Kevin and I talked about a lot of topics, but one topic that was of particular interest was getting information published in journals. As an active researcher Kevin has a laundry list of published articles to his credit, giving him keen knowledge of the process for publishing research in peer-reviewed journals. One thing that struck a chord with me was the effort and time required to get an article published. Apparently it can take multiple article revisions and upwards of a year to get an article accepted by a certain journals.

No one that’s been involved in the process would be shocked by this; not even me. I’ve heard this before from other people in my profession. The problem is that the model doesn’t work for informatics, automation and technology (IAT). The speed at which the field is evolving means that information is often obsolete by the time it hits the peer-reviewed journals.

The basic question is whether or not information about pharmacy IAT requires the same rigors as research aimed at the clinical side of pharmacy. Does a study of turnaround time during pharmacy distribution with carousel technology vs. robotics require the same intense scrutiny that a study looking at the use of an ACEI vs. an ARB in PWD and HTN would?  Not likely. While one could argue that the method of distribution may impact patient care it is unlikely that the impact would be worth little more than a friendly debatable among colleagues.

I browse the table of contents of many journals every week. In addition I subscribe to the MedInfoNow service, which alerts me to new literature articles based on my personalized search criteria. And what I see week after week is a lack of information in a field that is arguably the fastest growing pharmacy specialty in the profession. Can you name a pharmacy specialty that is growing faster than informatics? I can’t. Informatics residencies are springing up all over the country, I’m seeing more and more IAT related information in social media, the content for pharmacy informatics at the ASHP Midyear is increasing each year, and so on. Pharmacy informatics is no longer a topic that pharmacist don’t know about. It’s mainstream.

As pharmacy informatics gains in popularity, new ideas, experimentation, and tinkering will ultimately take place on a larger scale. Unfortunately most of us will never hear about it, or if we do the information will be so out of date that it won’t apply to current practice. We need a way to disseminate IAT information to the masses.

Two journals that provide IAT information in a timely manner are ComputerTalk for the Pharmacist and Pharmacy Purchasing & Products (PP&P). I read both. They both offer information regularly and provide worthwhile content for IAT. PP&P has become the de facto IAT journal by default. They pump out volumes of new, relevant content each month. Unfortunately both ComputerTalk for the Pharmacist and PP&P are considered ‘throw-aways’ and are clearly supported by industry advertising. I have no idea if that creates a conflict of interest or not. It would for journals publishing clinically relevant drug information, but I would argue that it’s probably not the case for IAT.

You might argue that JAMIA is what we’re looking for, but that journal is only published 6-7 times a year, is insanely expensive, is not pharmacy specific and contains some articles that are so granular that they rarely apply to current practice. While JAMIA is clearly worth reading if you have a subscription – which I don’t – it’s not quite what I think we need.

There are other journals similar to JAMIA, but you get the point.

During the conversation Kevin mentioned the possibility of using a post-publication review process similar to what the physics community is doing. Apparently this group has decided that getting the information in the hands of their colleagues is more important than the review process. Articles are published first, and then reviewed for content, appropriateness, rigor, etc. While one could point to potential problems with a system like this, I think it holds promise for something like Pharmacy IAT.

How about a wiki, you say? I’ve been harsh on things like Wikipedia because content is easily added, but not necessarily accurate. We all assume it is, but I wouldn’t want to use Wikipedia for drug information or patient care.  With that said it’s still a viable option. While not as rigorous as a peer-reviewed journal, it’s still a great way to compile information. Sounds like a winner, but then reality sets in. Who would curate such an effort? Who should have access? Limiting access for the purpose of control might be a solution, but this could potentially create a barrier to building content.  What type of information should be included and/or excluded, if any? Where would the information reside and who would own it? These are all good questions that should be answered, eventually.

My initial thought was that an organization like ASHP should support a Wiki for Automation and Pharmacy Information Technology (WAPIT – dot com already taken just in case you were wondering), but I quickly came to the realization that that would be a bad idea. ASHP is governed by rules that would eventually cause more harm than good. No, I think the effort would be best served by an individual or small group interested in advancing the field. It would have to be open source, and the content would have to be reviewed for gross oversight and inaccuracies. But who has the time? It would likely be a labor of love, full of late night frustration and long weekends. And even if someone decided to labor over something like this, finding people to add content would be difficult. Pharmacists as a whole are introverted and don’t like to put things out there for people to read. If you don’t believe me, just take a look at the number of pharmacists that blog or play in the social media arena compared to nurses or physicians. There’s quite a discrepancy.

