This document discusses pharmacy informatics, which encompasses healthcare technologies that improve medication safety and outcomes. It describes how informatics pharmacists use information systems and their medication expertise to enhance patient care. Current technologies like CPOE, CDSS, and bar coding are reviewed. The document also addresses challenges like alert fatigue, nearly universal order review, and the need for informatics education and training. Overall it provides an overview of the field of pharmacy informatics and its goal of using technology to improve the medication use process from prescribing to patient outcomes.

1. Pharmacy Informatics:From Bytes to Bedside

2. Objectives Describe what pharmacy informatics encompasses Describe components necessary to implement key healthcare technologies Identify current technology used in the medication use cycle Discuss future potential applications of healthcare technology Implement methods to analyze how human interactions with technology may lead to failures

3. Translational research, Translational IT Bytes to Bedside

4. What does an informatics RPh do? Writes drug information papers Improves patient outcomes using technology I don’t know Fixes the department’s printer

5. What does aninformatics RPhdo? Writes drug information papers Improves patient outcomes using technology I don’t know Fixes the department’s printer

6. PPMI Summit Recommendations http://www.ashp.org/DocLibrary/PPMI/Summit-Recommendations.aspx

7. What is pharmacy informatics Encompasses IT-enabled medication-related quality, efficacy, and safety initiatives Should be part of a single accountable process entity that makes decisions regarding the latter Traditional organizational structures for paper based systems did not account for the collaboration required for decisions to implement medicine within an electronic environment

8. What is pharmacy informatics? ...[informatic] pharmacists must use their knowledge of information systems and the medication-use process to improve patient care by ensuring that new technologies lead to safer and more effective medication use." http://www.ashp.org/DocLibrary/BestPractices/AutoITStInformatics.aspx Flynn, A. The Current State of Pharmacy Informatics Education in Professional Programs at US Colleges of Pharmacy. American Journal of Pharmaceutical Education 2005; 69 (4) 66.

9. To Err is Human: Building a Safer Health System Institute of Medicine (IOM) published a report in 2000 7,000 Americans die each year due to medication use errors IOM recommends: to “implement proven medication safety practices” reduce reliance on memory standardize terminology utilize constraints, force functions, protocols, and checklists minimize data handoffs and entering data more than once by hand Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. 1st ed. A report of the Institute of Medicine. Washington, DC: National Academy Press; 2000.

10. Who is a informatics pharmacist Dual specialization Pharmacotherapy Technology to facilitate the latter Pharmacy advocate to manage enterprise-wide deployment of systems that integrate medicine in an electronic environment

11. Role Medication safety Provide leadership and guidance with all technology initiatives that involve medication use Customize and maintain systems to the changing needs of professional pharmacy practice

12. Current Technology Overview Computerized Provider Order Entry (CPOE) Clinical Decision Support Systems (CDSS) Bar Coded Medication Administration (BCMA) Smart pumps Automated dispensing cabinets (ADC) Carousels

13. Remote IV telepharmacy High fidelity cameras for particulate Bar coded verification of ingred. Think of “snapshots” in current workflow Strive for standardized formulations Work with the board of pharmacy USP 797 compliant O'Neal B., et. al. Telepharmacy and bar-code technology in an i.v. chemotherapy admixture area. Am J Health-Syst Pharm. 2009; 66:1211-17

14. The President’s First Weekly Address “To lower health care cost, cut medical errors, and improve care, we’ll computerize the nation’s health records in five years, saving billions of dollars in health care costs and countless lives.” Saturday, January 24th, 2009

15. Question According an ASHP's survey, what percentage of hospitals in 2007 were fully electronic? 1. <10% 2. 10-50% 3. >50% 4. >80%

16. Question According an ASHP's survey, what percentage of hospitals in 2007 were fully electronic? 1. <10% 2. 10-50% 3. >50% 4. >80% Pedersen CA, Gumpper KF. ASHP national survey on informatics: Assessment of the adoption and use of pharmacy informatics in U.S. hospitals. American Journal of Health-System Pharmacy. 2008; 65 (23): 2244-2264.

17. Meaningful Use The use of a certified EHR in a meaningful manner, such as e-prescribing. The use of certified EHR technology for electronic exchange of health information to improve quality of health care. The use of certified EHR technology to submit clinical quality and other measures.

