John Poikonen, Pharm.D.
Medical Informaticist and Pharmacist
http://RxInformatics.com and http://RxDoc.org
John Poikonen, PharmD mail:jp@rxdoc.org
Clinical Decision Support is not a choice. Over the longer term CDS will have a profound and lasting impact on providing direct patient care. CDS will replace much of the order review that is taking away time from direct patient care. No More NUPOR!
http://rxinformatics.com/search/node/NUPOR
The link above has a number of posts on this disruptive idea.
Cast you vote http://www.ashp.org/ppmi
...and of course one more reason for CPOE over BCMA:)
Last weekend HIMSS sponsored a pharmacy symposium the day before all of the other festivities. Here is a brief summary and links to the PPTs.
First, thanks goes out to Michael McGregory PharmD, MBA for Chairing the event. I had the honor and privilege to serve with him on the planning committee.
First up was the Opening Keynote Address: Incorporating Evidence into Decision Making by the wonderful Anne Bobb. For those of you that do not know her, she is a informatics pro from Northwestern Memorial Hospital in Chicago, but hails from the Great State of Maine. She had the best line, not only of the day, but of the entire HIMSS week. Here is a Tweet that was ReTweeted many times through out the week. It only got better from there as she outlined the awesome evidence of CPOE and other interventions with pearls along the way.
Btw, I was live tweeting throughout the day. For a view of what caught my attention during the events check out my Twitter stream that has the hash tag #himss10
We then had a joint session with our Nursing colleagues for a romp around the medication use process and informatic interventions, entitled Multi-Disciplinary Joint Session: Medication Process, Closing the Loop
At Lunch Krista Pedley PharmD, MS, CDR, USPHS gave a HRSA Update. (most acronyms I have ever used in a sentence) The slides are not available on the HIMSS site (must be a government thing or that "Hail to Allah" slide<just kidding>) HRSA is doing some incredible things for the profession of pharmacy. They do not get enough press. "Hi I am from the goverment, and I am here to help." They really mean it! Very impressive.
Stan Kent, former ASHP Board member and DoP/VP at Northshore University Health System talked about Medication Reconciliation and Continuity of Care. If there is a more complicated process in health care, I do not know what it is. Here is a blog post on an interesting point he made about pharmacist verification, opps Perfection, that I think has profound implications for a new pharmacist practice model.
Holly Lilly, an emerging star in pharmacy informatics, consultant and Adjunct Faculty member in the ASHPFoundation Pharmacy Leadership Academy talked on Medication System Implementation Challenges: Fitting a Round Peg into a Square Hole. Topics included Oncology, Normalized Dosing, Pediatric Weight Dosing, CDS, Dose Range Checking, Rounding Logic, HCPCS Codes, Order Sets, Smart Pumps, phewww, I am getting tired just thinking about it. Nice Job.
Sandra Fisher, Pharmacy Informatics Specialist from Richmond, VA gave a presentation on Easing the Medication Information System Transition from Implementation to Maintenance. If you are implementing any system, check this ppt out. A number of implementation pearls are presented.
Lastly, I did not attend the closing session because: (a) Since I profoundly disagree with the speaker's view on the Eric Cropp travesty, how could his crystal ball be accurate? He has free choice on his views. My choice was not to attend his presentation. (b) The gold medal Olympic hockey game was happening at the same time. Still deciding which reason was the real one. His presentation was Pharmacy Practice and Informatics - What Does the Future Hold?
A good time was had by all at the annual pharmacy informatics get together, organized by Kevin Marvin! Hope to see you all next year.
Just so you do not think I am some anti-BCMA psychotic: Below is thoughtful essay on some of the (side) benefits of BCMA and the process.
Posted with permission from Michael Jones, Pharmacy Informatics Specialist (extraordinaire) at Univ of Colorado Hospital.
