The number of hospitals adopting electronic health records has more than tripled since 2009—a “revolution” in medical informatics that already has yielded major benefits in clinical pharmacy operations, according to David Bates, MD, MSc, the medical director of clinical and quality analysis-information systems at Partners HealthCare, in Wellesley, Mass.
“Pharmacists have an opportunity to see a wide array of data about patients that wasn’t previously possible,” Dr. Bates said in a recent interview with Pharmacy Practice News. “With pharmacists caring for 80 to 120 patients at a time, depending on the hospital, having a synopsis on each makes it a lot easier to do what needs to be done.”
Part of the synopsis Dr. Bates wants clinical pharmacists to be able to see in real time includes patient lab values, pharmaceutical orders and patient demographic data that, if acted on quickly, could help prevent adverse drug events (ADEs).
ADEs can be quite costly to hospitals and patients, according to Dr. Bates, a long-time advocate of real-time dynamic monitoring as a tool for reducing the incidence and effect of medication mishaps. His latest co-authored research on the topic demonstrated the value of a targeted ADE monitoring system in a 140-bed community teaching hospital (Drug Saf 2007;30:817-824). Over the six-month study period, 3,547 alerts were issued. A review of just the high-level alerts found two preventable ADEs—one led to a hypoglycemic episode in a patient with diabetes, and another led to hyperkalemia.
Based on the results, the researchers projected that there would be 37 ADEs the hospital could detect early by fully implementing the dynamic-monitoring technology used in the study (VigiLanz). Given an average cost per preventable ADE of $4,685 (1997 value), the annual cost of the 37 events would be $173,345. By contrast, the cost to implement and maintain the technology was $124,600 in year 1 and $81,900 in subsequent years, according to the study results.
Dr. Bates, who also serves as the chief quality officer for Brigham and Women’s Hospital, in Boston, said the hospital has developed a system with less frills than the one used in the Drug Safety study that currently saves the facility an estimated $950,000 per year. He also expects the hospital to implement Hospira’s TheraDoc technology later in 2013 to detect hospital-acquired infections.
“Every institution should do something in dynamic monitoring,” Dr. Bates urged. “There’s no doubt that automated real-time surveillance makes clinical pharmacists much more efficient at intervening in situations where it is likely to have a benefit.” Such an approach has the added benefit of resulting in “more cohesive work patterns” between pharmacists and other health care providers, he noted.
When a hospital first adopts the technology, it’s understandable that “some physicians resist listening to pharmacists. But as they realize pharmacists are armed with critical data and insights, physicians find it easier to accept suggestions,” Dr. Bates said. “We’ve tracked this. On the order of 90% of the time, when a pharmacist makes an action-oriented therapeutic suggestion based on dynamic monitoring, the provider team makes a change. That’s a high level of respect for pharmacists and also the underlying system.”
John Muir Medical Centers’ Approach
Indeed, at both campuses of John Muir Medical Centers, in Concord and Walnut Creek, Calif., which have a combined 600 beds, clinical pharmacy manager John Russillo, RPh, uses the VigiLanz Dynamic Monitoring Suite to help prevent ADEs, detect health care–associated infections, improve medication safety and patient outcomes—and, he emphasized, raise the clinical competency of the entire staff of 75 pharmacists. The rules-guided software package merges hospital-based drug therapy, laboratory findings, surgery, radiology, documentation and other clinical data for clinicians to quickly identify potential pharmacotherapy interventions where needed.
Contrasting with an estimated 85% of U.S. hospitals that still lack clinical decision support in electronic health records, Mr. Russillo was glad to blaze the trail with VigiLanz as its first client eight years ago. “I saw we’d be able to write exception-based rules to our own protocols and practice,” he said. For example: What’s the patient’s latest lab value? Which new drug is ordered? Did the patient have prophylaxis? Did the patient just come out of surgery?
These customized rules, he explained, trigger “intelligent,” clinically significant alerts, and thus Muir’s pharmacists feel confident these are actionable items. “I call it noise reduction—it’s huge for avoiding alert fatigue and building pharmacist acceptance,” Mr. Russillo said. He noted that Muir runs close to 1,000 rules, and VigiLanz issues 30 to 50 alerts per 100 patients each day.
Pharmacists can’t ignore any alerts because the system issues them to the various hospital units where they work, he added. A critical alert reaches a pharmacist on his or her iPad or iPhone while they are making rounds with physicians, where decisions to change medication therapy can be made promptly. In case of questions about an alert, the software describes the rule that triggered it, gives guidance for action needed, and shows links to further references such as a page on the FDA website—for instance, one describing a black box warning.
Pharmacist responses to alerts are also tracked, which ensures accountability with electronic audit trails. Mr. Russillo underscored the importance of this feature because clinical pharmacist interventions reduce the occurrence of avoidable ADEs, improve patient outcomes, and contribute to John Muir scoring higher on the 13 Medicare clinical measures. This, in turn, could help Muir potentially be eligible to recover some or all of the Centers for Medicare & Medicaid Services’ 1% base-payment withholding in 2013-2016 or 2% in 2017, which is part of the agency’s Value-Based Purchasing Program.
Muir initially used VigiLanz to help achieve safe and appropriate medication dosing, Mr. Russillo recalled. As trust in it built, he said John Muir began to use the software to help achieve best practices in medication safety; deliver consistent care quality via the application of evidence-based rules and the knowledge gained by pharmacists; and improve drug utilization and core-measure compliance with Joint Commission standards for treating specific conditions such as acute myocardial infarction, pneumonia and thromboembolism.
For example, John Muir has reduced its anticoagulation-related ADEs by more than 50% over a year’s time. This occurred during the hospital’s second year of use, and the automated technology continues to sustain the lower rate. In absolute numbers, avoidable anticoagulation ADEs have fallen from 30 to less than 10 ADEs per year, which by itself translates into a savings of $230,000 annually, Mr. Russillo said.
He estimated that the technology saves the hospital overall greater than five times its annual cost each year, while costing less than a full-time equivalent pharmacist to operate. Savings occur largely in pharmacists’ time—by making them more efficient, avoiding about two hours of manual screening time per pharmacist per day, and identifying more opportunities to improve medication oversight and utilization.
Moreover, John Muir uses VigiLanz as an antimicrobial stewardship program aid that allows it to efficiently, voluntarily report the hospital’s infection rates and antibiotic utilization to the Centers for Disease Control National Health Safety Network. Mr. Russillo said that by being one of only about 50 U.S. hospitals to report both outcomes, John Muir could more effectively analyze its use of antibiotics, identify where it could improve and benchmark its performance against others.
Other centers have had success with dynamic-monitoring protocols. The Methodist Hospital, a 900-bed unit of The Texas Medical Center in Houston, reported this year on its experience establishing seven pharmacotherapy alert rules to promote safe medication use. The rules were established to detect any improperly identified new medication orders for darbepoetin, filgrastim, fondaparinux and warfarin. In all, the real-time feedback from VigiLanz monitoring of newly verified orders reduced alerts by 36%, and the average number of alerts per day dipped from 1.0 to 0.6. The most frequently triggered rule targeted newly verified warfarin orders in the absence of a current documented international normalized ratio value. Pharmacists intervened within an average of 10.2 minutes of an alert, and their actions reduced the targeted ADEs by 39%, the researchers reported (Am J Health Syst Pharm 2013;70:48-52).
Mr. Russillo disclosed that he has consulted for VigiLanz. Dr. Bates disclosed that he has consulted for VigiLanz and has received research support from the company.