What about all those academics? This should appeal to them, right? Wrong. When I asked Kevin about contributing to something like a WAPIT, he simply said “peer-reviewed journals are the currency of academia”, meaning he gets to keep his job for getting his research published in a peer-reviewed journal. Pushing content to a free wiki where the focus would be on providing information over recognition and career advancement doesn’t help them keep their jobs. It’s hard to compete with that.

Creating a repository for Pharmacy IAT information is sorely needed, but getting it done would give new meaning to the phrase “beating my head against the wall“.

Android users rejoice. If you are an UpToDate subscriber, you now can download the new UpToDate Android app.

Description
Find clinical answers at the point of care or anywhere you need them! Now you can access current, synthesized clinical information from UpToDate® — including evidence-based recommendations — quickly and easily on your AndroidTM phone or tablet. This app is free to download. However, an individual subscription is required to log in and use it.
Features of UpToDate include:
• Persistent login
• Easy Search with Auto-complete
• Bookmarks and History
• Mobile-optimized Calculators
• Ability to earn CME/CE/CPD credit

This is the first public release of the Android app for UpToDate. Like the first UpToDate iOS mobile app, you need to login and you need an Internet connection. It is more convenient to have a native app rather than access UpToDate from the browser and you get more options than just the browser version. I suppose eventually UpToDate will release an “UpToDate Complete” for Android much like the iOS UpToDate Complete.
Update: It seems that this first release, although a free app, is available only to those who have access to the Google Play store in North America.

UpToDate is a great reference source for pharmacists; actually all healthcare professionals. It was my favorite reference when I was still a real pharmacist. My browser always had a tab open to UpToDate.

Based on The Palmdoc Chronicles article I went in search of the Android version of UpToDate. Not easy to find at the UpToDate site. Fortunately it only took me a second to find it on Google Play.

Note: UpToDate requires a subscription to get to all the information.

You can find more information on Lexi-Drugs here.

The dialogue lead to a couple of important discoveries.

First, I had no idea what MedInforNow could do. I was only using a fraction of its functionality. The product is much more powerful than I initially thought, and to say that I wasn’t using it to its full potential is an understatement. The company actually scheduled a 15 minute one-on-one webinar session with me to highlight all the major features and “hidden gems”. Since then I’ve spent some time optimizing my MedInfoNow settings. I’d still like to have access to more full articles, but overall the information I’m getting has improved. Optimizing my preferences, journal settings and library access made a significant improvement in my overall experience. MedInfoNow has promised to put a “hidden gems” post on their blog (Doody’s Views) in the near future. I’ll let you know when it’s up.

Second, when I was rummaging around Doody’s Views I saw a neat little literature search box in the upper right hand corner (see image below). When you click on it you get a pop-up window that allows you to do a quick literature search without leaving the site. You can filter by journal and/or timeframe. Results are displayed a la Medline style with the option to click through to the abstracts. I thought it was pretty cool. I liked it so much that I did what any good red-blooded American would do: I stole it and put it on my site. Actually I asked them for permission to add it to my site and they graciously agreed (image below).

And there you have it, a quick update on my experience with MedInfoNow.

While at HIMSS12 in Las Vegas last month I was asked to do a little review work. That’s not all that uncommon. People ask me to do things on occasion; review a blog post, review an app, give my opinion on something and so on. But this was completely different as Dr. Heather Leslie (@omowizzrd), Director of Clinical Modeling for Ocean Informatics and Editor for the openEHR Clinical Knowledge Manager asked me to review an archetype. A what? Yeah, that was my response when Heather and I first spoke about the topic nearly two years ago.

According to good ol’ Merriam-Webster an archetype is “the original pattern or model of which all things of the same type are representations or copies: also : a perfect example“. Simple enough, but still too vague for my brain so I went in search of a better explanation which I found at Heather’s blog – Archetypical.

According to the Archetypical site ”openEHR archetypes are computable definitions created by the clinical domain experts for each single discrete clinical concept – a maximal (rather than minimum) data-set designed for all use-cases and all stakeholders. For example, one archetype can describe all data, methods and situations required to capture a blood sugar measurement from a glucometer at home, during a clinical consultation, or when having a glucose tolerance test or challenge at the laboratory. Other archetypes enable us to record the details about a diagnosis or to order a medication. Each archetype is built to a ‘design once, re-use over and over again’ principle and, most important, the archetype outputs are structured and fully computable representations of the health information. They can be linked to clinical terminologies such as SNOMED-CT, allowing clinicians to document the health information unambiguously to support direct patient care. The maximal data-set notion underpinning archetypes ensures that data conforming to an archetype can be re-used in all related use-cases – from direct provision of clinical care through to a range of secondary uses.” That gave me a better understanding of what they were trying to do.

