Pharmacy Technology

The pharmacy news section of the MPA Web site is designed to provide members with immediate access to timely and relevant information about pharmacy and our Association. In this section, you will find information on MPA activities, Association members, the latest issues impacting the pharmacy profession and press releases from MPA and its affiliates.

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Pharmacy Technology

Improving Clinical Decision Support during BCMA and Preventing Workarounds
By Cherie Woodhams, R.Ph., IT lead analyst, Bronson Healthcare Group, Kalamazoo

The Leapfrog Group is a national nonprofit organization trying to improve the quality and safety of healthcare in the United States. The group collects and reports hospital performance through a survey hospitals complete. The survey asks questions related to computerized physician order entry systems (CPOE), surgery, maternity care, intensive care unit (ICU) physician staffing, safe practices, patient safety errors, medication safety and pediatric care.

Two of these measurements where organizations are falling short is to complete barcode medication administration (BCMA) and have processes and structures in place to prevent workarounds.1

The standard is for organizations to:

  • Implement a BCMA system in 100 percent of the hospital’s adult and pediatric medical and/or surgical units, obstetric units and medical intensive care units (adult, pediatric and neonatal).
  • Scan both the patient barcode (usually a wristband with barcode) and the medication bar codes 95 percent of the time during bedside medication administrations in the above listed units.
  • Use a BCMA system that includes the seven best practice clinical decision support (CDS) elements listed below:
    • Vital sign check.
    • Patient specific allergy check during BCMA.
    • Second nurse check when needed.
    • Wrong time (early/later warnings).
    • Wrong dose.
    • Wrong patient.
    • Wrong medication.
  • Implement all five best practice processes and structures to prevent workarounds of the BCMA system including:
    • A formal committee to oversee BCMA use.
    • Backup systems for hardware failures.
    • A help desk to respond to BCMA issues in real-time.
    • Conducting real-time observations of staff using the BCMA system.
    • Engaging with nursing leadership on BCMA usage.

Of the seven CDS elements for BCMA, the majority of hospitals are missing a built in vital sign check during BCMA. There are also deficiencies in monitoring and preventing workarounds.

Ideas on how to improve meeting the CDS standard include, but are not limited to:

  • Create required documentation of vital sign checks during medication administration of a list of medications approved by each facility if the vital signs have not been documented within so many hours from administration.
  • Display vital signs in the electronic medication administration workflow for easy access during medication administration.

Due to deficits in discouraging workarounds of the BCMA process, the Leapfrog Group will be implementing additional criteria for the next survey cycle with a meets standard of meeting six out of the eight criteria.2 These additional criteria include:

  • In the past 12 months, used the data and information to implement quality improvement projects that have focused on improving the hospital’s BCMA performance OR in the past 12 months, used the data and information to monitor a previously implemented quality improvement project focused on improving the hospital’s BCMA performance.
  • In the past 12 months, evaluated the results of the quality improvement projects and validated that these projects have resulted in higher adherence to the hospital’s standard medication administration process OR in the past 12 months, evaluated the results of the quality improvement projects and demonstrated continued adherence to the hospital’s standard medication administration process.
  • Talked to end users about the resolution of any system deficiencies and/or problems that may have contributed to the workarounds.

What is your organization doing to improve these two measurements? Post your response or request access to Michigan Society of Health-System Pharmacists IT List Serve if you don’t already have access at mshp-informatics@googlegroups.com, then post your response.

References

  1. The Leapfrog Group. New Report on Bar Code Medication Administration Finds Virtually All Hospitals Have the Technology, but Lack Requirements to Deploy it Effectively. PR Newswire website. https://www.prnewswire.com/news-releases/new-report-on-bar-code-medication-administration-finds-virtually-all-hospitals-have-the-technology-but-lack-requirements-to-deploy-it-effectively-300628344.html. Published April 12, 2018. Accessed October 29, 2018.
  2. The Leapfrog Group. Planned Updates to the Leapfrog Hospital Safety Grade Methodology: Request for Public Comment. Hospital Safety Grade website. http://www.hospitalsafetygrade.org/media/file/SafetyGrade-Methods-Change_Final.pdf. Accessed October 29, 2018.


