Transcript Nashville 2011 – Update on Clinical Surveillance

Update on Clinical Surveillance
Setting up Clinical Monitoring Utilizing Meditech
Muse International Conference
June 2, 2011
Clinical Decision Support
vs.
Clinical Surveillance
Clinical Decision Support
Decision Support focuses on making
the appropriate choices for a therapy
at a given point in time
Clinical Surveillance
Clinical Surveillance focuses on
maintaining the appropriate therapy
for an ongoing period of time
Today’s Goal
• To expand our understanding on how to
allow the system to assist in routine
surveillance opportunities by imbedding
triggers into the system
• How to optimize your system to take
advantage of these opportunities
• Step by Step instructions
Surveillance Survey
• What are you doing now?
• What else should you be doing?
• What will it take to get to the next level?
Surveillance
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Determine what needs to be “watched”
Establish Surveillance Opportunities
Understand the clinical parameters
Evaluate the system’s ability to capture
and relay data
• Batch vs. Real-time surveillance –(levels
of sophistication)
Surveillance Opportunities
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Patient Demographics
Renal Dosing
Antimicrobial Therapy Monitoring
A.D.E. / Black Box Warning Monitoring
IV to PO Conversion
Drug Disease Interactions
Non-Pharmacy Opportunities
Pharamcogenomic contraindications
Methodology
• The system contains patient specific
data.
• The Clinician works with specific
triggers of evidence.
• By embedding the triggers into the
system it can provide surveillance to
streamline the clinician processes
Understanding
By utilizing sophisticated clinical rules
and reports to identify potential drug
problems, monitor laboratory values
and alert the clinician to potential
patient risks. You can leverage your
current Meditech system to protect
patients against potential adverse
events and improve patient
outcomes
Tools for embedding
"KNOWLEDGE"
Customer Defined Screens
• Pharmacy
• Admissions
• Nursing (NUR – PCS)
• ITS - Radiology
• Other modules
Added Sophistication
• Utilizing Rules linked to fields on a
Customer Defined Screen (CDS).
• Activating rules by selecting
appropriate fields on the CDS.
Global Rules are attached in the Customer Defined
Parameters
Medication Screen
CDS
• PHA DRUG type screen
• Medication Specific Information
• Attached in PHA parameters
• Same for all formulary items
PHA.DRUG CDS
CDS Querie Possibilities
• Protocol - dosage calcs
• Do Not Crush - Do Not Shake
• Drug classification - chemo, contrast,
blood
• Rx label information - MCD
• MAR warnings
• Nursing documentation prompts
• Triggers for invoking global rules
Possibilities cont.
• Protocol - dosage calcs
• Do Not Crush - Do Not Shake
• Drug classification - chemo, contrast,
blood
• Rx label information - MCD
• MAR warnings
• Nursing documentation prompts
• Triggers for invoking global rules
Rx Screen
• PHA RX type screen
• Rx specific information
• Attached in Order Type dictionary
• Same for all orders of that Type
• Entered as Rx queries
Possibilities
• Lot numbers
• Expiration dates
• Used with transaction rules can send
information to B/AR
• Unique information
• “Key” for rule display
Possibilities
• Lot numbers
• Expiration dates
• Used with transaction rules can send
information to B/AR
• Unique information
• “Key” for rule display
ADE Monitoring
• Medications can be classified on the Drug CDS
as those causing specific ADE’s. Multiple ADE’s
can be associated with a single formulary item.
• A Rule is created for each potential ADE.
• By answering “Y” to the ADE query “Potential
ADE (Y/N)” and associating the appropriate
ADE’s at the “ADE:” prompt, these refill rules will
be invoked and display on the refill list.
Clinical Evidence transfer from
ADE Monitoring
Clinician to System - Triggers
• Medications can be classified on the Drug CDS
as those causing specific ADE’s. Multiple ADE’s
can be associated with a single formulary item.
• A Rule is created for each potential ADE.
• By answering “Y” to the ADE query “Potential
ADE (Y/N)” and associating the appropriate
ADE’s at the “ADE:” prompt, these refill rules will
be invoked and display on the refill list.
Clinical Evidence transfer from
ADE Monitoring
Clinician to System - Triggers
• Medications can be classified on the Drug CDS
as those causing specific ADE’s. Multiple ADE’s
can be associated with a single formulary item.
• A Rule is created for each potential ADE.
• By answering “Y” to the ADE query “Potential
ADE (Y/N)” and associating the appropriate
ADE’s at the “ADE:” prompt, these refill rules will
be invoked and display on the refill list.
