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Ross Koppel - Questions on Safety and HIT

Fri, 25 May 2012 12:03:27 -0700

Ross Koppel Professor, Professor at Univ of Pennsylvania, Chair of the AMIA Evaluation Working Group, delightful dinner guest, among other things, poses some interesting questions.

Minute - Teaser

04:00 – 40 Different ways to present blood preasure

05:51 – drug dosing listings

07:02 – Allergy entry insanity

09:04 – Cleaver drug dosing

09:57 – Warfarin dosing gone wrong

11:30 – My favorite; BCMA craziness, patient safety and productivity?

15:35 – Fat Cow; Precious.

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My comments to the Proposed Rule EHR Incentive Program-Stage 2

Mon, 07 May 2012 14:13:46 -0700

My comments to the Proposed Rule Medicare and Medicaid Programs: Electronic Health Record Incentive Program-Stage 2 (Document ID CMS-2012-0022-0001)
Not my most eloquent writing. Did in hurry to meet 5pm deadline.

Comment on Sec.170.314(a)(2) (Drug-drug, drug-allergy interaction checks)

This section outlines to “recommended limiting the ability to make adjustments to an identified set of users or available as a system administrative function.” For both Drug-Drug and Drug allergy interaction checking it is imperative that adjustment be made by providers. With false positive alarms of these checks still being very high it is imperative that providers are able to customize these alert to their practice sites.

In a study of the high rate of over rides in allergy alerts, recommendations have been made to decrease the incidence of overrides in allergy alerts. These recommendations have largely not been implemented in EHRs, causing the high override rates to remain. (Characteristics and Consequences of Drug Allergy Alert Overrides in a Computerized Physician Order Entry System. J Am Med Inform Assoc. 2004;11:482–491. DOI 10.1197/jamia.M1556)

Comment on Sec. 170.314(a)(17) (Inpatient setting only--electronic medication administration record)

There continues to be a lack of serious evidence on the use of technology to confirm the ”5 rights” of medication administration. The stated study (NEJM Medicine 362:1698-1707) realizes most of the benefit from an electronic medication record documentation and not the bar code scanning, or “5 right” checking itself.

Until there is sufficient evidence of return on investment in terms of outcomes or reduction in medication errors, I would suggest that the requirement for “5 right” checking be eliminated and electronic medication administration records remain.

*** Sad Note ***
It is very disappointing that I could not identify myself in a list of health care providers as a pharmacist. Nurses Aids was listed among many others. No pharmacist listing.

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Share Your Peripheral Brain

Thu, 19 Apr 2012 13:13:10 -0700

There are a couple of products that if used collectively by more pharmacists would be fantastic. At different lectures, myself and others (@kevinclauson, Felke and Fox*) have advocated the use of these tools. Most recently I discussed this at Western New England University's new College of Pharmacy.

Evernote is awesome. I could not live professionally without this product. It is a fantastic knowledge engine (my term). Rather than go on and on, take some time to understand what it is and how some folks are using it.

Springpad

A Boston based company (so I am biased) just had a major upgrade that pushes it over the top. See this LifeHacker article for a great overview. I have used Springpad for my consulting projects and am seriously thinking of using it more and even replacing Evernote. You can not go wrong either way.

Another new comer is http://www.memonic.com/ Very nice and clean. Functionality is much the same as EverNote and Springpad. All have nice clipping, file saving, sharing and ways to email files and notes. All have offline storage and are available everywhere on all devices. The only minor advantage I found in Memonic is that it has a nice picture clipping feature. For me this is not enough to leave Evernote and Springpad.

Sharing and Curation of Knowledge

We need more people making their Evernote or Springpad information publicity available. While Felke and Fox also suggest this, they do not share notebooks. Why not? Here is my public Pharmacoinformatics EverNotes for you to search and use. This is my expertise and I collect all of my notes and web clipping here (careful not to post non public items i.e. articles requiring subscriptions). There is even a RSS feed if you like. How cool would it be to get your file of expertise clippings and notes on Cardiology, Infectious Disease or whatever you are an expert on. Or our leaders (DoPs, Prof orgs) sharing a notebook of leadership articles that she/he reviews? We need more people sharing their peripheral brains. Here is mine. Let us know where yours is and what subject you can make public.

* While normally I would include the link to their great article on Evernote in Hospital Pharmacy, that journals web site is impossible to navigate.

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Meaningful Use Stage II Quick Hits and how they got a pharmacy principle wrong

Fri, 24 Feb 2012 04:35:00 -0800

Stage II of Meaningful Use hit yesterday, in a flurry of Tweets from HIMSS12. It was very interesting to watch all of the tweets. Here are some good quick hit analysis of what is in Stage II and how they got a fundamental pharmacy issue wrong.