John Poikonen, Pharm.D. | UMass Memorial Health Care | john.poikonen@umassmemorial.org | 508-334-1159 | 978-501-4887 mobile
From: Jones, Michael - Pharmacy
Sent: Tuesday, June
23, 2009 3:57 PM
To: Poikonen, John
Subject: RE: BCMA
Hi John,
Before we implemented BCMA I think I agreed with your current position. In fact, I’m sure I would agreed with you half way through our two year implementation. Now that we have completed implementation I’ve really grown to appreciate the benefits. Interestingly, for me the benefits go beyond the “5-rights …” everybody talks about.
Two important benefits of BCMA that seem to be missing from our discussions and the literature is:
In order for BCMA to work effectively, pharmacists really need to be decentralized, working with nurses as a team. One of the challenges we had to overcome was several pharmacists and nurses that liked the status quo. Some of these people learned to like the new working arrangement, some moved on. Nurses came to appreciate what pharmacists brought to the point-of-care. Pharmacists realized they had nothing to fear and gained significant respect for the work nurses, RTs and physicians do.
Bill Gates said in his book Business at the Speed of Thought, “… success in a high-tech environment requires high-touch professionals”. For pharmacists to continue to thrive with the numbers employed we currently have, in a “no more NUPOR” world we need to be close to our patients and really integrated in to a healthcare team.
Example #1: When a patient starts to crump the first questions are “what meds have the patient gotten?”, and when were the narcs given? If the nurse has not charted all day there is a huge information gap interfering with good decision making.
Importance to automated CDS:
1) Here at UCH our team is writing a medical logic module (MLM) for the medical emergency team (MET) a.k.a a rapid response team in some hospitals. Obviously accurate and timely charting of VS, meds, labs, procedures, etc, is very important to the specificity and sensitivity of the alerts.
2) I have also written a MLM for our pharmacokinetics service that is triggered by a Vancomycin SDC stored in the electronic patient record. It collects most the information they need including the actual times of the last two Vancomycin administrations. As you know, the actual time of med admin is a major vulnerability to the success of any PK service. This would be impossible without BCMA. I am also a strong advocate of point-of-care barcode scanning at the time of obtaining lab samples.
Medical Decision making (electronic or otherwise) is very dependent on accurate information, including accurate time of events.
Example #2: Scanning medications at the time of administration provide accurate information at the time of med administration that would otherwise be lost. Prior to BCMA nurses would gather their meds, ideally for one patient but nurses being efficient as they are will frequently gather meds for all their patients at that end of the hall. They will administer the meds the best they can while often dealing with multiple distractions that naturally occur from patients, family, visitors, physicians, and other nurses needing assistance. The 0900 meds he/she started passing at 0800 are not infrequently completed at 1030 or 1100. Busy as nurses are they frequently do not chart med administrations until the end of there shift. These days it seems the usual nursing shift is 12 hours, which means by the time the nurse finishes charting his/her shift may be 13 hours or more. Which by that time of the day they chart all their 0900 meds as administered at 0900 because they can’t remember what really happened. An unexpected benefit the nurses tell me is they actually are getting out on time more often, because their med administrations are charted throughout the day, so they have less to chart at the end of their shift. And this comes about because they are held accountable for their scanning rates, so scanning becomes a priority.
I’m sure there are other import reasons. If I think of more I’ll send them along.
I know it is expensive and a lot of had work to get a successful BCMA system up and working, but IMHO it is well worth it. Many of our CDS problems relate to accurate information, and I am now convinced that BCMA is an important part of the several solutions.
Thanks,
Mike
Dennis Tribble elaborates and articulates the issue in a thoughtful way.
Automating order review is delegation, not abdication
Dennis A. Tribble
Am J Health Syst Pharm 2009;66 1078-1079
The two other articles are now free to all.
Flynn AJ. The opportunity cost of pharmacists’ nearly universal prospective order review. Am J Health-Syst Pharm. 2009; 66:668–70.[Free Full Text]
Poikonen J. An informatics perspective on nearly universal prospective order review. Am J Health-Syst Pharm. 2009; 66:704–5. Letter.[Free Full Text]
It turns out Michael Maddux of Am College of Clinical Pharmacy supports the idea and puts forth some excellent points.
