TAQIH, a tool for tabular data quality assessment and improvement in the context of health data

BACKGROUND AND OBJECTIVES

Data curation is a tedious task but of paramount relevance for data analytics and more specially in the health context where data-driven decisions must be extremely accurate. The ambition of TAQIH is to support non-technical users on 1) the exploratory data analysis (EDA) process of tabular health data, and 2) the assessment and improvement of its quality.

METHODS

A web-based tool has been implemented with a simple yet powerful visual interface. First, it provides interfaces to understand the dataset, to gain the understanding of the content, structure and distribution. Then, it provides data visualization and improvement utilities for the data quality dimensions of completeness, accuracy, redundancy and readability.

RESULTS

It has been applied in two different scenarios. (1) The Northern Ireland General Practitioners (GPs) Prescription Data, an open data set containing drug prescriptions. (2) A glucose monitoring tele health system dataset. Findings on (1) include: Features that had significant amount of missing values (e.g. AMP_NM variable 53.39%); instances that have high percentage of variable values missing (e.g. 0.21% of the instances with > 75% of missing values); highly correlated variables (e.g. Gross and Actual cost almost completely correlated (∼ + 1.0)). Findings on (2) include: Features that had significant amount of missing values (e.g. patient height, weight and body mass index (BMI) (> 70%), date of diagnosis 13%)); highly correlated variables (e.g. height, weight and BMI). Full detail of the testing and insights related to findings are reported.

CONCLUSIONS

TAQIH enables and supports users to carry out EDA on tabular health data and to assess and improve its quality. Having the layout of the application menu arranged sequentially as the conventional EDA pipeline helps following a consistent analysis process. The general description of the dataset and features section is very useful for the first overview of the dataset. The missing value heatmap is also very helpful in visually identifying correlations among missing values. The correlations section has proved to be supportive as a preliminary step before further data analysis pipelines, as well as the outliers section. Finally, the data quality section provides a quantitative value to the dataset improvements.

[Closed-loop medication management: Results of a user survey]

BACKGROUND

New technologies, such as bar-code scanning systems, have played a significant role in enhancing medication processes over recent years. Despite the documented benefits, integration, acceptance, and user opinion continue to play an important role in the successful implementation of such systems. To date no studies have been carried out in Switzerland to assess the attitude or acceptance of nurses towards electronically supported medication systems after implementation. This study was conducted in order to close this gap.

METHODS

Following a four-month test phase of a closed-loop medication system on two mixed medical-surgical units in a tertiary teaching hospital, a cross-sectional online survey was conducted among the participating registered nurses (response rate: 62.5%).

RESULTS

The new system was evaluated positively by the majority (70%) of users. Accordingly, the barcode-assisted medication process was proven to be especially beneficial to users during the 24-hour medication preparation process and during the preparation of infusions. However, user compliance decreased significantly during the administration of bedside medication and the preparation of additional single doses. This was mainly due to a lack of time and inadequate system performance.

CONCLUSION

In the study, 75% of participants reported that they were open to or even enthusiastic about using the new technologies and were supportive of their introduction into the medication process. Overall, the majority rated the new system as beneficial to daily clinical practice, provided the technical performance was high.

Actionable Adherence Monitoring: Technological Methods to Monitor and Support Adherence to Antiretroviral Therapy

PURPOSE OF REVIEW

Current digital technologies are being used for "actionable adherence monitoring"; that is, technologies that can be used to identify episodes of non-adherence to ART in a timely manner such that tailored interventions based on adherence data can be provided when and where they are needed most.

RECENT FINDINGS

Current digital communication technologies used to monitor ART adherence include electronic adherence monitors (EAMs), digital ingestion monitors, cellular phones, and electronic pharmacy refill tracking systems. Currently available real-time adherence monitoring approaches based on cellular technology allow for the delivery of interventions precisely when and where they are needed. Such technology can potentially enable significant efficiency of care delivery and impact on adherence and associated clinical outcomes. Standard digital advances, such as automated reminders in EAM and electronic pharmacy records, may also achieve improvements with relatively lower cost and easier implementation. Future research is needed to improve the functionality of these approaches, with attention paid to system-level issues through implementation science, as well as acceptability and ethical considerations at the individual level.

Improving patient safety and efficiency of medication reconciliation through the development and adoption of a computer-assisted tool with automated electronic integration of population-based community drug data: the RightRx project

Background and Objective

Many countries require hospitals to implement medication reconciliation for accreditation, but the process is resource-intensive, thus adherence is poor. We report on the impact of prepopulating and aligning community and hospital drug lists with data from population-based and hospital-based drug information systems to reduce workload and enhance adoption and use of an e-medication reconciliation application, RightRx.