I started this site for a series of talks on the pharmacist and meaningful use. I will continue to maintain and send focused material on pharmacy practice and meaningful use to this site. http://mu4pharm.posterous.com/

Here are some good summaries

John Halamka, MD CIO from Beth Israel Deaconess Medical Center and Harvard Medical School 1st Look
Moving Up the Escalator by Margalit Gur-Ari (thanks to Jerry Farhni @JFahrni to turning us on to this post)
Brian Ahier's summary on Health, Technology and Goverment 2.0
Project Direct summary by Fred Trotter that is important for pharmaicsts to get rid of the fricking fax machines and share clinical documents.

The Office of the National Coordinator also got at least one thing wrong. It looks like they fell for the bar code medication administration (BCMA) dogma. I have been a critic of this practice because, oh idunno, I believe in evidence based and cost effective pharmacy practice. Neither applies to BCMA. While they emphasis electronic medication administration records, which are terrific, they mix up BCMA with bar codes in the pharmacy dispensing process. The will require "Automatically track medication orders using an electronic medication administration record (eMAR)" for hospitals". God is in the details, of course.

They cite Eric Poon's terrific NEJM article as justification. While I will post a more detailed critique of this,fully half of the benefit shown in this study is due to eMAR documentation and not the wonders of bar codes or BCMA.

Here is what they get completely mixed up. They cite Savario Maviglia's study as evidence of "A study done to evaluate cost-benefit of eMAR". Yet this study is not even about eMAR! It is about tracking medication through the dispensing process in the pharmacy, not for electronic medication administration. I put together a panel on technology and pharmacy practice at the ASHP Midyear meeting with Dr. Maviglia in explaining this practice. This practice of tracking medications through the dispensing process in the pharmacy has more evidence to decrease errors than BCMA does. Eric Poon tells me that a paper on the cost effectiveness of BCMA is in the works. I will look forward to that.

Formal comments to the ONC will follow. What say you.

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HIMSS hits world record for medical meeting tweets

Thu, 23 Feb 2012 08:11:52 -0800

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Meaningful Use Stage II

Wed, 22 Feb 2012 11:15:49 -0800

Breaking News from HIMSS Search Twitter for #HIMSS12 stage for a steady stream of early details.

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Pharmacogenomics 101 Podcast

Sun, 22 Jan 2012 14:58:30 -0800

At the Am Medical Informatics Association meeting in Nov 2011, I had the pleasure of meeting Yohan Lee, PhD, an energetic and knowledgeable genomic researcher. We had a conversation on some general principles on pharmacogenomics and pharmcogentics via Skype recently. Here is a podcast of that conversation.

Direct link to Podcast

http://rxinformatics.com/content/yohan-lee-phd-amia-pharmacoinformatics

Link to iTunes download

http://itunes.apple.com/us/podcast/rxinformatics.com-podcast/id321829051

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Fifty Usability Ideas for Pharmacy inspired by iTunes

Tue, 20 Dec 2011 11:11:00 -0800

It seems that this is the year of usability in medical applications. There are lots of studies and examples of how better usability impacts patient care and workflow. A couple of years ago Allen Flynn from the Univ of Michigan Hospitals and pharmacy informatics extraordinaire, presented this concept of a pharmacy profile, a la iTunes. This is awesome and a classic. Thanks to Allen Flynn for allowing to share his brilliant ideas. A image of the entire iTunes pharmacy profile is attached.

