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White Paper

                                       War against Medication Errors:
                                      Creating an Error-free Medication
                                                 Eco-system



A white paper on medication errors, medication pathway, causes, proposed
error-free medication ecosystem leveraging HIPaR BoDK - a wholistic body of
drug knowledge platform

                                         September 2010




                                                  Author
                          Venkateswar Reddy Melachervu
                 Head of Solutions and Technology, HealthNet Global

                                  Contributors
                              Dr.Sanjeev Sharma, MD
               Clinical Pharmacologist, Apollo Health City, Hyderabad

                                   Venu Madhav Thirukachi
                                 Team Leader, HealthNet Global




                                HealthNet Global Limited
    Ground Floor | Life Sciences Building | Apollo Health City Campus | Jubilee Hills | Hyderabad 500033| India
                          Phone: +91 40 2355 2322, 4433 4437 | Fax: +91 40 4433 4444
                                          www.healthnet-global.com

                                              © All rights reserved.
War Against Medication Errors: Body of Drug Knowledge




Copyright
The information contained herein is provided for the purposes of feedback and evaluation of the concepts touched
upon. The information contained herein is protected, among other things by the Trade Secrets Act, as codified, and
any improper use, distribution, or reproduction is specifically prohibited. No license or right of any kind whatsoever
is granted to any third party to use the information contained herein without a written agreement from the Author
and/or his organization. No other use of the information and data contained herein is permitted. Under no
condition should the information contained herein is re-used in any manner whatsoever by any third party without
first receiving the express written permission from the author and/or his organization.




                                            © All rights reserved. 2010.




White Paper                                                                             © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




“To err is human; To persevere, prevail and prevent the errors is a means beyond human
and towards divinity!”
                                                        - Unknown to most, known to few




       “Not by merely abstaining from work can one achieve freedom from reaction!
       Nor by renunciation alone can one attain perfection!!"
                              - Shrimadhbhagavad Gita, Karma Yoga (Chapter 3), Verse 4




White Paper                                                            © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




Acknowledgements
Some of the content on medication errors is compiled from various web resources which is
used as is. The immediate response of Dr.Sanjeev Sharma on forming some form of clinical
councils for my question of how do we achieve credibility and acceptability for the HIPaR BoDK
content was the genesis for the clinical governance model proposed in this paper.
Some of the impactful and visionary phrases used in this white paper (bold italics) are property
of the author and are being copyrighted.

I’d like to express my sincere thanks to Dr.Ranjith Roy Chaudhury, Governing Board Member,
Medical Council of India, for his valuable inputs and support for this initiative.

My sincere appreciations and thanks are due to Dr.Sanjeev Sharma for his contributions
towards the sections – the current state of HIPaR, Content Sources, Global Benchmarking,
Certification and reviewing and providing inputs for the rest of the sections.

My sincere appreciations and thanks are due to Venu Madhav for his contributions towards the
sections – Global Benchmarking, HIPaR Data Constructs.

It’d be unfair on my part if I do not thank for the kind support provided by Shri Sreerama
Murthy Seetepalli (father of one of my ex-colleagues Syam Sunder Seetepalli who co-ordinated
this for me) who authored Visual Bhagawad Gita in guiding me to find an apt verse from one of
the world’s most ancient Body of Knowledges for human beings – Shri Madhbhagawad Gita-
which I read as a child without fully comprehending and appreciating the complete meaning of
what I was reading which as the age passes by one feels to find more relevance and tries to find
more comfort in.




White Paper                                                              © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




                                                     Contents
Acknowledgements ............................................................................................................... 4
Objectives ............................................................................................................................. 7
Prologue................................................................................................................................ 7
Medication Errors .................................................................................................................. 7
Medication Pathway and Points of Failures............................................................................ 8
Causes ................................................................................................................................... 9
Prevention and Improved Patient Safety.............................................................................. 10
HIPaR: Body of Drug Knowledge (BoDK) ............................................................................... 13
    HIPaR BoDK Salient Features ........................................................................................... 13
    HIPaR BoDK Data Constructs ........................................................................................... 13
    HIPaR BoDK Offerings ..................................................................................................... 15
    Evolution of HIPaR .......................................................................................................... 16
Holistic Clinical Governance ................................................................................................. 17
Next Gen Content Administration System ............................................................................ 18
Content Sources .................................................................................................................. 22
Global Benchmarking .......................................................................................................... 22
Certification ........................................................................................................................ 23
Vision .................................................................................................................................. 23
HIPaR BoDK Applications ..................................................................................................... 24
Epilogue .............................................................................................................................. 26
About Author ...................................................................................................................... 26




White Paper                                                                                              © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




Document History
Version                      Date                             Description
0.2                          4th Sept 2010                    Concept inception and
                                                              creation of white paper
                                                              anatomy - Venkateswar
                                                              Reddy Melachervu
0.3                          23rd Sept 2010                   Content Update – Draft
1.0                          7th Oct 2010                     Completed the first draft
                                                              content




White Paper                                                           © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




Objectives
The objectives of this white paper are:
    To understand and analyze the medication errors
    Attempt to derive an error-free medication eco-system
    Arrive at quintessential role of Body of Drug Knowledge- BoDK
    Understand HIPaR BoDK
    To define and propose a model for HIPaR BoDK content update and administration that
       helps tackle medication errors
    Clinical Governance Model for HIPaR BoDK


Prologue
           Everyone falls ill sometime rather the other in one’s lifetime and takes medication, if
                not many times. Medication errors can occur at any point in the medication
                  process and in any care setting. Medication errors can cause long-lasting
                     problems and in the most severe cases, they can result in death. The
                               frequency of medication errors and preventable medication-related
                                  injuries represent a very serious cause for concern. Victims of
                                      medical mistakes frequently have to endure additional
                                        medical attention and as a result, face expensive medical
                                        bills that they are responsible for paying because of
                                        someone else's errors.


Medication Errors
In the US alone, 1.5 million Americans are sickened, injured or killed each year by errors in
prescribing, dispensing and taking medications of which 7,000 are deaths, annually1. On
average, at least one medication error per hospital per patient occurs each day which equals
400,000 errors each year, according to IMNA2, USA. The extra medical cost of treating drug-
related injuries occurring in hospitals alone, conservatively amounts to $3.5 billion annually3.

As defined by a dictionary, error is an act that through ignorance, deficiency, or accident
departs from or fails to achieve what should be done. Specifically, medication errors can be
defined as giving the wrong medicine and/or the wrong dose at the wrong time and can be



1                                                                          st
  Source : Medication Errors Harming Millions, The Washington Post Report, 21 July 2006,
http://www.washingtonpost.com/wp-dyn/content/article/2006/07/20/AR2006072000754.html and
                                                                                         st
Daily News Central, Health News, Medication Errors Cause 7,000 Deaths per Year, 21 July 2006 -
http://health.dailynewscentral.com/content/view/0002352/53/
2
  Institute of Medicine of the National Academies
3
  Source: Office of News and Public Information News from the National Academies, National Academy of Sciences
Medication errors injure 1.5 million people and cost billions of dollars annually: Jul 2006.
http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=11623




White Paper                                                                        © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




categorized into omissions (failure to act correctly) and commissions (acted incorrectly),
broadly.

The practice of medicine, pharmacy and nursing in a healthcare setting is complicated and
involves many steps from pen to patient. One study showed that the most common types of
medication errors were a wrong dose, a wrong drug or a wrong route of administration 4.
Medication errors can occur at any point during the medication process—procuring the drug,
prescribing, dispensing, administering and monitoring its impact—but occur mostly during
prescribing and administering stages.


Medication Pathway and Points of Failures
The following picture depicts various failures of medication errors at each point of what I define
as Medication Pathway, comprehensively.




