Evaluating standard terminologies for encoding allergy information.

OBJECTIVE: Allergy documentation and exchange are vital to ensuring patient safety. This study aims to analyze and compare various existing standard terminologies for representing allergy information. METHODS: Five terminologies were identified, including the Systemized Nomenclature of Medical Clinical Terms (SNOMED CT), National Drug File-Reference Terminology (NDF-RT), Medication Dictionary for Regulatory Activities (MedDRA), Unique Ingredient Identifier (UNII), and RxNorm. A qualitative analysis was conducted to compare desirable characteristics of each terminology, including content coverage, concept orientation, formal definitions, multiple granularities, vocabulary structure, subset capability, and maintainability. A quantitative analysis was also performed to compare the content coverage of each terminology for (1) common food, drug, and environmental allergens and (2) descriptive concepts for common drug allergies, adverse reactions (AR), and no known allergies. RESULTS: Our qualitative results show that SNOMED CT fulfilled the greatest number of desirable characteristics, followed by NDF-RT, RxNorm, UNII, and MedDRA. Our quantitative results demonstrate that RxNorm had the highest concept coverage for representing drug allergens, followed by UNII, SNOMED CT, NDF-RT, and MedDRA. For food and environmental allergens, UNII demonstrated the highest concept coverage, followed by SNOMED CT. For representing descriptive allergy concepts and adverse reactions, SNOMED CT and NDF-RT showed the highest coverage. Only SNOMED CT was capable of representing unique concepts for encoding no known allergies. CONCLUSIONS: The proper terminology for encoding a patient's allergy is complex, as multiple elements need to be captured to form a fully structured clinical finding. Our results suggest that while gaps still exist, a combination of SNOMED CT and RxNorm can satisfy most criteria for encoding common allergies and provide sufficient content coverage.

Effectiveness of interruptive alerts in increasing application functionality utilization: a controlled trial.

Medical applications frequently contain a wide range of functionalities. Users are often unaware of all of the functionalities available. More effective ways of delivering information about available functionalities to the users are needed. We conducted a pseudo-randomized controlled trial to determine whether interruptive alerts will increase utilization of several functionalities by the users of the Pre-Admission Medication List (PAML) Builder application at two academic medical centers. In a log-linear model, alerts increased total utilization of the promoted functionalities per PAML built by 70% compared to the controls at the site level (p<0.0001). At the user level, frequency of utilization of the PAML Builder functionalities by individual users increased by 0.03 for every extra alert shown to the user (p<0.0001). Alerts led to a nearly 2-fold increase in utilization of the promoted functionalities. Interruptive alerts are an effective method of delivering information about application functionalities to users.

An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies.

Many e-prescribing systems allow for both structured and free-text fields in prescriptions, making possible internal discrepancies. This study reviewed 2914 electronic prescriptions that contained free-text fields. Internal discrepancies were found in 16.1% of the prescriptions. Most (83.8%) of the discrepancies could potentially lead to adverse events and many (16.8%) to severe adverse events, involving a hospital admission or death. Discrepancies in doses, routes or complex regimens were most likely to have a potential for a severe event (p=0.0001). Discrepancies between structured and free-text fields in electronic prescriptions are common and can cause patient harm. Improvements in electronic medical record design are necessary to minimize the risk of discrepancies and resulting adverse events.

Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial.

BACKGROUND: Medication reconciliation at transitions in care is a national patient safety goal, but its effects on important patient outcomes require further evaluation. We sought to measure the impact of an information technology-based medication reconciliation intervention on medication discrepancies with potential for harm (potential adverse drug events [PADEs]). METHODS: We performed a controlled trial, randomized by medical team, on general medical inpatient units at 2 academic hospitals from May to June 2006. We enrolled 322 patients admitted to 14 medical teams, for whom a medication history could be obtained before discharge. The intervention was a computerized medication reconciliation tool and process redesign involving physicians, nurses, and pharmacists. The main outcome was unintentional discrepancies between preadmission medications and admission or discharge medications that had potential for harm (PADEs). RESULTS: Among 160 control patients, there were 230 PADEs (1.44 per patient), while among 162 intervention patients there were 170 PADEs (1.05 per patient) (adjusted relative risk [ARR], 0.72; 95% confidence interval [CI], 0.52-0.99). A significant benefit was found at hospital 1 (ARR, 0.60; 95% CI, 0.38-0.97) but not at hospital 2 (ARR, 0.87; 95% CI, 0.57-1.32) (P = .32 for test of effect modification). Hospitals differed in the extent of integration of the medication reconciliation tool into computerized provider order entry applications at discharge. CONCLUSIONS: A computerized medication reconciliation tool and process redesign were associated with a decrease in unintentional medication discrepancies with potential for patient harm. Software integration issues are likely important for successful implementation of computerized medication reconciliation tools.

Challenges in exchanging medication information: identifying gaps in clinical document exchange and terminology standards.

The availability of accurate medication history information is invaluable for making sound therapeutic decisions. The Continuity of Care Document (CCD) could serve as a mechanism for exchanging interoperable medication information between EHRs. We evaluate the feasibility of representing a medication and its underlying components in a Healthcare Information Technology Standards Panel (HITSP) compliant CCD. Our evaluation resulted in successfully mapping 94% of medication entries and greater than 92% of medication component mappings to CCD constraints. We identify gaps and provide recommendations for improving the representational adequacy of the Federal Medication Terminology (FMT) to fully represent orderable medication concepts.

Evaluation of an inpatient computerized medication reconciliation system.

We designed the Pre-Admission Medication List (PAML) Builder medication reconciliation application and implemented it at two academic hospitals. We asked 1,714 users to complete a survey of their satisfaction with the application and analyzed factors associated with user efficiency. The survey was completed by 626 (36.5%) users. Most (64%) responders agreed that medication reconciliation improves patient care. Improvement requests included better medication information sources and propagation of medication information to order entry. Sixty-nine percent of admitting clinicians reported a typical time to build a PAML of <10 min. Decreased reported time to build a PAML was associated with reported experience with the application and ease of use but not the average number of medications on the PAML. Most users agreed that medication reconciliation improves patient care but requested tighter integration of the different stages of the medication reconciliation process. Further training may be helpful in improving user efficiency.

The use of electronic medication reconciliation to establish the predictors of validity of computerized medication records.

Medication records in clinical information systems (CIS) are frequently inaccurate, leading to potentially incorrect clinical decisions and preventing valid decision support interventions. It is not known what characteristics of electronic medication records are predictive of their validity. We studied a dataset of 136,351 electronic medication records of patients admitted to two academic hospitals that were individually validated by admitting providers using novel medication reconciliation software. We analyzed the relationship between characteristics of individual medication records and the probability of record validation using a multivariable linear regression model. Electronic medication records were less likely to be validated if more time had passed since their last update (14.6% for every 6 months), if they represented an antiinfective (61.6%) or a prn (50.9%) medication, or if they were in an outpatient CIS rather than on an inpatient discharge medication list (18.1%); p<0.0001 for all. Several characteristics of electronic medication records are strongly associated with their validity. These findings could be incorporated in the design of CIS software to alert providers to medication records less likely to be accurate.

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network.

Confusion about patients' medication regimens during the hospital admission and discharge process accounts for many preventable and serious medication errors. Many organizations have begun to redesign their clinical processes to address this patient safety concern. Partners HealthCare, an integrated delivery network in Boston, Massachusetts, has answered this interdisciplinary challenge by leveraging its multiple outpatient electronic medical records (EMR) and inpatient computerized provider order entry (CPOE) systems to facilitate the process of medication reconciliation. This manuscript describes the design of a novel application and the associated services that aggregate medication data from EMR and CPOE systems so that clinicians can efficiently generate an accurate pre-admission medication list. Information collected with the use of this application subsequently supports the writing of admission and discharge orders by physicians, performance of admission assessment by nurses, and reconciliation of inpatient orders by pharmacists. Results from early pilot testing suggest that this new medication reconciliation process is well accepted by clinicians and has significant potential to prevent medication errors during transitions of care.

Designing an electronic medication reconciliation system.

Unintended medication discrepancies at hospital admission and discharge potentially harm patients. Explicit medication reconciliation (MR) can prevent unintended discrepancies among care settings and is mandated by JCAHO for 2005. Enterprise-wide, we are linking pre-admission and discharge medication lists in our outpatient electronic health records (EHR) with our inpatient order entry applications (OE) - currently not interoperable - to support MR and inform the development of comprehensive MR among hospitalized patients.