Fifty Usability Ideas for Pharmacy inspired by iTunes

1. Pharmacy Department’s on-screen message box

2. Patient selection via Venue -> Unit -> Name

3. Updating counts of orders to be verified in parenthesis (y)

4. Drug information summary box updated for current drug
5. Contextual hyperlinks to drug info databases as buttons

6. On-screen clock

7. Large name panel with age, sex, weight, CrCL

8. Name panel scrolls on command to show current visit details

8. Active, discontinued and home medications toggle

9. Dynamic search capability

10. Pharmaco-surveillance provided as patient-specific alert buttons

11. System status signal with double-click for detailed information

12. Active orders count

13. Note management functions include Add, Edit and Remove

14. Pause function

15. Expandable window

16. Drug list with column sort, columns add, column arrangement

17. Window-shade order detail view without dialog boxes

18. Step-wise order verification using dynamic evaluation panes

19. Order risk ranking based on drug, order and patient information

20. Order provenance information for ordering clinician and process

21. IV push guidelines directly integrated into verification workflow

22. Rule-based forcing functions for verification steps

23. Metadata Dosing Evaluator with statistical indicators

24. Metadata Characteristic Selectors control the metadata used

25. Metadata Frequency Evaluator based on previous orders

26. Supply chain analysis pane with ADM and inventory information

27. Related home medications by generic name and therapeutic class

28. Previous orders for same order item listing

29. Allergy review pane with allergy data collection forcing function

30. Related findings pane with lab, vital signs and physiologic data

31. Alerts and responses pane shows clinicians’ CDS responses

32. Ordering clinicians’ names with hyperlinks to paging system

33. Order level notes function

34. Patient level notes function

35. Hover over PRN column to see detail of prn reasons

36. Hover over Dose and Frequency column to see scheduled times

37. ADM product availability column updated by ADM system

38. Verified order check-box

39. PRN assessment pane

40. Add customized verification panes to the verification process

41. Active ingredient by active ingredient verification

42. Switch all oral dosage forms from solids to liquids and vice-versa

43. Change all appropriate IVPB diluents from D5 to NS or vice-versa

44. Calculated CrCL on screen has selectable equation options

45. Body surface area onscreen

46. User’s recently verified medication list (not shown)

47. Patient’s individualized IV compatibility chart (not shown)

48. Last 24 hours and cumulative lifetime dose (not shown) columns

49. Infusion titration history graph pane (not shown)

50. Unused PRN indicator

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Dennis Tribble's Acceptance Speech - Distinguished Service Award

Wed, 14 Dec 2011 07:51:19 -0800

While we disagree on the value and integrity of ASHP, I agree with everything in this speech. He is an unbelievable pioneer and innovator in pharmacy informatics. Congratulations to Dennis!

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Podcast with Terry Seaton, Pharm.D.

Sun, 11 Dec 2011 06:06:45 -0800

Dr. Seaton is the new AMIA Pharmacoinformatics Working Group Chairperson.

Here is a new podcast introducing him with his background and terrific ideas for pharmacy informatics and more.

iTunes <LINK> to RxInformatics Podcasts
iTunes <LINK> to this episode
Direct <LINK> to this episode

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The Pharmacist by Michael Cassidy due out in early Dec here is the trailer

Fri, 25 Nov 2011 10:42:00 -0800

The Pharmacist (Official Trailer) from Michael Cassidy on Vimeo.

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The Pharmacist by Michael Cassidy » Thanksgiving Treats and Trailer — Kickstarter

Fri, 25 Nov 2011 10:33:00 -0800

We hope this 90 second trailer gets you even more excited to see the full and final product. We hope you enjoy it!
On behalf of The Pharmacist Cast & Crew, Happy Thanksgiving!

via kickstarter.com

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ACCP Address includes CDSS

Wed, 16 Nov 2011 04:32:11 -0800

Lawrence Cohen is the incoming President of the American College of Clinical Pharmacy. His inspiring address entitled

Boldly Positioning Clinical Pharmacy in Volatile Times specifically singles out clinical decision support. <LINK> It is great and reassuring to see a pharmacy leader that "gets it".

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ASHP: Continually in pursuit of hypocrisy. Part II

Tue, 15 Nov 2011 11:00:00 -0800

Since this hypocrisy has to do with informatics, it is posted here. Other professional society craziness can be found on Google Plus in the links below.

The Am Society of Health System Pharmacists (ASHP) CEO report has a number of hypocritical and delusional aspects. Part I <LINK> addresses ASHP’s patient safety policy and handling of the State of Ohio’s “lynching” of a pharmacist. This one addresses ASHP's claim to being at the right table when policy is made. Subsequent posts will deal with the financial management and leadership aspects in the 2011 CEO report. Part III on taking unpopular positions is here <LINK>.

Under the heading of “Being at the right table” the ASHP CEO pounds his chest about being at the right table on health care policy and information technology issues. He notes the Pharmacy HIT Collaborative as an example. In the HIT and health reform land grab ASHP was no where near the table and are struggling to nibble on crumbs. There is not even a mention of pharmaicsts in any of the HITECH, ARRA or any health reform legislation. They seem to be coming to the table for scraps after everyone else has had a feast.

These legislative initiatives were the equivalent of the Oklahoma land give away, GI bill and moon shot for health information technology. Pharmacists, the most connected health professionals, should have been at least part of the HITECH act to be “eligible providers” around electronic prescriptions and CPOE. As it stands there is not even a requirement to receive eRx’s and CPOE orders electronically. So claiming to be at the right table is, well, hypocritical. It borders on delusion.

The Pharmacy HIT Collaborative is generally a very positive strategic initiative. It desires some thoughtful consideration. Please take a look at those efforts. Even at its best, this initiative does not put ASHP at the table at all. At its worst that it puts pharmacy farther down the hall by taking a counter productive approach to EHR involvement. The specific tactics of the collaborative are a bit confusing that I will address in a separate post.

What say you?