                                                                                        5
                                  Figure 1: Medication Pathway and Points of Failures




4
  Source: Phillips J, Beam S, Brinker A, Holquist C, Honig P, Lee LY,Pamer C. Retrospective analysis of mortalities
associated with medication errors. Am J Health Syst Pharm. Oct 2001. 58(19);1835-41
5
  © Copyrighted phrase.




White Paper                                                                                 © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




Causes
Medication errors may occur more because of contributing factors such as identical doses,
dosage forms or routes of administration, similar packaging or labeling, incomplete knowledge
of drugs, illegible handwriting, verbal order errors and even lack of an appropriate knowledge
base, performance and knowledge deficits of the drugs, non-availability of the up-to-date
information of the drugs like warnings, precautions etc. It is estimated that confusion regarding
drug is thought to account for 25 per cent of all medication errors. Most of these errors happen
either because of improper or lack of drug information, human errors in medication pathway
etc.

One more research report6 shown below depicts various causes for the medication errors.




                     Figure 2: Most Frequently Reported Causes of Medication Errors (Percentage):
                                                                             7
                                        Voluntary Reporting System 2000-2004
The below visual depicts the comprehensive causes for the possible medication failures at each
point of Medication Pathway.




6
  Source : Data - Santell, J.P.et al. 2005. MedMarx Data Report. USP Center for the Advancement of Patient Safety.
© 2005 The United States Pharmacopeial Convention Inc. All rights reserved. Failure to act in accordance with
education and training – McCarthy and Leatherman – Performance Snapshots. 2006 –
http://www.cmwf.org/snapshots
7
  Source : http://www.commonwealthfund.org/Content/Performance-Snapshots/Medication-Mistakes-and-
Adverse-Drug-Events/Medication-Mistakes--Types-and-Causes.aspx




White Paper                                                                              © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




                                                                               8
                                       Figure 3: Causes of Medication Errors


Paradoxically, what augments the problem is the absence of a Blame-free Medication Error-
Reporting Mechanism in healthcare provider setting that could keep account of errors through
an internal audit process recognizing the fact that human error as an inevitable consequence
and deploying systems in place to minimize consequences of medication errors. The world is
yet to witness such an established mechanism for blame-free medication error reporting and
management which accounts for the point of having hardly any data on medication errors in
healthcare provider settings, especially for countries like India.


Prevention and Improved Patient Safety
Every health care professional can recall that 9 out of 10 prescription errors are preventable. In
order to ensure error-free medication procedures, hospitals adopt what is known as 5 Rights:
    Right drug
    Right dose

8
    © Copyrighted phrase.




White Paper                                                                        © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




     Right route
     Right time
     Right patient

In spite of 5 Rights being followed diligently, it is observed that in different countries, up to
12.9% of hospitalized patients suffer at least one adverse event during their admission out of
which 10.8% to 38.7% per cent were caused by medication errors9.

There are two more rights that the global medical fraternity has added, of late, to this list
making it 7 rights:
    Right indication
    Right documentation
Notwithstanding, the world is yet to witness any significant improvement in prevention of
medication errors.

With the increased healthcare awareness, importance, growing concerns on the fatal un-
desirable consequences, reducing medication errors and improving patient safety by arresting
or minimizing medication errors has become one of the highest priority areas for the healthcare
eco-system players – healthcare providers, pharmacists, doctors, nurses, patients etc.
Enhancing patient safety by minimizing or arresting medication error requires a systems-based
approach in order to control the conditions that contribute towards errors.

A little more concentration, a little more discipline, little more process and systems, a little
more care, a little more faith can save the entire mankind from so many injuries, permanent
damages and deaths caused due to medication errors. After all, the motivation is for a better
healthcare that leads to beautiful lives.

Enhancing the judicious use of medications and minimizing medication errors have always been
key area for the healthcare fraternity but lacked the necessary systems, platforms, ever
increasing up-to-date drug knowledge of tens of thousands of generics and brands and the
optimal automation and integration with Hospital Information Systems along with the requisite
operational processes for seamless controls of tackling medication errors in the care settings.

With the emergence and deployment of pervasive IT systems in the healthcare settings like -
HIS, HMS, ePrescription - care providers have embraced the needed systems and platforms that
provide a base for tackling medication errors which can be supplemented by the manual
operational components enabling a seamless point and click systems that help the care givers in
reducing or arresting these errors. Additionally, IT can help build and deploy seamless, blame-
free medication error reporting and management systems that are equally important for this
endeavor for the fact that if you cannot measure it; you cannot improve it.10

9
  Source : Quality India - Safe Medication, Safe Healthcare - http://www.qcin.org/nbqp/qualityindia/Vol-3-
No1/medical.htm
10
   Source: Quote of Lord Kelvin, mathematical physicist, engineer and pioneer of thermodynamics.




White Paper                                                                           © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




The below visual depicts and summarizes the aforementioned concepts and notions in this War
Against Medication Errors11.




                                                                                  12
                                     Figure 4: Error Free Medication Eco-system


However, what is critically lacking today, is a comprehensive, up-to-date drug knowledgebase
that is quintessential and core of the whole solution for tackling this challenge that embodies
the ever increasing and changing knowledge and characteristics of the tens of thousands drug
molecules13 for it is increasingly becoming humanly impossible to remember the ever growing
brands, generics and their innumerable number of characteristics that play pivotal role in this
war against medication errors14 by the healthcare eco-system players. Nonetheless, reducing
medication errors is not a mere onetime activity but an ongoing process of quality
improvement in the care settings.




11
   © Copyrighted phrase.
12
   © Copyrighted phrase and conceptual model.
13
   It is estimated that there are around 50,000 generic brands and 6,000 generics prevalent in India alone today.
These numbers are expected to significantly go up in next 5 years as more generics get added that come out of
patent regime.
14
   © Copyrighted phrase.




White Paper                                                                            © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




HIPaR: Body of Drug Knowledge (BoDK)
HIPaR BoDK is the Embodiment of Comprehensive Drug Knowledge from HealthNet Global
offering complete drug related information such as drug - drug interactions, drug-lab
modifications, and drug-food interactions, drug-disease interactions, generic search, brand
search, combination drug search, alternate brands for a given brand/generic, adverse reactions,
indications, contra-indications, drug dosages, route of administration, precautions and
warnings, banned drugs, ATC15, retail pricing and packaging information, manufacturers details
etc.

HIPaR BoDK complies with international disease coding standards like ICD-10/9, HL-7,
EphMRA16, WHO indications standard etc. that make it easy to integrate with other
clinical/hospital management software, pharmaceutical software or any healthcare software. It
can also be shared across networks in hospitals, organizations and academic institutions etc.

HIPaR BoDK platform is designed keeping with the objective of helping the healthcare fraternity
in creating an integrated error-free medication eco-system automating various pharmacy and
pharmacological processes, 7 rights frameworks on top of a contemporary Body of Drug
Knowledge.