Anyway, when Heather asked me to review the Adverse Reaction archetype I was a little hesitant. The projects I’m asked to be involved with are typically much smaller in scale. This was something different and I felt a little intimidated. My gut reaction was to politely decline, but when someone asks you to do something face to face it makes excusing yourself for some lame reason a lot harder. So I agreed with more than a bit of trepidation.

The openEHR project utilizes a system called the Clinical Knowledge Manager (CKM). In the most basic terms, the CKM is an online content management system for all the archetypes being designed by the openEHR project, and it’s impressive. A more in depth description can be found  here.

Logging into the system was simple. The email invitation I received to review the Adverse Reaction Archetype contained a link that took me to the exact location I was supposed to be. From there things got a bit more complicated. The CKM is easy enough to navigate, but the amount of information and navigational elements within the system is staggering. It took me a while to figure out exactly what I was supposed to do. Once I figured it out I was able to quickly go through the archetype, read what other comments people had made and make a couple of minor notes myself. One thing I could never completely figure out was how to save my work in the middle and continue later. Sounds simple enough, but for whatever reason it just wasn’t obvious to me. I ended up powering through my “review” in one extended session because I was afraid I’d lose my place.

The archetype itself was impressive. It’s clear from the information and detail that people have spent a lot of time and effort developing the adverse reaction archetype. There’s no question that a lot of great minds had been involved in this work. The definition made sense as did the data that was being collected and presented. The archetype offered flexibility for information gathering that included the simplest form of adverse reaction to complex re-exposure and absolute contraindication notation (this is sorely missing in many systems I’ve used over my career). Overall I had little insight to offer during the review, only a couple of minor comments.

I’d say the entire process was pretty straightforward with some minor complications. Like everything else I’m sure the process would get easier over time and multiple uses.

Best session I attended was Care Coordination in Practice: Managing Data Volume and Data
Reconciliation. The presentation was all about big data and how we’re failing to use it appropriately in healthcare. The slide deck was great. It’s available here if you’re interested.

A couple of things I found interesting in the presentation:

1. There are approximately 1-2 billion clinical documents produced in the United States each year. That’s mind boggling if you stop and think about for a minute.
2. More than 60% of key clinical data are not found in coded lists.The remainder of the information is found in free text, scanned documents, etc. That’s a problem because a lot of clinical decision support is based on information in coded lists. So what are we missing? A lot.

The takeaway from the presentation: “Get massive amounts of data flowing, then build structure slowly and incrementally. Don’t wait.” The presenter referred to this as “the Google approach to data”. I’m a fan of all things Google so that works for me.

I had coffee with Pauline Sweetman yesterday (@psweetman). Pauline is a pharmacist from the UK that I’ve been tweeting back and forth with for a couple of years. We had a pretty interesting conversation around the differences and similarities between hospital pharmacy practice in the U.S. and UK. Good stuff.

I also had a great conversation with Dr. Heather Leslie (@omowizard), a physician out of Melbourne, Austrialia that’s doing a lot of work with the openEHR project. During our short visit she persuaded me to participate in their Adverse Reaction archetype review; as a pharmacist of course.She’s always looking for additional help if anyone is interested. It’s a worthwhile project so at least have a look.

I spent more time roaming around the exhibitor area, specifically looking at RFID technology. I’m a fan of RFID, but it doesn’t seem to be catching on in healthcare. There are several reasons why, but we should still be looking hard at it’s application. I’m not sure whether RFID will become important or it it’s a bridge technology to something else. But the only way to find out is start using it and see where it goes.

One product that uses RFID technology that I found particularly interesting comes from a company called MEPS Real Time, Inc. Their product features a dispensing cabinet with real-time RFID driven inventory management to go along with a RFID med tray tracking system. Of course you wouldn’t use RFID for everything because it would be labor intensive and expensive, but for high dollar drugs it might make sense. It was pretty impressive.

