Multi-site decision support tool for bugs and drugs

An antimicrobial stewardship software program known as eASY that was designed by clinicians from the Northern Sydney Local Health District (NSLHD) has undergone an update recently, with new functionality added that provides decision support on drug dosing and multi-site levels of restriction.

eASY has been in use at the Mona Vale and Manly hospitals in northern Sydney since March 2011, offering guidance to prescribing doctors on what antibiotics to use, quick communication between prescribers, pharmacists and infectious disease specialists, and real-time notifications of approval or refusal by reviewers.

eASY was developed by a team led by the director of pharmacy at Manly and Mona Vale hospitals, Noman Masood, and the director of operations at NSLHD, Andrew Montague, in association with vendor partner Healthcare Software (HCS) of Hobart.

Since its release, eASY has been implemented in hospitals throughout the district, including Mona Vale, Manly, Royal North Shore, Ryde and Hornsby, and discussions are underway to provide a free licence to use the product in any public hospital in NSW.

An updated version of the program was released earlier this year that features new functionality, including a tool that helps clinicians decide on the right dose of antibiotics by accessing the hospital's electronic medical record and calculating doses based on parameters such as kidney or liver function. The dose can then be individualised so drugs are administered at the right time and at the right dose for that particular patient.

Multi-site functionality has also been added so smaller hospitals that might not have an infectious diseases specialist on staff can add extra layers of restrictions to the prescribing of antibiotics. There are also plans to provide bacteria-based decision support to allow doctors to check the prevalence of antimicrobial resistance in different regions based on what type of bacteria it is.

Mr Masood said one of the biggest issues facing antimicrobial stewardship is the fact that medication management in hospitals has become far too complicated for one set of doctors to manage.

Most have now implemented a multidisciplinary approach to medication prescribing and have introduced a restricted process to accessing high-end antibiotics that are used for critical infections such as MRSA and VRE, he said.

However, paper-based systems don't really cut it anymore as they are prone to breakdown and have multiple risks with respect to monitoring of utilisation, Mr Masood said.

“The other obvious issue is that hospitals are frantic environments where discussions often happen in corridors or over the phone and quite often everybody who needs to know about those conversations don't know about those conversations.

“There is also a communication issue for the smaller or rural hospitals that sometimes rely on specialists that may not be on site. Those sort of communication barriers are quite a bit of a challenge.”

eASY was developed by Mr Masood and Dr Montague, who was at the time director of medical services at Mona Vale and Manly. They initially looked at two existing electronic systems – one used at John Hunter in Newcastle and the other at Royal Melbourne – but they decided for various reasons to build their own.

eASY is described as being what it says on the tin – easy to use and intuitive. Prescribing doctors are able to log in and retrieve the patient's information from the EMR. Based on the patient's details and the indication that the doctor has selected for the antibiotic, the system will highlight to the doctor the guidelines and recommendations for that indication.

Doctors have the option of going by the guideline-based therapy or overriding it, but as soon as they submit a request, the infectious diseases clinician and an antimicrobial stewardship (AMS) pharmacist are notified.

“The pharmacists, in the majority of cases, are the first ones to enter into the system,” Mr Masood said. “They look at that request and they can provide the information to the prescriber on whether the dose is right or not, whether this is the right antibiotic for the indication or not, and they can highlight to the infectious diseases clinician if there are any concerns.

“Then the infectious diseases clinician, hopefully within a few hours, will look at that request as well and then they can say they approve it or decline it and suggest a different therapy. If they have declined it, they'll have to give a reason, and when they give that reason it automatically goes back to the doctor explaining it.”

In the updated version, the developers have taken the clinical guidance module to a higher level by adding functionality for drug dosing.

“Drug dosing, especially with antibiotics, becomes very important because not only do you need to give the antibiotics at the right time but also at the right dose,” Mr Masood said. “Hospitals see a lot of elderly patients who have impaired kidney or liver function. What our system is designed to do now is it will draw data from the EMR and calculate their kidney function and recommend antibiotic dosage according to that.

“That basically means decision support. In the past we were saying which antibiotic to use but not how much to use. We can get the antibiotic dosing to the best possible level.”

The team has also built in multi-site functionality, allowing smaller hospitals that may require broader restrictions as they do not have easy access to infectious disease expertise on site to add separate sets of approval restrictions.

“We have built in that level of selectivity as well so that we can cater to organisational requirements.”

As Mr Masood puts it, there are hundreds of other functions that can be added to the system, but time and cost are the hurdles. The development team also believes that clinical decision support is the most valuable function, which is why they have concentrated on that.

They have left it up to the different hospitals to decide whether to provide access through smartphones or tablets – it is optimised for iPad and iPhone – but data security can be a challenge for some hospitals with a system that integrates remotely with the hospital's main servers.

“We are looking at those options, but the most important thing is the support system, so we are building an app so doctors can check what antibiotic to use and how much to use and to do that calculation without having to add the data,” Mr Masood said.

“That's something we have in our wish list but obviously there is a cost implication. Also, what we're looking at is to provide bacteria-based support as well so that when a doctor selects the bacteria, the system will tell them, based on the patient's location, what resistance factors there are for that area.

“There are hundreds of functionalities that we could add but it's the high level decision support that is the most important.”

Mr Masood said NSW Health now had a memorandum of understanding with NSLHD to allow other local health districts across NSW to assess the product if they so desire.

“We are marketing it on the basis of it not necessarily being a commercial product but more a patient safety product,” he said. “We are offering it to local health districts without any licensing fees as the idea is to make it available to hospitals so they can invest not in software but rather invest in people.”

Posted in Australian eHealth

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