Carlos CodinaServicio de Farmacia Hospital Clinic.Barcelona

Grupo Tecno. SEFH. 2010

Sistemas de Soporte a la Decisión Clínica

DefiniciónClinical Decision Support (CDS) is defined broadly as a clinical system, application or process that helps health professionals make clinical decisions to enhance patient care. Clinical knowledge of interest could range from simple facts and relationships to best practices for managing patients with specific disease states, new medical knowledge from clinical research and other types of information. (J Osheroff 2004)

Healthcare Information and Management Systems Society

HipótesisComputerized physician order entry (CPOE) & Pharmacy review & drug administration, with clinical decision support (CDS) has been promoted as an effective strategy to prevent the development of a drug injury defined as an adverse drug event (ADE).

ObjectivoDiseñar us sistema Prescripción – Validación –Administración y seguimiento, asistido que permita mejorar los resultados en salud de los pacientes

SAP® – Software – Plataforma IntegradaHospital Clinic. - Barcelona

SAP – MM – Financiero - Compras

SAP – ISH – Estación Clínica - HCE

SAP – FAR – Farmacia – PEA - ADMDATAWAREHOUSE

SAP / Enfermería / Plan de Curas y Cuidados

SAP / Urgencias; Consulta externa...

Módulos

Balanced Score Card“Cuadro de Mando”

Prescripción

Validación

Administración

SAP FAR – CPOE – PHARM - EMAR

CDS 5 RIGHTS AND MEDICATION MANAGEMENT STEPS

©2009 HIMSS

Selección de Medicamentos (Médico & Farmacéutico)Guías Clínicas; Protocolos Búsqueda libre (Criterios: formulario + dosis) Fármacos restringidos

Conciliación de tratamiento habitual (Médico; Farmacéutico; Enfermera) Recordatorios de carácter preventivo (Médico; Farmacéutico; Enfermera)Resultados de Laboratorio (Médico; Farmacéutico; Enfermera)Alertas (Médico; Farmacéutico; Enfermera)

Alergias; Interacciones; ajuste dosis por IR; Dosis Máxima; Duplicados; Embarazo…

Validación FarmacéuticaPharmacy rules; Listados cruzados; Intervenciones; condiciones; …

Información de Medicamentos (Médico; Farmacéutico; Enfermera)Medimecum ; Micromedex ;Intranet ; Bibliotecas,…

Información de Medicamentos al Paciente (Médico; Farmacéutico; Enfermera)

Iniciativas – Sistemas de Soporte a la Decisión Clínica

Diagnóstico,

Problema de Salud…

Admisión Paciente

“CPOE & CDS”

Admisión Paciente

“CPOE & CDS”

Alergias

Fármacos /indicación

Protocolos

Guías Clínicas,

Esquemas tto.

Edad

RAM

Función renal

Pruebas Laboratorio

Microbiología

- Perfil Farmacoterapeutico–

InteraccionesDuplicados,

Right MedicamentoRight DosisRight FrecuenciaRight VíaRight Duración

Conciliación Tto

CPOEPropuesta de

tratamiento con ajustes de dosis y/o justificación

de uso

Validación Tratamiento

Embarazo

Lactancia

Peso, altura

11

22

33

44

55

Fármacos /indicación

Protocolos

Guías Clínicas,

Esquemas tto

22

ConstantesPlan de curasPetición LabortDietasTratamiento

FarOtras pruebas

Protocol Xxx disease

AGE >

AllergicA

AGE <

Drug A

CL CR

Drug D

Other situat.

Drug F

Other..

Drug B

Drug C

Drug E

Drug G

Algorithm Example

Grupo Terapéutico / indicaciónFármaco A: Dosis /Pauta/VíaFármaco B: Dosis / Pauta /

VíaFármaco C: Dosis / Pauta /

Vía

Fármacos, dosis, pauta….