HIPaR BoDK Salient Features
          Generic search, brand search, combination drug search, alternate brands for a given
           brand/generic
          Indications, contra indications, drug-drug interactions, drug-Lab modifications, drug-
           food/alcohol interactions
          Adverse reactions, precautions and warnings, dosages
          Pharmacokinetics, Anatomic Therapeutic and Chemical Classification System - ATC
          Mechanism of Action of the drug
          Manufacturer search, retail price, packaging details
          Information on dose form, route of administration, Strength
          Disease classifications, ICD-10 coding
          Banned drugs, bar codes, essential drug list, storage conditions etc.
          Therapeutic duplication and equivalent
          Patient counseling messages
          Drug content administration, period updates (role-based user management for security
           and content quality)
          A platform approach that helps the healthcare fraternity in flexibly adapting, integrating
           for achieving their objectives

HIPaR BoDK Data Constructs

15
     Anatomic Therapeutic and Chemical Classification System
16
     European Pharmaceutical Market Research Association




White Paper                                                                    © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




                          Figure 5: HIPaR BoDK - Generics Data




                          Figure 6: HIPaR BoDK - Brands Data




White Paper                                                      © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




                      Figure 7: HIPaR BoDK - Drug Manufacturer Data




                         Figure 8: HIPaR BoDK Open Data Model


HIPaR BoDK Offerings




White Paper                                                           © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




                                                    HIS Integrated              HIPaR                  HIPaR
   HIPaR Doctor             Mobile HIPaR
                                                        HIPaR                  Web App                SaaS API



                             Mobile Phones
      Thick client                                       HIS/HMS               Custom Built            Web Service
                                – J2ME




       Installs and           Thin and thick            Drug Supply             Integration
                                                                                                      SOAP Support
      runs on a PC               clients                   Chain                with Portals




                                                       ePrescription




                                           Figure 9: HIPaR BoDK Offerings


Evolution of HIPaR
The product embodies the expertise and experience of almost 10 years of evolution of its
content and application logic from the group company of Apollo Hospitals founders. The
content quantity of HIPaR BoDK as of early 2010 is as below.

                      Parameter                                             Quantity
                      Brands                                                 15000
                      Generics                                                4065
                                             Indications                      1477
                                      Contra-indications                      1229
                                      Adverse reactions                       1182
                                              Drug-Drug                       669
                                     Dosage Information                       1098
                               Precautions and Warnings                       1312
                                                    MoA                       827
                      Manufacturers                                            935

The following set of next gen capabilities are the key drivers for the evolution of HIPaR BoDK
    Multi-tiered content aggregation, editing, update and administration process enabling
        logical separation of content activities - editing, review, approve, reject etc.
    Constitution of two-tiered clinical governance board - pharmacology and clinical
        practice – that enables the authenticity, sanctity and control over the content quantity
        that impacts lives
    Updating and releasing the clinical content periodically
    Enhancing the characteristics of drugs in the drug knowledgebase – special conditions
        and dosages, drug-disease, therapeutic duplication information, drug dosages for special
        conditions like renal failures etc.




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War Against Medication Errors: Body of Drug Knowledge




      Patient counseling messages - drug information to the patient in his language – is
       lacking


Holistic Clinical Governance
One of the critical points for an acceptable and credible body of drug knowledge is a clinically
governed and enterprise class content administration system. The HIPaR BoDK content
administration is clinically governed as below:
    Clinical governance of the HIPaR BoDK healthcare content by instituting the following
       councils:
            Clinical Pharmacologists Council – council of prominent clinical pharmacologists
               drawn across Apollo group
            Clinical Advisory Council – council of prominent clinical practitioners/medical
               services directors drawn across Apollo group
            Executive Governance Council – council/board comprising of technology, clinical
               experts and executives that drive the direction of HIPaR BoDK
    An enterprise class Next Generation Content Administration system
            Multiple content sources aggregation
            Multi-tiered
            Distinct roles with role-based user management
            Auditable and traceable content editing, update, rejection/approval and
               database administration
            A content administration team comprising of bachelor and master pharmacists
               lead by a clinical pharmacologist

This section focuses on the clinical governance and the next section on the Next Generation
Content Administration system.

The below picture summarizes the concepts visually for the holistic clinical governance
addressing the hitherto identified content sources.




White Paper                                                              © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




Next Gen Content Administration System
The core to the design of the Content Administration System is the fundamental concept of
multi-tiered, role-based, and clinically governed Content Update Process that we’ve uniquely
developed for this purpose considering the need to ensure the sanctity of the data that impacts
the lives of the human beings and the focus on the India specific content. The following picture
depicts the multi-tiered content update process that incorporates the Holistic Clinical
Governance addressed in the previous section.




White Paper                                                             © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




                     Figure 10: Next Generation Clinical Content Administration Platform


We at HealthNet Global have analysed, understood, recognized and built a tiered, role-based,
auditable enterprise class content management system as an integral part of Next Generation
HIPaR BoDK platform and have instituted content development team (pharmacists, clinical
pharmacologists etc.) and experienced software development team which have developed and
deployed an enterprise class Content Administration System for HIPaR BoDK where a special
team of pharmacists (B.Pharms and M.Pharms) lead by a senior clinical pharmacologist are
editing and updating the content aggregating the clinical content from various popular and
credible sources to it one of the world’s leading BoDK for India and beyond.

The BoDK Content Administrator offers drug content sources aggregation, content entry,
content review, content approval, audit information, content publishing using Internet
leveraging cloud technologies, role-based secured user management and database
administration etc. enabling a robust anytime and anywhere secured system. Some of the
screen captures of BoDK Content Administrator are shown below.




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War Against Medication Errors: Body of Drug Knowledge




                       Figure 11: HIPaR BoDK Content Administrator Role-based Login




              Figure 12: HIPaR BoDK Content Administrator Auto Suggest of Brands, Generics etc.




White Paper                                                                           © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




                   Figure 13: Content Administrator - Generic edit Screen




                            Figure 14: Content Approver Login




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War Against Medication Errors: Body of Drug Knowledge




                            Figure 15: Content Administrator - Approver Screen



Content Sources
The following are the content sources used hitherto for cleansing and updating the existing
content:
         Pharmaceutical Manufacturer Product Monographs
         Indian Pharmacopoeia Version 2010
         Wolters Kluwer’s Drugs in Pregnancy & Lactation Version
         Central Drugs Standard Control Organization website
                http://cdsco.nic.in/
         Australian Registry of Therapeutic Goods and Medicines -
           https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/PICMI?OpenForm&t=PI
           &k=0&r=/
         Health Canada website
                http://webprod.hc-sc.gc.ca/dpd-bdpp/start-debuter.do?lang=eng
         New Zealand Medicines and Medical Devices Safety Authority Website
                http://www.medsafe.govt.nz/
         US FDA website
                http://www.fda.gov/


Global Benchmarking
We’ve benchmarked HIPaR BoDK platform clinical fields/capabilities and content with some of
the national and international products used for the similar purposes and summarized below.
The benchmarking focus was more on the clinical fields/capabilities as the clear data on the
quantity of the content of these products is hardly available. Clearly HIPaR BoDK stands out and
on top with its longer list of supported capabilities.




White Paper                                                                      © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




                                Figure 16: HIPaR BoDK Global Benchmarking



Certification
Acceptability and credibility of the content is critical to the core of HIPaR BoDK given its impact
on human lives. This typically, comes with accreditation/certification by renowned institutions
and organizations globally that are independent and have acclaimed expertise in the relevant
subject matter. In our research, we are yet to find such a straight body that certifies drug
knowledge or drug database.

We are in the process of identifying and pursuing the certification with organizations that have
relevance to pharmacy and pharmacology.