Methods

The prototype e-medical reconciliation web-based software was developed for a cluster-randomized trial at the McGill University Health Centre. User-centered design and agile development processes were used to develop features intended to enhance adoption, safety, and efficiency. RightRx was implemented in medical and surgical wards, with support and training provided by unit champions and field staff. The time spent per professional using RightRx was measured, as well as the medication reconciliation completion rates in the intervention and control units during the first 20 months of the trial.

Results

Users identified required modifications to the application, including the need for dose-based prescribing, the role of the discharge physician in prescribing community-based medication, and access to the rationale for medication decisions made during hospitalization. In the intervention units, both physicians and pharmacists were involved in discharge reconciliation, for 96.1% and 71.9% of patients, respectively. Medication reconciliation was completed for 80.7% (surgery) to 96.0% (medicine) of patients in the intervention units, and 0.7% (surgery) to 82.7% of patients in the control units. The odds of completing medication reconciliation were 9 times greater in the intervention compared to control units (odds ratio: 9.0, 95% confidence interval, 7.4-10.9, P < .0001) after adjusting for differences in patient characteristics.

Conclusion

High rates of medication reconciliation completion were achieved with automated prepopulation and alignment of community and hospital medication lists.

Preliminary physician and pharmacist survey of the National Health Insurance PharmaCloud system in Taiwan

BACKGROUND

The PharmaCloud system, a cloud-based medication system, was launched by the Taiwan National Health Insurance Administration (NHIA) in 2013 to integrate patients' medication lists among different medical institutions. The aim of the preliminary study was to evaluate satisfaction with this system among physicians and pharmacists at the early stage of system implementation.

METHODS

A questionnaire was developed through a review of the literature and discussion in 6 focus groups to understand the level of satisfaction, attitudes, and intentions of physicians and pharmacists using the PharmaCloud system. It was then administered nationally in Taiwan in July to September 2015. Descriptive statistics and multiple regression were performed to identify variables influencing satisfaction and intention to use the system.

RESULTS

In total, 895 pharmacist and 105 physician questionnaires were valid for analysis. The results showed that satisfaction with system quality warranted improvement. Positive attitudes toward medication reconciliation among physicians and pharmacists, which were significant predictors of the intention to use the system (β= 0.223, p < 0.001). Most physicians and pharmacists agreed that obtaining signed patient consent was needed but preferred that it be conducted by the NHIA rather than by individual medical institutions (4.02 ± 1.19 vs. 3.49 ± 1.40, p < 0.01).

CONCLUSIONS

The preliminary study results indicated a moderate satisfaction toward the PharmaCloud system. Hospital pharmacists had a high satisfaction rate, but neither are physicians and community pharmacists. Continuously improvement on system quality has been performing based on the results of this preliminary survey. Policies and standardization processes, including privacy protection, are still warranted further actions to make the Taiwan PharmaCloud system a convenient platform for medication reconciliation.

A.S.P.E.N. Statement on Parenteral Nutrition Standardization

In response to questions regarding use of standardized parenteral nutrition (PN) formulations, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) developed a Task Force to address some of these issues. A.S.P.E.N. envisions standardized PN as a broader issue rather than simply using a standardized, commercially available PN product. A standardized process for PN must be explored in order to improve patient safety and clinical appropriateness, and to maximize resource efficiency. A standardized process may include use of standardized PN formulations (including standardized, commercial PN products) but also includes aspects of ordering, labeling, screening, compounding, and administration of PN. A safe PN system must exist which minimizes procedural incidents and maximizes the ability to meet individual patient requirements. Using clinicians with nutrition support therapy expertise will contribute to that safe PN system. The purpose of this statement is to present the published literature associated with standardized PN formulations, to provide recommendations, and to identify areas in need of future research.

Process mapping evaluation of medication reconciliation in academic teaching hospitals: a critical step in quality improvement

BACKGROUND

Medication reconciliation (MedRec) has been a mandated or recommended activity in Canada, the USA and the UK for nearly 10 years. Accreditation bodies in North America will soon require MedRec for every admission, transfer and discharge of every patient. Studies of MedRec have revealed unintentional discrepancies in prescriptions but no clear evidence that clinically important outcomes are improved, leading to widely variable practices. Our objective was to apply process mapping methodology to MedRec to clarify current processes and resource usage, identify potential efficiencies and gaps in care, and make recommendations for improvement in the light of current literature evidence of effectiveness.

METHODS

Process engineers observed and recorded all MedRec activities at 3 academic teaching hospitals, from initial emergency department triage to patient discharge, for general internal medicine patients. Process maps were validated with frontline staff, then with the study team, managers and patient safety leads to summarise current problems and discuss solutions.