Nota. Si existe mas de un problema el sistema debe ser capaz de realizar la comprobación de duplicidades

Petición de analisis

Radiología estudio,……

Plan de Curas, ….

Perfil de Paciente

Selección de medicamentos:

Guía Farmacoterapéutica.

Formularios : 1 - Pacientes Ingresados2 – Pacientes externos

Medicamentos no Guía. Programa de equivalentes terapéuticosEn caso de prescribir un medicamento fuera Guia, utilizar otro “tipo de letra”, para diferenciar

SAP – HCP 2010

Templates – Therapeutics Groups – Medical Service - Unit

Protocols – Medical Service - Unit

SAP – HCP 2010

Selección de Protocolos. Hospital Virgen de la Arrixaca. Murcia

Selección de Protocolos. Hospital Son Dureta. Palma de Mallorca

Selección de Protocolos. Hospital Ramón y Cajal. Madrid

Selección de Protocolos. Hospital Gregorio Marañón. Madrid

Selección de Protocolos. Brigham and Women’s Hospital. Boston

Selección de Protocolos. Brigham and Women’s Hospital. Boston

Selección de Protocolos. Brigham and Women’s Hospital. Boston

Selección de Protocolos. Brigham and Women’s Hospital. Boston

Selección de Protocolos. Brigham and Women’s Hospital. Boston

Selección de Protocolos. Brigham and Women’s Hospital. Boston

Selección de Protocolos. Brigham and Women’s Hospital. Boston

Anne Bobb 2010

Selección de Protocolos. Northwestern Memorial Hospital. Chicago

Anne Bobb 2010

Selección de Protocolos. Northwestern Memorial Hospital. Chicago

Posibilidad de incluir dosis en función del peso o superficie corporal

Conexión al Protocolo

SI NO

NO SI

SI NO

*En caso de EPOC o apnea del sueño se recomienda en todos los tipos de insomniozolpidem. Una alternativa es trazodona 50 mg antes de acostarse.*En pacientes geriátricos o en presencia de insuficiencia hepática se recomiendadisminuir la dosis a la mitad.*En embarazadas que no responden a higiene del sueño se recomienda utilizardoxilamina 10-20 mg/24h.

IC psiquiatría

Continuar

Zolpidem10 mg/24h

Dificultad de conciliación

Lorazepam1-2 mg/24h

Despertares nocturnos

Tipo de insomnio

¿El paciente responde?

Higiene del sueño Continuar tratamientoy revalorar al alta

Consumidor crónico de hipnóticos

Enfermedad psiquiátrica(ansiedad, depresión,...)

Intranet ProtocolosFormato PDF

BWH  2010

BWH  2010

BWH - 2010

Anne Bobb 2010

Kuperman et al.. 2007

LorazepamProblem list

Lorazepam 1 mg C/24 H N VOLorazepam 0,5 mg C/24 H N VOLorazepam 2 mg C/24 H N VOLorazepam 5 mg C/24 H N VOLorazepam …/…

Drug List

Order Set

Protocols

Therapeutic Group

ClonazepamDiazepamLorazepam LormetazepamZolpidemTrazodona…/…

Insomnio

Preop. Cirugia DigestivaQuioterapia

Medical Service

Drug; Therapeutic group; protocol; disease ; indication based…

Medical service, Unit, Department,..

Fast Drug Search (Drug name and route)

Drug dose and frequency (usual alternatives)

2

SAP – HCP 2010

Fármacos de Uso Restringido: Ej. Linezolid

Justificar su utilización

Nota:El Comité de Farmacia y Terapéutica aprobó el uso de Linezolid, en las siguientes Indicaciones. Seleccionar la que proceda o solicite la aprobación, del especialista en enfermedades infecciosas.

□ Indicación A

□ Indicación B

□ Indicación C

□ Otras _____________________________

Medication Use Guidelines

BWH  2010

Specialist Approval

BWH  2010

Pharmacy review

55 Medical Drug Prescription

New: patient status, or condition, or treatment?

