Medication List - Sorting things out

I'm going to take you on a journey of prescribing medications for a person with several chronic diseases visiting their family doctor. Along the way we're going to make three stops.

1. Seeing what medications the patient is already taking.
2. Figuring out if a change is required.
3. Picking the medication and making the change (or adding a new one).

One reason I'd like to take you on this journey, is to help you appreciate how well-designed tools make the job easier. If you've ever tried to fix something with a pair of pliers when you really needed a socket wrench, then you'll know what I mean.

Reviewing the list

As a family physician, I see people in my office with many chronic diseases (high blood pressure, diabetes, high cholesterol, osteoarthritis, depression, low back pain, obesity, etc.) who take quite a few medications. It's pretty common for somebody to have at least 10 chronic problems and 10 to 20 chronic medications. It's increasingly common for people to be on 3 or more blood pressure medications.

I need to refer to the medication list a few times during an office visit. Different versions of the list can make each task easier. Initially I look at the list to get an overview of what medications the person is taking.

What seems to be your problem today?

Then I look to see what problems might be needing some attention. Review lab. Talk to the patient. Look at recent reports from the emergency room or other specialists. Review phone call notes.

• Is the blood pressure controlled? 
• Are the latest lab results on target? 
• Is a preventive service due? (mammograms, Pap smear, colonoscopy, oil change, tire rotation) 

It's time for a change

If one of those issues requires a new prescription, then I need to look at the medication list again to see medications are already prescribed for that problem. 

Let's say that their blood pressure is not quite controlled and we need to make an adjustment in the medication. 

First, I look at the list to see what high blood pressure medications the person is already taking. I have to read the list and ask myself for each medication, "is this for high blood pressure? or this one? or this one?..." It takes quite a while and a lot of mental effort (that's called "cognitive load"). It would be a lot smarter if I could just glance and see all the high blood pressure medicines adjacent to one another (by sorting the list). It would be even easier if I could see only all the high blood pressure medications (by filtering the list), just for a second. 

Then, among those medications, I need to figure out what dose the person is taking, and if that's the maximum dose. If we've already reached maximum dose, then I'll have to pick a new medication.

If not, then I can increase the dose of the medication that hasn't reached to maximum dose.

Take your pick

If I do need to pick a new medication, then I will look at the problem list to simplify things and to avoid new conflicts.  I want to see what concurrent diesases (called "co-morbidities") the person has. If they also have migraines or irregular heartbeat, then I would choose a beta blocker or maybe a calcium-channel blocker. If they also have diabetes, that I might choose an ace inhibitor or and ARB (angiotensin-receptor blocker), if they're not already taking one of those drugs. In some cases, I avoid a particular drug (no Actos for you if you have heart failure already).

So you see, it's quite a bit of mental effort to just figure out how to add one more drug.

A well-designed EHR will lighten the cognitive load dramatically. All the required information needs to be viewed in a single view without scrolling and without navigating around. At a minimum, that information includes the patient's active problem list, and all the current medications with those details visible. It's important to not include more information than necessary, because the extra information just clutters the view and makes it harder to think or to notice what's important. If you've ever driven through an unfamiliar, busy urban highway intersection and had to read multiple signs at once, you'll appreciate the difficulty. Aircraft crew flight deck (control panels) design teams pay close attention to this, aiming for "quiet dark".

Now you try it

I made a little interactive widget you can play with here. 

[Note: Blogger and my HTML tool Tumult Hype don't allow me to embed the widget. I guess I'll move to Squarespace hosting soon.]

Ask your self these questions: 

1. In the first screen, can you tell which medications are prescribed for high blood pressure (hypertension)?
2. With the diagnoses visible, does it matter how the drug names are sorted?
3. How much extra time does it take to find all the high BP medications in the different views?
4. Can you tell if a medication dose is the maximum dose for that medication? (Hint: no, but I'll show you a cool way to do that in a later post.)

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:

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"):

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.

Can't you just include a picture of my pill?

