The Case for Decision Support: Safer Medication Management and Lower Costs

PDF File: 

hct4_3_wp_osheroff_moore_thomsonhealth.pdf

Thomson Healthcare Micromedex

Putting the right information in the handsof the right people at the right time via a systematic deploymentprocess is a key success factor in an organization’s ability toensure the safety and quality of medication use while managingdrug costs.

“First do no harm” is a foundational principle in healthcare. Because of that principle, medication safety moved to the forefront of discussion with the Institute of Medicine’s (IOM) 1999 revelation that more than 7,000 people in the United States die annually from medication errors.[1] Subsequently, the July 2006 IOM report “Preventing Medication Errors”[2] again focused the nation’s attention on the problem of medication safety by highlighting that every year millions are hurt or killed by medication errors.Moreover, several broad-based studies during the past 15 years have demonstrated that injuries resulting from adverse drug events (ADEs) account for up to 41 percent of all hospital admissions.[3]

In addition, the very survival of a healthcare organization rests on the administration’s ability to control costs. In real dollars, ADEs represent more than $2 billion annually in inpatient costs.[3] Medical errors also divert significant opportunity costs – dollars are spent repeating diagnostic tests or offsetting ADEs and are thus unavailable for other purposes.[3]

The combined costs of medication error – in human life, healthcare quality and administrative dollars – have made medication safety progressively one of the most important issues for healthcare administrators. To manage safety and improve quality, administrators must ensure that all clinicians have the information they need to support optimal decisions and actions at every point of the medication use cycle. Moreover, to manage drug costs and formularies, healthcare administrators must, in accord with the Pharmacy & Therapeutics (P&T) Committee, have access to comparative pricing and efficacy data to evaluate the safety and cost-effectiveness of drugs.

The bottom line: Putting the right information in the hands of the right people at the right time via a systematic deployment process is a key success factor in an organization’s ability to ensure the safety and quality of medication use while managing drug costs.

The Evolving Role of Drug Knowledge Solutions in Medication Safety

Though the IOM reports were explosive, healthcare organizations had begun to understand the need for drug knowledge resources nearly a decade before and had been purchasing drug databases as a tool for clinicians. However, in the 1990s, two factors transformed drug information from tools used by physicians to care for individual patients to strategic tools for driving organizational efforts to enhance the quality, safety and cost of medication use.

The Omnibus Budget Reconciliation Act of 1990 (OBRA '90) included a provision for Prospective Drug Use Review, the Medicaid-specific prospective drug utilization review system requiring pharmacists to evaluate prescribed drug therapy before dispensing medications to ensure they are appropriate, medically necessary and not likely to cause ADEs. Second, the proliferation of networking technologies and Web protocols gave the information in drug knowledge tools enterprisewide accessibility.

A mandate from the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) for a formal medication reconciliation process has highlighted another opportunity for drug knowledge resources to support medication safety.[5] Other initiatives fueling the use of clinical knowledge to improve medication safety include: The Institute for Healthcare Improvement’s (IHI) 100,000 Lives Campaign (100K Lives),[6] JCAHO’s National Patient Safety Goals and The Patient Safety Act of 2005 (H.R. 4349).[7]

To meet these increasing demands, drug knowledge resources are evolving from fairly static and verbose repositories to more robust tools that are tightly integrated into various information systems and clinician and patient work flows. They contain more granular information to efficiently meet focused needs, and they are tightly integrated with other knowledge resources covering the evaluation and management of clinical conditions. Updating in near-real time helps ensure that the latest information is available.

But what constitutes “quality“ in a drug knowledge resource?

Defining ‘Quality’ in Medication Information

To effect better medication use, medication decision support tools must be of the highest quality with the following characteristics that facilitate:

