Data surrounds us. It’s in everything we do, from the bank statements we receive in our personal life to the mountains of data collected by every healthcare institution. Regardless of the data collected, there are basically three things that can be done with it. Data can be ignored, it can be archived or it can be used. Unfortunately only one of those three things is truly useful; using it. Many people chose to ignore or archive data not because the information isn’t valuable, but because they are overwhelmed with the amount of information they receive and the way that the information is presented.

Presentation is everything when it comes to data. The methods we chose to present information can make the difference between the information being useful or being useless. The significance of such a problem creates a quagmire for pharmacists as theirs is a data driven environment. Pharmacists spend a great amount of time emerged in data; patient data, lab data, micro data, kinetics data, drug data, usage data, nursing data, physician data, and so on.

Data visualization and dashboards can help. They provide us with the tools to better understand the information around us, and therefore improve efficiency in the process.

Data visualization
Acording to an article by Michael Friendly in 2008 (1) data visualization is “information which has been abstracted in some schematic form, including attributes or variables for the units of information”. In other words it’s data that’s put on display in a format that’s easier for the end user to understand, i.e. the use of an image to represent tables full of data.

It’s difficult to conceptualize the benefits of data visualization until you see it in action. This was recently demonstrated to me at the unSUMMIT in the form of a poster on data visualization by Charles Boicey, MS,RN-BC, PMP, Informatics Solutions Architect from the University of California, Irvine Medical Center. The poster demonstrated the value of data visualization by utilizing several different methods to present information collected from bar-code medication administration (BCMA) override scans. The information was displayed in table format along with various types of graphs and images. The tabular information was virtually useless as it was difficult to wade through the data and make sense of it. However, the visual representation of the data created a much more powerful statement that made the data easier to understand.

According to Vitaly Friedman (2) the “main goal of data visualization is to communicate information clearly and effectively through graphical means”. While the concept is simple, the application is more difficult and requires a keen eye and the ability to think in abstract ways. If you can get it right, it’s powerful stuff.

Dashboards
Dashboards take data visualization one step further by aggregating several different pieces of visual information in a single location. Think of it as an information control panel where the end user controls what information is gathered and how it’s presented. A simple search for “dashboards” in Google Images reveals several excellent examples.

Even though the concepts are useful and commonly used in business applications, the use of data visualization and dashboards remain relatively uncommon in healthcare, which is unfortunate because they could go a long way in helping pharmacists understand what’s really going on around them.

References:
(1) Michael Friendly (2008). “Milestones in the history of thematic cartography, statistical graphics, and data visualization”

(2) Vitaly Friedman (2008) “Data Visualization and Infographics” in: Graphics, Monday Inspiration, January 14th, 2008

As healthcare inches forward interoperability of systems will hold a key role in the success of the government’s plan for electronic health records. So as Rob and I discussed how to integrate various services and products we pondered how one goes about creating a standard that everyone can live with. Well, how does one create a standard that everyone will use? Heck if I know, but we decided that there are basically two approaches. The first is to create a standard and try to cram that standard down everyone’s throat. Microsoft has been fairly successful with this approach. With that said, few people have the resources that Microsoft has to throw at a problem. The second approach is to offer the standard as part of a free solution that comes with your product; this way people can use your product and use your free, open-source solution to tie the systems together. I assume this is the smart approach for companies that have limited resources; kind of a grassroots approach. Of course it would be wise to build this free, open-source solution on top of an existing standard that’s prominent in the market, otherwise you’re trying to re-invent the wheel. And we all know what happens when someone re-invents the wheel. Uh, you get a wheel. We don’t really need any more of those. Both approaches have pros and cons.

Now the question becomes which standard makes sense as you design your solution. If only I had a crystal ball. We’re at least a decade away from having a truly inter-operable healthcare system; optimistic, I know.  Ultimately, the standard of choice won’t be driven by what makes sense, but rather will be driven by adoption rates. Things often become a standard without even trying.

Here’s an HL7 feed from a ketorolac order. Note the red lettering:

PID|||0000194291^9^M10^KDHCD^PN~3017197^^^KDHCD^MR|3017197|ZZZTESTINGDRAEGRXXXX, ZZZTESTING||19740525|F|||361 N ABC AVE^^VISALIA^CA^93291|||||S|UNK|00001942919|||
PV1||I|3N^29^A||||TEST, A DOCTOR|||OP|||||||TEST, A DOCTOR |||||||||||||||||||||||||||200810231335||||||
ORC|NW|1|||||^Q6H&0600,1200,1800,2400&^^201004292400^201004302400^^^11111110||201004281226||JFT|TEST, A DOCTOR|||201004290000||
RXE||543^KETOROLAC TROMETHAMINE^2502190|30||MG|VIAL|THIS IS ONLY A TEST…..|||1|||AM1405427|JFT|||||||||||
NTE|||EVERY 6 HOURS|RXR|IV||||

Pyxis doesn’t recognize 2400 as a “real” time, and rightfully so. For those of you that don’t know, 2400 hours doesn’t exist in military time. Midnight is 0000 hours. Why would Siemens use 2400 hours to represent midnight? I have no idea, but Pyxis didn’t like it so it refused to deal with the order and simply discontinued it. The fix was a programmatic change by Siemens.

