Improving Patient Care with Meaningful%09Medication Therapy Alerts_final w notes

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Valley Health System & Dearborn Advisors, LLC®

Improving Patient Care with Meaningful Medication Therapy Alerts: A CASE STUDY IN ALERT FATIGUE REDUCTION

John Heeren, RPh, MSApplication Analyst, Pharmacy

David Troiano, RPh, MSIA, CPPSDirector of Service Development


Session Description

2

Methodology used to analyze the initial state of alerts

Development of a program to address alerts

Approaches taken for each type of alert

Findings: quantitative and qualitative

Results achieved for each type of alert

Lessons Learned: adjustments made to the program

WE WILL COVER:


Learning Objectives

3

IDENTIFY COMPONENTS

•

Describe the components of a successful Alert Fatigue Reduction Program including: •Governance•Analysis•Overall approach •Ongoing maintenance

IDENTIFY APPROACH

Describe the appropriate approach to analyze and address each type of alert

DEVELOP METHODOLOGY

Describe how MEDITECH and FDB product capabilities are employed to address each type of alert


Valley Health System

4

Integrated Delivery Network

located in Ridgewood, NJ

451-bed Patient Centered Community Non-Profit hospital:

Valley Home Care

Valley Medical Group

Recipient of multiple awards:

J.D. Power and Associates Distinguished Hospital ProgramSM

– 9 years in a row

Magnet facility for nursing excellence since 2003

Leapfrog Top Hospital recipient with a Straight A Safety Score – 5 years in a row


Dearborn Advisors, LLC®

5

Founded in 2001 Advisory Services

Focused on adoption by Clinicians to achieve the benefits of clinical systems investments

Services to address the continuum of needs throughout the lifecycle of clinical systems

Transformation for Value®

Clinical

Strategy and Value

Project Management

Implementation


Presenter Backgrounds

6

John HeerenRPh, MS

Years CPOE Implementation/Support

Application Analyst, Pharmacy

Valley Health

Years with EHR Vendor

[email protected]

David TroianoRPh, MSIA, CPPS

Years with EHR Vendor

Years of Healthcare Consulting

Director of Service Development

Dearborn Advisors, LLC

[email protected]

mailto:[email protected]



Background

7

“Upgrade” from MEDITECH Magic to 6.14 on 5/30/2015

Change of drug interaction DB from MediSpan To FDB

Go-Live went well but with numerous physician complaints about alerts

Pre Go-live Preparation: All controls within MEDITECH used:

• Suppressed alerts within order sets• Limited duplicate checking to individual items• Providers received only level 1,2 Severity, Pharmacists Level 1,2,3• Home Meds- DI checking for 2 days• Dose checking - Fully Utilized FDB Content to replace In-House version• Dc’d Orders- DI checking for 1 day


Summary Of Med Alerts

8

105,768 alerts (providers & pharmacists)

• 56,573 duplicates

• 38,945 drug Interactions

• 4635 dose/dose set

• 3585 food (pharmacy only)

• 1720 allergy

• 237 Adverse reaction

• 54 errors(vaccine duplicates)

• 20 rules(PPI)

June 20 to July 20

96% over-ridden

67% no comment

96%

67%


Alert Reduction Program

9

Reduce Alert Fatigue by providing

meaningful alerts

Improve communication between

providers entering orders and

pharmacy on the

response/assessment of alerts

received

GOALS

Improve Scope and Efficiency of Analysis• Data repository access & custom

report(data dump) requested

Alert Analysis• Incorporate all med alerts into analysis• Identify high frequency alerts

– Frequency of occurrence, % over-ridden, comments

• Research evidence/experience of clinical significance

Bring change recommendations to PAC for approval

APPROACH


First Pass

10

Allow providers to suppress individual DI’s by patient/all Pts

Shut down: Dc’d Order checking Home Med-IP Med Checking

Analyze Duplicates

Suppress top duplicates Marked items as “excipients” to continue allergy checking,

but to avoid duplicate alerts:

• Oxytocin – 1900• Acetaminophen – 3700• Diphenhydramine – 1200• Fentanyl – 4500

• Hydromorphone – 3500• Ondansetron – 3300• Oxycodone – 15,000


Alert Reduction Efforts to Date (Aug. 5)

11

Duplicate Suppression(July 28):

Eliminated 40,000/month

Individual Provider DI suppression:

5 interactions by 3 providers

Identification of top 30, next 120 DIs(of 1760)