The application, called iCare, was quite nice. It had a nice flow to it and some pretty solid functionality. It gave physicians access to the patient medical record, medication lists, laboratory results, in addition to allowing physicians to record billing information and generate sign out notes for other physicians. It’s an Apple fanboy’s wet dream.

A few things that I thought were of particular interest:

• Dr. Rehman said that they didn’t ask for help collecting data from any of their vendors because “they wouldn’t get it [the help they needed]”. That speaks volumes for what UHS thinks of their HIT vendors.
• Dr. Rehman eluded to the fact that UHS was willing to dummy down their security measures because physicians didn’t like long passwords. Someone from the audience pointed this out and asked how he was able to convince IT to allow 4 character passwords. His response was a bit of a grin and “we had to twist their arms”.
• UHS has given the iCare application to physicians with iPhones, but will not allow nurses to use it because they feel it is too big of a security risk. I can’t decide exactly what that means. The security risk is the same whether it is a physician or nurse. Are they saying that the number of nurses represents a greater potential for risk, or does it mean that they don’t trust nurses? I didn’t have the opportunity to ask the question.

I attended my first ever Tweepup at the HP booth in the exhibitor area. The event was sponsored by HP and brought together about 10 participants. I was able to meet Dr. Joseph Kim, which was a treat. I read a lot of his blog posts and share his interest in all things tablet PC related. We only had a few minutes to talk, but I enjoyed it.

The exhibitor area for HIMSS12 dwarfs the exhibitor area for ASHP Midyear. I couldn’t see everything today. I’ll have to go back for more tomorrow; maybe even on Thursday depending on how far I get. Two things I took away from what I was able to see today:

1. It’s all about the data. Everyone had something to say about collecting data, mining it and using business intelligence to put it to good use. There were a number of products on display in the vendor area, including small standalone systems to large integrated solutions from some of the big boys. How important will data be to the future of healthcare? Hard to say, but a lot of people are betting the house on it.
2. Tablets are pervasive in healthcare. Tablets are the new smartphone. Everyone is carrying one and all the vendors are trying to take advantage of it. Anyone trying to sell any type of EHR, documentation system, imaging system, etc. is pushing the idea of using a tablet. Companies like Panasonic, Motion Computing, HP and Fujitsu had their lineup displayed in full force. To top it off just about every vendor in the place is offering up an iPad2 as a drawing prize. Have we seen the end of the desktop? Hardly, but it’s obvious where we’re headed.

Overall I’d call day 2 a rousing success

The real action for me will start tomorrow with the opening keynote delivered by Biz Stone, Co-founder of Twitter at 8:00 am. From there it’s pretty much one session after another until the Exhibit area opens at 1:00 pm, which is always my favorite part of a conference like this. The exhibit area is a place to see what’s going on in healthcare without having to stick to a schedule. There’s a Tweetup hosted by @HPHealthcare at 3:00 pm in the Sands Expo and Convention Center that I’m planning on attending as well. Should be a good day.

The only problem I see is the tough choices I’ll have to make on which sessions to attend; it’s a pretty impressive list.

I’ll be Tweeting off and on all week using the #HIMSS12 Hashtag (@JFahrni).

Update: Looks like they got it working within 5 minutes of me posting this. It’s a nice format. Check it out for yourself here.

I’ve said it many times before, the IV room (a.k.a. the cleanroom) in hospital pharmacies is in need of a major overhaul. Sure, we went through the big USP <797> thing a few years ago, but we didn’t really change anything inside the IV room.

After following the stream of cool technology coming out of CES 2012 a couple of weeks ago I’ve decided that new IV hoods need to make use of the following:

- Continuous data collection. An IV hood should be smart. It should collect information in real time; air quality, flow, etc, and provide feedback to the user as well as anyone else that needs to monitor these things.

- IV hoods need to have a heads-up display made from Samsung’s Transparent Smart Window. Basically it’s a full blown Windows 7 machine built into a transparent LCD screen; pretty stinking cool. It could be used to view patient information like allergies, current medication regimen, labs, etc. In addition the Smart Window could offer the person in the hood feedback on what they’re making. Two-way video communication with a pharmacist outside the IV room? No problem. Or you could just use it to check your social media.

- The surface of the hood should be something similar to Microsoft Surface. As things are placed inside the hood the surface could collect and analyze information on the item, including what it is (barcode, RFID, NFC), whether or not it’s compatible with other things in the hood, if air flow is blocked, check the items against the patient for whom the compounded is being made via clinical decision support tools, and so on. Real-time clinical and operational information.