Medicines Management

1. Guideline Management Medicines Management Rob Brenninkmeijer, pharmacist Digitalis Rx bv, Amsterdam Two systems, one approach

2. Digitalis started 20 years ago in the Netherlands as an enterprise • for digital pharmaceutical care and medicines management by ways of: • Publishing, content management & distribution of electronic prescription guidelines • Implementation of electronic guidelines and integration in GP prescribing practice (Electronic Prescribing System, Prescriptor) • Production, content management, desk editing & publication of interactive web & workshoptools for the rational and transparent selection of medicines

3. Prescriptor • e-Prescribing system (EPS) for applying therapy guidelines • Software component bolt on to electronic patient record (ePR) systems • First module ready 1988 • Rudimentary techniques and systems • Not ‘the end’ • Not even the ‘beginning of the end’ • Getting doctors to agree (motto: when two doctor’s agree, one is not a doctor….)

4. Prescriptor • e-Prescribing system (EPS) for applying therapy guidelines • Software component bolt on to electronic patient record (ePR) systems • First module ready 1988 • Rudimentary techniques and systems • Not ‘the end’……. • Not even the ‘beginning of the end’ • Getting doctors to agree (motto: when two doctor’s agree, one is not a doctor….)

5. Prescriptor-EPS: why? • Development of a road atlas versus a navigation system: • Therapeutic network has vastly expanded in the last 20 years. • Printed guidelines: not effective, and hard to manage • Digital guidelines: flexible and easy to maintain; higher level of integration in the care process • Autonomy prescriber as the “driving force” is guaranteed • Regional and/or national implementation of electronic medication record of the patient: • Facilitating exchange of medication history of the patient between care providers • GP and pharmacist share a higher level of mutual responsibility to prevent medication-conflicts and adverse reactions • GP can process online notifications of ‘traffic incidents’ more efficiently with an EPS!

6. First NL article published in 1988

7. Prescriptor: UK publications

8. First introduction in the UK 1993: Prodigy

9. Prescriptor revisited • First phase sponsored by the NHS, however not much direct involvement • Therapy decision tree linked to READ diagnostic codes • Based on translated Dutch Guidelines (Nijmegen regional formulary) • Reasonable balance between technical brilliance and daily practice

10. NHS takes over….. • Renames Prescriptor UK to Prodigy • Prescribing RatiOnally with Decision support In General practice studY • Rolled out 1996 – 1997 • Prescriptor was used as a reference model and integrated in three GP-systems • Pilot worked in a way

11. BMJ 1996

12. Prodigy Phase II • Rebuild from scratch in 1997 • Launched around 2000 • Bad, reasonable and good implementations in many different GP systems • Part success - part failure: too much top down • Too little effort in making it work in the field: not enough bottum up • Phase III never left the drawing board! • NHS kept on developing Prodigy guidelines until 2007 • NHS should have focused on a more bottum up implementation instead

13. In the meantime….Prescriptor NL • National sponsored project on national Electronic Prescribing System started in 1998 • Prescriptor initially left out of it • Eventually part of EPS project thanks to active lobby of GP user groups • Connected to 6 major GP-systems and installed base of 70% of all GP practices in NL • Also implemented in combination with all 3 out of hours call management systems; • In use in all medical departments of penitentiary institutions and within the military services • Some implementations in large nursing homes

14. Demo:

15. Anatomy of a Prescriptor Guideline The tree

16. The IndicationClinical Recommendation

17. Connected to a classificatione.g. Read, ICPC, ICD, SNOMED: the trunk

18. Therapy SchemeClinical Scenario’s: the branches

19. Therapy Cluster

20. Prescription

21. FiltersSelection criteria

22. Formulary Management www.prescriptor.nl www.formularium.nl Electronic Prescribing System Local adjustments Reference formularies EPS-Pyramid Local Regional / Transmural formularies STEPSelect National formulary (e.g. derived from national guidelines)

23. Summary Prescriptor • Supports goal oriented therapeutic navigation within prescribing process: from complaint or disease to treatment. • GP is driving force and is responsible for minor adjustments • Supports multisource national, regional and/or local prescription formularies • National guidelines and Patient information leaflets • Integration of a national “Drug Dictionary” • Prospective Medication Surveillance is integrated