1. Clinical decision support (CDS): Medication safety demands CDS in the form of drug knowledge whenever and wherever needed, especially at medication administration cycle transition points – prescribing, dispensing, administering, educating and monitoring (see Figure 1). CDS includes:
   • Reference information – To avoid medication errors in a world with more drugs available than any human can fully master, clinicians and patients need timely access to the latest evidence-based, bestpractice treatment recommendations for common and uncommon conditions. Once optimal management has been identified, drug reference information should answer specific questions about a wide range of drugs, including FDAapproved and investigational prescription and nonprescription drugs, non-U.S. preparations and complementary and alternative medications. The information should be easy to understand, address the myriad common considerations affecting their use and be consistent for the full spectrum of users – from clinicians to patients.
   • Proactive information – Targeted patient-specific alerts can notify clinicians of potential medication use problems of which they might not otherwise be aware. Optimally, the guidance should be delivered via the most appropriate channel at the most appropriate point in the clinician’s work flow, e.g., via computerized physician order entry for physicians, work flow tools for pharmacists, medication administration systems for nurses and personal health records for patients.
2. Business decision support – To close the loop on appropriate medication use, healthcare administrators need comprehensive data to:
   • Determine and compare costs – Resources should help organizations identify, analyze and compare an inclusive list of drug products to inform a wide range of decisions, from determining the efficacy of substituting a generic, more costeffective drug to managing claims adjudication.
   • Manage formularies – Formulary data is vital for containing rising drug costs and promoting patient safety. To ensure clinician compliance, this data must be immediately accessible throughout the facility. In addition, drug summary reports and trending reports can improve the accuracy and streamline the development of P&T committee presentations.

A Systematic Approach for Improving Medication Use and Outcomes

Effective implementation of medication decision support ensures the right stakeholders have the knowledge they need to drive better outcomes. A systematic approach to this information delivery can help ensure success. Books are available that guide organizations through developing, implementing and evaluating clinical decision support programs, for example, “Improving Outcomes with Clinical Decision Support: An Implementer’s Guide.”[8]

To improve medication use, CDS programs should focus on top-priority organizational goals, which may include reducing dosage errors associated with particular drugs or ensuring that particularly dangerous or expensive medications are used only in appropriate situations. Providers can implement specific CDS interventions, such as order sets; context-sensitive drug reference information for clinicians and patients; and alerts, within the organization’s information systems in a manner to ensure achieving these goals.

Collaboration: The Future of Successful Medication Management

Patients, clinicians and healthcare organizations are assuming greater accountability for the safe, appropriate and cost-effective use of medications. As a result, robust medication decision support solutions are increasingly critical for informed decisions at all points of the medication use cycle. A significant challenge, indeed, but the journey to safe, high-quality, cost-effective medication management is both essential and rewarding. Collaboration among all stakeholders – healthcare organizations, CDS and clinical information system providers, clinicians and patients – can help ensure the success of this journey.

Endnotes

1. Kohn L, ed, Corrigan J, ed, Donaldson M, ed., To Err Is Human: Building a Safer Health System.Washington, D.C.: The National Academies Press; 1999, p 2.
2. Aspden, Philip,Wolcott, Julie, Bootman, J. Lyle, Cronenwett, Linda R., Preventing Medication Errors,Washington, DC: The National Academies Press; 2006.
3. Nebeker JR, Hoffman JM,Weir CR, Bennett CL, Hurdle JF, High rates of adverse drug events in a highly computerized hospital. Arch Intern Med., May 23, 2005, 165(10):1111-6.
4. Warholak-Juarez T, Rupp MT, Salazar T, Foster S., Effect of Patient Information on the Quality of Pharmacists’ Drug Use Review Decisions., J Am Pharm Assoc (Wash)., 2000 Jul-Aug;40(4):500-8.
5. Institute for Healthcare Improvement (IHI),Web&ACTION: Preventing Adverse Drug Events Through Medication Reconciliation, http://ihi.org/IHI/Programs/ ConferencesAndTraining/WebActionADE.htm.
6. What You Need to Know about Medication Errors: A Fact Sheet for Patients and Their Family Members retrieved December 7, 2005 from http://www.ihi.org/NR/rdonlyres/ 2703D9D5-0113-4DD9- ABFE-C8FC37357D6F/0/MedicationReconciliationPtsandFam.pdf
7. Artz M, Conant R, Lennox C., Federal Update: The Patient Safety Act of 2005 is reintroduced, AJN., Jan 2006:106(1):36
8. Osheroff J A, Pifer E A, Sittig D F, Jenders R A, Teich J M., Improving Outcomes with Clinical Decision Support: An Implementer’s Guide, Healthcare Information and Management Systems Society (HIMSS), Chicago, 2005, http://marketplace .himss.org/acct618b/ Default.aspx?tabid=44&action=INVProductDetails&args=507.