Vision
Transform HIPaR into next generation ubiquitous body of drug knowledge platform that plays
a pivotal and core role in the prevention of medication errors, integrated medicine
management throughout the medication pathway empowering healthcare fraternity with a




White Paper                                                                 © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




comprehensive, ever up-to-date, seamless, credible body of drug knowledge at a touch of a
button that endeavors to create an error-free medication eco-system


HIPaR BoDK Applications
                                               Generic based Drug Inventory control using HIPaR BoDK helps
Efficient Drug Inventory Management            achieve efficient control on stock refills.
                                               HIPaR BoDK helps the Pharmacist conduct a prescription audit
Prescription Audit                             providing indications for the prescribed drugs in Hospital
                                               HIPaR BoDK can be used as education and drug awareness by the
Drug Education for Patients                    patients
                                               HIPaR BoDK helps drug regulators to avoid Look Alike, Spell Alike
Efficient Drug Licensing                       and Sound Alike drugs while licensing

                                               HIPaR BoDK enables nurses for educating the Patients on Drugs
Drug Education for Nurses                      and monitoring Patients on drug therapy

                                               HIPaR BoDK helps students with a comprehensive drug
Drug Education for Medical Students            knowledge base
                                               HIPaR BoDK enables Pharmacist and Doctors find a Brand
Brand Equivalent                               Equivalent of a Drug
                                               HIPaR BoDK helps patients conveniently identify a Drug for
Convenient drug identification by patients     consumption based on the Color/Image?
                                               HIPaR BoDK enables healthcare providers especially public health
Generic Based Prescription                     care providers in implementing a generic based prescribing in
                                               place of brand based prescribing
                                               HIPaR BoDK enables Insurance Providers to Validate the
Claims Validation                              Insurance Claims related to Drugs - Age, Gender, and Disease
                                               HIPaR BoDK enables doctors to adjust drug dosage for patients
Drug Dosage adjustments for Renal Failure      with renal failure.
                                               HIPaR BoDK enables doctors to adjust drug dosage for patients
Drug Dosage adjustments for Hepatic Failure    with hepatic failure.
                                               HIPaR BoDK can alert the doctors about the contraindications of
Contra Indications                             the drug they are prescribing enhancing the Patient Safety
                                               HIPaR BoDK enables Health Care Providers in preventing dosage
Dosage Error Prevention                        errors
Prevention of Drug Errors in Pregnancy         HIPaR BoDK enables Health Care Providers/Doctors in preventing
/Lactating Women                               Drug Errors for Pregnancy/Lactating Women
                                               HIPaR BoDK enables dietitians in creating a customized dietary
Customized Dietary Plan for Chronic Patients   plan for Patients on Pharmacotherapy in case of chronic
                                               conditions
                                               HIPaR BoDK enables doctors in preventing therapeutic
Prevention of Therapeutic Duplication          duplication of the drugs
                                               HIPaR BoDK enables health care providers in institutionalizing
Institutionalized Body of Drug Knowledge       drug knowledge across the organization sans boundaries
                                               HIPaR BoDK enables healthcare providers, pharmaceutical
Find Manufacturer of a brand                   companies, regulators to find manufacturers for a given
                                               generic/brand




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War Against Medication Errors: Body of Drug Knowledge




                                                HIPaR BoDK can act as a reference tool for financial decisions by
Price reference for Drug Purchases              healthcare providers, pharmacies, insurance providers and
                                                patients
                                                HIPaR BoDK enables doctors, pharmacists, pharmacologists for
                                                identifying drug - drug interactions and taking necessary actions
Drug-drug interactions                          for enhanced patient safety. Helps medical students, pharmacists
                                                in learning.
                                                HIPaR BoDK enables biochemists, micro biologists and doctors in
Drug-lab interactions                           right interpretation of lab results avoiding unnecessary or wrong
                                                treatment.
                                                HIPaR BoDK enables dietitians and doctors plan a customized
Drug-food interactions                          dietary for a patient for the better management of a disease
                                                avoiding treatment failure and adverse effect.
                                                HIPaR BoDK enables anesthetists to plan anesthesia for patient
Drug-anesthesia interactions                    on drug therapy avoiding mishaps during the anesthesia.

                                                HIPaR BoDK enables doctors to warn the patients regarding the
Drug-Alcohol interactions                       alcohol consumption for mishaps while patient is on drug
                                                therapy.
                                                HIPaR BoDK enables doctors in assessing the risk benefit ratio to
Precautions, warnings                           prescribe drugs to special category cases(Pregnancy, Lactation,
                                                Pediatric and Geriatric etc..)
                                                HIPaR BoDK enables researchers and medical students in
Pharmacokinetics                                analyzing and understanding Pharmacokinetic profile of drugs.
                                                HIPaR BoDK enables researchers for doing drug utilization studies
ATC information and DDD                         and better inventory planning control
                                                HIPaR BoDK enables medical students in learning about the
Pharmacological category and sub-category
                                                pharmacological classification system and helps the pharmacist
information                                     in identifying therauptic substitutes.
                                                HIPaR BoDK enables Hospital nursing staff in proper
Nursing considerations                          reconstitution, storage, administration and monitoring the
                                                patient on drug therapy.
                                                HIPaR BoDK provides unique opportunity in India for regulatory
                                                agencies, Manufacturers, Insurance providers, health care
HIPaR Unique Article Code                       providers etc. To uniquely and unambiguously address the health
                                                care item across the systems.
                                                HIPaR BoDK provides the ICD10 Disease code information for any
ICD-10 Information                              given disease and vice versa.
                                                HIPaR BoDK enables medical students and doctors in learning
Drug Search by Disease                          drug therapy for various diseases.
                                                HIPaR BoDK enables doctors and patients in knowing and tackling
Drug Side Effects                               the side effects while drug therapy.
                                                HIPaR BoDK enables patients and pharmacists to identify
OTC information of a drug                       whether a drug is OTC drug or not.
                                                HIPaR BoDK enables doctors and pharmacists to identify the
Generic Synonyms                                global generic synonym.
                                                HIPaR BoDK enables doctors, regulators, pharmacists, nurses and
Look Alike, Sound Alike and Spell Alike Drugs
                                                patients in preventing the medical errors and enhancing patient
Information                                     safety.




White Paper                                                                    © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




 Drug Packaging - bulk packaging and                     HIPaR BoDK enables pharmacy and health care providers in
 retail/selling packaging information                    maintaining the better inventory management.
                                                         HIPaR BoDK Platform helps the healthcare providers and
                                                         regulators in automating the process and deploying the system
 Integrated Pharmaco-vigilance                           online for seamless easy-to-use access for pharmaco-vigilance in
                                                         reporting and verifying the adverse effects along with periodic
                                                         reports



Epilogue
As per a latest article in a medical journal17 (2008), the medical errors kill anywhere between
48,000 – 80,000 Americans annually and the article claims majority part is due to Medication
Errors. Imagine saving a fraction percentage of these lives by creating an error-free medication
eco-system which can still run into saving tens of lives annually which is more than the meaning
for our endeavor of War Against Medication Errors and we firmly of the view that this
transformation should pick up the momentum now and should not stop at saving mere tens of
lives.

We humbly appeal to the healthcare fraternity through this white paper to come forward for a
collaborative endeavor, join hands with us for an inclusive effort to wage and win the War
Against Medication Errors18.

Together, let us march forward and work towards ushering in an Error-free Medication Eco-
system19 leveraging the comprehensive Body of Drug Knowledge, first in the IP care setting and
then beyond IP care setting in the journey of Touching Lives.


About Author
Venkateswar Reddy Melachervu
Venkat is a well-rounded professional with technology expertise, business acumen and proven
timely results in conceiving profitable ideas and transforming these profitable ideas into
products and solutions across multiple domains leveraging cutting-edge technologies ushering
positive impacts to the top lines and bottom lines – start-ups or grown-ups, locally or globally.

Venkat is the member of the founding team of HealthNet Global and currently associate vice
president and head of technology and solutions. In this role, he heads technology and solutions
and is responsible for company’s solutions, services, technology strategy, roadmap and concept
selling to - enterprises, governments, partners and investors.

Venkat earned bachelor's degree in electronics and communications engineering with
distinction where he was first exposed to the nature and significance of electronics,

17
   Source : Clinical Review: Medication Errors in Critical Care: Critical Care 2008
18
   © Copyrighted phrase.
19
   © Copyrighted phrase.




White Paper                                                                             © All rights reserved. 2010
War Against Medication Errors: Body of Drug Knowledge




telecommunications and information technology convergence and the power there-of, while
developing hardware, software and firmware for his final year project Digital Filters Utilizing
Microprocessors on Intel 8085. This work has significantly influenced his professional journey he
has embarked there on.