RESULTS

Across all of the 3 hospitals, 5 general problem themes were identified: lack of use of all available medication sources, duplication of effort creating inefficiency, lack of timeliness of completion of the Best Possible Medication History, lack of standardisation of the MedRec process, and suboptimal communication of MedRec issues between physicians, pharmacists and nurses.

DISCUSSION

MedRec as practised in this environment requires improvements in quality, timeliness, consistency and dissemination. Further research exploring efficient use of resources, in terms of personnel and costs, is required.

Critical Care Pharmacy Services in United States Hospitals

Background:

Critical care pharmacy activities have been described as fundamental, desirable, and optimal, but actual services provided have not been evaluated.

Objective:

To characterize the type and level of pharmacy services provided to intensive care units (ICUs).

Methods:

A 38 question survey was sent in 2 consecutive mailings to all US institutions (N = 3238) with an ICU. Questions were categorized according to clinical, educational, administrative, and scholarly activities, with levels of services stratified as fundamental, desirable, or optimal.

Results:

Completed surveys were received from 382 (11.8%) institutions encompassing 1034 ICUs. Direct clinical pharmacy activities were provided at 62.2% of ICUs. The pharmacists in those programs attended rounds 4.4 ± 1.5 days/wk, mean ± SD, and had a workweek that consisted of patient care (43% of hours worked), drug distribution (26.2%), administration (12.6%), education (10.9%), and scholarly activities (7.3%). Fundamental clinical activities performed during at least 75% of patient ICU days were providing drug information, drug therapy evaluation, drug therapy intervention, and pharmacokinetic monitoring. Conducting inservices (92.8%), a fundamental service, was the only educational activity frequently provided. Most respondents were involved with at least one multidisciplinary committee, and 45.5% conducted scholarly activities. Desirable or optimal activities were not frequently provided across all service categories.

Conclusions:

Clinical pharmacists are directly involved as caregivers in nearly two-thirds of ICUs in the US. Although they provide a range of clinical and administrative services, involvement in educational and scholarly activities is variable. The level of services provided is consistent with the criteria deemed fundamental for improving patient care. Higher-order services are far less likely to be provided.

New transfer of care initiative of electronic referral from hospital to community pharmacy in England: a formative service evaluation

OBJECTIVES

To evaluate an electronic patient referral system from one UK hospital Trust to community pharmacies across the North East of England.

SETTING

Two hospital sites in Newcastle-upon-Tyne and 207 community pharmacies.

PARTICIPANTS

Inpatients who were considered to benefit from on-going support and continuity of care after leaving hospital.

INTERVENTION

Electronic transmission of an information related to patient's medicines to their nominated community pharmacy. Community pharmacists to provide a follow-up consultation tailored to the individual patient needs.

PRIMARY AND SECONDARY OUTCOMES

Number of referrals made to and received by different types of pharmacies; reasons for referrals; accepted/completed and rejected referred rates; reasons for rejections by community pharmacists; time to action referrals; details of the follow-up consultations; readmission rates at 30, 60 and 90 days post referral and number of hospital bed days.

RESULTS

2029 inpatients were referred over a 13-month period (1 July 2014-31 July 2015). Only 31% (n=619) of these patients participated in a follow-up consultation; 47% (n=955) of referrals were rejected by community pharmacies with the most common reason being 'patient was uncontactable' (35%, n=138). Most referrals were accepted/completed within 7 days of receipt and most rejections were made >2 weeks after referral receipt. Most referred patients were over 60 years of age and referred for a Medicines Use Review (MUR) or enrolment for the New Medicines Service (NMS). Those patients who received a community pharmacist follow-up consultation had statistically significant lower rates of readmissions and shorter hospital stays than those patients without a follow-up consultation.

CONCLUSIONS

Hospital pharmacy staff were able to use an information technology (IT) platform to improve the coordination of care for patients transitioning back home from hospital. Community pharmacists were able to contact the majority of patients and results indicate that patients receiving a follow-up consultation may have lower rates of readmission and shorter hospital stays.

Clinical Relevance of Automated Drug Alerts From the Perspective of Medical Providers

The authors used a real-time survey instrument and subsequent focus group among primary care clinicians at a large healthcare system to assess usefulness of automated drug alerts. Of 108 alerts encountered, 0.9% (n = 1) represented critical alerts, and 16% (n = 17) were significant drug interaction alerts. Sixty-one percent (n = 66) involved duplication of a medication or medication class. The rest (n = 24) involved topical medications, inhalers, or vaccines. Of the 84 potentially relevant alerts, providers classified 11% (9/84), or about 1 in 9, as useful. Drug interaction alerts were more often deemed useful than drug duplication alerts (44.4% versus 1.5%, P < .001). Focus group participants generally echoed these results when ranking the relevance of 15 selected alerts, although there was wide variance in ratings for individual alerts. Hence, a "smarter" system that utilizes a set of mandatory alerts while allowing providers to tailor use of other automated warnings may improve clinical relevance of drug alert systems.