18. Meaningful Use Starts in 2011… 19/24 objectives must be met 14 required core objectives 5 objectives may be chosen from the list of 10 menu set objectives

21. Question You are the person in charge of implementing the foundations of an EHR at your hospital. Which do you implement first? CPOE BCMA CDS eMAR

22. Computerized Provider Order Entry (CPOE) Physicians and other providers input orders directly into a computer, thereby eliminating problems with handwriting legibility and order transcription Guide the ordering provider to make good clinical decisions and appropriate choices based on an individual patient’s data in an electronic health record combined scientific medical evidence

23. Clinical Decision Support Basic drug-allergy checks basic dosing guidance, formulary decision support duplicate therapy checking drug–drug interactions Advance dosing support for renal insufficiency and specific populations (eg., geriatric patients) guidance for medication-related laboratory testing drug–disease contraindication checking drug–pregnancy checking

24. RxNorm Standardized nomenclature for clinical drugs and drug delivery devices Produced by the National Library of Medicine (NLM) Key to interoperability between two or more systems that do not “speak the same language” Why interoperability? Data mapping NDI vs. RxNorm

25. RxNorm Before: DoD could understand 45 percent of VA’s mapped terms and VA could understand 26 percent of DoD’s mapped terms After implementation: DoD understood 74 percent of VA terms and VA understood 58 percent of DoD terms

26. Clinical Relationships

27. Applications of RxNorm Drug Allergies Medication Reconciliation “Bupropion continued at same dose.” RxNORM

28. Case Study Urology service administers medications to clinic patients via a text order to nurses  Nurses grab drugs out of the Pyxis There is usually no pharmacist involvement, allergy check, or documentation of drugs given How can we mitigate this issue?

35. Guidance on CDS What is the optimal method to present alerts to providers? How can you balance usefulness vs. annoyance When does “alert fatigue” happen? Where there are multiple presentation modes, whichmode is most appropriate for any given alert? Which member of the health care team the best recipientof any kind of alert? Should physicians and pharmacists see the same drug related alerts

37. Mandated and strongly recommended by JCAHO and ASHP, respectively

38. Can systems automate the review of some medication orders without pharmacist review and still safely ensure effective outcomes?

39. Medication Order Review vs. Medication interventionsAmerican Society of Health-System Pharmacists. ASHP guidelines: minimum standards for pharmacies in hospitals. Am J Health-Syst Pharm. 1995; 52:2711-7. Mahoney CD, Berard-Collins CM, Coleman R et al. Effects of an integrated clinical information system on medication safety in a multi-hospital setting. Am J Health-Syst Pharm. 2007; 64:1969-77.

40. Nearly Universal Prospective Order Review “Most data onmost patients is mostly normal most ofthe time.” - Korpman R. The need for a computerized medical record, a sales seminar presentation on ULTICARE. 1986 Aug.

41. Opportunity Cost of NUPOR Study by Mahoney showed 0.07% of CPOE orders needed renal dosage adjustments and 0.019% of orders needed dosage adjustments for [serum drug] out of therapeutic range Risk based stratification Flynn., Opportunity cost of pharmacists’ nearly universal prospective order review. Am J Health-Syst Pharm. 2009; 66:668-70

42. State of Informatics Education Limited New pharmacists entering practice will need to understand EHR systems and how to utilize, query, and report data Much like the advent of the Pharm.D. degree and residency training, the use of potentially complex, technically sophisticated software tools will be the next milestone in the training of a contemporary clinical pharmacist

43. Resources and Training Residency Training Vanderbilt University Medical Center University of Utah Hospitals and Clinics University of Michigan Hospitals and Health Centers Oregon Health and Science University Hospitals and Clinics Clarian Health Partners James A. Haley Veterans Hospital University of Louisville Health Care VA San Diego and Tampa Healthcare System The Johns Hopkins Hospital University of California San Francisco Ohio State Medical Center

44. Resources and Training http://healthit.hhs.gov http://www.nlm.nih.gov/ http://www.himss.org https://www.amia.org/ http://www.ashp.org/menu/MemberCenter/SectionsForums/SOPIT.aspx @HHSGov @HIMSS @NPRHealth @ASHPOfficial @pharmacists @AMIAinformatix

45. The Five Rights Distributive Rx: right drug, right patient, right dose, right frequency, and right time Information systems: right information, in the right format, at the right time, in the right hands With pharmacists being as entrenched in the medication use process as they are… They have two options: 1) Sit back and complain how unintuitive their workflow and IT systems are or… 2) Get involved with the implementation process Tribble et. al. Whither Pharmacy Informatics. Am J Health-Syst Pharm. 2009; 66: 813-815.