Posted in: Pharmacy Technology
In-TEG®-rating Thromboelastography Into Clinical Practice

By Zack LaDuke, Pharm.D., PGY1 pharmacy resident, St. Joseph Mercy Hospital, Ann Arbor

 

First introduced in 1980, thromboelastography (TEG®) is a diagnostic process that analyzes components of a patient's blood and allows clinicians to get a clearer picture of a patient's intrinsic hemostatic activity. Over the years, the technology has evolved into a point-of-care machine that can be used in multiple different clinical situations, including, but not limited to pre-operative, post-operative and trauma patients. On a general level, the different hemostatic components of the blood that the TEG® system analyzes includes: coagulation factors, heparin, cross-linked fibrin and platelets. To go more in depth, a demonstration of the TEG® interpretation result can be seen below (Figure 1). The R-value represents the time it takes for the patient to form the initial clot. A prolonged R-time is indicative of a clotting factor deficiency. The "Clot Strength (Fibrin)" component represents the amplitude of only the cross-linked fibrin clot. The "Clot Strength (Total)" component represents both the strength of the cross-linked fibrin and the aggregated platelets. Intuitively speaking, one would then be able to calculate the platelet component by subtracting the fibrin clot strength from the total clot strength. By analyzing each of these components, the clinician can determine if, and what type of, transfusion or procedure may need to be initiated for their patient.

 

Figure 1. Thromboelastography Interpretation Guide. Reference Ranges: R (4.6-9.1 mins), Fibrin Clot Strength (15-32 mm), Total Clot Strength (52-70 mm).

Several studies have shown that TEG® is an early predictor of coagulopathy. For example, at a level one trauma center that sees approximately 1,000 activations per year, TEG® was able to identify that of the patients with major active bleeding, 45 percent demonstrated hypercoagulability, 16 percent demonstrated hypocoagulability and nine percent had primary hyperfibrinolysis as the major cause of the bleed.1 Furthermore, there have been studies that show use of the TEG system has been associated with decreased resource utilization due to its ability to analyze each patient's hemostatic activity, resulting in targeted therapy. At The Toledo Hospital, usage of the TEG® system led to a 62 percent, 50 percent and 23 percent reduction in fresh frozen plasma (FFP), cryoprecipitate and platelets, respectively, per procedure. There was also a 50 percent reduction in reoperations for bleeding. This resulted in an estimated $250,000 annual savings for the hospital.2

As part of the primary care team, pharmacists have an opportunity to be involved in the interpretation of the TEG® assay and the subsequent treatment choice. Medications are either a cause or a solution to most of these hemostasis instabilities; therefore, it makes sense that a pharmacist would have a hand in the utilization of a TEG® assay. One instance where pharmacists would be valuable is deciding whether or not there is a need for prothrombin complex concentrate (PCC) for reversal of pre-admission use of either warfarin. By analyzing the R time, pharmacists will be able to interpret the affect that the anticoagulant agent may be having on the patient's hemostatic state. If the R-time is prolonged (>9.1 minutes), the patient would be deemed hypocoagulable, indicating that the patient may still have the anticoagulant on board and that administration of PCC would be appropriate. Another instance where a pharmacist would be involved in determining an appropriate course of action would be for the possible reversal of pre-admission antiplatelet use. For example, if the total clot strength is normal, but the fibrin component is larger than the normal reference range, then that would indicate that the patient is deficient in platelets and administration of 1-deamino-8-D-arginine vasopressin (DDVAP) may be appropriate if the patient was on an antiplatelet agent at home. A platelet infusion may be an appropriate intervention as well if the DDAVP proves to be inadequate.

