Conflict of Interest Declaration - vhpharmsci.com · component of an optimal professional practice...

R.M. Balen PharmD 1

Optimizing Personal Digital Assistant Use in Your Pharmacy Practice: A Look at What’s New, What’s Useful and Future Implications.

Robert M. Balen BSc(Pharm), PharmDInformatics Coordinator CSU Pharmaceutical SciencesVancouver General HospitalEmail: [email protected]

RM Balen PharmD - PPC 2005 2

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Greetings from Steveston BC


Outline

Practice ChallengesDocumentationPoint of need resource materialData confidentiality / security

Questions


Conflict of Interest Declaration

No financial conflicts of interests to declare


Nicholson Cove,Ladysmith, BC

R.M. Balen PharmD 2


Conclusion

Competent PDA use skills are a valuable component of an optimal professional practice information management strategy.


Pharmacy Practice

Research

Patient Care

Teaching


Practice Challenge: Documentation

ContextPatient care interventions

Departmental requirementsMedical record

Research Q/ADUEStudies


Pharmacist Intervention Documentation:US Survey

N = 433 Pharmacy Directors62% Mandatory intervention documentation31% Optional but highly encouraged61% Report dissatisfaction“PDA could improve documentation efficiency”

Youngmee K, Schepers G. Pharmacist Intervention Documentationin US Health Care Systems. Hosp Pharm 2003; 38 (12): 1141-1147


Pharmacist Intervention Documentation: VGH

Collective evolution:Internal patient monitoring recordsHealth record progress note copiesSome summary data reflecting processes

ProblemsComplianceNo outcomesData not readily analyzableNo characterization of Drug Related Problems


Documentation: PDAs

What’s new?Non technical database development software

Pendragon Forms www.pendragonsoftware.com

Increasing 3rd party servicesHealthProLink www.healthprolink.com

PIDS www.pidsware.com

CliniTrends Mobile www.ashp.com

R.M. Balen PharmD 3


PDA-Based Documentation

Database: Build it or buy it? Options:

Internally developed projectCommercially available product

ConsderationsSupportNeeds / expertiseIntegration with organization IT

Fox,BI, Felkey BG. Considerations for PDA-Based Intervention Documentation. Hosp Pharm 2003; 38(12):1180-82URL: http://www.factsandcomparisons.com/assets/hospitalpharm/dec2003_pda.pdf


Documentation: Some Site Built PDA-based Systems in the Literature

Bosinski TJ et al. Using a personal digital assistant to document pharamcotherapeutic interventions. Am J Health-Syst Pharm 2004; 61:931-4.

Collins MF. Measuring performance indicators in clinical pharmacy services with a personal digital assistant. Am J Health-Syst Pharm 2004; 61:498-501.

Reilly JC et al. Tracking pharmacists interventions with a hand-held computer. Am J Health-Syst Pharm 2001;58:158-61

Lynx DH et al. Use of a PDA-based pharmacist intervention system. Am J Health-Syst Pharm 2003;60:2341-44.

Ong SW et al. Application of a Palm OS patient monitoring tool in an infectious diseases consult service. Can J Hosp Pharm 2003;56:218-25.


PDA-based Data Management

VGH we built our own infrastructureReasons

Unique needsSpecific information needs

Short term vs. long term data collection

Infrastructure & process scalable to upcoming needsDUE / Medication Use Management InitiativesInformation “push” – e.g. DUE / Cost update reports

User friendly “non technical” development software available Standard office software for analysisIn house experience & expertise


Data Collection: The Challenge

Seamless with workflowUnobtrusive processMeaningful

Data → information → knowledge → actionImpetus for service improvementService justificationQuality assurance

Paper vs Electronic Forms

Lau A, Balen RM, Lam R, Malyuk DL. Using a personal digital assistant to document clinicalpharmacy services in an intensive care unit. Am J Health-Syst Pharm. 2001; 58:1229-32

R.M. Balen PharmD 4


PDA-based Data Management: VGH Evolution

Service characterization & consult managementIVRN ServiceOutpatient Antibiotic Therapy ProgramPeripherally Inserted Central Line ProgramClinical Pharmacists Interventions

DRP tracker database

ResearchDrug Related Hospitalizations StudyDUE data collection

Simple

IncreasingComplexity


PDA-based Data Management

Levels of complexity1 user: 1 PDA

Local database > 1 user: 1 shared PDA

Local databaseMultiple user: Multiple PDA

One shared databaseLocalNetworked Merging data


VGH IVRN Consult Management Database

Existing patientWorkload fields

Consult type Pop-up choices


PDA Database: VGH IVRN Consult Management Data Analysis

Bosma L, Balen RM, Davidson E, Jewesson P. Point of Care Use of a Personal Digital Assistant for Patient Consult Management: Experience of an Intravenous Resource Nurse team in a Major Canadian Teaching Hospital. CIN 2003; 21 (4): 179-185

