Welcome to

St. Abrutis Healthcare*

A proposedClinical Decision Support System

to improve managementof prescription medicationsamong our elderly patients

* St. Abrutis Healthcare is a wholly owned subsidiary of the MDM-VanHalen International Corporation

St. Abrutis

Healthcare

St. Abrutis Healthcare

Catchment area:241,8205 rural counties

Acute Hospitals: 200 bed 75 bed 30 bed CAH

LTC/SNF:2 >100 bed3 <50 bed

Providers:64% Primary Care 41% Specialty Care

41,300 Medicare

Elders and ADEs

St. Abrutis

Healthcare

Increased susceptibility to … SedationfallsCoagulation problemsKidney damage

Leading to … Unnecessary hospitalizationRe-hospitalization

Elders and ADEs

St. Abrutis

Healthcare

Potentially Inappropriate Medicataions (PIMs)Beers Criteria

In NH, the risk: - Hospitalization OR=1.274

- Death OR=1.464

1 in 20 adults1

59% of hospitalized patients2

85% discharged from ICU3

1- Bourgeois 2010; 2- Fleming 2008; 3- Morandi 2013; 4- Dedhiya 2010

Elders and ADEs

St. Abrutis

Healthcare

41,300 x 13.81 ADE /1000 …

At St. Abrutis Healthcare

569 ADEs per year!

$1,9831 per ADE …

$1,130,191 per year!

1- Field 2005

Elders and ADEs

St. Abrutis

Healthcare

Using Beers Criteria works …

Education 24 – 31% reduction in PIM1,2

Baseline 2% reduction2

Only 2% d/c’ed meds resumed3

1- Keith 2013; 2- Monane 1998; 3- Garfinkle 2013

St. Abrutis

Healthcare

CDS to reduce PIMs?Med Rec moduleIncorporate multiple Med listsAlerting to PIMs

Post d/c follow-up visitsImprove provider workflowInfuse evidence about Meds

ProposedSystem Specification

St. Abrutis

Healthcare

Knowledge

Source/ Acquisition/ Representation

St. Abrutis

Healthcare

Beers CriteriaEncoded into rulesRepresented in XML documentsUsing RxNorm terms

SystemArchitecture

St. Abrutis

Healthcare

Medication List Screen

Changesto Med Listneeded? Print Prescriptions

or ePrescribeas needed

Moreadjustments

needed?

Adjust, or D/C aspecific medication oradd new medication

No

NO

Yes

Yes

Medication Reconciliation Screen

PCP wantsinformation

about amed?

Mouseovermed name

Clickinfobutton

Infobutton resultdisplayed in window

If on Beers Listinformation displayed

in a pop-up box

Reconcile 1st med

ContinueMedication?

Click "A" Click "X"

All MedsReconciled?

Go to nextmedication on list

Go to next formin EHR note

PCP enters EHR,Opens note

PCP works through EHR noteto medication reconciliation

screen

RN creates HospFUVisitnote in EHR

RN enters nursingdata in EHR

RN exits EHR note,passes note to PCP

Compositemed list w/

Beer's MedsHighlighted

Provider finishes EHR note

End of Patientencounter

Patient beginsF/U visit

Moving to Med Rec screenin EHR triggers CDS module

(see architecture

diagram for details)

This is "traditional" Med Listscreen that is unchanged in theoutpatient EHR

This Medication Reconciliation Screenis the new screen that the CDSSimplements into the existing workflowin the outpatient EHR

Yes

No

Yes No

No Yes

Workflow Integration

St. Abrutis

Healthcare

Demo Use CaseMary, 72yo with mild dementia, moved to assisted livingSlipped, fell last week, was in pain so went to hospitalDiagnosed with back strain and spasm, discharged

Vicodin 10/500 mg tabs, 1 po q4-6 hr painMeloxicam 15mg tabs, 1 po qdayCyclobenzeprine 10mg tabs, 1 po TID

Mary is back at the office today for her hospital follow-up visit

St. Abrutis Healthcarewishes to thank…

The board of MDM-VanHalen International

Jenny AlderdenMohammad AljouaidJustin ClutterChad HodgeCasey RommelTeresa Taft

St. Abrutis Healthcare

No, really, it’s over,Even the Aclepius fell off -

You can stop now.