In addition to determining appropriate transfusions for a bleeding patient, pharmacists will be able to assess certain drug therapies that the patient may be taking as an outpatient. By analyzing the clot strength of the platelets that the patient has, the pharmacist can determine if a patient on an antiplatelet agent, such as clopidogrel, is being treated with an appropriate dose. Furthermore, using this same analyzation could prove useful in determining when a patient who was using antiplatelet agents prior to surgery would be an appropriate candidate for operating. Instead of waiting an arbitrary amount of time before operating, the TEG® assay can be used to determine when the patient is back to normal platelet function.

With the implementation of the point-of-care TEG® system at St. Joseph Mercy Hospital Ann Arbor, the hospital is taking another step in the right direction for providing high-quality care for patients. Furthermore, the hospital will likely experience the added benefit of cost savings from utilizing less blood product resources in bleeding patients.

References

1. Johansson, PI. Treatment of massively bleeding patients: introducing real-time monitoring, transfusion packages and thromboelastography (TEG®). ISBT Science Series 2007;2(1):159–167.

2. Shapiro S, Fleming K, Rachwal W, Morant M. Case Study: The TEG® system has helped The Toledo Hospital save approximately $250,000 annually. Haemonetics Corporation website.

Posted in: Pharmacy Technology
CHEST Changes Antithrombotic Recommendations for Management of Venous Thromboembolism

by Karl Renius, Pharm.D., BCPS, staff pharmacist, Crittenton Hospital, MSHP IT Task Force member

Approval of direct oral anticoagulants (DOACs) has shaken up anticoagulation treatment, which has been up until recently predominantly low-molecular weight heparins (LMWH) and vitamin-k antagonist (VKA) therapy. The American College of Chest Physicians has issued a 2016 guideline on the treatment of venous thromboembolism (VTE) disease, in an update from the last edition in 2012. The new guidelines are available in full on the CHEST website.1

While many of the guideline recommendations remain the same, there is a major change in terms of preferred anticoagulants. For VTE in patients without cancer, the CHEST guidelines now recommend dabigatran, rivaroxaban, apixaban or edoxaban over VKA therapy for initial and long-term treatment (grade 2B). The guidelines specifically state that no single DOAC is preferred over the others. If DOACs are not used, the guidelines recommend VKA therapy over LMWH. The guidelines state that the DOACs are as effective as VKA therapy with the benefits of reduced risk of bleeding and increased convenience. Following completion of anticoagulant therapy in patients with unprovoked VTE, the guidelines also recommend initiating aspirin to prevent recurrent VTE in patients without a contraindication to aspirin.1

For cancer-associated thrombosis, LMWH remains the recommended first-line option. The guideline included the recently published CATCH trial (which did not demonstrate a difference in recurrent VTE in patients who received tinzaparin or warfarin for six months) in its analysis of trials that compared LMWH versus VKA in patients with cancer-related thrombosis.2 The relative risk of recurrent VTE with LMWH versus VKA therapy in this patient population is stated as 0.59 (95% CI: 0.44-0.78), still favoring the use of LMWH.

Some additional changes to the guideline include:1

  • In subsegmental pulmonary embolism without deep venous thrombus (DVT) and a low risk for recurrent VTE, clinical surveillance is preferred over anticoagulation
  • A recommendation against inferior vena cava filters for VTE treated with anticoagulants
  • A recommendation against use of compression stockings to prevent post-thrombotic syndrome in patients with DVT

As a side note, there is currently no consensus on an acronym for the new class of anticoagulants. While this article refers to them as DOACs, they have also been called target-specific oral anticoagulants (TSOACs) and novel/new oral anticoagulants (NOACs). The 2016 CHEST guideline for treatment of VTE uses the term NOACs. However, the Institute for Safe Medication Practices recommends against using NOACs as an acronym.3 The recommendation is because NOAC has been interpreted in practice as NoAC, or No AntiCoagulation. To avoid the potential for accidental discontinuation of anticoagulation, use of NOAC to refer to these medications should be discouraged.