Drug alerts, rules behind, or modification

is needed

Medical justificationis needed

JustificationReasonable

yes

no

yes

Pharmacist verificationapproval

noPharmacy proposal Intervention is open

automatically

no

Patient Drug Profile

yes

Pharmacy Intervention is open

Conciliación Tratamiento

Asistencia Primaria

• Perfil de medicación

Hospital

Paciente Ingresado

• Drug profile

Paciente externo, alta

• Hospital de Día• Consulta externa• Urgencias• Alta Hospitalaria•…/…

Drug List Inpatient Discharge

Nombre Genérico – Especialidad Farmacéutica - Dosis - Frecuencia – Vía – Fecha de inicio - Duración

□ Continue □ Modify □ Stop□ Discharge□ Continue □ Modify □ Stop□ Discharge□ Continue □ Modify □ Stop□ Discharge□ Continue □ Modify □ Stop□ Discharge

□ Continue □ Modify □ Stop□ Discharge□ Continue □ Modify □ Stop□ Discharge□ Continue □ Modify □ Stop□ Discharge

Conciliación al ingreso y al alta

Furosemida 40 mg c/24h VODigoxina 0,25 mg c/24h –SyD VOAtenolol 50 mg c/24h VO

Paracetamol 500 mg c/8h VO

Metformina 850 mg c/12h

Digoxina 0,25 mg c/24h – SyD VO

Amoxicilina 500 mg c/8h VOGentamicina 240 mg c/24h IV

Insulina NPH 10 UI C/12h SC

Medicación habitual domiciliaria Medicación paciente ingresado

Continuar… Continuar…

Conciliación al ingreso y al alta

Furosemida 40 mg c/24h VODigoxina 0,25 mg c/24h –SyD VOAtenolol 50 mg c/24h VOAmoxicilina 500 mg c/8h VO

Paracetamol 500 mg c/8h VO

Metformina 850 mg c/12h

Digoxina 0,25 mg c/24h – SyD VO

Amoxicilina 500 mg c/8h VOGentamicina 240 mg c/24h IV

Insulina NPH 10 UI C/12h SC

Medicación habitual domiciliaria Medicación paciente ingresado

Continuar… Continuar…

PAML Builder: Action on Admission

BWH

Lab results; Microbiology; Medical records,….

SAP – HCP 2010

Creatinin

SAP – HCP 2010

Electronic Health Record (EHR)

SAP – HCP 2010

Allergies

Age

ADR

Renal Function

Lab results

Microbiology

- Drug Profile –Drug InteractionsDrug Duplicates

Drug Class Duplicate

Drug reconciliation

Pregnant

Lactation

Weight - Tall

33 Age. Contraindications / Beers criteria

Drug dosing depending on weight / tall / Body surface..

Pregnant (contraindications) Lactation (contraindications)

Allergies (contraindications)

Adverse Drug Reactions (information)

Dose adjust depending on Clearance (Cockroft –Gault)

Lab results contraindication / adjustment proposal

Microbiology antibiogram sensitivity (information)

Patient Drug profile and drug reconciliation

Drug interaction level 1 (contrain); Drug Duplicates (info)

Aviso de Interacción. Hospital Son Dureta. Palma de Mallorca

Aviso de Interacción. Hospital Ramón y Cajal. Madrid

Aviso de Interacción. Hospital Gregorio Marañón. Madrid

Aviso de Interacción. Hospital Virgen de la Arrixaca. Murcia

Alerts: Allergies; Drug-Drug Interactions; Duplicates; Drug adjust RI; Age >65; Max. Dose (daily & doses); Pregnant.External Drug Data Base located at Hospital Intranet -

