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 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 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.

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.

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

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. 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 Bruce.Matthias@theingroup.com