He believes in technology in isolation has no meaning neither to business nor to humans unless
seen in a problem solving or value creation context, dares to dream, cares to win and works
towards transforming the lives through technology. More details can be found about him on
Linkedin.


------------------------------------------------ End of White Paper----------------------------------------------------




White Paper                                                                               © All rights reserved. 2010

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White paper - War against medication errors and creating an error-free medication eco-system v1.2 - ga

  • 1. White Paper War against Medication Errors: Creating an Error-free Medication Eco-system A white paper on medication errors, medication pathway, causes, proposed error-free medication ecosystem leveraging HIPaR BoDK - a wholistic body of drug knowledge platform September 2010 Author Venkateswar Reddy Melachervu Head of Solutions and Technology, HealthNet Global Contributors Dr.Sanjeev Sharma, MD Clinical Pharmacologist, Apollo Health City, Hyderabad Venu Madhav Thirukachi Team Leader, HealthNet Global HealthNet Global Limited Ground Floor | Life Sciences Building | Apollo Health City Campus | Jubilee Hills | Hyderabad 500033| India Phone: +91 40 2355 2322, 4433 4437 | Fax: +91 40 4433 4444 www.healthnet-global.com © All rights reserved.
  • 2. War Against Medication Errors: Body of Drug Knowledge Copyright The information contained herein is provided for the purposes of feedback and evaluation of the concepts touched upon. The information contained herein is protected, among other things by the Trade Secrets Act, as codified, and any improper use, distribution, or reproduction is specifically prohibited. No license or right of any kind whatsoever is granted to any third party to use the information contained herein without a written agreement from the Author and/or his organization. No other use of the information and data contained herein is permitted. Under no condition should the information contained herein is re-used in any manner whatsoever by any third party without first receiving the express written permission from the author and/or his organization. © All rights reserved. 2010. White Paper © All rights reserved. 2010
  • 3. War Against Medication Errors: Body of Drug Knowledge “To err is human; To persevere, prevail and prevent the errors is a means beyond human and towards divinity!” - Unknown to most, known to few “Not by merely abstaining from work can one achieve freedom from reaction! Nor by renunciation alone can one attain perfection!!" - Shrimadhbhagavad Gita, Karma Yoga (Chapter 3), Verse 4 White Paper © All rights reserved. 2010
  • 4. War Against Medication Errors: Body of Drug Knowledge Acknowledgements Some of the content on medication errors is compiled from various web resources which is used as is. The immediate response of Dr.Sanjeev Sharma on forming some form of clinical councils for my question of how do we achieve credibility and acceptability for the HIPaR BoDK content was the genesis for the clinical governance model proposed in this paper. Some of the impactful and visionary phrases used in this white paper (bold italics) are property of the author and are being copyrighted. I’d like to express my sincere thanks to Dr.Ranjith Roy Chaudhury, Governing Board Member, Medical Council of India, for his valuable inputs and support for this initiative. My sincere appreciations and thanks are due to Dr.Sanjeev Sharma for his contributions towards the sections – the current state of HIPaR, Content Sources, Global Benchmarking, Certification and reviewing and providing inputs for the rest of the sections. My sincere appreciations and thanks are due to Venu Madhav for his contributions towards the sections – Global Benchmarking, HIPaR Data Constructs. It’d be unfair on my part if I do not thank for the kind support provided by Shri Sreerama Murthy Seetepalli (father of one of my ex-colleagues Syam Sunder Seetepalli who co-ordinated this for me) who authored Visual Bhagawad Gita in guiding me to find an apt verse from one of the world’s most ancient Body of Knowledges for human beings – Shri Madhbhagawad Gita- which I read as a child without fully comprehending and appreciating the complete meaning of what I was reading which as the age passes by one feels to find more relevance and tries to find more comfort in. White Paper © All rights reserved. 2010
  • 5. War Against Medication Errors: Body of Drug Knowledge Contents Acknowledgements ............................................................................................................... 4 Objectives ............................................................................................................................. 7 Prologue................................................................................................................................ 7 Medication Errors .................................................................................................................. 7 Medication Pathway and Points of Failures............................................................................ 8 Causes ................................................................................................................................... 9 Prevention and Improved Patient Safety.............................................................................. 10 HIPaR: Body of Drug Knowledge (BoDK) ............................................................................... 13 HIPaR BoDK Salient Features ........................................................................................... 13 HIPaR BoDK Data Constructs ........................................................................................... 13 HIPaR BoDK Offerings ..................................................................................................... 15 Evolution of HIPaR .......................................................................................................... 16 Holistic Clinical Governance ................................................................................................. 17 Next Gen Content Administration System ............................................................................ 18 Content Sources .................................................................................................................. 22 Global Benchmarking .......................................................................................................... 22 Certification ........................................................................................................................ 23 Vision .................................................................................................................................. 23 HIPaR BoDK Applications ..................................................................................................... 24 Epilogue .............................................................................................................................. 26 About Author ...................................................................................................................... 26 White Paper © All rights reserved. 2010
  • 6. War Against Medication Errors: Body of Drug Knowledge Document History Version Date Description 0.2 4th Sept 2010 Concept inception and creation of white paper anatomy - Venkateswar Reddy Melachervu 0.3 23rd Sept 2010 Content Update – Draft 1.0 7th Oct 2010 Completed the first draft content White Paper © All rights reserved. 2010
  • 7. War Against Medication Errors: Body of Drug Knowledge Objectives The objectives of this white paper are:  To understand and analyze the medication errors  Attempt to derive an error-free medication eco-system  Arrive at quintessential role of Body of Drug Knowledge- BoDK  Understand HIPaR BoDK  To define and propose a model for HIPaR BoDK content update and administration that helps tackle medication errors  Clinical Governance Model for HIPaR BoDK Prologue Everyone falls ill sometime rather the other in one’s lifetime and takes medication, if not many times. Medication errors can occur at any point in the medication process and in any care setting. Medication errors can cause long-lasting problems and in the most severe cases, they can result in death. The frequency of medication errors and preventable medication-related injuries represent a very serious cause for concern. Victims of medical mistakes frequently have to endure additional medical attention and as a result, face expensive medical bills that they are responsible for paying because of someone else's errors. Medication Errors In the US alone, 1.5 million Americans are sickened, injured or killed each year by errors in prescribing, dispensing and taking medications of which 7,000 are deaths, annually1. On average, at least one medication error per hospital per patient occurs each day which equals 400,000 errors each year, according to IMNA2, USA. The extra medical cost of treating drug- related injuries occurring in hospitals alone, conservatively amounts to $3.5 billion annually3. As defined by a dictionary, error is an act that through ignorance, deficiency, or accident departs from or fails to achieve what should be done. Specifically, medication errors can be defined as giving the wrong medicine and/or the wrong dose at the wrong time and can be 1 st Source : Medication Errors Harming Millions, The Washington Post Report, 21 July 2006, http://www.washingtonpost.com/wp-dyn/content/article/2006/07/20/AR2006072000754.html and st Daily News Central, Health News, Medication Errors Cause 7,000 Deaths per Year, 21 July 2006 - http://health.dailynewscentral.com/content/view/0002352/53/ 2 Institute of Medicine of the National Academies 3 Source: Office of News and Public Information News from the National Academies, National Academy of Sciences Medication errors injure 1.5 million people and cost billions of dollars annually: Jul 2006. http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=11623 White Paper © All rights reserved. 2010