Case Study: Identifying Potential Problems at the Human/Technical Interface in Complex Clinical Systems

Many who would like to improve patient safety in health care have advocated for the widespread adoption of computerized physician order entry and electronic medical records. However, unforeseen consequences of this new technology may put patients at greater risk of harm, not less. The authors present a clinical scenario that demonstrates system vulnerabilities in the interface between humans and such technology. Furthermore, the authors suggest that managers could anticipate these vulnerabilities by using techniques such as cause-and-effect analysis or failure mode and effect analysis, both before the installation of electronic medical records and as ongoing surveillance mechanisms. The case study demonstrates that adoption of technology is not a quick fix to the patient safety issue; proactive and ongoing efforts to address the human factors issues raised by the introduction of new technology will be required to prevent patient harm.

An Observational Study of the Impact of a Computerized Physician Order Entry System on the Rate of Medication Errors in an Orthopaedic Surgery Unit

Aim

To assess the impact of the implementation of a Computerized Physician Order Entry (CPOE) associated with a pharmaceutical checking of medication orders on medication errors in the 3 stages of drug management (i.e. prescription, dispensing and administration) in an orthopaedic surgery unit.

Methods

A before-after observational study was conducted in the 66-bed orthopaedic surgery unit of a teaching hospital (700 beds) in Paris France. Direct disguised observation was used to detect errors in prescription, dispensing and administration of drugs, before and after the introduction of computerized prescriptions. Compliance between dispensing and administration on the one hand and the medical prescription on the other hand was studied. The frequencies and types of errors in prescribing, dispensing and administration were investigated.

Results

During the pre and post-CPOE period (two days for each period) 111 and 86 patients were observed, respectively, with corresponding 1,593 and 1,388 prescribed drugs. The use of electronic prescribing led to a significant 92% decrease in prescribing errors (479/1593 prescribed drugs (30.1%) vs 33/1388 (2.4%), p < 0.0001) and to a 17.5% significant decrease in administration errors (209/1222 opportunities (17.1%) vs 200/1413 (14.2%), p < 0.05). No significant difference was found in regards to dispensing errors (430/1219 opportunities (35.3%) vs 449/1407 (31.9%), p = 0.07).

Conclusion

The use of CPOE and a pharmacist checking medication orders in an orthopaedic surgery unit reduced the incidence of medication errors in the prescribing and administration stages. The study results suggest that CPOE is a convenient system for improving the quality and safety of drug management.

Report of the 2013 AMCP Partnership Forum on electronic solutions to medication reconciliation and improving transitions of care

BACKGROUND

The Affordable Care Act (ACA) is driving the evolution of reimbursement from a fee-for-service model to an outcomes-based system. Accountable care organizations (ACOs) are 1 component of this evolution, and 1 of their charges is to reduce hospital readmission rates for key diagnoses such as congestive heart failure (CHF) and other cardiovascular comorbidities. Lack of patient follow-up and adherence are 2 major causes of readmission. Providing strong medication management is 1 of the common factors in successful readmission programs. We discuss here how electronic solutions might strengthen these medication management programs.

OBJECTIVE

To explore the key issues and strategies that affect the use of electronic medication reconciliation processes and to identify the role the Academy of Managed Care Pharmacy (AMCP) can play in spearheading the adoption of electronic solutions.

METHODS

This was a descriptive analysis of the medication reconciliation process and the factors that promote or limit the application of electronic solutions to medication reconciliation and transitions of care processes. AMCP convened a panel of managed care, hospital, community, ACO, and medication therapy management pharmacists; technology vendors; and other health care stakeholders with an expertise or interest in transitions of care.

RESULTS

In the last few years, there has been considerable uptake of electronic solutions to the admission medication reconciliation process, largely due to increasing penetration of vendors using sophisticated medication history tools. The current electronic solutions to the admission medication reconciliation record are remarkably similar in content. Some pilots for electronic solutions to discharge medication reconciliation are emerging.

CONCLUSIONS

The focus group recommended specific programs AMCP can pursue to increase the adoption of electronic solutions for medication reconciliation. One important aspect to address is developing a business case that documents the return on investment (ROI) for electronic solutions. Besides electronic efficiencies, the ROI needs to include hospital readmission penalties, loss of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) incentives, avoidance of duplicative efforts, and payer costs for readmissions. Managed care pharmacy needs to be engaged in assessing its incentives for promoting electronic solutions.