September Drug Interactions Suppressed

12

Enoxaparin – Ketorolac 19

Aspirin – Ketorolac 3

Ketorolac – Ibuprofen 2

Mag Hydrox/AlHydrox/Simethicone –Potassium & Sodium Phosphates 2

Promethazine – Metoclopramide 2

Fondaparinux – Ketorolac 1

Metoclopramide – Promethazine 1

Omeprazole – Clopidogrel 1

Suppressed Interactions:0.07% of total Interaction count 31 of 41,559

by Individual Providers


DI Review – First Effort

13

Compared FDB severities with Micromedex to identify DIs not needed

Reviewed all >1600 DIs

Downgraded 180 from severity 2 to 3

Removed from Physician view, still seen by pharmacy


Sample of Interactions Downgraded

14

Acitretin/Ethyl Alcohol

Amifampridine/Possible QT Prolonging Agents

Amphotericin B/Corticosteroids; Corticotropin (ACTH)

Antidiabetic Agents/Gymnema

Aspartame; Phenylalanine; Tyrosine/Nitisinone

Bevacizumab/Sunitinib

Bortezomib/Ascorbic Acid (Vitamin C)

Certolizumab/Rituximab

Cisapride/Stiripentol

Colistimethate/Cephalothin

Contraceptives/Chloramphenicol

Cyclosporine/Sulfonamides

Dapsone/Didanosine


First Round: Over-Rated Severity

Drug Interactions

15

Second Round: High Volume/Low Value Added

Based upon how/when they are ordered

Suppressed for Pharmacy and Providers

Developed criteria shown

Providers Pharmacists Total

Baseline 7115 32,325 39,440

First Pass 6856 32,144 39,000

% Change (3.6%) (0.6%) (1.1%)

1

2


16

Drug

Interaction

Provider

FrequencyFDB Mechanism of Interaction

ONC

Status

FDB

Severity

FDB Chgs

Pending

Hospital

Experience

Expert Alert

Recommend-

ation

FDB Type of

EvidenceRecommendation

Aspirin-Ketorolac MediumPossible additive or synergistic

side effects.None 1

Typically 81 mg

ASA for

anticoagulant

therapy

None None Remove for all users

Aspirin-Warfarin High

Salicylate doses greater than 3

gm daily decrease plasma

prothrombin levels. Aspirin is an

irreversible platelet inhibitor.

Salicylates may cause

gastrointestinal(GI) bleeding.

None 2 3

Typically 81 mg

ASA for

anticoagulant

therapy

NoneHuman Clinical

TrialsRemove for all users

Doxycycline-

Magnesium High

Di- and trivalent cations may form

chelation complexes with

tetracyclines, preventing their

absorption.

None 2administration

timing issueNone

Human Clinical

Trials

Remove for all users,

enter timing guidance

in label comment for

nursing

Furosemide-

Lisinopril Low

The ACE inhibitors inhibit the

formation of angiotensin II and

angiotensin II receptor antagonists

block the action of angiotensin II,

thereby lowering aldosterone

levels with subsequent sodium and

water depletion. Agents such as

the loop diuretics that cause

sodium and water loss may

exaggerate the hypotensive state.

None 2Likely Home

MedsNone

Human Clinical

TrialsRemove for all users


Home Med/Prescription Alerts

17

805 duplicate alerts

245 Drug Interaction alerts

Checking is done with both IP and Home/RX Meds

• Only if convert IP to home med w/o change then no checking with itself

• Any change results in all checking with ALL IP & Home Meds

‒ IV-PO, change dose, change form

Shut off duplicate checking for providers not working in purely ambulatory settings

Monitor DI checking

REVIEW – 1 WEEK OF DATA ACTIONS


Anticoagulant – Antibiotic

18

Reflex INR order from anticoagulant order

Receive P&T approval & structure program for pharmacy to order/monitor INR

• Pharmacy currently has approval to order baseline INR

• Provide monitoring mechanism: report/dashboard of patients on anticoag without INR and with INR out of range

Turn off for pharmacy and providers when INR monitoring program is in place

Alert Recommendations


Allergy Alerts

19

Over-rides 83%acetaminophen 16

amoxicillin 18aspirin 46

codeine 346lactose 58

latex 36hydrocodone 41

hydromorphone 59ibuprofen 21

meperidine 21morphine 215

NSAID 18opiods 28

oxycodone 151penicillins 170tramadol 60

Top Alerts Received


Allergy/ADR Entry Analysis

20

Highly variable use of severity and reaction

Highly variable use of allergy vs. ADR

Few un-coded allergies used

Frequent duplicate allergies

• Drug and class• Same drug • Drugs in same class

Environmental allergies:

• cats, seasonal allergies, dust seen occasionally

Key Findings

Use of ADR to flag patient conditions/issues (e.g. liver fct., bleeding risk)

Some allergies listed when med is a home med and prescription written at discharge

Allergies in header often confusing (NKA & allergies) and usually incomplete


21

Hydrocodone, hydromorphone & oxycodone allergy –oxycodone home med & RX


22

•Good use of severities & reactions•Only amiodarone appears to be an allergy based

upon the reactions• Lactose allergies generate alerts on many tablets

without much value•Seasonal allergies, caffeine add to long list,

NKA(latex) - why?•Statin ADR & home med with reaction/comment-

good way to highlight risk


Allergies

23

Immune reaction Mechanism Clinical manifestations Timing of reactions

Type I

(IgE-mediated)

Drug-IgE complex binding to

mast cells with release of

histamine, inflammatory

mediators

Urticaria, angioedema,

bronchospasm, pruritus,

vomiting, diarrhea,

anaphylaxis

Minutes to hours after drug

exposure

Type II

(cytotoxic)

Specific IgG or IgM antibodies

directed at drug-hapten

coated cells

Hemolytic anemia,

neutropenia,

thrombocytopenia

Variable

Type III

(immune complex)

Tissue deposition of drug-

antibody complexes with

complement activation and

inflammation

Serum sickness, fever,

rash, arthralgias,

lymphadenopathy, urticaria,

glomerulonephritis,

vasculitis

1 to 3 weeks after drug

exposure

Type IV

(delayed, cell-

mediated)

MHC presentation of drug

molecules to T cells with

cytokine and inflammatory

mediator release

Allergic contact dermatitis,

maculopapular drug rash*

2 to 7 days after cutaneous

drug exposure

Adverse Drug Reactions: Types and Treatment OptionsMARC A. RIEDL, M.D., and ADRIAN M. CASILLAS, M.D., Am Fam Physician. 2003 Nov 1;68(9):1781-1791


MILD

Severity

24

Asymptomatic or mild

symptoms

Clinical or diagnostic

observations only

Intervention not indicated

INTERMEDIATE

Minimal, local, or noninvasive

intervention indicated

Limiting age-appropriate

instrumental activities of daily

living (ADL)

A change in treatment

(e.g., modified dosage,

addition of a drug), but not

necessarily discontinuation of

the drug, is required; specific

treatment may be required

SEVERE

Medically significant but not

immediately life-threatening

Hospitalization or

prolongation of

hospitalization indicated

Disabling;

limiting self-care ADL

Life-threatening

consequences

Urgent intervention indicated


P&P Change Summary

25

Use drug class when appropriate rather than multiple drugs in class

Enter environmental allergies (dust, pets) into pt history

Officially sanction the use of ADR for patient conditions

Non-licensed staff to enter unverified allergies

Enter lactose as ADR not allergy

Enter single ingredient entries not combination product allergies/ADRs

Integration with ADR reporting is needed


Dose Checking

26

Utilized Alternate FDB Units to

correct for Salt vs Base for many

products. Identified products where

Dose Range Check units of measure

did not match Drug File.

Compared FDB data to NeoFax and

other references to adjust as issues

noted.

June 289 changes

July 228 changes

August 12 changes

September 31 changes

October 9 changes

MONTHLY CHANGES SINCE GO-LIVE:


Review of Approach

27

• Alert Fatigue Work Group Approved• Analysis of Alerts• Turned off selected high volume duplicates

• Classification of drug interactions: Over-rated severity: Removed from Provider View Nuisance alerts: meds used correctly, interaction irrelevant Drug-food interactions: nonspecific so turned off Allowed providers to turn off individual alerts for patient, their pts

• Drug Allergy/ADR Identified poor use of allergy field, internal work group formed to resolve

• Dose Checking Researched dose alerts for applicability

‒ Finding mismatched units, appropriate alerts

Responded to Provider Complaints


28

QUESTIONS COMMENTS

David Troiano, RPh, MSIA, CPPS

[email protected]

John Heeren, RPh, MS

[email protected]

Wrap-Up – Thank You


Documents

Improving Patient Care with Meaningful%09Medication Therapy Alerts_final w notes