  • 8. War Against Medication Errors: Body of Drug Knowledge categorized into omissions (failure to act correctly) and commissions (acted incorrectly), broadly. The practice of medicine, pharmacy and nursing in a healthcare setting is complicated and involves many steps from pen to patient. One study showed that the most common types of medication errors were a wrong dose, a wrong drug or a wrong route of administration 4. Medication errors can occur at any point during the medication process—procuring the drug, prescribing, dispensing, administering and monitoring its impact—but occur mostly during prescribing and administering stages. Medication Pathway and Points of Failures The following picture depicts various failures of medication errors at each point of what I define as Medication Pathway, comprehensively. 5 Figure 1: Medication Pathway and Points of Failures 4 Source: Phillips J, Beam S, Brinker A, Holquist C, Honig P, Lee LY,Pamer C. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm. Oct 2001. 58(19);1835-41 5 © Copyrighted phrase. White Paper © All rights reserved. 2010
  • 9. War Against Medication Errors: Body of Drug Knowledge Causes Medication errors may occur more because of contributing factors such as identical doses, dosage forms or routes of administration, similar packaging or labeling, incomplete knowledge of drugs, illegible handwriting, verbal order errors and even lack of an appropriate knowledge base, performance and knowledge deficits of the drugs, non-availability of the up-to-date information of the drugs like warnings, precautions etc. It is estimated that confusion regarding drug is thought to account for 25 per cent of all medication errors. Most of these errors happen either because of improper or lack of drug information, human errors in medication pathway etc. One more research report6 shown below depicts various causes for the medication errors. Figure 2: Most Frequently Reported Causes of Medication Errors (Percentage): 7 Voluntary Reporting System 2000-2004 The below visual depicts the comprehensive causes for the possible medication failures at each point of Medication Pathway. 6 Source : Data - Santell, J.P.et al. 2005. MedMarx Data Report. USP Center for the Advancement of Patient Safety. © 2005 The United States Pharmacopeial Convention Inc. All rights reserved. Failure to act in accordance with education and training – McCarthy and Leatherman – Performance Snapshots. 2006 – http://www.cmwf.org/snapshots 7 Source : http://www.commonwealthfund.org/Content/Performance-Snapshots/Medication-Mistakes-and- Adverse-Drug-Events/Medication-Mistakes--Types-and-Causes.aspx White Paper © All rights reserved. 2010
  • 10. War Against Medication Errors: Body of Drug Knowledge 8 Figure 3: Causes of Medication Errors Paradoxically, what augments the problem is the absence of a Blame-free Medication Error- Reporting Mechanism in healthcare provider setting that could keep account of errors through an internal audit process recognizing the fact that human error as an inevitable consequence and deploying systems in place to minimize consequences of medication errors. The world is yet to witness such an established mechanism for blame-free medication error reporting and management which accounts for the point of having hardly any data on medication errors in healthcare provider settings, especially for countries like India. Prevention and Improved Patient Safety Every health care professional can recall that 9 out of 10 prescription errors are preventable. In order to ensure error-free medication procedures, hospitals adopt what is known as 5 Rights:  Right drug  Right dose 8 © Copyrighted phrase. White Paper © All rights reserved. 2010
  • 11. War Against Medication Errors: Body of Drug Knowledge  Right route  Right time  Right patient In spite of 5 Rights being followed diligently, it is observed that in different countries, up to 12.9% of hospitalized patients suffer at least one adverse event during their admission out of which 10.8% to 38.7% per cent were caused by medication errors9. There are two more rights that the global medical fraternity has added, of late, to this list making it 7 rights:  Right indication  Right documentation Notwithstanding, the world is yet to witness any significant improvement in prevention of medication errors. With the increased healthcare awareness, importance, growing concerns on the fatal un- desirable consequences, reducing medication errors and improving patient safety by arresting or minimizing medication errors has become one of the highest priority areas for the healthcare eco-system players – healthcare providers, pharmacists, doctors, nurses, patients etc. Enhancing patient safety by minimizing or arresting medication error requires a systems-based approach in order to control the conditions that contribute towards errors. A little more concentration, a little more discipline, little more process and systems, a little more care, a little more faith can save the entire mankind from so many injuries, permanent damages and deaths caused due to medication errors. After all, the motivation is for a better healthcare that leads to beautiful lives. Enhancing the judicious use of medications and minimizing medication errors have always been key area for the healthcare fraternity but lacked the necessary systems, platforms, ever increasing up-to-date drug knowledge of tens of thousands of generics and brands and the optimal automation and integration with Hospital Information Systems along with the requisite operational processes for seamless controls of tackling medication errors in the care settings. With the emergence and deployment of pervasive IT systems in the healthcare settings like - HIS, HMS, ePrescription - care providers have embraced the needed systems and platforms that provide a base for tackling medication errors which can be supplemented by the manual operational components enabling a seamless point and click systems that help the care givers in reducing or arresting these errors. Additionally, IT can help build and deploy seamless, blame- free medication error reporting and management systems that are equally important for this endeavor for the fact that if you cannot measure it; you cannot improve it.10 9 Source : Quality India - Safe Medication, Safe Healthcare - http://www.qcin.org/nbqp/qualityindia/Vol-3- No1/medical.htm 10 Source: Quote of Lord Kelvin, mathematical physicist, engineer and pioneer of thermodynamics. White Paper © All rights reserved. 2010
  • 12. War Against Medication Errors: Body of Drug Knowledge The below visual depicts and summarizes the aforementioned concepts and notions in this War Against Medication Errors11. 12 Figure 4: Error Free Medication Eco-system However, what is critically lacking today, is a comprehensive, up-to-date drug knowledgebase that is quintessential and core of the whole solution for tackling this challenge that embodies the ever increasing and changing knowledge and characteristics of the tens of thousands drug molecules13 for it is increasingly becoming humanly impossible to remember the ever growing brands, generics and their innumerable number of characteristics that play pivotal role in this war against medication errors14 by the healthcare eco-system players. Nonetheless, reducing medication errors is not a mere onetime activity but an ongoing process of quality improvement in the care settings. 11 © Copyrighted phrase. 12 © Copyrighted phrase and conceptual model. 13 It is estimated that there are around 50,000 generic brands and 6,000 generics prevalent in India alone today. These numbers are expected to significantly go up in next 5 years as more generics get added that come out of patent regime. 14 © Copyrighted phrase. White Paper © All rights reserved. 2010