The social act of electronic medication prescribing

Prescribing medication is embedded in social norms and cultures. In modern Western health care professionals and policy makers have attempted to rationalize medicine by addressing cost-effectiveness of diagnostic and therapeutic treatments and the development of guidelines and protocols based on the outcomes of clinical studies. These notions of cost-effectiveness and evidence-based medicine have also been embedded in technology such as electronic prescribing systems. Such constraining systems may clash with the reality of clinical practice, where formal boundaries of responsibility and authorization are often blurred. Such systems may therefore even impede patient care. Medication is seen as the essence of medical practice. Prescribing is a social act. In a hospital medications may be aimed at treating a patient for a specific condition, in primary care the professional often meets the patient with her or his social and cultural notions of a health problem. The author argues that the design and implementation of electronic prescribing systems should address the social and cultural context of prescribing. Especially in primary care, where health problems are often ill defined and evidence-based medicine guidelines do not always work as intended, studies need to take into account the sociotechnical character of electronic prescribing systems.

Supporting drug prescription through autocompletion

Computerized prescription is a central component in modern clinical information systems. It allows scheduling drugs delivery, exams and other types of care. It is thought to be a useful tool for the reduction of medication errors and for the improvement of medication logistics. Whereas the success of the computerized prescription depends on the unambiguous selection of the manipulated concepts, there is a strong variability between the preferred terms of clinicians of different backgrounds. Moreover, users sometimes want to use synonyms or don't know the exact spelling of the term. This makes the search for desired procedure name through large size vocabularies time-consuming for users. In order to facilitate the prescriptions process, we have built a tool that proposes the most likely terms based on the first letters inputted by the user. The tool helps selecting the most appropriate term by ranking the possible results in a clever manner. Experimental evaluation shows promising results and indicates the tool ease the terminology manipulations.

Electronic medication ordering with integrated drug database and clinical decision support system

Medication errors have been identified as one of the most important causes of adverse drug events. Computerized physician order-entry (CPOE) systems, coupled with decision support (Medication allergy checking, drug interactions, and dose calculations), are considered to be appropriate solutions for reducing medication errors and standardizing care. It is quite useful if clinical information system (CIS) supports order sets, which help with standardizing care, preventing omission errors, and expediting the ordering process. Order sets are predefined groups of orders pertinent to one or more specific clinical conditions or diagnoses. The article describes how a clinical information system can be used to support medication process (prescribing, ordering, dispensing, administration and monitoring) and offer participating medical teams real time warnings and key information regarding medications and patient status, thus reducing medication errors. Integrated electronic prescribing support system benefits for total parenteral nutrition (TPN) are discussed at the end.

Comparison of a basic and an advanced pharmacotherapy-related clinical decision support system in a hospital care setting in the Netherlands

OBJECTIVE To compare the clinical relevance of medication alerts in a basic and in an advanced clinical decision support system (CDSS).

DESIGN

A prospective observational study.

MATERIALS AND METHODS

We collected 4023 medication orders in a hospital for independent evaluation in two pharmacotherapy-related decision support systems. Only the more advanced system considered patient characteristics and laboratory test results in its algorithms. Two pharmacists assessed the clinical relevance of the medication alerts produced. The alert was considered relevant if the pharmacist would undertake action (eg, contact the physician or the nurse). The primary analysis concerned the positive predictive value (PPV) for clinically relevant medication alerts in both systems.

RESULTS

The PPV was significantly higher in the advanced system (5.8% vs 17.0%; p<0.05). Significant differences were found in the alert categories: drug-(drug) interaction (9.9% vs 14.8%; p<0.05), drug-age interaction (2.9% vs 73.3%; p<0.05), and dosing guidance (5.6% vs 16.9%; p<0.05). Including laboratory values and other patient characteristics resulted in a significantly higher PPV for the advanced CDSS compared to the basic medication alerts (12.2% vs 23.3%; p<0.05).

CONCLUSION

The advanced CDSS produced a higher proportion of clinically relevant medication alerts, but the number of irrelevant alerts remained high. To improve the PPV of the advanced CDSS, the algorithms should be optimized by identifying additional risk modifiers and more data should be made electronically available to improve the performance of the algorithms. Our study illustrates and corroborates the need for cyclic testing of technical improvements in information technology in circumstances representative of daily clinical practice.