24. Consequences of decision support e-Prescribing • Prescribing less experience/intuition driven • Prescribing less “spinal” driven, adhoc, soloistic, but is more conditioned, based on mutual professional agreements • Consensus on therapy guidelines and selection procedures of medicines become more rational group processes • The dynamics to issue, maintain, distribute and implement guidelines AND to enhance appropriate prescribing will increase • Improved infrastructure / communication chain within the domain of pharmacotherapy

25. Guidelines and medicines • root: clinical evidence & experience • trunk, branches: guideline • leaves: precriptions, medicines

26. Medicines Management • “Encompassing the entire way that medicines are selected, procured, delivered, prescribed, administered and reviewed to optimise the contribution that medicines make to producing informed and desired outcomes of patient care” • Medicines Management and Guideline Management are complimentary!

27. Medicines management: why • The present healthcare system faces great challenges: • increasing numbers of adverse events • poor adherence • increasing numbers of medication incidents • inadequate communication across the primary/secondary care interface. • Furthermore, expenditure on medicines is one of the major cost elements in healthcare.

28. Lack of integrated Product Use • This is identified as a significant element in inefficiency of the current medicines management system. • fragmented and dispersed application and use of agents within a therapeutic class • different generics being used • discontinuity between primary and secondary care • use of parallel imports in primary care • confusion for patients, particularly the elderly • avoidable drug-related hospital admissions

29. STEPSelect: Northern Irish–Dutch collaboration • Incorporated in several approaches: • Medicines governance (policy) • Integrated Medicines management (prescribing, dispensing, procurement) • Guideline Management

30. STEPSelect: 4 stages • STEP I – clinical evaluation: Evaluation and continuous updating of all available evidence relating to efficacy, evidence, safety, tolerability, ease of use, medical interactions and experience is carried out. This pre-selection of medicines within a therapeutic class is purely based on clinical criteria. • STEP II – risk assessment: This phase focuses on factors that impact upon the safe use of the various products during routine use by patients. This assessment is carried out on both the packaging and instructions, to minimise difficulties for patients and help them safely and optimally use their medicines.

31. STEPSelect: 4 stages • STEP III – budgetary impact analysis: This phase entails looking at the impact of the use of the agents in a therapeutic class on the complete healthcare economy, in both primary and secondary care. • STEP IV – final procurement: The procurement model also allows for a radical redesign of the medicine tariff based upon safety, efficacy and economy. Flexibility is built into the process as it does not demand 100% compliance with the product selections, but rather, only requires a reasonable percentage compliance (70 – 80% depending on the group)..

32. www.stepselect.com • Facilitates clinical fase I of STEPSelect • Online matrix modules by which rational considerations are made using review criteria to select preferred medicines. • Process: • collection of literature data • production of matrix, article and scores • review by experts, industry and patient groups • (virtual) workshops with prescribers

33. STEPSelect in N-I: outcomes • quality(Q) and safety(S) result in both health improvement(I) and better efficiency(E): Q+S=I+E • effectively linking clinical evidence with the procurement process resulting in a much more integrated, less fragmented approach to medicines management that exists in the field of communication and decision-making within primary and secondary care chains of prescribers, suppliers and procurers of pharmaceutical care (Q and E). • evidence based reduction in the incidence of hospitalisation due to the inappropriate use of medicines (S and I) • Cost reduction by efficiency improvement that can (also) make room for innovative new drugs: all in all….investments outweighted the costs involved (E but….Q, S and I first!!!

34. The guideline is patient but the doctor is not....*) • Lessons learned…. • Allow multisource national and/or regional FLEXIBLE implementation of guidelines • Minimize distance between guideline management and medicines management: ownership practitioners • Correct focus, less technique, more implementation • Teaching doctors how to improved use of electronic medical records and better ways to share information • Shift from professional-centric – towards a more interdisciplinary approach • See the little picture, don’t create ONE BIG UNIVERSE or pursue a BIG BANG *) free after Joseph Joubert (1754-1824): the paper is patient but the reader is not.