  • 13. War Against Medication Errors: Body of Drug Knowledge HIPaR: Body of Drug Knowledge (BoDK) HIPaR BoDK is the Embodiment of Comprehensive Drug Knowledge from HealthNet Global offering complete drug related information such as drug - drug interactions, drug-lab modifications, and drug-food interactions, drug-disease interactions, generic search, brand search, combination drug search, alternate brands for a given brand/generic, adverse reactions, indications, contra-indications, drug dosages, route of administration, precautions and warnings, banned drugs, ATC15, retail pricing and packaging information, manufacturers details etc. HIPaR BoDK complies with international disease coding standards like ICD-10/9, HL-7, EphMRA16, WHO indications standard etc. that make it easy to integrate with other clinical/hospital management software, pharmaceutical software or any healthcare software. It can also be shared across networks in hospitals, organizations and academic institutions etc. HIPaR BoDK platform is designed keeping with the objective of helping the healthcare fraternity in creating an integrated error-free medication eco-system automating various pharmacy and pharmacological processes, 7 rights frameworks on top of a contemporary Body of Drug Knowledge. HIPaR BoDK Salient Features  Generic search, brand search, combination drug search, alternate brands for a given brand/generic  Indications, contra indications, drug-drug interactions, drug-Lab modifications, drug- food/alcohol interactions  Adverse reactions, precautions and warnings, dosages  Pharmacokinetics, Anatomic Therapeutic and Chemical Classification System - ATC  Mechanism of Action of the drug  Manufacturer search, retail price, packaging details  Information on dose form, route of administration, Strength  Disease classifications, ICD-10 coding  Banned drugs, bar codes, essential drug list, storage conditions etc.  Therapeutic duplication and equivalent  Patient counseling messages  Drug content administration, period updates (role-based user management for security and content quality)  A platform approach that helps the healthcare fraternity in flexibly adapting, integrating for achieving their objectives HIPaR BoDK Data Constructs 15 Anatomic Therapeutic and Chemical Classification System 16 European Pharmaceutical Market Research Association White Paper © All rights reserved. 2010
  • 14. War Against Medication Errors: Body of Drug Knowledge Figure 5: HIPaR BoDK - Generics Data Figure 6: HIPaR BoDK - Brands Data White Paper © All rights reserved. 2010
  • 15. War Against Medication Errors: Body of Drug Knowledge Figure 7: HIPaR BoDK - Drug Manufacturer Data Figure 8: HIPaR BoDK Open Data Model HIPaR BoDK Offerings White Paper © All rights reserved. 2010
  • 16. War Against Medication Errors: Body of Drug Knowledge HIS Integrated HIPaR HIPaR HIPaR Doctor Mobile HIPaR HIPaR Web App SaaS API Mobile Phones Thick client HIS/HMS Custom Built Web Service – J2ME Installs and Thin and thick Drug Supply Integration SOAP Support runs on a PC clients Chain with Portals ePrescription Figure 9: HIPaR BoDK Offerings Evolution of HIPaR The product embodies the expertise and experience of almost 10 years of evolution of its content and application logic from the group company of Apollo Hospitals founders. The content quantity of HIPaR BoDK as of early 2010 is as below. Parameter Quantity Brands 15000 Generics 4065 Indications 1477 Contra-indications 1229 Adverse reactions 1182 Drug-Drug 669 Dosage Information 1098 Precautions and Warnings 1312 MoA 827 Manufacturers 935 The following set of next gen capabilities are the key drivers for the evolution of HIPaR BoDK  Multi-tiered content aggregation, editing, update and administration process enabling logical separation of content activities - editing, review, approve, reject etc.  Constitution of two-tiered clinical governance board - pharmacology and clinical practice – that enables the authenticity, sanctity and control over the content quantity that impacts lives  Updating and releasing the clinical content periodically  Enhancing the characteristics of drugs in the drug knowledgebase – special conditions and dosages, drug-disease, therapeutic duplication information, drug dosages for special conditions like renal failures etc. White Paper © All rights reserved. 2010
  • 17. War Against Medication Errors: Body of Drug Knowledge  Patient counseling messages - drug information to the patient in his language – is lacking Holistic Clinical Governance One of the critical points for an acceptable and credible body of drug knowledge is a clinically governed and enterprise class content administration system. The HIPaR BoDK content administration is clinically governed as below:  Clinical governance of the HIPaR BoDK healthcare content by instituting the following councils:  Clinical Pharmacologists Council – council of prominent clinical pharmacologists drawn across Apollo group  Clinical Advisory Council – council of prominent clinical practitioners/medical services directors drawn across Apollo group  Executive Governance Council – council/board comprising of technology, clinical experts and executives that drive the direction of HIPaR BoDK  An enterprise class Next Generation Content Administration system  Multiple content sources aggregation  Multi-tiered  Distinct roles with role-based user management  Auditable and traceable content editing, update, rejection/approval and database administration  A content administration team comprising of bachelor and master pharmacists lead by a clinical pharmacologist This section focuses on the clinical governance and the next section on the Next Generation Content Administration system. The below picture summarizes the concepts visually for the holistic clinical governance addressing the hitherto identified content sources. White Paper © All rights reserved. 2010
  • 18. War Against Medication Errors: Body of Drug Knowledge Next Gen Content Administration System The core to the design of the Content Administration System is the fundamental concept of multi-tiered, role-based, and clinically governed Content Update Process that we’ve uniquely developed for this purpose considering the need to ensure the sanctity of the data that impacts the lives of the human beings and the focus on the India specific content. The following picture depicts the multi-tiered content update process that incorporates the Holistic Clinical Governance addressed in the previous section. White Paper © All rights reserved. 2010
  • 19. War Against Medication Errors: Body of Drug Knowledge Figure 10: Next Generation Clinical Content Administration Platform We at HealthNet Global have analysed, understood, recognized and built a tiered, role-based, auditable enterprise class content management system as an integral part of Next Generation HIPaR BoDK platform and have instituted content development team (pharmacists, clinical pharmacologists etc.) and experienced software development team which have developed and deployed an enterprise class Content Administration System for HIPaR BoDK where a special team of pharmacists (B.Pharms and M.Pharms) lead by a senior clinical pharmacologist are editing and updating the content aggregating the clinical content from various popular and credible sources to it one of the world’s leading BoDK for India and beyond. The BoDK Content Administrator offers drug content sources aggregation, content entry, content review, content approval, audit information, content publishing using Internet leveraging cloud technologies, role-based secured user management and database administration etc. enabling a robust anytime and anywhere secured system. Some of the screen captures of BoDK Content Administrator are shown below. White Paper © All rights reserved. 2010
  • 20. War Against Medication Errors: Body of Drug Knowledge Figure 11: HIPaR BoDK Content Administrator Role-based Login Figure 12: HIPaR BoDK Content Administrator Auto Suggest of Brands, Generics etc. White Paper © All rights reserved. 2010
  • 21. War Against Medication Errors: Body of Drug Knowledge Figure 13: Content Administrator - Generic edit Screen Figure 14: Content Approver Login White Paper © All rights reserved. 2010
  • 22. War Against Medication Errors: Body of Drug Knowledge Figure 15: Content Administrator - Approver Screen Content Sources The following are the content sources used hitherto for cleansing and updating the existing content:  Pharmaceutical Manufacturer Product Monographs  Indian Pharmacopoeia Version 2010  Wolters Kluwer’s Drugs in Pregnancy & Lactation Version  Central Drugs Standard Control Organization website  http://cdsco.nic.in/  Australian Registry of Therapeutic Goods and Medicines - https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/PICMI?OpenForm&t=PI &k=0&r=/  Health Canada website  http://webprod.hc-sc.gc.ca/dpd-bdpp/start-debuter.do?lang=eng  New Zealand Medicines and Medical Devices Safety Authority Website  http://www.medsafe.govt.nz/  US FDA website  http://www.fda.gov/ Global Benchmarking We’ve benchmarked HIPaR BoDK platform clinical fields/capabilities and content with some of the national and international products used for the similar purposes and summarized below. The benchmarking focus was more on the clinical fields/capabilities as the clear data on the quantity of the content of these products is hardly available. Clearly HIPaR BoDK stands out and on top with its longer list of supported capabilities. White Paper © All rights reserved. 2010
  • 23. War Against Medication Errors: Body of Drug Knowledge Figure 16: HIPaR BoDK Global Benchmarking Certification Acceptability and credibility of the content is critical to the core of HIPaR BoDK given its impact on human lives. This typically, comes with accreditation/certification by renowned institutions and organizations globally that are independent and have acclaimed expertise in the relevant subject matter. In our research, we are yet to find such a straight body that certifies drug knowledge or drug database. We are in the process of identifying and pursuing the certification with organizations that have relevance to pharmacy and pharmacology. Vision Transform HIPaR into next generation ubiquitous body of drug knowledge platform that plays a pivotal and core role in the prevention of medication errors, integrated medicine management throughout the medication pathway empowering healthcare fraternity with a White Paper © All rights reserved. 2010
