1. Update on Clinical Surveillance
Setting up Clinical Monitoring Utilizing Meditech
Muse International Conference
June 2, 2011

2. Clinical Decision Support vs. Clinical Surveillance

3. Clinical Decision Support
Decision Support focuses on making the appropriate choices for a therapy at a given point in time

4. Clinical Surveillance
Clinical Surveillance focuses on maintaining the appropriate therapy for an ongoing period of time

5. 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

6. Surveillance Survey What are you doing now?
What else should you be doing?
What will it take to get to the next level?

7. Surveillance 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)

8. Surveillance Opportunities
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

9. 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

10. 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

11. Tools for embedding "KNOWLEDGE"
Customer Defined Screens
Pharmacy
Admissions
Nursing (NUR – PCS)
ITS - Radiology
Other modules

12. Added Sophistication
Utilizing Rules linked to fields on a Customer Defined Screen (CDS).
Activating rules by selecting appropriate fields on the CDS.

13. Global Rules are attached in the Customer Defined Parameters

14. Medication Screen CDS PHA DRUG type screen
Medication Specific Information
Attached in PHA parameters
Same for all formulary items

15. PHA.DRUG CDS

20. 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

21. 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

22. 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

23. Possibilities Lot numbers Expiration dates
Used with transaction rules can send information to B/AR
Unique information
“Key” for rule display

24. Possibilities Lot numbers Expiration dates
Used with transaction rules can send information to B/AR
Unique information
“Key” for rule display

25. 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.

26. ADE Monitoring
Clinical Evidence transfer from 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.

27. ADE Monitoring
Clinical Evidence transfer from 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

28. 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

29. 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

30. ADE Monitoring
Global rules will indicate a potential ADE and the order that may be causing the adverse effect.

31. 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 “_RESTM^MSG,
Q(MSG,RESDT,RESTM);[f rx reject]};
[f rx reject]};

32. 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,
1^FND}},
FND;

33. 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.

34. Real-time Clinical Surveillance Display

35. Right Arrow for Detail of Order

36. 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.

37. 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

38. IV to PO Real-time Clinical Surveillance Display Sample

39. 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.

40. Order Type CDS
An Additional field can be added to the order type CDS. The CDS is attached in the Order Type dictionary

41. 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.

42. 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

43. Querie Responses - Abx

44. Microbiology Warning

45. 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.

46. 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.

47. 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.
Edit Drug dictionary and activate drugs to monitor and what to monitor.
Run Clinical Review Board

48. Review

49. Questions / Discussion

50. Contact Information