St. Abrutis Healthcare*

A proposedClinical Decision Support System

to improve managementof prescription medicationsamong our elderly patients

* St. Abrutis Healthcare is a wholly owned subsidiary of the MDM-VanHalen International Corporation

Handout

Figu

re 1

–

Syst

em A

rchi

tect

ure

Figure 2 – Large-scale Workflow Integration

Medication List Screen

Changesto Med Listneeded? Print Prescriptions

or ePrescribeas needed

Moreadjustments

needed?

Adjust, or D/C aspecific medication oradd new medication

No

NO

Yes

Yes

Medication Reconciliation Screen

PCP wantsinformation

about amed?

Mouseovermed name

Clickinfobutton

Infobutton resultdisplayed in window

If on Beers Listinformation displayed

in a pop-up box

Reconcile 1st med

ContinueMedication?

Click "A" Click "X"

All MedsReconciled?

Go to nextmedication on list

Go to next formin EHR note

PCP enters EHR,Opens note

PCP works through EHR noteto medication reconciliation

screen

RN creates HospFUVisitnote in EHR

RN enters nursingdata in EHR

RN exits EHR note,passes note to PCP

Compositemed list w/

Beer's MedsHighlighted

Provider finishes EHR note

End of Patientencounter

Patient beginsF/U visit

Moving to Med Rec screenin EHR triggers CDS module

(see architecture

diagram for details)

This is "traditional" Med Listscreen that is unchanged in theoutpatient EHR

This Medication Reconciliation Screenis the new screen that the CDSSimplements into the existing workflowin the outpatient EHR

Yes

No

Yes No

No Yes

Figure 3 – Outpatient Workflow Integration

References - p1Bates, D. W., Kuperman, G. J., Wang, S., Gandhi, T., Kittler, A., Volk, L., …Middleton, B. (2003.). Ten commandments for effective

clinical decision support: Making the practice of evidence-based medicine a reality. Journal of the American Medical Informatics Association : JAMIA, 10(6), 523–30.

Beers, M. H., Ouslander, J., Rollingher, I., Brooks, J., & Beck, J. C. (1991). Explicit criteria for determining inappropriate medication use in nursing home residents. Archives of Internal Medicine; 151(9), 1825-32.

Borgeois, F.T., Shannon, M.W., Valim, C, & Mandl, K.D. (2010). Adverse drug events in the outpatient setting: An 11-year national analysis. Pharmacoepidemiology & Drug Safety, 19(9), 901-910.

Campanelli, C. M. (2012). American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults: The American Geriatrics Society 2012 Beers criteria update expert panel. Journal of American Geriatrics Society, 60(4), 616–631. doi:10.1111/j.1532-5415.2012.03923.x.American

Dedhiya, S. D., Hancock, E., Craig, B. A., Doebbeling, C. C., & Thomas, J. (2010). Incidence, use, and outcomes associated with potentially inappropriate medication use in older adults. The American Journal of Geriatric Pharmacotherapy, 8(6), 562–70. doi:10.1016/S1543-5946(10)80005-4

Field, T. S., Gilman, B. H., Subramanian, S., Fuller, J. C., David, W., Gurwitz, J. H., & Bates, D. W. (2005). The costs associated with adverse drug events among older adults in the ambulatory setting. Medical Care, 43(12), 1171–1176.

Hale, L.S., GRifin, A.E., Cartwright, O.M., Moulin, J, Alford, S.J., & Fleming, R.M.. (2008). Potentially inappropriate medication use in hospitalized older adults : A DUE using the full Beers criteria. Formulary, 43(9), 326.

