1. Top 10 Myths of Pharmacy Interoperability John Poikonen, Pharm.D. Office of Patient Safety Partners HealthCare System Boston, MA

5. Upon this gifted age, in its dark hour, Rains from the sky a meteoric shower Of facts . . . They lie unquestioned, uncombined. Wisdom enough to leech us of our ill is daily spun, but there exists no loom to weave it into fabric. Edna St. Vincent Millay

8. Formulary, purchasing decisions Inventory management Dispense/ distribute medication The Inpatient Medication Management Process FCG/VHA Obtain Medication-related History Document Medication History Diagnostic/ Therapeutic Decisions Made Medication Ordered Evaluate order Select medication Educate patient regarding medication Order verified and submitted Prepare medication Educate staff regarding medications History-Taking Ordering Pharmacy Management Education Select the correct drug for the correct patient Administer according to order and standards for drug Document administration and associated information Assess and document patient response to medication according to defined parameters Intervene as indicated for adverse reaction/error Administer Medication Monitor/Evaluate Response Document Medication Inventory Management Administration Management Incident/adverse event surveillance and reporting Surveillance

12. Barriers to CPOE Captain, let me make something clear to you: I’m a doctor!... not a !&#$%! computer programmer!

13. Order = Dispense = Administer Orderable Item Dispensable Item Administrable Item Amox. 500mg Q6H Amox. Susp. 250mg/5ml 80ml Bottle Amox. Susp. 500mg (10ml) PO 12-6-12-6

14. Order = Dispense = Administer Orderable Item Dispensable Item Administrable Item Dopamine 1-3mcg/kg/min Dopamine 400mg in 100ml D5W Dopamine 0.9ml/hr

15. Ordering Medications Medication Name Routed Med Routed Doseform Med Strength / Units Routed Med Strength / Units

19. Systemic Interoperability Taxonomy* No PC/information technology Fax/Email Structured messages, non-standard content/data Structured messages, standardized content/data *CITL Report on Healthcare Information Exchange and Interoperability Secure e-mail of free text and incompatible/proprietary structured messages, HL-7 msgs Machine-organizable data 3 PC-based and manual fax, e-mail, or scanned documents Machine-transportable data 2 Mail, phone Non-electronic data 1 EDI of structured messages with controlled terminology Machine-interpretable data 4 Examples Description Level

20. 10-Year Cumulative Net Return by HIEI Level Level 4 (standardized content/data) in billions $(200) $(100) $- 0 $100 $200 $300 $400 1 2 3 4 5 6 7 8 9 10 Years Level 1 (paper) Level 2 (fax, email) Level 3 (structured message/HL7)

23. Current Case: How is Interoperability Achieved Moving data between Applications – Level 3 Messages may be structured, e.g. HL7 ver2, but all data must be mapped (if possible) ~Map! DB Application 1 Meds Problems Allergies Labs Meds’ Problems’ Allergies’ Labs’ DB Application 2

24. Future Case: How is Interoperability Achieved Moving data between Applications – Level 4 Messages are structured AND data meaning is explicit (based upon standard) = DB Application 1 Meds Problems Allergies Labs DB Application 2 Meds Problems Allergies Labs

31. Graduated Levels of Electronic Prescribing eHealth Initiative. Electronic Prescribing: Toward Maximum Value and Rapid Adoption, April 2004 1. Basic electronic reference only. Drug information, dosing calculators, and formulary information are available, but are not automatically shown while prescribing. 2. Standalone Prescription Writer: search by drug name and create prescription; no long-term data about patient is accessible 3. Supporting patient data is included (Demographics, Allergy, Formulary, and/or Payer Information) 4. Medication Management: Prior medications are available for renewal, interaction checks, etc. 5. Connectivity: MDs Office, Pharmacy, PBM and Intermediaries 6. Integration with EMR

33. Medsinfo-ED Health Affairs 2005;24:1197-1204

36. The Impact of Computerized Physician Order Entry on Medication Error Prevention JAMIA 6:313, 1999 Pharmacist Participation on Physician Rounds and Adverse Drug Events JAMA, 282:267,1999

46. Perfect Standards live in a Perfect World

47. Clinical Data, Information and Knowledge Standards Data Information Knowledge

48. Information Knowledge Active Ingredient = FDA Unique Ingredient Identifier (UNII) code Dosage form and package = FDA/CDER data standard Drug Product = National Drug Code(NDC) Clinical Drug = RxNorm Drug Classification = VA NDF-RT Reference Data

54. Information Knowledge Wisdom Active Ingredient = FDA Unique Ingredient Identifier (UNII) code Dosage form and package = FDA/CDER data standard Drug Product = National Drug Code(NDC) Clinical Drug = RxNorm Drug Classification = VA NDF-RT Reference NCPDP Claims NCPDP Script 8.x NCPDP SIG NCPDP History Segment IT Certification Standards AMCP DDI Standards? P4P / CMS driven? Data CDS Standard?

55. Ingredient : a chemical or biological component of a drug. USP/NF representation Generic ingredient set : the set of one or more therapeutically active ingredients present in a drug. RxNorm Clinical drug : a set of strength-specific therapeutically active ingredients intended in any single clinical circumstance for concurrent administration by one of a set of appropriate potential routes in a specific dose form. RxNorm Manufactured drug : one or more components which together are intended for concurrent administration. Each component is a specific clinical drug produced by a specific manufacturer. A Manufactured Drug may also optionally include an associated drug device. Most Manufactured Drugs are single-component. RxNorm Packaged drug product : a marketed drug product as it is packaged by a specific manufacturer and sold in a specific country; contains one or more manufactured drugs. NDC Representation Ingredient Generic Ingredient Set Clinical Drug Manufactured Drug Packaged Drug Product