POSTED: APRIL 13, 2009
There’s a movement afoot questioning the current approach of having pharmacists review nearly all drug orders. Although proponents of near universal drug order review (NUPOR) argue that the practice is needed to ensure the accuracy of drug orders, others pushing for change maintain that the value of such review has not been quantified, and it is provided at great cost because it keeps pharmacists, who are still in short supply, from other important clinical responsibilities…..
This response to Allen Flynn's first commentary on NUPOR hit the presses last night.
This might only be available to subscribers of Am J Health Syst Pharm. If you would like a copy, drop me an email.
Along with this commentary from Bill Zellmer will give you an idea of the future of pharmacy
John Poikonen
john@poikonen.net
http://twitter.com/poikonen
http://pharmacyinformatics.wordpress.com
http://www.evernote.com/pub/poikonen/PublicPharmacoinformatics
The ongoing series on No More NUPOR can be seen by clicking the link to the left. It is part of a new and improved RxInformatics.com site.
The following statement was put forth at the Am Soc Health System Pharmacist's (ASHP) House of Delegates in Seattle in June of 2008.
Use of Clinical Decision Support to Limit Need for Near-Universal Pharmacist Order Review -- ASHP should advocate study of the potential use of clinical decision support in the place of the current practice of near-universal pharmacist order review.
It was turf’ed to the ASHP’s Council of Pharmacy Management for guidance. Their report has recently become available (page 8).
My ‘glass is half full’ interpretation of the Council’s report is that they fully and unequivocally support this recommendation. This is fantastic and hope that research interest and dollars follow.
Now the rest of the story….. Here is the write up with my comments inserted, followed by comments of the current and future Chairperson of the ASHP Section on Pharmacy Informatics and Technology.
Use of Clinical Decision Support to Limit Near-Universal Pharmacist Order Review.
In response to a Recommendation from the ASHP House of Delegates, the Council discussed the desirability of using clinical decision support systems (CDSS) to limit universal pharmacist order review. The Council discussed the current status of CDSS. According to a 2007 ASHP survey only 12% of US Hospitals have implemented CPOE with a robust CDSS. Up to 90% of hospitals are looking at this technology in the next three years. While every CPOE computer system includes commercially developed CDSS, extensive local customization is required to achieve optimal performance and patient outcomes.
When implemented and properly customized with dedicated pharmacist resources there is substantial evidence that CDSS can have positive patient outcomes.
[Unlike some other popular technologies being advocated i.e. BCMA]
However, the extensive customization required by these systems has limited the widespread use of CDSS,
[not sure this is the case, but ok]
especially for the purpose of limiting pharmacists’ review of medication orders.
[At least that is getting published. Many are doing it, none the less.]
The Council supported further research and pilot projects to demonstrate the value of CDSS. Research validating CDSS algorithms, as well as human factors research
[kudo’s to note human factor research – not enough of this either]
in the application of CDSS, would be valuable.
The impact of CDSS on the pharmacist review of orders should be aggressively evaluated.
The Council did not support the use of CDSS to replace pharmacist review of medication orders at this time.
[That is why we do research]
The Council did not believe that the technology has evolved to a point where it could replace the pharmacist’s role in medication review.
[I completely disagree with this, but did I mention that is why we do research]
The Council also did not think it would be wise to create policy that conflicted with Joint Commission requirements for pharmacist medication order review.
[Unless you have a death wish]
The Council did support the use of CDSS to improve medication use, believing that there may be more value in focusing efforts on the use of CDSS in improving the use of high-risk medications.
Responses to Section of Pharmacy Informatics and Technology Chairs
I like the rationale. We simply do not have enough adoption of EHRs with robust CDSS to make widescale recommendations on limiting the RPh role. However, this is not to say the "elite and progressive" health systems shouldn't be pioneering and researching the possibility.
And….
The attributes of a CDSS system that would serve as a filter for pharmacist review are decidedly different than the attributes of a CDSS that interacts with us on every order we review. It is clear that the council does not appreciate the difference.
Most, if not all, of our complaints about CDSS right now are that it is “unintelligent”, that it fails to recognize when it shouldn’t alert us, that it causes “alert fatigue”. I know of very few cases where the CDSS failed to detect something it should have known.