DOACs have some major pharmacologic advantages over VKA’s, including predictable pharmacokinetics, rapid onset and elimination, fewer drug interactions, and no requirement for routine monitoring. However, use of these agents is limited by cost and complicated by altered dosing regimens depending on renal function and indication. Though pharmacists may see decreased involvement in routine monitoring of anticoagulation due to the shift to DOACs, there is still plenty of room for pharmacist involvement to ensure quality of care.

References:

1.         Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, et al. Antithrombotic therapy for VTE disease: Chest guideline. Chest [Internet]. 2016 Jan 7 [cited 2016 Jan 8]; Available from: http://dx.doi.org/10.1016/j.chest.2015.11.026

2.         Lee AYY, Kamphuisen PW, Meyer G, Bauersachs R, Janas MS, Jarner MF, et al. Tinzaparin vs Warfarin for Treatment of Acute Venous Thromboembolism in Patients With Active Cancer: A Randomized Clinical Trial. JAMA. 2015 Aug 18;314(7):677–86.

3.            ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations. Institute for Safe Medication Practice; 2015 [cited 2016 Jan 21]. Available from: http://www.ismp.org/tools/errorproneabbreviations.pdf
Posted in: Pharmacy Technology
Join the MSHP IT Committee’s Listserv to Stay Current on Informatics and Technology

by Heather Somand, Pharm.D., BCPS, and Joel West, Pharm.D., MSHP Informatics and Technology Committee

This year, the Michigan Society of Health-System Pharmacists (MSHP) Pharmacy Informatics and Technology Committee worked with MPA staff to develop an online informatics and technology listserv for health care professionals in Michigan. This listserv was our attempt at increasing opportunities for informatics professionals to network with one another, ask questions, learn how others approach problems and benchmark across the state. We encourage any health care professionals engaged in informatics and technology at their institution to strongly consider joining our Google group and participate in the listserv.

The listserv membership is privately shared, so it will not appear if you search Google groups. Rather, you may request to be added to the Google group by any of our MSHP Pharmacy Informatics and Technology Committee members (membership list located at www.MichiganPharmacists.org/mshp/committees/it) or by contacting MPA staff liaison Eric Roath at Eric@MichiganPharmacists.org for access. Although we just kicked off the listserv, we have more than 30 participants already signed up.

As more and more health care professionals join, we hope you will take the opportunity to post questions or ideas. Google groups makes it easy to stay on top of what’s going on in the listserv by providing members the option to have posts sent directly to their e-mail so you don't have to remember to log in to see what’s happening. From sharing operational workflows, to discussing challenges with electronic prescribing of controlled substances, the listserv provides us all with an opportunity to learn how others are practicing.

We hope you will strongly consider joining the Google group and participating in the discussions!

Posted in: Pharmacy Technology
National Experts Seek to Improve Drug Interaction Clinical Decision Support

by Bruce Chaffee, Pharm.D., FASHP, MSHP IT Committee

The advent of the Health Information Technology for Economic and Clinical Health (HITECH) Act, a component of the American Recovery and Reinvestment Act of 2009, spurred the rapid proliferation of electronic health record (EHR) adoption in hospitals. Once EHRs are implemented, hospitals have been incentivized to meet the requirements of a three-phased program which defines the “meaningful use” of health information technology. These phases are designed to improve the safety, quality and efficiency of health care while improving the coordination of care, enhancing population health, reducing health disparities, and better engaging patients and families.

Health care technology implementation is complex and necessitates standardization. Considerable effort is spent by hospitals in determining the proper system configuration to meet their workflows; those which best balance patient safety and clinician efficiency. As with any new technology, process or system, unintended consequences can and do arise. One area where consequences have become acutely tender to prescribers has been alerting within the clinical decision support (CDS) component of computerized prescriber order entry (CPOE) systems. In brief, the collective experience of most prescribers is that excessive alerting occurs leading to alert fatigue, a condition under which prescribers begin to ignore alerts, including those which might prove beneficial.