Garfinkel, D., & Mangin, D. (2013). Feasibility study of a systematic approach for discontinuation of multiple medications in older adults. Archives of Internal Medicine, 170(18), 1648–1654.

Gurwitz, J. H., Field, T. S., Rochon, P., Judge, J., Harrold, L. R., Bell, C. M., … Bates, D. W. (2008). Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting. Journal of the American Geriatrics Society, 56(12), 2225–33. doi:10.1111/j.1532-5415.2008.02004.x

Hustey, F. M., Wallis, N., & Miller, J. (2007). Inappropriate prescribing in an older ED population. The American Journal of Emergency Medicine, 25(7), 804–7. doi:10.1016/j.ajem.2007.01.018

Keith, S. W., Maio, V., Dudash, K., Templin, M., & Del Canale, S. (2013). A physician-focused intervention to reduce potentially inappropriate medication prescribing in older people: a 3-year, Italian, prospective, proof-of-concept study. Drugs & Aging, 30(2), 119–27. doi:10.1007/s40266-012-0043-y

Kawamoto, K., & Lobach, D. F. (2006). Design, implementation, use, and preliminary evaluation of an UMLS-enabled terminology Web service for clinical decision support. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium, 979. doi:86251 [pii]

References - p2

Lattanzio, F., Laino, I., Pedone, C., Corica, F., Maltese, G., Salerno, G., … Incalzi, R. A. (2012). Geriatric conditions and adverse drug reactions in elderly hospitalized patients. Journal of the American Medical Directors Association, 13(2), 96–9. doi:10.1016/j.jamda.2011.04.006

Monane, M., Matthias, D. M., Nagle, B. A., & Kelly, M. A. (1998). Improving prescribing patterns for the elderly through an online drug utilization review intervention: a system linking the physician, pharmacist, and computer. JAMA : The Journal of the American Medical Association, 280(14), 1249–52.

Morandi, A., Vasilevskis, E., Pandharipande, P., Girard, T., Solberg, L., & Neal, E. (2013). Inappropriate medications in elderly ICU survivors: Where to intervene? Archives of Internal Medicine, 171(11), 2011–2013.

Nixdorff, N., Hustey, F. M., Brady, A. K., Vaji, K., Leonard, M., & Messinger-Rapport, B. J. (2008). Potentially inappropriate medications and adverse drug effects in elders in the ED. The American Journal of Emergency Medicine, 26(6), 697–700. doi:10.1016/j.ajem.2007.12.007

O’Connor, M. N., Gallagher, P., Byrne, S., & O’Mahony, D. (2012). Adverse drug reactions in older patients during hospitalisation: are they predictable? Age and Ageing, 41(6), 771–6. doi:10.1093/ageing/afs046

Terrell, K. M., Heard, K., & Miller, D. K. (2006). Prescribing to older ED patients. The American Journal of Emergency Medicine, 24(4), 468–78. doi:10.1016/j.ajem.2006.01.016

Terrell, K. M., Perkins, A. J., Dexter, P. R., Hui, S. L., Callahan, C. M., & Miller, D. K. (2009). Computerized decision support to reduce potentially inappropriate prescribing to older emergency department patients: a randomized, controlled trial. Journal of the American Geriatrics Society, 57(8), 1388–94. doi:10.1111/j.1532-5415.2009.02352.x

Teymoorian, S. (2011). Association between postdischarge adverse drug reactions and 30-day hospital readmission in patients aged 80 and older. Journal of the American Geriatrics Society, 59(5), 948–950.

Yourman, L., Concato, J., & Agostini, J. V. (2008). Use of computer decision support interventions to improve medication prescribing in older adults: a systematic review. The American Journal of Geriatric Pharmacotherapy, 6(2), 119–29. doi:10.1016/j.amjopharm.2008.06.001