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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