That very property makes it an ideal anti-NUPOR filter. You WANT to be certain that nothing escaped detection, no matter how absurd. If you have that confidence, you can proceed to auto-approve any orders for which there are no alerts. There will still be orders we look at and ask “why did it make me look at that?”, but there will be a significant number that just sail through.
But, to echo John’s earlier sentiment, it is not clear at all that current CDSS are insufficient to the tasks of screening orders. It is only clear that we find them annoying when they tweak us during the process of order entry.
Wait there is more...
My personal opinion is that the standard FDB/Medispan based CDSS is what most of the country uses, and what we are referring to when we talk about mainstream adoption. This is no where near being useful enough clinically to limit NUPOR. The advanced CDSS goes much further, but adoption is very spotty. An alert for a patient on warfarin that has not had an INR in the past 14 days is a decent example. These have to be custom built into most systems these days.
Perfect example. I guarantee you that warfarin orders on patients that have not had an INR in 14 days are not being questioned and are being verified without question at any number of Medical Centers. With CDS it would be caught, questioned and corrected. Hence better care.
Your thoughts?
Opportunity cost of pharmacists’ nearly universal prospective order review by 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 15th 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.
The original ‘No More NUPOR’ post is here. To remind you - NUPOR is Near Universal Pharmacist Order Review, the current state of practice for medication orders. There is a group of informatics professionals that are questioning this scared cow. Here is the latest in what will be a series of commentaries on the subject.
The following is a series of email conversations with some very high placed influential pharmacy leaders. Their names are not revealed as the points are more important than who said them.
First this was noticed in the March 2009 Journal of Health System Pharmacy.
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.”
This position more or less endorses the concept of NUPOR that is clearly not universally accepted, yet a standard of practice in the US.
The next suggestion was that this statement
“is essentially the "endorsed" preamble to (no more) NUPOR....”
Which was then noted that
“This is essentially the internationally "endorsed" preamble to (no more) NUPOR....”
It occurred to me that some may take pot shots that the US is far better than most countries, to which I shot back (with out thinking beyond that)
“I can hear is now “what do those for-ners know’, we are better than that. That’s when you pull out this graph (below). [not from Michael Moore but a software biz plan]”
This is an amazing graph from a presentation at the 2008 Connected Health Seminar at Harvard by Brian Bosworth founder of Keas, Inc.
Wouldn’t you know it? This was received within seconds:
“I attended and participated in the global conference in Basel and I also sit on the Joint Commission International (JCI) standards committee. I would caution any of you about looking at the statements from the conference or the JCI standards as something to which we should aspire in this country. For these groups the bar is set pretty low in order to establish a minimum baseline toward which to strive. For example, many countries don’t even have pharmacists in hospitals at this point in time – so I couldn’t even get the JCI committee to agree that a pharmacist should designated as being responsible for pharmacy services in hospitals.”
Clearly the person had not seen my post, so I thought I was going to be in big trouble. I responded back:
Opps. I better qualify my previous email. My only point in the slide I sent (which strikes me as incredible) is that if Life Expectancy is a macro indicator of how well a health system does, then we suck and are paying way too much. A socialist view is that it is all insurance company greed and overhead, which, I admit is partly my view. Culture (mostly obesity) comes into it, so does delivery of pharmaceuticals. So, from a micro pharmacy view, looking at other countries health delivery systems need to be looked at and not dismissed out of hand.
Phew, dodged a bullet on that with the response
I agree 100% with you John that most of the money spent on healthcare in this country is a waste - and going to insurance executives, pharmaceutical companies, administrative overhead, bureaucratic BS and consultants. And individuals need to start taking responsibility for their own health – like all the third world countries. Then we would have much more money to give to GM!
John Poikonen, Pharm.D.
Medical Informaticist and Pharmacist
http://RxInformatics.com and http://RxDoc.org
John Poikonen, Pharm.D.
Medical Informaticist and Pharmacist
http://RxInformatics.com and http://RxDoc.org
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