Transcript medication reconciliation

MEDICATION RECONCILIATION
Using PH-Doc
June 12, 2012
Presented by
Daniel Jensen, Associate Director of Public Health, Olmsted County
Deb Castellanos, Technical Manager/Project Manager, Xerox Corporation
Powerpoint and Demo
of the “PH-Doc” software
Intellectual property of MCCC, powered by Xerox Corp.
Software installed in 28
local public health agencies
in South East Minnesota
What is local public health
in MINNESOTA?
Public Health Documentation System
Software application
owned and managed by the users
long-standing relationship with the developers
First program written in 1984
“Re-engineered” several times over 28 years
Electronic Chart
and
Practice Management System
Years 2008 - 2012
“re-engineering for interoperability” when along came the
SE Minnesota Beacon Project
Community of hospitals, clinics, counties and schools sharing
clinical health information
Mayo Clinic – GE’s EMR
Mayo Health Systems – Cerner’s EMR
Olmsted Medical Center – Med3000’s EMR
Winona Health – Cerner’s EMR
Allina Health – Epic’s EMR
11 counties in SE MN – PH-Doc Health Record
46 school districts in SE MN - PH-Doc Portal
SE Minnesota Beacon Project
April 2010 – April 2013
These clinics, hospitals and counties are exchanging clinical data
using the National Health Information “NwHIN” specifications and
open source software; GATEWAY at each site with the ability to
perform peer-to-peer communications
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Uses SOAP webservices over HTTPS
Wraps payload in SAML assertions
Includes auditing and logging
Enables the exchange of CDA Documents
What is a CDA Document?
Structured XML document based on the HL7 V3 RIM
activities, entities, participants, roles, moods
Standard HEADER section
patient information, title, date, author, custodian, authenticator
Sections of clinical content – preferably structured and coded
medications, allergies, problems, immunizations, vital signs,
procedures, advance directives, payers, results, plan of care,
family history, social history, pregnancy, visit notes, comments
Under the Beacon project …
several enhancements were made to PH-Doc
o structured medications and allergies
RXNORM, UNI, NUI, Snomed
o structured CDA documents
Summary of Care, Laboratory Studies, Asthma Action Plans
Public Health CDA (environmental, social factors, behavioral factors)
o live feeds to Regenstrief Institute
patient visits and quality of life indicators
Under the Beacon project …
infrastructure was added to each county
to host its gateway
An appliance (from Mirth corporation) was ordered for each of the
11 counties
Mirth Appliance
The appliance hosts communication services; SFTP, HTTP,
WebServices, LLP …
… and includes the Aurion Gateway
… ‘open source’ with support
Firewall
Mayo Clinic
Mayo Health
Olmsted Medical
PH-Doc
Application
Server
DMZ
MIRTH
Connect
Gateway
Public Health Nurse
• Patient
Correlation
• Security and
Authentication
• Audits and Logs
Winona Health
Allina Health
Internet
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Outgoing REQUEST – one per patient
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Patient Demographics – used to match at destination site
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Requestor – name and Role
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Purpose for request
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Destination Gateway(s) – based on Release of Information
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Type of document(s)
Each request becomes a thread
Don’t want to tie up the nurse.
Depending on number of documents and gateways, could take a
few minutes
ALERT when the request has finished processing
Status of documents that have been pulled
Each document stored as XML with stylesheet
Each document rendered/stored as PDF
Each document parsed for structured data
Parsing the Coded Data
.NET shop
Used C# and XPATH
Specifications from HITSP
C32
C83
C80
C154
Parsing the CCD
Details from
HITSP
C80/C83
Mayo
Mayo
Structured data
elements &
code tables
To develop our
parsing rules
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Parsing the CCD
Details from
HITSP
C80/C83
Structured data
elements &
code tables
To develop our
parsing rules
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Now that we have parsed data…
able to tackle “reconciliation”
As defined by the JACHO, medication reconciliation is "the
process of comparing a patient's medication orders to all of the
medications that the patient has been taking. This reconciliation is
done to avoid medication errors such as omissions, duplications,
dosing errors, or drug interactions. It should be done at every
transition of care in which new medications are ordered or existing
orders are rewritten. Transitions in care include changes in setting,
service, practitioner or level of care. “
… we’ve done it before …
Designed as an INTERACTIVE process
• nurses working with the patient in the home/school/jail
Our first reconciliation screen dealt with IMMUNIZATION data
coming from the state of Minnesota’s IMMUNIZATION registry
Used a secure webservice to request data. We used the codes
we received from the state and mapped to CPT/CVX codes.
Design Standards
Side by side presentation of two lists
LEFT – incoming data
RIGHT – PH-Doc Chart
Pink coding identifies information missing from PH-Doc
Easy drag and drop
(or click multiples and press ARROW)
Medication Reconciliation
Even better ….
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RXNORM codes
Multiple sources
More data – dosing, physician, reaction, text
Current and History
Medication Reconciliation
Nurse works with the patient to reconcile the two lists
• Sometime multiple sources - pull most recent and show others
• Pull to current vs pull to history
• “History” – requires REASON – only text today. Hope to make this
more robust, able to share these reasons with clinicians
• “Too expensive”
• “Upsets my stomach”
• “Heard rumors about possible side effects”
Once an accurate medication list
has been documented
… hopefully all associated with RXNORM codes
Time for DRUG-TO-DRUG interactions check
Allergy Reconciliation
Same concept for reconciling allergies
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Request external documents
Parse data and store in ‘auxiliary tables’
Present side-by-side
Allow external data to be merged with existing data