Automated plan-recognition of chemotherapy protocols

Cancer patients are often treated with multiple sequential chemotherapy protocols ranging in complexity from simple to highly complex patterns of multiple repeating drugs. Clinical documentation procedures that focus on details of single drug events, however, make it difficult for providers and systems to efficiently abstract the sequence and nature of treatment protocols. We have developed a data driven method for cancer treatment plan recognition that takes as input pharmacy chemotherapy dispensing records and produces the sequence of identified chemotherapy protocols. Compared to a manually annotated gold standard, our method was 75% accurate and 80% precise for a breast cancer testing set (110 patients, 2,029 drug events), and 54% accurate and 63% precise for a lung cancer testing set (53 patients, 670 drug events). This method for cancer treatment plan recognition may provide clinicians and systems an abstracted view of the patient's treatment history.

Analysis of information flows in interaction networks: implication for drug discovery and pharmacological research

Frequent failures of experimental medicines in clinical trials question current concepts for predicting drug-effects in the human body. Improving the probability for success in drug discovery requires a better understanding of cause-effect relationships at the organism, organ, tissue, cellular, and molecular levels, each having a different degree of complexity. Despite the longstanding realization that clinical and preclinical drug-effect information needs to be integrated for generating more accurate forecasts of drug-effects, a road map for linking these disparate sources of information currently does not exist. This review focuses on a possible approach for obtaining these relationships by analyzing causes and effects on the basis of the topology of network interaction systems that process information at the cellular and organ system levels.

Evaluating health information technology's clinical effects

In 2009 the federal government appropriated $34 billion in stimulus-related funding to promote the "meaningful use" of health information technology among Medicare and Medicaid providers and hospitals. One of the key elements of this technology is the adoption of computerized physician order entry (CPOE) systems for inpatient drug prescribing. The potential for CPOE to improve prescribing patterns and prevent adverse events is large, and as yet, unrealized. Amidst enthusiasm for the benefits of CPOE, providers and policymakers are becoming aware that CPOE could introduce new errors into the system and cannot simply be assumed to "work." This Issue Brief reports on the experience of one hospital system that used its CPOE to reduce the incidence of a serious drug interaction. This rigorous test of a specific CPOE intervention shows that an electronic alert system can be effective in changing prescribing, but may also have unintended consequences for patient safety.

Prescribing history to identify candidates for chronic condition medication adherence promotion

Poor adherence to long-term prescription medication is a frequent problem that undermines pharmacological control of important risk factors such as hypertension. A medication possession ratio (MPR) can be calculated from Practice Management System (PMS) data to provide a convenient indicator of adherence. We investigate how well prior MPR predicts later MPR, taking MPR&lt;80% as indicative of 'non-adherence,' to assess the potential value of MPR calculation on PMS data for targeting adherence promotion activities by general practices. We examine PMS data for two New Zealand metropolitan general practices, one with a predominantly Pacific caseload, across 2008 and 2009. We find prevalence of non-adherence in 2009 to be 51.63% (95% confidence interval [CI] 47.9-55.3) for patients at the Pacific practice and 28.09% (95% CI 25.0-31.1) at the other practice for patients who are demonstrably active with the practice in 2009. The positive predictive value (PPV) of 2008 non-adherence for 2009 non-adherence is 71.80% (95% CI, 66.5-77.1) and negative predictive value (NPV) 61.52% (95% CI 56.9-66.1) for the Pacific practice; PPV is 61.38% (95% CI 54.6-68.2) and NPV is 82.19% (95% CI 79.2-85.2) for the other practice. The results indicate good potential for decision support tools to target adherence promotion.

Building the technical infrastructure to support a study on drug safety in a general hospital

We describe reorganization steps and the required technical infrastructure to support a multidisciplinary research project aimed at improving the safety of drug therapy in an emergency department (ED) of a community hospital. Assessment of drug safety required consolidation of data from various sources in a single source approach. We solved this by transferring digital data from the hospital information system (HIS) and attached clinical systems into a pseudonymized study database (secuTrial), which is also used as a web based data capturing tool to rate drug associated risk situations, extended by a technical extension for dynamic upload of further data. Paper-based documentation in the ED was digitized using a digital pen technology.

Contextualization of automatic alerts during electronic prescription: researchers' and users' opinions on useful context factors

Computerized Physician Order Entry (CPOE) Systems can reduce the number of medication errors and Adverse Drug Events (ADEs). However, studies have shown that users often override alerts, as they feel these are too unspecific for the given patient context. It is unclear, however, how alerts could be contextualized, that is adapted to the clinical context. Based on a literature search, we developed a list of 20 possible context factors. We asked 69 international CPOE researchers and 120 physicians from four hospitals in two countries to judge the usefulness of each factor. Researchers judged the following factors as most important: 1.) Severity of the effect, 2.) Clinical status of the patient, 3.) Probability of occurrence, 4.) Risk factors of the patient, 5.) Strength of evidence. Physicians judged the following factors as most important: Severity of the effect, clinical status of the patients, complexity of the case, and class of drug. These top-ranked context factors could be used to re-design the way alerts are presented in CPOE systems, to increase sensitivity of alerts, to reduce overriding rates, and to improve medication safety.

