Medication Reconciliation in Electronic Health Information Exchange

Medication Reconciliation in electronic health information exchange

November 2013

Presented by: Tomasz Adamusiak MD PhD ( @7omasz)

Mary Shimoyama PhD

Technology Innovations 1

Slide 1

Conflict of Interest Disclosure

Tomasz Adamusiak

Mary Shimoyama

Have no real or apparent

conflicts of interest to report.

Slide 2

Using medication reconciliation to

prevent errors

The process of comparing a patient's

medication orders to all of the

medications that the patient

has been taking.

The Joint Commission. Medication reconciliation. Sentinel event alert. Issue 35. 2006

Slide 3

Aim: avoid polypharmacy

Excessive or unnecessary medications acquired at interfaces of care—when a patient is

admitted to, transferred within, or discharged from a health care facility

Slide 4

Aim: avoid adverse drug events

Slide 5

More complex than it seems

• Acetaminophen with HYDROcodone

• Acetaminophen (Tylenol)

• Albuterol orders

• Azithromycin (Zithromax) 250 mg IVPB daily X 4

days

• Azithromycin (Zithromax) 500 mg IVPB once

• CefTRIAXone (Rocephin)

• Codeine

• Echinacea

• Furosemide (Lasix)

• Ipratropium (Atrovent Neb)

• Lisinopril

• MetFORMIN

• Oseltamivir (Tamiflu)

• Ranitidine (Zantac) 150mg

• Sodium chloride

• Zolpidem (Ambien 5 mg)

~ 800 000 drug form names

• acetaminophen with HYDROcodone

• acetaminophen (Tylenol

• Al hydroxide/Mg hydroxide/ simethicone

(Mylanta)

• albuterol orders

• azithromycin (Zithromax) 250 mg daily X4 days

• azithromycin (Zithromax) 500mg once

• cefTRIAXone (Rocephin)

• codeine

• echinacea

• furosemide (Lasix)

• ipratropium (Atrovent Neb)

• levofloxacin (Levaquin)

• lisinopril

• metFORMIN

• oseltamivir (Tamiflu)

• famotadine (Ranitidine /Zantac 150mg)

Reconcile

List 1 List 2

Slide 6

4. Clinical information reconciliation. Enable a user to electronically

reconcile the data that represent a patient’s active medication,

problem, and medication allergy list as follows. For each list type:

(i) Electronically and simultaneously display (i.e., in a single view)

the data from at least two list sources in a manner that allows a

user to view the data and their attributes, which must include, at a

minimum, the source and last modification date.

(ii) Enable a user to create a single reconciled list of medications,

medication allergies, or problems.

(iii) Enable a user to review and validate the accuracy of a final set of

data and, upon a user’s confirmation, automatically update the list.

Meaningful Use Stage 2 Context

§ 170.314 2014 Edition electronic health record certification criteria

45 CFR Part 170, Federal Register/ Vol. 77, No. 171 / Tuesday, September 4, 2012

http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-20982.pdf










Slide 7

Stage 2 Measure

The EP, eligible hospital or CAH performs medication reconciliation

for more than 50 percent of transitions of care in which the patient is

transitioned into the care of the EP or admitted to the eligible hospital’s

or CAH’s inpatient or emergency department (POS 21 or 23).

Improve care coordination

STAGE 2 OBJECTIVES AND MEASURES

42 CFR Parts 412, 413, and 495, Federal Register/ Vol. 77, No. 171











Slide 8

d) Medications.

(1)Standard. Any source vocabulary that is included in

RxNorm, a standardized nomenclature for clinical drugs

produced by the United States National Library of

Medicine.

(2)Standard. RxNorm, a standardized nomenclature for

clinical drugs produced by the United States National

Library of Medicine, August 6, 2012 Release

(incorporated by reference in § 170.299).

Medications will be encoded in a standard

uniform way across all certifed EHRs

§ 170.207 Vocabulary standards for representing electronic health information.

45 CFR Part 170, Federal Register/ Vol. 77, No. 171 / Tuesday, September 4, 2012











Slide 9

<manufacturedProduct classCode="MANU">

<templateId root="2.16.840.1.113883.10.20.22.4.23"/>

<manufacturedMaterial>

<code code="310965"

codeSystem="2.16.840.1.113883.6.88"

codeSystemName="RxNorm"

displayName="Ibuprofen 200 MG Oral Tablet">

</code>

</manufacturedMaterial>

</manufacturedProduct>

Only structured information

allowed in MU 2 Transition of Care

Consolidated CDA

HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation

http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258



Slide 10

<manufacturedProduct classCode="MANU">

<templateId root="2.16.840.1.113883.10.20.22.4.23"/>

<manufacturedMaterial>

<code code="310965"

codeSystem="2.16.840.1.113883.6.88"

codeSystemName="RxNorm"

displayName="Ibuprofen 200 MG Oral Tablet">

</code>

</manufacturedMaterial>

</manufacturedProduct>

Only structured information

allowed in MU 2 Transition of Care

Consolidated CDA

HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation


Medication

Information

Template

RXCUI

Normalized

Drug Name

Slide 11

RxNorm

http://www.nlm.nih.gov/research/umls/rxnorm/overview.html

• Normalized naming system for generic and

branded drugs

• Semantic integration of 12 drug

vocabularies

• Strength + Ingredient + Dose Form

+ Brand name

• FDA Unique Ingredient Identifiers (UNIIs)

• 11-digit HIPAA format National Drug Codes

(NDCs)