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IPE request

Initial

FollowUp

VGH OPAT Program Consult Management


Selected OPAT Outcomes

completed home IV therapy17%

ongoing therapy6%

pt deteriorated-readmitted1%

therapy extended 4%

regional program follow-up31%

non OPAT Candidates39%

ADR - pt admitted1%

catheter pulled out-chg to po1%

R.M. Balen PharmD 5

Implementation of a Personal Digital Assistant (PDA)-Based

Drug Related Problem (DRP) Documentation Tool for Pharmacy Practice

S. Raybardhan BSc (Pharm), R.M. Balen Pharm D., N. Partovi Pharm D. FCSHP, P. Loewen Pharm D. FCSHP,

G. Liu Pharm D., P.J. Jewesson PhD. FCSHP


Objective

Implement and evaluate a multi-site PDA-based documentation tool to collate targeted pharmacist clinical intervention data


Data -> Information -> Action

What are the DRPsWhere are they occurringWhat can we change or implement to:

Better Prevent DRPBetter resolve DRPMost effectively use clinical resources

Scaleable database for expanded use


Results: PDA Database User Interface


PDA-Based Data Collection Infrastructure

Site 1Multiple PDAs (approx 28)Personal & corporateMultiple sync stations

Site 2Multiple PDAs (4)Corporate onlyOne sync station

Central Data Repository LAN-Based Data transmission

Site 3One PDA Corporate One sync station

One database


Results

Twenty-eight PDAs deployed (39 Pharmacists)Successful cross-network data transmissionData Analysis

MSAccess / MSExcel

User feedback:Easy to useEasy to learn

Documentation time ≤ 30 min/day (85%)

R.M. Balen PharmD 6


Report Example: DRP TotalsCount of DRPType SiteQuarter Period VGH UBCH GFS Grand TotalQ1-2005 2005-01 1511 145 27 1683

2005-02 1559 116 64 17392005-03 1706 153 82 19412005-04 2290 179 70 2539

Q2-2005 2005-05 1591 191 34 18162005-06 1814 140 87 20412005-07 1956 166 60 2182

Q3-2005 2005-08 2224 197 63 24842005-09 2032 137 55 22242005-10 1580 40 16 1636

Grand Total 18263 1464 558 20285


Report Example: DRP TypesCount of DRPType SiteDRPType VGH UBCH GFS Grand Totalneed to add drug 6184 305 65 6554unnecessary drug 2867 182 197 3246high dose 2234 165 85 2484wrong/suboptimal drug 2234 149 64 2447low dose 2195 123 30 2348compliance 963 355 45 1363ADR 920 66 21 1007non-formulary drug 279 56 11 346Drug interaction 237 33 23 293Pt counselling 150 30 17 197Grand Total 18263 1464 558 20285


Report Example: DRP Details DRPType DRPDetails Totalneed to add drug continue current dosing 45

continue for chronic condition 304IV/po stepdown candidate alt. drug(s) 1low serum levels 1new medical condition 781other 74synergistic effect 14to optimize therapy 314

need to add drug Total 1534unnecessary drug excessive treatment duration 199

no valid indication 356nondrug therapy preferred 21not most cost effective 1other 39substance abuse 3treating avoidable ADR 3unecessary multi drug regimen 165

unnecessary drug Total 787


PDA DRP Database: Conclusions

Successful infrastructure / implementationSuccessful cross-network transmission

Documentation tool easy to learn and useEfficient data analysis

PDA DRP Database Demo


PDA-Based Data Collection:Facilitating Research

Drug Related Hospitalizations StudyDrug Use Evaluation

Carbapenem initiativeQuinolone evaluationSurgical antibiotics


Drug-Related Hospitalization to Internal Medicine: Prospective, Observational Study

Principal InvestigatorPeter J. Zed, B.Sc., B.Sc.(Pharm), Pharm.D.

Pharmacy ResidentLeslie Samoy, B.Sc.(Pharm)

Co-InvestigatorsKerry Wilbur, B.Sc.(Pharm), Pharm.D.Robert M. Balen, B.Sc.(Pharm), Pharm.D.Mark Roberts, M.D.Riyad B. Abu-Laban, M.D., M.H.Sc., FRCPC

R.M. Balen PharmD 7


DRH Study: ObjectiveTo determine:

IncidenceClassificationSeverityPreventabilityEconomic impactRisk factors

Of drug-related hospitalization to internal med


DRH Study Data Algorithm

Not Drug Related

Severity Preventability

Discharge

Resolution of DRP

DRP Details

Drug Related-Hospitalization

Patient Work-Up

Included Excluded

Patients Admitted toInternal Medicine Service


DRH Study PDA Database

Census infoimported via fileextract from PCIS

DRH StudyData Fields All Patients


DRH Study Data Fields: DRH Positive


PDA-based Documentation

Turn-key solutionsHealthprolinkPediswareClinitrend mobile

R.M. Balen PharmD 8

RM Balen PharmD - PPC 2005 44www.healthprolink.com


TWO-WAY DATA EXCHANGE

www.healthprolink.com


Clinical Intervention Documentation



http://www.pidsware.com/index.html

RM Balen PharmD - PPC 2005 49www.ashp.com

R.M. Balen PharmD 9


PDA-Based Documentation Infrastructure

Should you do it yourself?Benefits

Very customizableTarget to specific needs

Facilitate research DUE

CautionsHidden costsLacking formal IS support?Takes time and skills to developWhat if the “expert" leaves?


PDA-Based Patient Tracking


Commercially Available Patient Tracking Software

Patient Tracker

Patient Keeper

E-patient

www.handheldmed.com

http://www.patientkeeper.com/

http://www.iatrosoft.com/


Patient Tracker

www.handheldmed.com



http://www.patientkeeper.com/



www.iatrosoft.com/

R.M. Balen PharmD 10


PDA Patient Tracking

Issues:Data backupConfidentiality / securityVarying practice approachesCorporate strategy / support lacking

Recreating medical record

Lack of integration with hospital IT systemsRedundant data entry

Commercial databases aimed at MD approach


Practice Challenge: Point of Need Access To Resources


What’s New: PDA Hardware

R.I.P.

Dell AximTM X50v HandheldVGA displayAccelerated GraphicsIntegrated 802.11b and Bluetooth

Palm Tungsten T5256 MB memoryFlash memoryLarge screenBluetooth

Sony Clie


What’s New: PDA Hardware

Wrist PDA FX2008Palm OS Personalized 'dial' when not in PDA modeA stylus is integrated into the buckle.


What’s New: Resource Software

More titlesMore frequent updatesPractice guidelinesBetter office software integration



Clinical References: More Titles

Major Vendors:Lexi-comp ( www.lexi.com )

Skyscape ( www.skyscape.com )


www.skyscape.com www.skyscape.com

www.skyscape.comRM Balen PharmD - PPC 2005 67

PDA-Based Clinical Guidelines

http://www.guideline.gov/resources/pda.aspx



PDA Clinical Resources: Guidelines

Mobile Medica – Apprisorwww.apprisor.com

Skyscapewww.skyscape.com


Decision Support: Guidelines on PDA

www.apprisor.com





www.skyscape.com




PDA Guides: Clinical Trials Database



PDA Guides: Clinical Trials Database


PDA Drug Info Software

“Classics”

www.skyscape.comAHFS DI / ASHP

New

www.epocrtates.comePocrates Rx™ / ePocrates, Inc.

www.skyscape.comA2Z Drug Facts / Facts and Comparisons

www.lexi.comLexi-Drugs™ / Lexi-Comp, Inc.

Vendor WebsiteSoftware/ Publisher


Lexi-Drugs


Lexi-Drugs Categories of Information


Drug Information: ePocrates qRxDrug Info: Adult & Pediatric dosing, Interactions, ADR, MOA, pregnancy & lactation

http://www.epocrates.com/RM Balen PharmD - PPC 2005 79

http://www.epocrates.com/



The Best Drug Information Software

Many may meet your needsLightweight quick look up vs. comprehensive database

Few objective comparisonsLexi-Drugs one of the most comprehensive

Anecdotal experienceEnders SJ et al. Pharmacotherapy 2002; 22(8):1036-1040


PDA Software: Disease Info

www.skyscape.comHandbook of Applied Therapeutics, 7/e) / Lippincott Williams & Wilkins

“Classics”

New

www.skyscape.comWashington Manual Wash Mnl™/Lippincott William & Wilkins/

www.skyscape.comwww.lexi.com

Griffith's: 5 Minute Clinical Consult / Lippincott William & Wilkins



5-Minute Clinical Consult: Categories of Information


Handbook of Applied Therapeutics


Handbook of Applied Therapeutics


PDA Software:Drug Interaction Analysis

ePocrates Rx™/ ePocrates, Inc.

MosbyIx™ (2002)/ Mosby, Inc.

Lexi-Interact™/ Lexi-Comp, Inc.

