Challenges of interoperability with medications management

St Vincent's Hospital in Sydney's Darlinghurst is further down the track than most in terms of using electronic medications management (EMM), having first piloted the MedChart system way back in 2005.

The system was implemented in all wards of the hospital by 2010 and then in emergency in 2011, and is now being used for medicines reconciliation at both admission and discharge, with a current medicines list accompanying the patient throughout their journey.

The EMM is interfaced with the hospital's electronic medical record to enable a complete list of discharge medicines to be added to the discharge summary, which is then sent up to the PCEHR and out to local GPs.

This has been working quite well for the hospital for a couple of years, but St Vincent's is working on making the system interoperable with its pharmacy dispensing system, automatic dispensing machines and smart IV infusion pumps. It is also considering how to go about sending data – and what sort of data – to the National Prescription and Dispense Repository.

For Kate Richardson, the pharmacist in charge of eMedicines management at St Vincent's, the ultimate will be the day when it is possible to directly import medicines information out of the PCEHR or GP systems straight into MedChart, particularly for the medicines on admission list.

However, as Ms Richardson told the eHealth Interoperability Conference in Sydney recently, a lot of work needs to be done to achieve true interoperability between the different clinical systems used in hospitals, as well as the challenges being faced in mapping the Australian Medicines Terminology (AMT) to SNOMED CT-AU.

“My nirvana is that I’m actually going to be able to magically import the medicines out of these documents into my meds management system, specifically into my meds on admissions list,” Ms Richardson said. “I want to create a list of medicines that I know that patient is currently taking and then possibly record things that they took in the past.

“[For] allergies and adverse reactions, they are going to magically likewise be imported into your clinical information system of preference. We’re going to need both AMT and SNOMED CT terminologies to support the identification of medicines and adverse reactions, but also there is a lot more coding and atomisation of data across both primary and acute care to actually enable true interoperability.

“We are going to have to do a lot more work on to have get this interoperability happening.”

Ms Richardson said St Vincent's uses its medicines on admission list to reconcile medications throughout patient transfer and the patient journey, with all wards and ICU using the same system so clinicians don't have to re-enter information.

MedChart is used for all of St Vincent's prescribing, administration, pharmacy reviews and reconciliation throughout the whole patient journey, and at discharge the hospital can create a complete list of discharge medicines in the EMM.

“We import those directly into the electronic discharge summary and then we shoot them up to the PCEHR and send them point to point to our GPs,” she said.

What Ms Richardson wants to see is three-fold: complete, accurate and safe on-screen display of medicines information; the clear articulation of the method of administration; and systems that fit medical and nursing workflows while also enabling sophisticated use of clinical decision support.

To get there, however, will require a lot more work. St Vincent's is using the AMT to overcome the most obvious difference between primary and acute care prescribing practices – GPs prescribe by brand while hospitals use generic terms – but the AMT is still very much a work in progress.

Dose strengths and instructions are also described very differently, and routes of administration are much more complex in the hospital setting.

“The other thing we do is take three medicines or three prescriptions and we blend them into one,” she said. “So this is where a GP prescribes a 10mg, a 25 and a 50mg capsule, because we take one of each twice a day for an 85mg dose.

“But in hospital we just have one order on the chart. Doctors hate having to edit every time a dose changes, having to cease the 25 mg, change the 10 to a 20mg because your dose has changed to 70, then after three days your therapeutic drug monitoring comes back and you’ve got the change your dose again.

“They want one order on the chart, it needs to describe everything about that drug order satisfactorily, and the nurses only want one order to administer off. They’ve got to do co-signs, they’ve got to get double checks. They don’t want to have to get three signatures for the three different products every time they sign off.”

St Vincent's has overcome some of the problems by writing its own clinical decision support and is also working with the AMT team at NEHTA to add more information to the descriptors for generic drugs.

It has also created its own synonyms for certain descriptors so that how things are described in the prescribing system links to the AMT and to the NSW Hospital Product Pharmacy List for the dispensing label so all terms marry together.

When it comes to discharge, however, the terminologies used within the hospital cannot yet be turned back into the original GP product concepts, she said.

“At discharge, we have a complete list of medicines and we’ve got a whole lot of processes to make sure everything is reconciled and all the things that are withheld with admission are put back on the discharge list.

“We then send it off to a discharge summary and we’ve got no transcription errors here as it's a simple click and send process.

“But at this stage we’re not asking the doctors or the pharmacists to retype all of these back into those original GP product concepts. So I have been looking for help from the clever programmers to be able to do this. I’m not going to ask my doctors to go and spend more time, particularly when they are dealing with 20-plus medicines at discharge, to go and retype them all out in the beautiful format that will be in the primary care AMT concepts.

“Others may choose to do that, but I think I need the eHealth community to give me a really good business case to prove the value-add to my doctors about this before we go forward.”

Despite these hurdles, St Vincent's has been successful in sending out vastly improved medication information, she said. Independent research shows that 93 per cent of orders are complete in the electronic discharge summary.

“They are not in beautiful AMT-CDA discharge summary acceptable terms, but they are going out and they are legible.”

Similar problems are obvious with allergies and adverse reactions. Documenting allergies at admission is tricky, Ms Richardson said, as hospitals are often relying on anecdotal evidence from the patient.

“You’re going to have patients that present to hospital and they’ve written down '? penicillin' [as an allergy]. Is that all the penicillins? Did they self-diagnose? How do I code a question mark? And an allergy is a specific type of immune response so this term shouldn’t be used.”

Ms Richardson is an advocate for a change to the terminologies used for allergies and adverse reactions, believing it is far more useful to talk about intolerances, sensitivities, hypersensitivities, side effects and severity.

When it comes to interoperability, however, this has wider problems. Drug sensitivities are one thing, but there are also food intolerances that have to be mapped within the CBORD dietetics system, sensitivities to agents such as dyes used in radiology, and other categories such as allergies to latex, bee stings and cat dander.

This all then needs to be mapped to how agents are described in SNOMED CT, which is not fit for use with medicines, she said.

The key consideration for allergies and adverse reactions is what should be the source of truth, she said. “It definitely has got to be where your clinical decision support lies.

“In GP and retail pharmacy land is quite easy for them, because they’ve just got one system. They’ve got their practice software system, but in hospitals we’ve got heaps of different systems. So where is your source of truth? We haven’t quite solved it.

“We actually can’t enter a drug allergy in our EMR. You get plonked over to the EMM and it writes back straight away, so we’ve got a record in both. One day it will be beautiful because we’ll have SNOMED and they will talk to one another, but I think that’s what we’ve got to do in the interim.”

Even mapping terms such as plasters is difficult. Plasters is a generic term and appears in SNOMED, but most systems will list them under brand names such as Band-Aids, Micropore or Elastoplast.

“When is Brazil nut just a nut? Well, luckily in SNOMED it can be both, but in the EMR system it needs to just be nut, because when it gets down to CBORD and dietetics, it just needs to be nuts.

“There is no standardised class structure anywhere. Every reference text, every knowledge base will have their own. They have all developed their own and they’re all very good, but they are not all the same.”

While these challenges are extraordinarily complex, there is light at the end of the tunnel, she said. “I’m not going back to paper and we’ve got work to do, but I think it is a very exciting space to work in over the next few years.”

Posted in Australian eHealth

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