© 2013 Medical College of Wisconsin


Slide 12

1. Anatomical Therapeutic Chemical Classification System

2. Gold Standard Drug Database

3. Medi-Span Master Drug Data Base

4. Medical Subject Headings (MeSH)

5. Multum MediSource Lexicon

6. Micromedex RED BOOK

7. FDA National Drug Code Directory

8. FDA Structured Product Labels

9. FDB MedKnowledge (formerly NDDF Plus)

10.Veterans Health Administration National Drug File - Reference

Terminology

11.US Edition of SNOMED CT (drug information)

12.Veterans Health Administration National Drug File

12+1 RxNorm sources


Since 8/13


Slide 13

Normalized drug names, e.g.,

Warfarin Sodium 1 MG Oral Tablet

• Generic drugs Ingredient Strength Dose Form

• Branded drugs Ingredient Strength Dose Form [Brand Name]

• Generic drug packs {# (Ingredient Strength Dose Form) / # (Ingredient Strength Dose Form)} Pack

• Branded drug packs {# (Ingredient Strength Dose Form) / # (Ingredient Strength Dose Form)} Pack

[Brand Name]

RxNorm as its own source

SAB=RXNORM

Slide 14

RxNorm relations

Link concepts that contain the same ingredient or dose form.

You can navigate between an ingredient and a fully-specified drug.

String Relationship Attribute String

Acetaminophen 325 MG Oral Tablet has_tradename Acetaminophen 325 MG Oral Tablet

[Tylenol]

Acetaminophen part_of Acetaminophen / Diphenhydramine

Acetaminophen 325 MG Oral Tablet

[Tylenol]

has_dose_form Oral Tablet

Oral Tablet dose_form_of Acetaminophen 325 MG Oral Tablet

[Tylenol]

Slide 15

The Anatomical Therapeutic Chemical

Classification System with Defined Daily Doses

(ATC/DDD)

http://www.whocc.no/atc/structure_and_principles/

Furosemide

RXCUI: 4603

ATC: C03CA01

http://www.whocc.no/atc/structure_and_principles/

Slide 16

RxNorm translation between

American and European standards

Winnenburg R, Bodenreider O. Stud Health Technol Inform. 2013;192:827-31.

Exploring pharmacoepidemiologic groupings of drugs from a clinical perspective.

• Not all drugs in ATC available in US

• Only about half of the ATC drugs can be associated with

drug properties in NDF-RT

• Many drugs not associated with therapeutic intent,

mechanism of action or physiologic effect properties in

NDF-RT

• Not a complete mapping

Slide 17

RxNorm and UMLS release cycles

UMLS 6 months

RxNorm 1+3 weeks

Slide 18

RxNorm reconciliation scenario:

patient on multiple painkillers

550 mg naproxen sodium b.i.d. 200 mg ibuprofen q.d.s.

Slide 19

RxNorm reconciliation scenario:

patient on multiple painkillers

550 mg naproxen sodium b.i.d. 200 mg ibuprofen q.d.s.

Ibuprofen 200 MG Oral Tablet

RxCUI: 310965

1036 NDCs

34 branded drugs, e.g., Advil

6 contraindications, e.g.,

asthma

Naproxen sodium 550 MG

Oral Tablet

RxCUI: 849431

225 NDCs

2 branded drugs, e.g.,

Alfaxen

2 contraindications, e.g.,

Pregnancy Third Trimester

Anti-Inflammatory Agents, Non-Steroidal

N0000175722

Slide 20

Human-Computer Interaction Lab, University of Maryland

User Interface and Visualization for Medication Reconciliation

http://www.cs.umd.edu/hcil/sharp/twinlist/

Twinlist

http://www.cs.umd.edu/hcil/sharp/twinlist/

Slide 21

RxNorm support provided by NLM

Slide 22

MyMedicationList beta

http://mml.nlm.nih.gov/

http://mml.nlm.nih.gov/

Slide 23

RxNav – visualizing RxNorm

http://rxnav.nlm.nih.gov/

http://rxnav.nlm.nih.gov/

Slide 24

The Computational Photography

Project for Pill Identification C3PI

http://rximage.nlm.nih.gov/

http://rximage.nlm.nih.gov/

Slide 25

Our experience at MCW

Pilot: 1300 patients

https://clinminer.hmgc.mcw.edu

user: himssdemo password: himssdemo

4% unmapped observations

31% codes unable to map

120k codes total (Epic/MediSpan) 600k Rx entries total

https://clinminer.hmgc.mcw.edu/

Slide 26

4% FDA-supplied NDCs

not in RxNorm scope (July 2013)

Slide 27

Practical reconciliation via RxNorm

Part 1 – NDC search

https://clinminer.hmgc.mcw.edu/clinminer#ontology/search/0573-0150-48


NDC: 0573-0150-48

325 TABLET, COATED

in 1 BOTTLE

Pfizer Consumer

Healthcare

https://clinminer.hmgc.mcw.edu/clinminer





Slide 28

Practical reconciliation via RxNorm

Part 2 – Exploration

https://clinminer.hmgc.mcw.edu/clinminer#ontology/term/C0593505



Slide 29

Thank you

This project was funded in part by the Advancing a

Healthier Wisconsin endowment at the Medical College of

Wisconsin and the National Center for Research

Resources and the National Center for Advancing

Translational Sciences, National Institutes of Health,

through grant UL1 RR031973. The content is solely the

responsibility of the authors and does not necessarily

represent the official views of the NIH.

We thank Stacy Zacher, Glenn Bushee, and Bradley

Taylor for their help.