2011 Report of the Executive Vice President and Chief Executive Officer: ASHP: Continually in pursuit of truth (right)

http://www.pharmacyhit.org/

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Google Plus discussion group from the UK on Hospital eRx and Admin

Sat, 12 Nov 2011 06:35:06 -0800

Google Plus is the real deal for social networking. That is a topic for another post. +Pauline Sweetman is a pharmacist informatics guru in the UK that is a must follow person in your RxInformatics circles. She points out a Google + site that will be of interest to this group.

There is now a Google+ page on UK Electronic Prescribing and Medication Administration. Another good site to add to your circles.

https://plus.google.com/u/0/111017406789447114550/posts

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ASHP: Continually in pursuit of hypocrisy.…

Mon, 07 Nov 2011 06:14:00 -0800

ASHP: Continually in pursuit of hypocrisy. Part III

This is Part III on the hypocrisy in the American Society of Health System Pharmacists (ASHP) ASHP CEO 2011 report that he entitled Continually in the Pursuit of the Truth. Here are links to Part I and Part II on other hypocrisy's in the report. At least a couple more items are in the works.

https://plus.google.com/u/0/107878174927164666208/posts/7iKCyimcCnn
https://plus.google.com/u/0/107878174927164666208/posts/TqbAaGXw9A1

In talking about pharmacists as leaders the CEO boasts about taking positions that are not popular. He cites telling the truth about the contributions of pharmacists in light of some negative AMA statements. How is this not popular? This does not seem all that brave to me. Standing up to physicians is what he is bragging about? Oh my, I see pharmacists and nurses do this every day in the course of their job. Doing this directly and in the heat of patient care takes a lot more courage than writing an opinion piece and throwing it over the wall. Of course he must defend the role of the pharmacist, that is his job. That was not exactly going out on a limb for the truth or taking a unpopular position. A true leader should be able to do better than that. I have the pleasure and honor see pharmacy leaders working with and challenging physicians at the academic medical center where I work all of the time.

There is a really good sequence in a movie Ratatouille. It is a commentary on critics. In many ways the work of a critic is easy. I do not pretend to be better or even know how to run a professional organization. However, like the famous quote about pornography “you know it when you see it”, I know incompetence and arrogance when I see it. I see it in ASHP all of the time in representing their members and the way they approach professional issues. Part IV and V of ASHP’s continual pursuit of hypocrisy to come.

In criticizing the ASHP, I am sensitive that this might start to be perceived as the ramblings of a disgruntled member. But, as a member of ASHP for 30+ years and a former elected official in the organization, I care deeply about the organization and its impact on the pharmacy profession. Their stewardship of this organization, with its actions and arrogant aristocratic airs, has reached a point that I must speak out. It is my sincere hope that the leadership take this criticism in a constructive manner.Edit

Ratatouille final taste

via plus.google.com

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Bar Code Comments needed (add RxNorm)

Fri, 28 Oct 2011 11:34:49 -0700

Your comments are needed. Please see this for the specifics:

http://www.ofr.gov/(S(j45ojizo0zqw1ugj34vngo5j))/OFRUpload/OFRData/2011-27657_PI.pdf

Most of the questions revolve around the technology requirements. The real issue and need is to get rid of the NDCs (or supplement them) and add RxNorm Codes for product identification. My 2 cents. Better people than me can comment on the pure technology issues.

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Favorite Steve Jobs posts

Thu, 06 Oct 2011 04:40:20 -0700

I had a few tears in my eyes this morning driving to the airport. Here are some terrific links in tribute to Steve Jobs

http://www.forbes.com/sites/carminegallo/2011/10/05/steve-jobs-he-saw-genius-in-our-craziness/

http://www.ted.com/talks/steve_jobs_how_to_live_before_you_die.html

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Clinical Informatics Becomes a Board-certified Medical Subspecialty

Fri, 23 Sep 2011 10:52:00 -0700

Clinical Informatics Becomes a Board-certified Medical Subspecialty Following ABMS Vote

September 22, 2011

AMIA to offer prep courses for clinicians who sit for Board Exam

via amia.org

Wow. Meanwhile pharmacy org and pharmacists are left in the dust. There are some dedicated people that have made a go of making Pharmacy Informatics a specialty. It remains in the distant future. It is my hope that this kicks us in the behind....

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More important than Informatics - Courage

Thu, 08 Sep 2011 11:16:00 -0700

Some things are more important than informatics. Yes I know for this group that is hard to believe.
Please take the opportunity to see this months editorial in Hospital Pharmacy, entitled "Having the courage to do the right thing". I was deeply moved by it.
Now, consider the non-actions and mis-directions of one of pharmacy's professional organizations, ASHP, elaborated in this piece: Continually in pursuit of hypocrisy. Part I
I welcome your comments.

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