The idea of standardization isn’t new or limited, yet its use continues to elude healthcare. The concept is applicable to not only data, but processes as well. Unfortunately not everyone buys into the idea. I’ve even heard some argue that standardization removes clinical decision making from healthcare. What? That doesn’t even make sense. Standardized processes can actual create clinical decision making time by simplifying a repetitive task and creating consistency designed to prevent errors.

I spent several wonderful years working in a compounding pharmacy in the Bay Area; 3 years as an intern and about 2 years as a pharmacist. Many extemporaneous compounding formulas are complex so the owner of the pharmacy, whom I had tremendous respect for, had a rule that ingredients were placed to the left of a compound prior to use and to the right after use. If you’ve ever worked in a busy pharmacy then you understand interruptions and how easy it is to forget something in a hectic environment. The rule was a simple one, but saved my bacon on more than one occasion. And it certainly didn’t impair my clinical judgment. Similar standardized systems are used in hospital cleanrooms where attention to ingredient detail is paramount.

Other standardized processes that I’ve found beneficial over the years include:

• Standardized doses for pediatrics. I spent a few years working in a pediatric ICU. The facility I worked for had a robust set of policies that allowed the pharmacist to round doses ordered in mg/kg to the nearest “standardized dose”. For example let’s say a physician orders metoclopramide 0.15 mg/kg in a 1.85kg child. The resulting dose is approximately 0.28mg. As a pharmacist I was allowed to round that dose to 0.3mg, which was an available standardized dose. The advantages were obvious: fewer dosage sizes meant less waste, less labor for preparation and fewer opportunities for error, i.e. grabbing the wrong dose. In addition, many of the dosing increments requested were too small to be accurately measured by a syringe and would have been an estimate anyway.
• Standardized drip concentrations. Many hospitals use standard drip concentrations for pressors and other vasoactive medications, i.e. dopamine, norepinephrine, dobutamine, etc. This makes order entry easier and faster, reduces waste, reduces the risk of programming errors on pumps and creates a less complex process for drug dictionary maintenance on smart pumps.
• Standardized administration times. I love the use of standardized administration times. What’s a standardized administration time? I’m glad you asked. That’s when a hospital defines the times a drug will be administered based on the latin sig used, i.e. Q6H may be represented by 0000, 0600, 1200, 1800 or TID may be 0700, 1300, 1800. There are many possibilities. The use of standardized administration times has many advantages including easier and quicker order entry, consistency among nursing staff and less variability for the patient. Those that argue that this is a bad idea because it is difficult to get on a standardized schedule, just give me a call. There is absolutely no pharmacokinetic or pharmacodynamic reason why medications cannot be administered on a standardized schedule while in an acute care setting. You can try to argue that you can’t wait an extra 12 hours to give a multi-vitamin or that you can’t give cefazolin 2 hours early, but you won’t win based on any science that I’ve studied.

One thing to remember when creating a standardized process is to keep it simple. We often forget that complicated processes are fraught with opportunity for error. Everything we do should be broken down into the fewest possible steps and still remain safe and effective. Personal experience tells me that we’ve done a poor job of simplification in healthcare. We tend to complicate a process more often than simplify it; double and triple checks with multiple initials, paper trails, sign-off sheets, pharmacokinetic tracking forms, SBAR forms, manual lot number tracking, etc. If you’re using a paper form in this age of technology, you’re doing something wrong.

Don’t feel bad, we’re not the only ones responsible for creating a bloated and oftentimes overly complex system. Every time something goes wrong in healthcare the federal, state and local governments enact new regulatory processes that requires a barrage of paperwork and complex procedures. It’s an all-out assault on simplification, standardization and common sense.

Have you ever wondered why it takes so long to train a pharmacist after they’ve been hired? Every pharmacist has a similar core skillset that can be applied to most situations, right? Right. Their lengthy on the job training has nothing to do with their drug knowledge or decision making skills, but everything to do with learning all the idiosyncrasies associated with practicing pharmacy in an acute care setting. They have to spend time learning the rules, then the exceptions to the rules, then the exceptions to the exceptions and so on down the line. I’ve worked in six different hospitals during my benign career, so believe me when I tell you that it’s true. Some of the systems I’ve been exposed to were so old and complex that no one could remember when they were implemented, but everyone was afraid to change them.