SAP – HCP 2010

SAP – HCP 2010

Condiciones del sistema idealProducto externoUbicado en la Intranet del HospitalActualización automática por internetPosibilidad de adecuación de los niveles de alerta según centro y usuarioDisparo de la consulta según el tipo y nivel de la alertaEn alertas graves, proponer cambio de tto, (proactivo)Posibilidad de solicitar un motivo al sobrepasar una alertaSistema de registro de alertas sobrepasadasAlergias y RAM deberían registrarse en la Historia

Clínica

Alergias. Historia Clínica

SAP – HCP 2010

i

Pharmacy Intervention, is waiting for you (proposal)

Pharmacist InterventionsMedication ErrorsAdverse Drug ReactionsAllergies- EMR

Allergies RAM

SAP – HCP 2010

Medical Drug Prescription

New: patient status, or condition, or treatment?

Drug alerts, rules behind, or modification

is needed

Medical justificationis needed

JustificationReasonable

yes

no

yes

Pharmacist verificationapproval

noPharmacy proposal Intervention is open

automatically

no

Patient Drug Profile

yes

Pharmacy Intervention is open

Antibiotics Prescription

Indication correct?

Renal function Correct?

Lab Res & Micro labsCorrect?

Is drug dose adjusted?

Is it modified?

Is it justified?

yes

yes

Pharmacy approval pending

yes

DDI, Allergies,.Correct?

Dose, route, Frequency..

Correct?

Is it modified?

Is it modified?

Pharmacy interventionIt’s opened

yes

no

no

no

no

no

no

no

no

no

no

yes

iPharmacy Intervention, is waiting for you (proposal)

Pharmacy Intervention (closed)

Pharmacy Interventions

Med Errors ADR

SAP – HCP 2010

Pharmacy Screen

SAP – HCP 2010

Pharmacy System

SAP – HCP 2010Prioritize PI

Información de medicamentos1 – Catalogo de especialidades2 – Micromedex

(Médico – Farmacéutico- Enfermera)SAP – HCP 2010

PEA – Mismo procedimiento que en paciente ingresado

Alta Hospitalaria

SAP – HCP 2010

SAP – HCP 2010

SAP – HCP 2010

Validación del FarmacéuticoSAP – HCP 2010

Patient discharge. Proposal (I)

Drug reconciliation SAP – HCP 2010

Perico de los Palotes

Perico de los Palotes

SAP- Lloc de treball- Sol·licituds- Consulta d’altres episodis: Patient Organizer

HCO: IPA Obstetricia- Registres assistencials- Consulta d’informes (IA, IR)- Generació d’iformes

Projecte Pilot IPA - Servei MaternofetalModel Funcional Fase I

Hospital ClinicMedical Informatics 2010

Projecte Pilot IPA - Servei MaternofetalNivell de presentació

Hospital ClinicMedical Informatics 2010

Clinical Pharmacy tool

Plan estratégicoPresentar y consensuar proyecto en el Servicio de FarmaciaPresentar proyecto a la Dirección del HospitalCrear un Grupo multidisciplinar de Trabajo

Médico; Farmacéutico, enfermera, informático, …Seguir las recomendaciones del ISMP en la creación de Guías Clínicas o peticiones agrupadasDiseñar los esquemas de las Guías Clínicas en formato excelEstablecer la lista de medicamentos de uso restringido y crear los diálogos asociadosDiseñar los diálogos y o condiciones de apertura de Intervenciones FarmacéuticasPresentar propuestas al Comité de FarmaciaPilotar en una Unidad de HospitalizaciónEvaluar y/o continuar

ccodina@clinic.ub.es

Degrees of computerization(1) The computer offers no assistance; humans must do it all. (2) The computer offers a complete set of action alternatives, and (3) narrows the selection down to a few, (4) suggests one, and (5)executes that selection if the human approves, or (6) allows the human a restricted time to veto before automatic execution, or (7) executes automatically, then necessarily informs the human, or (8) informs him or her after execution only if he or she asks, or (9) informs him or her after execution only if it, the computer, decides to. (10) The computer decides everything and acts autonomously, ignoring the human.

