Dewey Howell MD, PhD is founder and CEO of Design Clinicals of Seattle, WA.
Business is good. We’re seeing more and more interest in med rec and what we’re doing, not only with medication reconciliation, but some of the stuff we’ve added to our platform around Core Measures and a number of modules that extend beyond that med rec fit into organizations’ Meaningful Use plans quite well. Like every vendor in the space, we’re definitely seeing an uptick in business because of all the Meaningful Use discussion.
I think most of the readers know what medication reconciliation means, but in case someone doesn’t, can you give a description?
Medication reconciliation is nothing new. It’s something that doctors, nurses, and pharmacists have been doing for decades. It’s just the process of gathering medications when a patient arrives at your organization, reviewing that list, and making sure it’s accurate. Then every time you write new orders or change a patient’s care, you review that list again and make sure that they aren’t pieces of that list that you need to re-address. Finally, when you send the patient back home, looking over their home medications before they arrived at the organization, making sure the patient knows exactly what you want them to do at home or how you want them to proceed with any instructions around the medications. Again, med school, nursing school, and pharmacy school 101.
When we talked three years ago, you said hospitals were just checking off Joint Commission’s medication reconciliation box but not really improving patient safety because of low compliance with paper-based processes. Is that still the case?
We are primarily still seeing folks doing this on paper. That’s because so many of the vendor systems still haven’t provided electronic solutions and work flow that is manageable in the context of the other systems.
I think the real problem is that we consider med rec a very broad piece that touches nurses, pharmacists, and doctors. In many hospital systems, those functions are very different applications. To really make it work, you need a process that touches all of those users. That’s hard to do in the silo design of a lot of those systems.
Do you think that doctors are adequately involved or it is it just being turfed off to nurses and pharmacists?
I think as a hospital moves to physician order entry, doctors are by necessity involved, because at that point when they’re writing their orders, it’s at those points that the medication reconciliation needs to happen. If the doctors are doing that electronically, it had better be included into their electronic workflow.
A lot of nurses and pharmacists are still carrying the brunt of reconciling. That’s because it has been perceived as an administrative task. Just document it on paper so we can have it on the medical record that we’ve touched these meds and looked at them, as opposed to having it as a real integral part of the clinician’s thought process at the time of ordering.
The rules change as of July 1, right?
Joint Commission surveyed med rec for a few years in 2006. Then in 2009, Joint Commission stopped scoring med rec because hospitals weren’t able to meet the strict language of the mandate. Hospital after hospital was getting cited on their survey, so Joint Commission took a couple years off.
They just recently announced that coming July 1, they’ll be re-scoring it again. They’ve revised the goal. They put out that goal for public review several months ago. Now it’s been finalized and published for scoring on July 1.
Do you think the nature of medication reconciliation will change with interoperability and HIEs?
I think it will. Medication reconciliation has been put into Meaningful Use. It’s in that discretionary set or menu set for Phase 1, but it’s very clear that it’s going to continue to be an important part of the Meaningful Use standards in Phase 2 and 3.
You mentioned HIEs. I think in an HIE environment, it becomes really critical to have a tool that allows you to reconcile medications across multiple sources. HIEs are great for bringing a wide variety of data, including medications, together from hospital after hospital and a variety of clinics in a connected community. But to make that data usable still requires a human reconciliation process because there’s a limit to what can be reconciled electronically by computer logic.
Compared to either paper or functions that vendors would typically call medication reconciliation, what are the key functionality points of your application and why is it superior?
The first one starts out on intake. We’ve taken a great deal of care to make sure that the medication list that’s gathered by nursing, or if they use pharmacy or pharmacy techs on intake, that the list is as accurate as possible. One of the first challenges with med rec is getting as accurate a list as is possible. There’s a component that is never going to be solved by any solution because patients don’t know what they take.
Whenever possible, if the solution can help with things like common misspellings get translated automatically and ensuring that the doses and the routes and the frequencies are relevant to that med. The idea is that the path of least resistance is medication sentences and orders documented on the med history list that makes sense. You don’t end up with these really dirty lists that the doctors don’t know what to do with and that don’t make clinical sense.
The other two pieces that have become critical are allowing the doctor to review that list at the time of ordering — not as a separate process, but an integral part of the ordering process. Just by doing admission med orders, med rec has been satisfied, as opposed to doing your admission orders, then coming over to a piece of paper or another system or screen and doing med rec. It should be integrated right into the way the doctor orders. That’s how we’ve done since Day One.
The other really superior piece is translating that intent to the doctor at the reconciliation steps into a very usable, patient-friendly, complete instruction sheet for the patient. It tells the patient in very clear language what to stop, what to continue, and what’s changed. It all gets translated. Even free text stuff that the doctor types gets translated. A lot of folks will say they translate in patient lay language, but there’s a lot of sort of techie challenges around doing that in a practical way. We’ve been doing it that way for four years, so it ends up being really quite complete.
We have support for something we call minimal use workflow. In the new mandate, they call it 24-hour areas or something along those lines. It allows you to designate certain areas of your hospital — whether that’s the ED or day surgery or endoscopy, these outpatient treatment center areas — where you don’t have to do the full-blown reconcile and address every single med, but rather in an abbreviated process that really makes a lot of clinical sense.
You got more live sites then when we talked last time. What are you learning from them?