Using pharmacogenetics knowledge to increase accuracy of alerts for adverse drug events

Adverse drug event (ADE) has significant implications on patient safety and is recognized as a major cause of fatalities and hospital expenses. Although some medical systems today can help reduce the number of ADE occurrences, these primarily take into account clinical factors-even though recent studies show the significance of genetic profiles in ADE detection. Incorporating pharmacogenetics knowledge and data from genetic test results into these systems can improve the accuracy of preliminary alerts about potential ADEs. However, pharmacogenetics knowledge is unstructured, making it inappropriate for use in a system that involves automatic processing. We propose a methodology that can help incorporate the pharmacogenetics knowledge. Specifically, we show how pharmacogenetics knowledge can be expressed in a medical system and used together with the patient genetic data to provide alerts about ADEs at the point of care.

Contextualization in automatic extraction of drugs from hospital patient records

Information Extraction (IE) from medical texts aims at the automatic recognition of entities and relations of interests. IE is based on shallow analysis and considers only sentences containing important words. Thus IE of drugs from discharge letters can identify as 'current' some past or future medication events. This article presents heuristic observations enabling to filter drugs that are taken by the patients during the hospitalization. These heuristics are based on the default PR structure and linguistic expressions signaling temporal and conditional markers. They are integrated in a system for drug extraction from hospital Patient Records (PRs) in Bulgarian language. Present evaluation results are summarized as well.

Achieving standardized medication data in clinical research studies: two approaches and applications for implementing RxNorm

The National Institutes of Health has proposed a roadmap for clinical research. Test projects of this roadmap include centralized data management for distributed research, the harmonization of clinical and research data, and the use of data standards throughout the research process. In 2003, RxNorm was named as a standard for codifying clinical drugs. Clinical researchers looking to implement RxNorm have few template implementation plans. Epidemiological studies and clinical trials (types of clinical research) have different requirements for model standards and best implementation tools. This paper highlights two different (epidemiological and intervention) clinical research projects, their unique requirements for a medication standard, the suitability of RxNorm as a standard for each, and application and process requirements for implementation. It is hoped that our experience of selecting and implementing the RxNorm standard to address varying study requirements in both domestic and international settings will be of value to other efforts.

Even when physicians adopt e-prescribing, use of advanced features lags

Physician practice adoption of electronic prescribing has not guaranteed that individual physicians will routinely use the technology, particularly the more advanced features the federal government is promoting with financial incentives, according to a new national study from the Center for Studying Health System Change (HSC). Slightly more than two in five physicians providing office-based ambulatory care reported that information technology (IT) was available in their practice to write prescriptions in 2008, the year before implementation of federal incentives. Among physicians with e-prescribing capabilities, about a quarter used the technology only occasionally or not at all. Moreover, fewer than 60 percent of physicians with e-prescribing had access to three advanced features included as part of the Medicare and Medicaid incentive programs--identifying potential drug interactions, obtaining formulary information and transmitting prescriptions to pharmacies electronically--and less than a quarter routinely used all three features. Physicians in practices using electronic medical records exclusively were much more likely to report routine use of e-prescribing than physicians with stand-alone e-prescribing. systems. Other gaps in adoption and routine use of e-prescribing also exist, most notably between physicians in larger and smaller practices

The use of electronic pharmacy data to investigate prescribed medications and fatal motor vehicle crashes in a military population, 2002-2006

The authors examined the association between prescribed medications and fatal motor vehicle crashes (MVCs) in an active duty military population between 2002 and 2006. Using a case-control design, MVC deaths were ascertained using a military mortality registry, and an integrated health system database provided information on health system eligibility, pharmacy transactions, and medical encounters. Cases and controls were matched on comparable observation time outside periods of deployment. Among selected categories, only one, antidepressant medications, was an independent predictor of fatal MVC (odds ratio, 3.19; 95% confidence interval, 1.01-10.07). Male gender, Black race, enlisted rank, service branch (Navy and Marine Corps), and selected co-morbidities were also independent predictors. Unexpectedly, the odds of younger age quartiles (< 27 years) and history of deployment were reduced for MVC cases. Although results need to be considered in the context of data limitations, the association between prescribed antidepressants and fatal MVC may reflect unmeasured co-morbidities, such as combined effects of prescribed and over-the-counter medications and/or alcohol or other substance abuse. Younger individuals, representing new military accessions in training or returning from deployment with serious injuries, may have fewer opportunities to operate vehicles, or targeted efforts to reduce MVC following deployment may be showing a positive effect.