Sheridan TB, Thompson JM. People versus computers in medicine. In: Bogner MS, (ed). Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, 1994, pp 141–59.

10 commandments

Speed is everythingAnticipate needs and deliver in real timeFit into the user’s workflowLittle things can make a big differenceRecognize that physicians will strongly resist stoppingChanging direction is easier than stoppingSimple interventions work bestAsk for additional information only when you really need itMonitor impact, get feedback, and respondManage and maintain your knowledge base systems

Bates D. J Am Med Inform Assoc. 2003; 10:523-530

CDS – Five Rights1 Right Information2 Right Person3 Right CDS intervention format4 Right Channel5 Right Time in workflow

Applying CDS to Medication Management

1 - Medication Selection / Reconciliation2 - Ordering3 - Verification / Dispensing4 - Administration5 - Education6 - Monitoring

Osheroff et al. Improving Medication Use and Outcomes with Clinical Decision Support: A Step by Step Guide. 2009

1 - Medication Selection/Reconciliation

Select, for a clinical condition, a medication that is safe and effective. Based on clinical evidence, patient characteristics and cost effectiveness.The selection requires access to patient information, clinical history, weight, height and ageAccess to disease management knowledge and drug information Support medication reconciliation with an accurate list of the patient’s medication.

2 - OrderingCreate a medication order/prescription (ideally linked to the indication)Provide dosing recommendations, ideally specific to patient and clinical conditionConduct automatic check for contraindications, duplications, DDIs, drug –lab interactions, allergies, right dose/route/frequency.

3 – Verification/Dispensing

Double check for interactions, appropriateness / contraindications, right dose / route / frequency / timing.Math prescription/ order to correct dose and dose formCheck for proper concentration and volume to minimize pump programming errors, incompatibilities.

4 - AdministrationMake positive medication and patient identificationAsses patient and document pertinent parameters (such as blood pressure, heart rate, blood glucose, pain level) prior to administrationCheck for incompatibilities/interactions, such as between parenteral medications, between medications and foods, etc.Recheck right dose/route/frequency, administration technique and timing, monitoring guidelinesProvide reminder/guidance when medications are not administered at the appropriate time or are delayed or missed

Future dosing decision support research should focus on:

1. Determining the most effective way to deliver dosing decisionsupport (e.g., when are default suggestions or post-hoc critiques more effective).2. Developing robust dosing knowledge for the general population as well as special populations (pediatrics, geriatrics, oncology, renal impairment).3. Determining how best to increase compliance with dosing suggestions.4. Identifying medications that are most likely to be incorrectly dosed and/or have narrow therapeutic windows that could be the target of high-priority, advanced efforts.5. Determining how best to disseminate dosing knowledge broadly so that each institution does not have to “reinvent the wheel.”6. Determining the best ways to reconcile when multiple factors are present that may impact on optimal dose (e.g., more than one of advanced age, impaired renal function, and impaired liver function).

Kuperman et al. J Am Med Assoc. 2007; 14:29-40

Recommendations to Research Community

The area of clinical decision support is replete with opportunities for further research. Examples of CDS-related areas where research is needed include:To what extent does alerting impact on clinician behavior and patient outcomes?What is the optimal way to present alerts to prescribers?How can clinicians’ sense of satisfaction with alerts and other kinds of decision support be increased, i.e., so clinicians find decision support useful and not annoying?When does “alert fatigue” happen?What is the best way for organizations to share alert knowledge?How can commercial medication knowledge bases be edited to yieldclinically valuable knowledge bases?Where there are multiple presentation modes, which mode is most appropriate for any given alert?Which member of the health care team—for example, physician, nurse, pharmacist, other—is the best recipient of any kind of alert?Should physicians and pharmacists see the same drug related alerts?

Kuperman et al. J Am Med Assoc. 2007; 14:29-40