Using a CDS Query to invoke a
Global Rule
By answering “Y” to the ADE
query “Potential ADE (Y/N)” and
associating the appropriate
ADE’s at the “ADE:” prompt,
these refill rules can be invoked
and display on the refill list
Multiple ADE responses
can be entered for a
specific formulary item
Clinical Parameters
(sample triggers)
CDIFF
Positive Stool culture for C.diff
PC<50000
Platelet count less than 50,000
PTT>100
PTT greater than 100 seconds
INR>6
INR greater than 6
Retcount>2
Absolute reticulocyte count greater than
2%
Bili>10
Seum bilirubin greater than 10 mg/dL
ALT>150
Serum ALT > 150 Units/L
IncreaseCR
Increasing Creatinine
IncreaseALT
Increasing ALT(20%)
Hyperkalemia
Serum Potassium greater than 6.5
mmol/L
ADE Monitoring
• Global rules will indicate a potential ADE
and the order that may be causing the
adverse effect.
Sample ADE Rule
; This rule will display patient with cyclosporine > 500 receiving
cyclosporine drug
;
[f rx med]^M,
"PHA.ADEGRP"^GRP,
"CYCLOSPRNE"^CDS,
IF{[f z.get.cds.resp](M,GRP,CDS) ""^RES,
[f rx nth ver Res-RES]("CYCL1",1)^RES,
RES#”1,”^RESDT,RES#”2,”^RESTM,RES#"0,"^RES,
IF{RES>500 "Potential ADE, cyclosporine serum level = "^MSG,
MSG_RES_” on “_RESDT_” @ “_RESTM^MSG,
Q(MSG,RESDT,RESTM);[f rx reject]};
[f rx reject]};
Sample Custom Keyword
z.get.cds.resp
%PHA.RX.zcus.tig.npr.rx.rules.M.get.resp(
; This program will get the ADE group Response from the formulary
Dictionary
; A - Med
; B - Query
; C - Response to check for
;
A^PHA.DRUG.mnemonic,
B^PHA.DRUG.query,
""^PHA.DRUG.query.mult.q^FND,
DO{@Next(PHA.DRUG.query.mult.q)&'FND
IF{@PHA.DRUG.query.mult.resp=C 1^FND}},
FND;
Added Sophistication
An NPR Report printed to the screen that
promotes the ability to provide real-time
intervention on patients when time may be
of the essence.
Real-time Clinical Surveillance Display
Right Arrow for Detail of Order
IV to PO Conversion
• Fields can be added to the Drug CDS.
• The first field identifies if the medication can be
converted to a PO medication.
• The second field will define the dose of the oral form that
is equivalent to the IV form.
• The global refill rule provides the following information.
For patients with active orders for the medications
identified that can be converted to PO. It searches
through the active orders of the patient for any other
active orders for oral dosage forms that have a schedule
of SCH. If that is the case the rule will display a
message that the patient is receiving an IV medication
that may be suitable for a specific PO substitution.
IV to PO Conversion Set-Up
Answering “Y” to this field
identifies if the medication
can be converted to PO.
Oral Equivalent
information to display
can be entered here
IV to PO Real-time Clinical Surveillance
Display Sample
Additional Sophistication
• If after reviewing an IV order, if it is
determined that the IV should continue, an
additional field can be added to the order
type CDS to remove the rule message
from displaying on the refill list or real-time
display.
Order Type CDS
An Additional field can
be added to the order
type CDS. The CDS is
attached in the Order
Type dictionary
Sample Order Type CDS
Once a user puts in a review Date
and Time, the order will drop off
the view board and resets the RX
so that a new reported lab will
trigger it to appear on the board
again if indicated.
Review notes added to note any
changes or notes for that date.
Micro – CS Surveillance
• Displays if patient has been on
antimicrobial therapy greater than x days
(x customer defined)
• Warns if patient is on antibiotic and micro
reports resistance to that antibiotic
• Warns if micro reports positive growth but
patient not on Antibiotic
Querie Responses - Abx
Microbiology Warning
Additional Surveillance
• Change in patient weight > X%
• Warns if patient creatinine clearance
changes by greater than X amount
• Pharmacogenetic Monitoring
–
IN.CYP2C10
• Poor Metabolizer for Plavix.
Step By Step
1.Upload into Meditech all reports in zip file
called Clinical Review Board.
2.Re-file and translate reports.
3.Build Group Responses found in word file
Group Responses.
4.Build Queries found in word file Queries.
5.Build Customer Defined screens found in
word file CDS.
Step By Step (cont.)
6.Build Keywords found in word file Keywords.
7.Build Rules found in word file Rules.
8.Attach Drug CDS and Rx Query CDS.
9. Edit Drug dictionary and activate drugs to
monitor and what to monitor.
Run Clinical Review Board
Review
Questions / Discussion
Contact Information
http://www.theingroup.com
[email protected]