Automated mapping of pharmacy orders from two electronic health record systems to RxNorm within the STRIDE clinical data warehouse

The Stanford Translational Research Integrated Database Environment (STRIDE) clinical data warehouse integrates medication information from two Stanford hospitals that use different drug representation systems. To merge this pharmacy data into a single, standards-based model supporting research we developed an algorithm to map HL7 pharmacy orders to RxNorm concepts. A formal evaluation of this algorithm on 1.5 million pharmacy orders showed that the system could accurately assign pharmacy orders in over 96% of cases. This paper describes the algorithm and discusses some of the causes of failures in mapping to RxNorm.

Assessing the impact of an educational program on decreasing prescribing errors at a university hospital

BACKGROUND

Several complex and costly interventions reduce medication errors. Little exists on the effectiveness of providing education and feedback to institutional clinicians as a means of reducing errors.

OBJECTIVE

To determine the impact on prescribing errors of a pharmacist-led educational intervention.

DESIGN

Prospective, interrupted time series study.

SETTING

This study was conducted among internal medicine residents at the 320-bed University of Toledo Medical Center.

INTERVENTION

The educational intervention was conducted during a 6-month period beginning in November 2006. The intervention included an initial hour-long lecture followed by biweekly and then monthly discussions that used timely, institution-specific examples of prescribing errors.

MEASUREMENTS

Data were collected at 5 time points: month 0 (preintervention period); months 1, 3, and 6 (intervention period); and month 7 (postintervention period). Errors were identified, transcribed, coded, and entered into a database. The primary outcome was the frequency of prescribing errors during each period. A Bonferroni-adjusted chi-square analysis was conducted with an a priori experiment-wise alpha of 0.05.

RESULTS

A reduction in prescribing errors of 33% following the first intervention month and a mean 26% reduction during the study period were observed (P<0.0025). The frequencies of preintervention and postintervention errors did not differ significantly.

CONCLUSIONS

A straightforward educational intervention reduced prescribing errors during the period of active intervention, but this effect was not sustained. Ongoing communication and education about institution-specific medication errors appear warranted.

Nonadherence to medications among pharmacy clients and their attitude toward medications kept a medicine cabinet at home

OBJECTIVES

To assess self-reported adherence among pharmacy clients and to detect if there are any differences in medication use or storage between genders.

MATERIAL AND METHODS

The data were collected by means of questionnaires. A standard 45-item questionnaire was developed and used to assess adherence and nonadherence to medications. It was distributed to all pharmacy customers who entered pharmacies chosen by us.

RESULTS

Of the 162 (45 men and 117 women) pharmacy clients participating in the study, 36.42% were considered nonadherent. No significant difference in adherence rates between genders was observed (P>0.05). Women more often named themselves as being responsible for a medicine cabinet at home (P<0.001) and used more sources of information on medications (P<0.05). Women also more frequently checked the expiry date of medications in a medicine cabinet home than men (P<0.05).

CONCLUSIONS

The problem of nonadherence to medications exists among pharmacy clients. There is no significant difference in the rate of self-reported adherence between male and female pharmacy clients. Women are the ones named as responsible for a medicine cabinet at home. They also are important health decision makers. Women are more interested in information on medicines and their use; therefore, this demand should be satisfied.

Aggregation of pharmacy dispensing data into a unified patient medication history

The Regenstrief Medication Hub system collects pharmacy data from two different sources: Wishard Health Services, and dispensing claims provided by RxHub. These lists are indexed, aggregated, and filtered, to create a single Medication History for each patient. This history is then provided to the Gopher computerized prescribing system. The Medication Hub is a scalable system, capable of integrating additional sources of pharmacy data.

Pharmacy informatics in controlled substances research

Pharmacies have become essential components in support of clinical research. Their operations become highly complex when preponderance of prescriptions is composed of controlled substances. Application of informatics will result in more efficient operations. We present the Pharmacy Information Management System (PIMS) that includes a set of decision support systems to address the pharmacy challenges and is integrated into our electronic health record system.

Reducing unintended consequences of e-prescribing on the path to nuanced prescriptions

A frequency value of "as directed" was added to all medications available for an ambulatory EMR to reduce the number of prescriptions with contradictory instructions. The new frequency value has been rapidly adopted and its use has increased by 15%.