I've been involved in numerous conversations about medication lists that our healthcare organizations give to patients, and meaningful use rules require the lists. I used to think it was a hopeless cause to get the picture of the pill your pharmacist gave you at your last refill into your personal medication list.

I am not so hopeless, but I remain sanguine. The incentives aren't aligned yet among all the stakeholders. The data doesn't flow freely. It's a rare patient that would use their smartphone to photograph their pills (good lighting and backgrounds are hard!) to include them in their Personal Health Record (PHR), if they are one of the rare people who maintain a PHR.

So, to give you a taste of the challenges, here is a short video showing the different colors and shapes of one single generically available pill: lisinopril. I captured it from ePocrates, which is a wonderful tool for providers.



If it's a brand name drug (for example, Crestor), getting a picture is far easier.



There is a code called the NDC code that tells the pharmacist which exact generic version of your lisinopril you are taking, but your doctor doesn't know (or care, generally) which NDC code is your particular lisinopril. But as we (patients, nurses, doctors, and pharmacists) start coming to expect the pill pictures as part of our conversations, then the NDC code sharing will become more important.

It's in our future, but not our present.

Information Overload or Filter Failure?

Clay Shirkey gave a talk at Web 2.0 Expo in NY  a while back titled "It's Not Information Overload. It's Filter Failure". He challenges the idea that we've got information overload problems, and he was mostly talking about media and the web. It applies in our healthcare lives as well. It is not so much information overload as a series of filter failures. Our systems for managing information abundance are swamped by the amount and growth of data that healthcare providers must manage.


Here's the presentation.

It's Not Information Overload. It's Filter Failure.

Video (23:50)

Information Chaos

Researchers at the University of Wisconsin recently published a conceptual article on Information Chaos titled "Information Chaos in Primary Care: Implications for Physician Performance and Patient Safety" (J Am Board Fam Med, Nov-Dec 2011, 24:6, 745-751).

Figure from the article at bit.ly/InfoChaos

I had never heard the concept of "Information Scatter" articulated before, but it resonated strongly with my experience as a family physician using a variety of EMRs over the past decade.

I recently did a post on using Information Dashboards. Think of a dashboard serving the same purpose as the dashboard in your car. It gives you the critical information you need for the task at hand.

• When you start the car, you get the messages like "time to service your car" or "hey! check your engine".
• When you are driving, you get speed, fuel status, turn signal indicators, bright light indicators, etc. 
• You don't have to navigate somewhere else for additional information to do the task of driving.
• You don't get unnecessary information that is not actionable during the act of driving.

Dashboards are well suited to reducing information scatter, and they help manage information overload when skillfully designed. A key feature that is often overlooked is to pare away all unnecessary data elements (removing words that don't add value).  For example, "lisinopril 10 mg daily", and not "lisinopril 10 mg 1 tablet oral daily".

Why dashboards?

Dashboard views should be the rule rather than the exception in EHR design
Physicians and nurses have to deal with complex data involving a number of realms, making quick judgments based on the overview of the patient's story.

Dashboards beat nested navigation in several ways:

1. They minimize navigation.
2. They reduce cognitive load by presenting the needed information in a single view. 
1. Users don't have to think "What next? Where next? 
2. Users don't have to use visual memory to recall the last page view: "What was that potassium value I saw seconds ago? Was that drug dose once a day or twice day?"
3. Users can "scan the scene" to quickly see if there are any abnormals. If the view is "clean", then we can move on.
3. They accommodate a variety of workflow styles. Methodical  or meandering paths work equally well when only the eye (and not the finger) does the walking. ABCDE sequence is as easy as AEDCB.
4. They can be customized or personalized to meet unique user needs.

There are some caveats.

1. Provide only the information needed for the tasks at hand. No more, and no less. That may mean leaving out detail from the grand view, while making that detail available when drilling down.
2. Use visual cues. They don't have to be words. They do need to be recognizable at a glance. Think icons and traffic lights. 
3. Try the designs out on real world users.

YouTube - The Meaningful Yoose Rap

YouTube - The Meaningful Yoose Rap

Our faculty group was discussing the need to keep our residents better informed about health IT policy. Here's a nice training tool!