  • 24. War Against Medication Errors: Body of Drug Knowledge comprehensive, ever up-to-date, seamless, credible body of drug knowledge at a touch of a button that endeavors to create an error-free medication eco-system HIPaR BoDK Applications Generic based Drug Inventory control using HIPaR BoDK helps Efficient Drug Inventory Management achieve efficient control on stock refills. HIPaR BoDK helps the Pharmacist conduct a prescription audit Prescription Audit providing indications for the prescribed drugs in Hospital HIPaR BoDK can be used as education and drug awareness by the Drug Education for Patients patients HIPaR BoDK helps drug regulators to avoid Look Alike, Spell Alike Efficient Drug Licensing and Sound Alike drugs while licensing HIPaR BoDK enables nurses for educating the Patients on Drugs Drug Education for Nurses and monitoring Patients on drug therapy HIPaR BoDK helps students with a comprehensive drug Drug Education for Medical Students knowledge base HIPaR BoDK enables Pharmacist and Doctors find a Brand Brand Equivalent Equivalent of a Drug HIPaR BoDK helps patients conveniently identify a Drug for Convenient drug identification by patients consumption based on the Color/Image? HIPaR BoDK enables healthcare providers especially public health Generic Based Prescription care providers in implementing a generic based prescribing in place of brand based prescribing HIPaR BoDK enables Insurance Providers to Validate the Claims Validation Insurance Claims related to Drugs - Age, Gender, and Disease HIPaR BoDK enables doctors to adjust drug dosage for patients Drug Dosage adjustments for Renal Failure with renal failure. HIPaR BoDK enables doctors to adjust drug dosage for patients Drug Dosage adjustments for Hepatic Failure with hepatic failure. HIPaR BoDK can alert the doctors about the contraindications of Contra Indications the drug they are prescribing enhancing the Patient Safety HIPaR BoDK enables Health Care Providers in preventing dosage Dosage Error Prevention errors Prevention of Drug Errors in Pregnancy HIPaR BoDK enables Health Care Providers/Doctors in preventing /Lactating Women Drug Errors for Pregnancy/Lactating Women HIPaR BoDK enables dietitians in creating a customized dietary Customized Dietary Plan for Chronic Patients plan for Patients on Pharmacotherapy in case of chronic conditions HIPaR BoDK enables doctors in preventing therapeutic Prevention of Therapeutic Duplication duplication of the drugs HIPaR BoDK enables health care providers in institutionalizing Institutionalized Body of Drug Knowledge drug knowledge across the organization sans boundaries HIPaR BoDK enables healthcare providers, pharmaceutical Find Manufacturer of a brand companies, regulators to find manufacturers for a given generic/brand White Paper © All rights reserved. 2010
  • 25. War Against Medication Errors: Body of Drug Knowledge HIPaR BoDK can act as a reference tool for financial decisions by Price reference for Drug Purchases healthcare providers, pharmacies, insurance providers and patients HIPaR BoDK enables doctors, pharmacists, pharmacologists for identifying drug - drug interactions and taking necessary actions Drug-drug interactions for enhanced patient safety. Helps medical students, pharmacists in learning. HIPaR BoDK enables biochemists, micro biologists and doctors in Drug-lab interactions right interpretation of lab results avoiding unnecessary or wrong treatment. HIPaR BoDK enables dietitians and doctors plan a customized Drug-food interactions dietary for a patient for the better management of a disease avoiding treatment failure and adverse effect. HIPaR BoDK enables anesthetists to plan anesthesia for patient Drug-anesthesia interactions on drug therapy avoiding mishaps during the anesthesia. HIPaR BoDK enables doctors to warn the patients regarding the Drug-Alcohol interactions alcohol consumption for mishaps while patient is on drug therapy. HIPaR BoDK enables doctors in assessing the risk benefit ratio to Precautions, warnings prescribe drugs to special category cases(Pregnancy, Lactation, Pediatric and Geriatric etc..) HIPaR BoDK enables researchers and medical students in Pharmacokinetics analyzing and understanding Pharmacokinetic profile of drugs. HIPaR BoDK enables researchers for doing drug utilization studies ATC information and DDD and better inventory planning control HIPaR BoDK enables medical students in learning about the Pharmacological category and sub-category pharmacological classification system and helps the pharmacist information in identifying therauptic substitutes. HIPaR BoDK enables Hospital nursing staff in proper Nursing considerations reconstitution, storage, administration and monitoring the patient on drug therapy. HIPaR BoDK provides unique opportunity in India for regulatory agencies, Manufacturers, Insurance providers, health care HIPaR Unique Article Code providers etc. To uniquely and unambiguously address the health care item across the systems. HIPaR BoDK provides the ICD10 Disease code information for any ICD-10 Information given disease and vice versa. HIPaR BoDK enables medical students and doctors in learning Drug Search by Disease drug therapy for various diseases. HIPaR BoDK enables doctors and patients in knowing and tackling Drug Side Effects the side effects while drug therapy. HIPaR BoDK enables patients and pharmacists to identify OTC information of a drug whether a drug is OTC drug or not. HIPaR BoDK enables doctors and pharmacists to identify the Generic Synonyms global generic synonym. HIPaR BoDK enables doctors, regulators, pharmacists, nurses and Look Alike, Sound Alike and Spell Alike Drugs patients in preventing the medical errors and enhancing patient Information safety. White Paper © All rights reserved. 2010
  • 26. War Against Medication Errors: Body of Drug Knowledge Drug Packaging - bulk packaging and HIPaR BoDK enables pharmacy and health care providers in retail/selling packaging information maintaining the better inventory management. HIPaR BoDK Platform helps the healthcare providers and regulators in automating the process and deploying the system Integrated Pharmaco-vigilance online for seamless easy-to-use access for pharmaco-vigilance in reporting and verifying the adverse effects along with periodic reports Epilogue As per a latest article in a medical journal17 (2008), the medical errors kill anywhere between 48,000 – 80,000 Americans annually and the article claims majority part is due to Medication Errors. Imagine saving a fraction percentage of these lives by creating an error-free medication eco-system which can still run into saving tens of lives annually which is more than the meaning for our endeavor of War Against Medication Errors and we firmly of the view that this transformation should pick up the momentum now and should not stop at saving mere tens of lives. We humbly appeal to the healthcare fraternity through this white paper to come forward for a collaborative endeavor, join hands with us for an inclusive effort to wage and win the War Against Medication Errors18. Together, let us march forward and work towards ushering in an Error-free Medication Eco- system19 leveraging the comprehensive Body of Drug Knowledge, first in the IP care setting and then beyond IP care setting in the journey of Touching Lives. About Author Venkateswar Reddy Melachervu Venkat is a well-rounded professional with technology expertise, business acumen and proven timely results in conceiving profitable ideas and transforming these profitable ideas into products and solutions across multiple domains leveraging cutting-edge technologies ushering positive impacts to the top lines and bottom lines – start-ups or grown-ups, locally or globally. Venkat is the member of the founding team of HealthNet Global and currently associate vice president and head of technology and solutions. In this role, he heads technology and solutions and is responsible for company’s solutions, services, technology strategy, roadmap and concept selling to - enterprises, governments, partners and investors. Venkat earned bachelor's degree in electronics and communications engineering with distinction where he was first exposed to the nature and significance of electronics, 17 Source : Clinical Review: Medication Errors in Critical Care: Critical Care 2008 18 © Copyrighted phrase. 19 © Copyrighted phrase. White Paper © All rights reserved. 2010
  • 27. War Against Medication Errors: Body of Drug Knowledge telecommunications and information technology convergence and the power there-of, while developing hardware, software and firmware for his final year project Digital Filters Utilizing Microprocessors on Intel 8085. This work has significantly influenced his professional journey he has embarked there on. He believes in technology in isolation has no meaning neither to business nor to humans unless seen in a problem solving or value creation context, dares to dream, cares to win and works towards transforming the lives through technology. More details can be found about him on Linkedin. ------------------------------------------------ End of White Paper---------------------------------------------------- White Paper © All rights reserved. 2010