It has been a busy month, so I won’t make any promises, but over the next couple of weeks I hope to present a couple of additional examples of where standardization is needed in pharmacy and why it’s necessary. Stay tuned.

With that said, my view of the medical literature is starting to change. The information in journals today is out of date by the time it’s published. This is especially true when it comes to any journal articles related to technology. A recent conversation with a friend and colleague verified this when he mentioned that much of his research findings could take as long as a year to grace the pages of a journal. That’s just plain crazy. If advancing technology has taught us one thing it’s that no one should have to wait a year to become better informed.

This may not apply to all information; facts need to be checked, calculations verified and references scrutinized, but if the material is informational only then it should be throw out there immediately for the rest of the world to digest. I want to know what technology you’re using to make your pharmacy safer and more efficient, and I want to know now. It does me no good to read about your problems implementing BCMA six months after I’ve already done it. However, that information would have saved me a lot of headaches if it would have appeared in journal form three months before I did it.

I’ve only been published once during my career; back in 2002. The article was informational and described currently available pharmacy software for the Palm Pilot. The article appeared in a “throw away” journal, but the entire process took a few months from submission until it appeared in print. Today I could throw the equivalent information up on my website in about 30 minutes, and the information would be no less accurate or valuable to those people reading it. The downside of course is fewer people would be exposed to the article on my site versus a journal, but you get the point.

We’ve done healthcare an injustice by creating a process that is riddled with old school thinking and ridged requirements that shouldn’t necessarily apply to all published material. This is especially true when you consider the nature of e-publishing, blogs, newsletters, etc. The ability to disseminate information has never been simpler.

Not only is the lag of printed journal articles creating a lack of information, it’s creating dangerous situations as well. Sometimes bits and pieces of information from a study involving medication will find its way into practice without all the facts. This is because word of mouth travels faster than the published literature. Unfortunately the information isn’t always complete or accurate, which creates poor practice habits that are hard to break.

I am encouraged by organizations like ASHP that appear to be moving in the right direction. They provide me with electronic newsletter updates on a regular basis, but most of the information is readily available other places for those willing to look. It’s the new information they should be pushing out to their members.

Waiting several months for information may have been fine when print journalism was our only way of communicating, but things have changed and journals like JAMA, NEJM, JAMIA, AJHP, etc need to also change. If the cause of the delay is the actual production process then maybe it’s time to abandon paper in favor of technology. And if you’re not keen enough to use available technology to access the information then perhaps you shouldn’t be practicing in today’s healthcare environment. I’m just sayin’.

The blog speaks specifically to the ownership of personal data versus allowing companies to sit on it and possibly hold it hostage secondary to a lack of compatibility with other systems. The information you throw onto the internet defines who and what you are, more now than ever before, and you need to be able to move it around anytime from anywhere.

Louis calls for people to host their own data in a standardized format instead of having data stored by one service provider or another. He goes on to say:

If I chose to log in with GMail one day, I would authenticate who I was, and GMail would pull down my e-mail stream, complete with e-mail activity history (such as replies and forwards). The data would not be stored on GMail, but instead be more like a read-only process, whereby changes to data, including sent items, would not be stored in GMail, but written back to my personal “cloud”, if you will.

Hosting one’s own personal cloud with our own data is not an end run around large corporations in fear of Big Brother, but instead, for real, true, portability. In this situation, a longtime iPhone user could pick up an Android phone, enter my own personal ID (be it through OpenID or some other standard), and pull down my details into all of Google’s native applications.

My brother, Robert spoke of something similar back in June of 2009 when he questioned how to identify and distinguish oneself from all the other people roaming the internet.

I find it interesting that Robert and Louis both mention OpenID as a possible standard. OpenID is a decentralized standard for telling websites who you are. It’s a very interesting concept; one that healthcare could benefit from. Think of carrying your electronic ID with you from place to place. No more learning ten new user id’s and passwords each time you change jobs. How nice would that be? Another option would be to have only one user id and password that gave you access to all the data you were looking for from a centralized hub.

If you look a little deeper though, you’ll find that Robert and Louis stumbled upon a common problem in the healthcare industry; how to handle the stream of data coming form patients and how to standardize it and distinguish it from everyone else’s data. Let’s face it, pharmacy is all about data. We collect it, store it, mine it and analyze it. When you’re looking at a patient’s lab work you’re looking at data; when you’re looking at a patients medication list you’re looking at data. How about their medical history, allergies, radiology results, endoscopy report? Yep. Data, data, data and oh yeah, data.

The problem with healthcare in general, and specifically pharmacy, is lack of a standard to collect, house and access this mountain of data. Some talk about HL7 and XML, but that’s just the box that moves the data from place to place. It’s just a standardized shuttle craft.