IFactsTM (Drug Interaction Facts)/ Facts & Comparisons


www.epocrates.com

www.skyscape.com

www.lexi.com

www.skyscape.com



iFacts Drug Interaction Analysis Categories of Information


ePocrates qRx:Drug Interaction Analysis

http://www.epocrates.com

Multi drug interaction check available


PDA Software: Infectious Diseases

Miller SM, Beattie MM, Butt AA. Personal Digital Assistant Infectious DiseasesApplications for Health Care Professionals. CID 2003; 36:1018–29


John Hopkins ABX Guide

Search by diagnosisSearch by pathogenSearch by antibiotic

http://hopkins-abxguide.org/

New


John Hopkins Antibiotic Guide

http://hopkins-abxguide.org/download_center/learn_to_use.cfm?device=palm&section=diagnosis

Search by diagnosis (HEP C)• Click on the Diagnosis tab on right

• Select GI from the pull out menu

• Click diagnosis tab on right

• Select GI


Infectious Diseases: Sanford Guide

PDA Print

Electronic may not always be better



PDA Software: Natural Medicines

Classic

Natural Medicines Comprehensive Databasewww.naturaldatabase.com/skyinfo.asp

NewNatural Standard the Authority on Integrative Medicine

www.naturalstandard.com


www.naturalstandard.com

RM Balen PharmD - PPC 2005 94www.kingguide.com/palmos_edition.htm


IV Compatibility Software: King Guide


Clinical Pharmacology OnHand IV AlertIV compatibility report tool for checking the compatibilityof two or more intravenous products and/or solutions whenmixed in solution or a syringe, or via a Y-site administration

http://www.cponhand.gsm.com/



Creating Your Own Resource Material Office Software Integration


Office Software Integration

Word Processing / Spreadsheet / PresentationDocuments to Go

Word Processing / SpreadsheetQuick Office

Word Processing OnlyWordsmith

Adobe acrobat filesAdobe reader for Palm OS

www.dataviz.com

www.cesinc.com/quickoffice/

www.bluenomad.com/

www.adobe.com/products/acrobat/readerforpalm.html


www.dataviz.comRM Balen PharmD - PPC 2005 101

RM Balen PharmD - PPC 2005 102 RM Balen PharmD - PPC 2005 103

http://www.quickoffice.com/



WordSmith

http://www.bluenomad.comRM Balen PharmD - PPC 2005 105

http://www.adobe.com/products/acrobat/readerforpalm.html


Clinical References: The “VGH Package”

Clinical resourcesLexi-drugs, Lexi-interact, 5MCC

CalculatorsScientificMedicalKinetics spreadsheet

Documentation & Research DatabasesPendragon Forms

Relevant practice guidelines – coming soon


Practice challengeData Security


Data Security / Pt Confidentiality

RequirementsHIPPA (USA)PIPEDA (CAN)

For commercial transactions

GoalsAccess controlAudit control

StrategiesPassword protectionData encryptionHardware security


Data confidentiality: Options

Database software featuresPassword protection

Palm OS featuresPassword protectionData encryption on some

Commercial security softwarePDA Defense Pro



PDA Defense Pro

PDA Defense ProPassword protectionBombing features

Erases data

Data encryption

http://www.pdadefense.com/RM Balen PharmD - PPC 2005 111

Some PDA Defense Options


PDA Defense: Data Encryption


Future Implications

Bunny or a duck? Depends how you look at it


Future Implications

↑ PDA presence in clinical information environmentEasier access to dataIncreased “client” expectationsTechnology To Facilitate Practice Goals

Covenant with patientsMeet medication therapy needsPrevent and solve drug related problems

New essential skills for pharmacists


Practical Technology Integration



Easier Access To Information & Sharing

Systems IT InterfaceWireless

resource accesscommunication

DocumentationData collection & sharing


Wireless Access To Data

WIFIBluetooth


www.jmir.org(J Med Internet Res 2004;6(4):e42)


Conclusion: This study suggests that SMS collection of asthma diary data is feasible, and that SMS may be a tool for supporting the self-management of asthma (and possibly other chronic diseases)…



Patient Monitoring: Wireless

N Engl J Med 2003;348:2526-34RM Balen PharmD - PPC 2005 123

PDA & PCIS Interface: Mercury MD

www.mercurymd.com


Mercury MD: MData


Using MData With Pendragon Forms

Customize Data Fields• ADR• DRP• Research• Outcomes• Interventions


Summary

Practice ChallengesDocumentationPoint of need resource materialData confidentiality / security


Conclusion

Competent PDA use skills are a valuable component of an optimal professional practice information management strategy.


Optimizing Personal Digital Assistant Use in Your Pharmacy Practice: A Look at What’s New, What’s Useful and Future Implications.

…Questions?

Robert M. Balen BSc(Pharm), PharmDInformatics Coordinator CSU Pharmaceutical SciencesVancouver General HospitalEmail: [email protected]

Conflict of Interest Declaration - vhpharmsci.com · component of an optimal professional practice...

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