In response to this challenge, prescribers have tried a number of remedies. Some have asked hospitals to categorically turn off lower severity alerts to reduce the cognitive load imposed by excessive alerting. While this action treats the symptom, it also may result in missed safety warnings and does not address the root cause of the problem, which involves a mixture of pathologies ranging from lower-than-advertised risks, to poorly-timed alerts, to duplicative alerts, among other maladies. Others have formed their own councils to rank or rate the most important drug-drug interactions (DDI), but this process is time consuming, requires ongoing maintenance and may fail to meet standards sufficient for appropriate evidence-based decision making. Finally, some have approached either their EMR or drug database vendor for help, but this typically does not provide additional remedies beyond the ones suggested above. In summary, alerting lacks the required sensitivity and specificity to be effective within the context of clinician workflow.

In 2012, an interdisciplinary council was convened to discuss the problem of alert fatigue and identify potential pathways toward improvement for one aspect of CDS – DDI. The DDI CDS Conference Series, led by Dan Malone, Ph.D., from the University of Arizona, took a three-pronged approach to encapsulating the problems and describing pathways for improvement related to DDI usability, evidence and content. Three groups were formed consisting of 18-24 national and international experts with experience, including one or more of the following domains: clinical practice, academia, health information technology (IT) vendors (EMR and drug database), health care organizations and the Office of the National Coordinator for Health IT. Each participant had significant experience with one or more of the following: DDIs, clinical pharmacology, CDS, informatics, computer interface design and/or establishing health care quality initiatives. These domain groups met regularly, either in-person or via conference call, to define the problems and devise evidence-based and/or consensus-based recommendations for improvement.

The result of this work is represented in two recently released publications and one that has been submitted. Readers are encouraged to obtain and review these in-depth to gain a better appreciation for the work and status of DDI evaluation, content and usability.

  • “Consensus Recommendations for Systematic Evaluation of Drug-drug Interaction Evidence for Clinical Decision Support,” published in Drug Safety in February 2015. The evidence group focused on the following questions:
    • What is the best approach to evaluate DDI evidence?
    • What evidence is required for a DDI to be applicable to an entire class of drugs?
    • How should a structured evaluation process be vetted and validated?

Group discussions centered on defining recommendations for the systematic evaluation of evidence used to document DDIs from the scientific literature, drug product labeling and regulatory documents. 

  • “Recommendations for Selecting Drug-drug Interactions for Clinical Decision Support” has been submitted for publication and should be available to readers soon. The content group addressed four important questions:
    • What process should be used to develop and maintain a standard set of DDIs?
    • What information should be included in a knowledge base of standard DDIs?
    • Can/should a list of contraindicated drug pairs be established?
    • How can DDI alerts be more intelligently filtered?

  • “Recommendations to Improve the Usability of Drug-drug Interaction Clinical Decision Support Alerts,” published online in the Journal of the American Medical Informatics Association in March. The usability group addressed three important questions with respect to DDI:
    • What, how, where and when do we display DDI decision support?
    • Should presentation of DDI decision support vary by clinicians?
    • How should effectiveness of DDI decision support be measured?

Group discussions focused on establishing optimal strategies for presenting DDI clinical decision support alerts to clinicians during patient care activities.

This conference series represents an important, collaborative effort to achieve consensus on best practices surrounding DDI CDS. Clinicians, EHR/EMR vendors and drug database vendors should heed the advice provided in the white paper reports from this series and sources for financial support should be identified to help establish and maintain an expert group tasked with evaluating the content and evidence needed for the appropriate provision of DDI CDS within EHR systems.

References available upon request from MPA office.

Posted in: Pharmacy Technology
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