Some organizations, like ASHP, are discussing the use of standardized nomenclature systems like SNOMED CT and RxNorm to control the structure of the information inside the shuttle. Like Louis’ GMail and smartphone examples from above, a patient should be able to access their data from any device at anytime in a format that can easily be read by any commercial healthcare system in the world. Of course healthcare would have to adopt some form of centralized data storage, but that’s just part of the solution. Imagine no longer transporting medical records to your physician or having to give your medication history to a pharmacist at the 24 hour Walgreens because the mom & pop pharmacy you usually go to is closed. It’s something to think about. With all the money the government is throwing around to increase the use of health information technology the timing is right to build a foundation like the one Louis writes about. Just a thought.

PandoraVIA is the next generation of data crunching software from the company. According to the PDS website “PandoraVIA is the new, full-featured reporting system from Pandora Data Systems. It’s designed to be a highly scalable and affordable platform built with Microsoft’s latest technologies. These technologies take the full functionality from our Pandora (Legacy Edition) and PandoraSQL products and move them to the next level.”

The new software framework is designed to accommodate various modules depending on the needs of the customer. The system currently supports Pyxis, AcuDose, Omnicell, MedDispense and Cerner. However, after spending some time with the Pandora representatives at AHSP Midyear they informed me that their new system could add custom data from almost any source based on need.

PandoraVIA utilizes XML, SOAP, and WSDL to meet the needs of the healthcare system, and is capable of a host of reports that can be exported in a variety of formats.

A system that can aggregate data from many different sources offers real value to many healthcare disciplines, especially pharmacy which is often driven by data. Data mining is important, but not always easy because of the myriad of systems utilized and the general poor quality of integration. In addition, many IT departments aren’t equipped with the necessary resources to handle a project of this magnitude; believe me, I’ve tried.

Data I would like pulled into such a system include our Alaris Smart Pump data, our pharmacy information system (Siemens Pharmacy) data, our automated dispensing cabinet (Pyxis) data, our carousel, packaging and inventory control (Talyst) data, and our bar code medication administration data. Aggregate data from these systems could be mined for an infinite number of possible trends and uses.

Posted via email from fahrni’s posterous

Like many other professions, pharmacists don’t particularly like change. So when I offered to relieve them of their 3×5 index cards with a more high tech solution they were a little hesitant. It took some persuasion, but I was finally able to convince them that all the information they needed was readily available in electronic format. Unfortunately the information was scattered throughout several systems, requiring multiple clicks and views. The solution was to create a “rounds report” that would pull information from the various systems and display it in a single location.

I’m certainly not an expert with database design, but I can get around ‘ok’. The report displayed below is the final version of the pediatric rounds report that was created. I also created one for ICU rounds. The information displayed in the report is pulled from various SQL tables on the back end of the pharmacy system in addition to a little visual basic used to grab the most recent lab values from the laboratory system. With a little encouragement I was even able to get the pharmacists to use the “Notes” section in our pharmacy system to leave information for each other regarding the patient. Paired with a tablet PC, the report has given the pharmacist a giant, electronic, real-time index card. Sweet!

Pulling the data via a query was simple enough, but I didn’t want to have to present each case and sum the results on the actual report. Took me a couple of days, and a little help to find this little beauty…Sum(1). That’s it. Counted each unique drug instance over the period identified in the query. In this case all instances of a medication used less than 10 times in 2008.

The SQL is below. Note the location of the red text.

SELECT dbo_DrugFormulary.RX_NUMBER, dbo_DrugFormulary.GENERICNAME, Sum(1) AS totaluse, dbo_DrugFormulary.STR, dbo_DrugFormulary.UNIT, dbo_DrugFormulary.BRANDNAME, dbo_DrugFormulary.VOLUME, dbo_DrugFormulary.VOLUME_UNIT
FROM dbo_DRUGUSAGE_ARCHIVE RIGHT JOIN dbo_DrugFormulary ON dbo_DRUGUSAGE_ARCHIVE.DRUG_CODE = dbo_DrugFormulary.RX_NUMBER
WHERE (((dbo_DRUGUSAGE_ARCHIVE.START_DATE) Like “*2008*” Or (dbo_DRUGUSAGE_ARCHIVE.START_DATE) Is Null) AND ((dbo_DRUGUSAGE_ARCHIVE.PTNAME) Not Like “*zzz*”))
GROUP BY dbo_DrugFormulary.RX_NUMBER, dbo_DrugFormulary.GENERICNAME, dbo_DrugFormulary.STR, dbo_DrugFormulary.UNIT, dbo_DrugFormulary.BRANDNAME, dbo_DrugFormulary.VOLUME, dbo_DrugFormulary.VOLUME_UNIT
HAVING (((dbo_DrugFormulary.RX_NUMBER) Not In (“99999″)) AND ((Sum(1))<10))
ORDER BY dbo_DrugFormulary.GENERICNAME;

Resuts: