Tuesday, April 22, 2008

Decision Support for Inpatient Systems

I've written about the 10 projects that keep me up at night and published my clinical systems mid year strategic update. In addition, as a physician CIO, I tend to have a few projects that receive more attention and guidance from me than others.

The three areas that are my passion and focus in 2008-2010 are Clinical Documentation, Decision Support, and an Integrated Electronic Record throughout the community. I wrote about Clinical Documentation last week. The Integrated Electronic Record is next week. I've covered Outpatient Decision Support earlier, so this week is an overview of all our Inpatient Decision Support efforts at Beth Israel Deaconess. You'll see that we have thousands of decision support rules, updated regularly, which are fully integrated into our inpatient systems.

Drug interactions and alerts
a) Drug duplicate warnings - Identifies duplicates using chemical component information that is included with First Data Bank (FDB), the commercial drug database underlying our pharmacy and provider order entry systems. Component information is updated via monthly FDB updates.
b) Drug-drug interactions - Identifies interactions using chemical components and rules included with the FDB database. Displays only the classes of alerts identified as clinically significant by Pharmacy, to ensure clinicians are not overwhelmed with minor interactions. Rules are updated via monthly FDB updates. Clinical significance filters are maintained in a dictionary by Pharmacy.
c) Drug-allergy interactions - Identifies interactions using chemical components included with the FDB database. Components are updated via monthly FDB updates.
d) Drug Substitutions – Alerts the ordering provider with suggested substitutions for therapeutic equivalents on the inpatient formulary, which is maintained by Pharmacy.

Default dosing
There are currently 1,545 entries in the Pharmacy Provider Order Entry dictionary with default dosing schemas defined. These are maintained by Pharmacy.

Renal Dosing
Targeted drugs, rules and default dosing are maintained in a dictionary by Pharmacy. There are currently 48 renally dosed drugs.

Diagnosis or Indication based dosing
Target drugs, rules and default dosing are maintained in a dictionary by Pharmacy, such as ciprofloxacin and chemotherapy agents used for non-oncological reasons such as cytoxan.

Geriatric alerts
Beers criteria are used to alert physicians to age-specific medication issues. Information is updated via monthly FDB updates.

Heparin, insulin and enoxaparin
Ordering of these high risk medications is done via automated protocols and guidelines to promote best practice dosing. These are updated as best practices change.

Information Displayed on Medication Ordering Screens
a) Screens display the patient’s most recent relevant labs specific to the drug being ordered. The relationship between drug and lab(s) to display is maintained in a dictionary by the Pharmacy
b) Informational text about ordering parameters for the drug is displayed. These are maintained in a dictionary by the Pharmacy. A link to Micromedex is also available on the ordering screen.

Nurse instructions for drug handling
Custom instructions are displayed on Medication Administration Record labels. These are maintained by the Pharmacy.

Information Displayed on Lab Ordering Screen
a) Messages appear during ordering that inform clinicians about best practices such as guidance for ordering heparin dependent antibodies. These are maintained in a dictionary by the Lab.
b) Links appear to the online lab manual for each test ordered. Thousands of lab tests are documented including all the details on how the specimen is collected and processed. The Lab updates this manual regularly.

Blood bank
Specialized screens appear to provide pertinent clinical information when blood products are ordered.

Total Parenteral Nutrition
Guidelines, relevant labs and prior day’s TPN order appear automatically.

Consequent Orders
a) IV access flush ordering -POE automatically generates the correct flush order when documenting IV status
b) Blood products – POE gives current information about active specimens in the blood bank and can generate a type and screen if necessary
c) Mechanical ventilation- POE automatically suggests mouth care orders after ventilation is ordered

Quick access to reference/informational screens
Specific links to guidelines/web sites appear on many POE screens. For example, a link to the current weaning protocol is available directly on the mechanical ventilation order screen.

Quick access to patient specific data in other clinical systems
Specific links to data in other information systems appear on many Provider Order Entry screens. For example, a link to display transfusion restrictions available in the Blood Bank system appears on the blood product ordering screen.

Alerts and reminders for items such as pneumovax and influenza
Providers are prompted at appropriate points over the course of a hospital admission to order and document outcomes.

Order sets
"Packages" of orders that can be rapidly entered as a group are available to all clinicians. These are updated as clinical practice changes. There are currently 95 inpatient admission, postoperative, transfer and procedure order sets (5 megabyte download) and 195 outpatient chemotherapy regimens.

Hydration protocol to minimize risk of iodinated contrast nephropathy
Provider Order Entry recommends specific IV fluid orders when ordering pre-procedure prep orders.

You can see that the task of providing comprehensive decision support for our inpatient systems involves thousands of rules, kept updated by pharmacy, lab, and IS staff, as guided by our various steering committees. Only through the use of this much decision support can we ensure that data is transformed into information, knowledge and wisdom.


Art Vandelay said...

How did you go about developing your order sets - process, clinical sponsors, people involved and support from technology tools (e.g., content managers, Zynx)?

Rajat Dhameja said...

In regards to decision support tools for inpatient care management as well as EHR initiatives, it will be nice to learn about interoperability with Predictive Modeling applications.

Rajat Dhameja, MHA

Unknown said...

Inpatient drug rehabilitation is a superior method to help individuals addicted to harmful substances. Inpatient drug rehabilitation provides strong support and service to its clients. It modifies their attitudes and behaviors related to drug and alcohol abuse, and increase healthy life skills.


Deepak said...

There are numerous treatment options available for those looking to recover from drug addiction. Individuals who feel their drug addiction has affected their lifestyle such as their family, friends, or work will benefit greatly from inpatient treatment. This form of treatment provides the recovering drug addict with support 24-hours a day. Additionally, removing the individual from their former surroundings (in regards to drug using friends and the individual's personal drug using paraphernalia) helps them to adjust to living a drug-free lifestyle. The benefits of inpatient treatment also include the reduced likelihood of the individual using alcohol or drugs while in treatment as well as highly structured days.