Update on Clinical Surveillance

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

2. Clinical Decision Supportvs.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 ScreenCDS • 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)

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 “_RESDT_” @ “_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, DO{@Next(PHA.DRUG.query.mult.q)&'FND IF{@PHA.DRUG.query.mult.resp=C 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 http://www.theingroup.com Bruce.Matthias@theingroup.com