We have good coverage now around the country. I think what we’re seeing is that, similar to what we saw early on but it’s just been repeated many times now, if you engage your doctors in a process of medication reconciliation that makes sense to them, the process goes a lot better if doctors, nurses, and pharmacists are all engaged, as opposed to saying “this is a nursing problem” or “this is a pharmacy problem”.
You tell the doctors, “We’re not taking something that was previously a clerical job and making them do it. What were doing is enhancing the normal work and thought process that you do anyway, while at the same time, satisfying the med rec mandate.” With that kind of explanation and understanding, I think docs engage.
CIOs are worried about CPOE because it’s hard to implement. What advice would you have for the CPOE designers?
Our application is a great way to start off in CPOE and to meet that CPOE portion of Meaningful Use, because 30% of patients have to have at least med order done electronically. Across all of our sites, the organizations that are using our product meet that level of performance just by doing med rec and admission transfer and discharge. It’s a very easy to meet that part of the mandate.
Really? They meet the new more stringent medication reconciliation criteria plus count as a a CPOE order each time you do it on a patient?
That’s exactly right.
That’s pretty cool.
Yeah, exactly. We have a few of our newer customers and some of our existing clients that are specifically using the use of our product as meeting those two parts of the mandate.
Go ahead, I didn’t mean to interrupt you.
Vendors have struggled with CPOE. When they put together those systems, they were so focused on medications and medication ordering, and I think it’s a real chilly feel for a lot of CPOE system. There’s a couple of reasons. A lot of CPOE systems were historically started with experience that industry had from pharmacy ordering systems, and doctors aren’t pharmacists, as you know. Taking something from pharmaceuticals and what’s dispensable and what’s on the pharmacy shelf to an order that the doctor expects is a very difficult process.
I think the approach that many vendors have had is that CPOE systems basically spend six to nine months building that abstraction or taking the order from the pharmacy level to the physician level. You end of making a lot of decisions in a conference room with a small group of people. Maybe they’re not all clinically relevant decisions, so you end of doing a whole lot of reiteration and it can be a big mess, depending on the expertise on your team and how much resource you have to build those systems.
We did something very different. We started out with a product from First DataBank called Order View. This was brand new when we started the company. We built our application from scratch around it. It’s a product that was specifically designed for CPOE systems. Going from pharmacy-level data, that First DataBank had been very good at obviously, to physician-level orders. What’s brilliant about the product is you have the ability to present data to the doctors in the way they expect to see it, but at the same time, you can turn that into a pharmacy-fillable order without a lot of effort. It comes out of the box ready to do that.
With CPOE, most of the real patient benefit involves medications. You can’t make a patient better with diagnostic testing or lab tests along and you’re not going to harm a patient in most cases by doing those incorrectly. Without meds, there’s not much of a CPOE patient safety story.
Absolutely right. I think that’s why going with a product like ours — that is really so focused on medications and has spent four and half years getting medication ordering right — as your initial strategy into CPOE makes a lot of sense. It’s where the big bang for the buck is, for two reasons. One, as you mentioned, in patient safety. And two, for physician usability.
With CPOE systems, it’s an order of magnitude easier to make entering a nursing order or a rad or or diet orders — making that entry process easy for doctors is an order magnitude simpler than making a pharmacy order easy and effective.
If you look down the road, where do you see the company and the medication reconciliation piece going?
I think organizations realize the importance of medication reconciliation. I think as we’ve grown and gotten more market share, people are relaxing that here’s a solution to med rec that works. They don’t have to change their corporate strategy. They don’t’ have to change their HIE or HIS strategy and still implement this third-party vendor. My hope is we’re going to see a lot more traction in helping with that medication ordering space.
We talked about the inpatient all in this interview so far, but we actually have a fair amount of use in outpatient areas as well. Beyond that market penetration for medication reconciliation, we have a couple of development partners that we’ve built this medication reconciliation out to full CPOE. It was a logical next step for us, because as we just talked, we got the medication ordering and that very central portion of CPOE done right and better than most vendors out there have been able to achieve. It made sense to layer in the additional clinical modules to have a complete system.
So you’re now able to operate as an integrated CPOE system?
That’s right. It’s a standalone CPOE system that stands outside of the HIS vendor, but it integrates with the HIE or HIS strategy, sharing data back and forth as needed for effective CPOE. It’s pretty tough to have a fully standalone island CPOE system because there are so many dependencies, but coming in the very first part of Quarter 1, we’re going have our CPOE system up and running.
What kind of customers would be prospects for it?
Since we just have a couple of development partners and are just building out the project, we haven’t done a market analysis. My guess is it’s going to be the small- to medium-sized hospitals, a couple hundred beds and less, that maybe have a system where their docs have tried to do some portions of the order entry and it hasn’t gone very well, so they’ve really struggled to get adoption and they’re not sure how they’re going to get the doctors to become Meaningful Users.
Most organizations are in the very low percentages of adoption. These small organizations, to have a CPOE system that actually promotes physician adoption while at the same time being easy to employ without requiring a big, extensive build and implementation process, is a pretty attractive thing.
Any final thoughts?
We didn’t talk much at the beginning about how the medication reconciliation mandate has changed. I think it is probably pretty important to note that the mandate is a bit different from the original one. It gives organizations a little bit more flexibility. The thing I like the most about the changes to the mandate is it’s less prescriptive. It says that we recognize that med rec isn’t the same everywhere — it’s not even the same within a given organization. This enables organizations to meet the mandate, following the sprit of the mandate as opposed to following the letter of the law without it accomplishing much. That’s what I like most about the changes to the mandate.