CDS

Happy new years! With a new year and 6 solid months of pharmacy informatics experience, it is time to re-visit "Internal Med? There's an app for that!" with an another perspective.

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Timothy Cole asked an intriguing question on ASHP Connect regarding an "Apple friendly Hospital":

Hello everyone!

I'd like to know if anyone out there knows of or has worked for an Apple based hospital or at least an Apple friendly hospital? The hospital I work at uses Meditech and PCs and it just seems like there HAS to be a better way to do things.
What is your experience / opinion of the most user friendly EMR / PHA module / system? What about one that is the most consistent or the most efficient?

Clinical decision support is equal parts aiding the clinician to 'automagically' make the right decision and presenting options in a way that is intuitive. Being afforded the luxury to design the user interface of clinical design support advisors also brings up unique challenges. The clinical information may be very precise and accurate, but there is a need to present it in a way that facilitates a good user experience.

Speaking to programmers and developers, there is one usability book that is universally recommended: "Don't Make Me Think" by Steve Krug.

I'm going to pick up a copy and review it shortly.

Whether you hate Apple or love them, they also have a very good set of usability guidelines here.

via rxinformatica

Learning a variety of computer and markup languages can be very useful in helping understand interoperability in the informatics world. Lately, since so much of the clinical decision support I work on deals with a web interface, knowing HTML, CSS, and javascript is a must. Along this line, I have also gotten to understand XML a little better. There's no doubt you've probably heard of "XML"; it ranks with "Web 2.0" in regards to one of the most hyped terms of the last decade. So what's the big deal with XML?

XML, or Extensible Markup Language, provides a foundation for creating data and data documents. XML is great in terms of interoperability because it is very standardized, yet simple. Multiple systems can all understand well formed XML without having to convert it into another (often proprietary) format.

It is called extensible because XML provides a solid standard which other standards may incorporate. For example, look at the following XML code:

<XML>
<pharmacy_orgs>
<title>American Pharmacists Association</title>
<abbreviation>APhA</abbreaviation>
</pharmacy_orgs>
</XML>

XML is self descriptive; the individual element tags can be named whatever the developer desires. This leads to the code being easier to understand without actual programming knowledge. Depending on what document type definition (DTD) is declared, specific rules are then evoked in order to parse or make sense of the XML. Where HTML concerns itself with displaying data, XML is used as a way to store it.

XML also stores data in a hierarchal structure. In the above example, it would look like:

There is a nice article in the November 2009 issue of Hospital Pharmacy on the use of clinical surveillance in pharmacy. I've mentioned these types of systems before here and here.

From the article:

Clinical surveillance tools are atype of clinical decision support system (CDSS), providing pharmacists with patient information that has been filtered according to predefined criteria and is presented at appropriate times to enhance patient care. These tools pull data from 3 sources—admission/discharge/transfer (ADT), laboratory, and pharmacy—and use clinical rules to analyze the data and alert the user of instances that meet the rules’criteria. Though there is some variability in methods across the different vendors’ products, these Webbased applications enerally function by interfacing (HL7) with the hospital’s information systems to securely pull the data to the vendor’s server where the data are analyzed against a set of clinical rules. Some vendors allow the client to build their own rules, some provide a foundational set of rules, and others do not allow user-defined rules. This is an important distinction to make when evaluating the different applications.

For more information try visiting John's Evernote repository for Clinical Decision Support.

Bio-IT World

An motivated pharmacist at the Children's Hospital of Philidelphia worked to create a pediatric knowledgebase. The innovative result provided physicians and pharmacists with pharmacotherapy guidance and adequate electronic health information. The difference here is the close ties to patient data.

Isaac T, Weissman JS, Davis RB; et al. Overrides of medication alerts in ambulatory care. Arch Intern Med. 2009;169(3):305-311. FREE FULL TEXT  [the follow up letters below]

Overrides of Medication Alerts in Ambulatory Care
Stephen N. Rosenberg; Maureen Sullivan; Iver A. Juster; Jeffrey Jacques
Arch Intern Med. 2009; 169:1337.  EXTRACT | FULL TEXT | PDF

I have thought the checking of inappropriate medications with Beers and the lesser known Zhan Criteria was a “no brainer” with CDS in ePrescribing and inpatient CPOE.   All of the drugs in the criteria make no sense to be given to elderly folks and have alternatives that are less likely to cause adverse events.   This article and related editorial gives a needed pause and gut check prior to implementing a wide CDS intervention.  I still think it is the right thing to do, just proceed with caution and understanding.

Agreement Between Drugs-to-Avoid Criteria and Expert Assessments of Problematic Prescribing

http://archinte.ama-assn.org/cgi/content/abstract/169/14/1326?etoc

Clinical Decision Support Systems: State of the Art

http://healthit.ahrq.gov/images/jun09cdsreview/09_0069_ef.html

and…..

Clinical Practice Improvement and Redesign:  How Change in Workflow Can Be Supported by Clinical Decision Support

http://healthit.ahrq.gov/images/jun09cdsworkflow/09_0054_ef.html

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