 MFMER | slide-33
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Outside Data if Available
©2011 MFMER | slide-34
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SureScripts Data
©2011 MFMER | slide-35
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Which of the following is NOT included in the surescripts data elements?
A. Medication name
B. Frequency of administration
C. Medication strength
D. Medication route
©2011 MFMER | slide-36
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HIT Tools
Pharmaceutical Care
Clinical Decision Support
Patient scoring
CPOE
Automation
Reporting/ Analytics
HIE
©2011 MFMER | slide-37
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Improving the Medication Review Process
• Targeting high risk patients• Risk stratification
©2011 MFMER | slide-38
Nazanin F et. al; AJHP February 2014, 71 (4) 311-320
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Development of an electronic patient prioritization tool for clinical pharmacist interventions
• Middlemore Hospital, Auckland, New Zealand
• Implemented electronic medication reconciliation
• Large patient numbers and high patient turnovers
• Purpose was to develop an electronic tool to help prioritize patient review
©2011 MFMER | slide-39
Nazanin F et. al; AJHP February 2014, 71 (4) 311-320
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Design
Scoring Tool
Admission History
Chronic Disease
Patient Profile
High risk medications
Laboratory Values
©2011 MFMER | slide-40
Nazanin F et. al; AJHP February 2014, 71 (4) 311-320
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Scoring
• Top 10th percentile = High Risk
• Next 15th percentile = Medium Risk
• Remaining 75th percentile = Low Risk
©2011 MFMER | slide-41
Nazanin F et. al; AJHP February 2014, 71 (4) 311-320
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Results and Conclusion• During 8 month period
• 765 high-risk patients were prioritized for discharge support services
• 526 medication errors were prevented• 174 errors deemed moderate to major
• Positive clinical pharmacist feedback
©2011 MFMER | slide-42
Nazanin F et. al; AJHP February 2014, 71 (4) 311-320
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Inpatient pharmacy scoring dashboard
©2011 MFMER | slide-43
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Inpatient pharmacy scoring dashboard
©2011 MFMER | slide-44
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Discharge summary dashboard
©2011 MFMER | slide-45
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MTM Scoring Report
©2011 MFMER | slide-46
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MTM Scoring Report
©2011 MFMER | slide-47
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©2011 MFMER | slide-48
Objectives• State the current gaps in pharmaceutical care
• Identify tools within electronic health record that can assist pharmacists in improving care
• List challenges in optimizing pharmaceutical care with Health Information Technology (HIT)
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Challenges and Barriers
• Financial
• Work force
• Technical
• Cultural
• Structural
• Privacy and security issues
©2011 MFMER | slide-49
Siska M, Tribble D; AJHP 2011; 68:1116-26
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Financial Challenges
• Most of these features are not out of the box
• Cost of implementing HIT systems can be high
©2011 MFMER | slide-50
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Workforce
• Resources for development of these tools can be challenging• Electronic patient prioritization tool
• 2000 hours to program the tool• 320 hours of testing• 160 hours to review flags
©2011 MFMER | slide-51
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Technical
• Interoperability
• Communication standards
• Electronic Pharmacy Claims Data• Capture of over the counter medications• Not all pharmacies send data to surescripts
• Pharmacy Scoring Tools• Use of discrete data fields
©2011 MFMER | slide-52
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Which of the following is NOT a challenge identified with implementing HIT
A. Financial constraints
B. Workforce resources
C. Converged workflows
D. Technical considerations
©2011 MFMER | slide-53
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Summary - Patient Scenario
©2011 MFMER | slide-54