decisionsupport

Delightful Demo of Medication Reconciliation Prototype

Our colleagues at the University of Maryland Human-Computer Interaction Lab have produced a dramatically effective prototype for medication reconciliation. It is amazingly effective, and gets better with each revision (I'm aware of three versions).

What is medication reconciliation?

That's when a healthcare provider has to compare two versions of your medication list. Say you go see your physician, who gives you a printed copy of your medication list as it was the last time you visited them. Now, you compare it to your personal list (or sack of bottles) of medicine. Do they match? If not, what's missing, what's extra, or what has changed?

If you think that sounds easy, you might think otherwise if you happen to be taking a dozen different medications. It's not that far fetched if you have the big 4 (diabetes, high blood pressure, high cholesterol, and obesity), and then toss in a couple more problems (depression, arthritis, sexual disorders). It's easy to rack up 1-3 medicines per problem.

Watch this short video to see what reconciliation involves. Dr. Catherine Plaisant narrates.



What's the big deal?

When I show this to physicians and nurses who have to do this job manually every day, they are amazed and impressed, and they want it NOW in their own electronic health record software!

Here are some features that make it so effective:

  • Animation: The logic becomes transparent
  • Proximity: Like items merge, unlike items move farther apart
  • Alignment: Columns convey meaning, and condensing adds visual efficiency
  • Color: Meaningfully employed. Green is ready to go, gray is retired to the sidelines.
  • Cognitive effort reduced: Software does the matching, rearranging and condensing, then proposes "near matches" for human adjudication.
  • Highlight differences: The text that doesn't match in two items is highlighted, adding efficiency, accuracy, and safety.

Dashboards - Quality Performance at the Point of Care

I used to get quality reports once a year, then once a quarter. They were long, opaque, boring, and too detailed to digest. I was usually looking at them when I was too tired (at the end of a long day) and away from the battlefield. As a result, nothing much changed.

So, our team decided to provide "just in time" quality feedback to physicians at the point of care, and only for diabetes, and only for 8 quality indicators (there are dozens competing for my attention). The hope was that by giving feedback as the physician was about to see the patient, then she could take action and address the issues of concern. Here's what we built:

diabetes dashboard
Fig 1. Diabetes Dashboard

Here's a closer view of just the bottom of the dashboard showing the Quality Performance Indicators (back then, the Medicare Quality Program was called "PQRI"):
quality panel of Diabetes Dashboard
Fig. 2 The "quality panel" of the Diabetes Dashboard

I call the little red, gray, and white circles "idiot lights". A more socially acceptable term is "traffic lights". They alert the physician to the actionable items for the task at hand: "Change the medications or diet to lower the blood sugar, order the cholesterol tests and annual urine micro-albumin test, and send the patient to the eye doctor."

Does this approach work?
Yes and no.

It is much easier to see what needs to be done. The effort to navigate around to find these 8 items used to take 60 clicks and about 6 minutes to find all 8 measures in our EHR. With the dashboard, it takes 6 clicks and a minute or two. That's a huge gain in efficiency and reduction in cognitive load. It's also safer and more accurate, because, frankly, most physicians would stop looking for that last item or two (the foot exam and eye exam are hardest to find) before wasting the the whole 6 minutes.

Do physicians improve their quality scores by making this more available?
Not necessarily. It's not a required view, and it's on page 2. If my nurse prints it out, circles the items needing attention, and thrusts it in my face (we are a finely-tuned team), then things happen. Otherwise, the 15 other details may get in the way. Information helps, but system processes need to change to get results.

Refill alerts on a medication list - help reduce unnecessary work

What if the doctor and patient took care of all the necessary work at a visit for managing chronic disease?

Disclosure: I hate getting calls and faxes for refill requests. It seems totally avoidable. I’m not winning this battle.

It’s fairly common for primary care physician offices to get dozens of phone calls or faxes a week about medication refills.

    It might be about a patient I just saw last week.
  • These calls take time and money: mine and the staff.
  • This is unreimbursed work.
  • I get whiney about it.

If there is a discrepancy between the pharmacy (or patient) request and my records, it gets a lot worse.

Then calls go back and forth, trying to reconcile the difference, and the outcome is not always satisfactory.

So, what can we do about it?

How about adding a little alert to the medication list?

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  • Don’t make me think (that is, don’t make me “sort by last refill date”, figure out the interval since last refill, count the meds and remember their names), just show me!
  • Dark red (or gray) could mean “due for refill in <3 months”.
  • Pink (or lighter gray) could mean “due for refill in <6 months”.
  • These intervals (3 and 6 months) match the numbers for “frequency of diabetic lab tests” and “limit on controlled substance refills”.

With this information right in my face, it would be easy to see if, and which, medications need to be refilled today. That avoids an extra call for the patient, an extra fax/call or two for my staff, and a headache for me.

That makes me happy!

(special thanks for the idea to Phil Vinyard at University Physicians Family Medicine Clinics)

EHR's should help clinician users manage the whirlwind of Childhood Immunizations

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As a family physician for about 30 years now, and former “Immunization Czar” in my private practice, I lament the current state of Childhood Immunizations.

Why?

I lament the simple olden days, when a few immunizations existed, and new ones came along rarely.

I could memorize the list, and provide advice and prevention efficiently.

For simplicity, I will only refer to childhood immunizations here. Adult immunizations have some unique features.

Progress brought complexity.

New vaccines came along every year. The guidelines changed every year, in stages (ACIP recommended; then later all the authorities approved; then insurance payors reimbursed; and finally states mandated). I had new memorization to learn every year. Sometimes, I had blowback: a vaccine was not yet covered by insurance, or it was in short supply, or it required a new refrigerator for which we had neither space nor funding.

Now, it’s even more complex:

  1. We have rolling shortages, which might be national or local.
  2. We have combination vaccines, in overlapping, but not identical patterns.
  3. A particular single component vaccine might be available from two different manufacturers, but have different admin schedules (3 doses for one, but 4 doses for the other).
  4. Government-sponsored programs might require special ordering and tracking. The government choice of vaccines might differ from my organizations prior choices.
  5. Consumers are demanding customizations (break up my MMR into the 3 separate components) that fragment and complicate matters even further. This item alone could have me ranting for pages. I won’t rant, for now.
  6. The CDC schedule is offered as a range of choices, adding complexity at most well child visits. I order as individual vaccine components (MMR, or Tdap, or HiB/HepB). The nurse draws up the vaccine from a bottle marked with a brand name. He or she might have to adjust for temporary shortages, using Pediarix one week, and something else next week, depending on local supplies.

How can a human brain handle all this?
Not very well.

How can this be safe?
I think it is not.

How can this be made more efficient?
Our software could do this, but the design requirements are challenging.

Ideally, the decision support would be embedded in our EHRs.

The vaccine requirement/availability database that is used by our EHR would be maintained nationally, by the CDC, or by another entity along the lines of Multum (which maintains prescription drug databases).

The availability database could be modified locally, to reflect institutional formulary choices, or pharmacy shortages.

The decision support would examine a patient’s age, previous immunizations, and recommend a preferred dose for today (and acceptable alternatives).

The EHR database would communicate with regional or national immunization registries. That way, patients who move, or who must change providers, or who use multiple providers (the ED, the primary care physician, the developmental pediatrician, the pulmonologist) would have their immunization progress schedule available to all the providers.

Dear reader, do you know of an application or institution doing it well?

Jeff Belden MD

beldenj@health.missouri.edu