Abstract

Background: People with cystic fibrosis have a high treatment burden. While uncertainty remains about individual patient level of adherence to medication, treatment regimens are difficult to tailor, and interventions are difficult to evaluate. Self- and clinician-reported measures are routinely used despite criticism that they overestimate adherence. This study assessed agreement between rates of adherence to prescribed nebulizer treatments when measured by self-report, clinician report, and electronic monitoring suitable for long-term use.

Methods: Seventy-eight adults with cystic fibrosis were questioned about their adherence to prescribed nebulizer treatments over the previous 3 months. Self-report was compared with clinician report and stored adherence data downloaded from the I-Neb [2] nebulizer system. Adherence measures were expressed as a percentage of the prescribed regimen, bias was estimated by the paired difference in mean (95% CI) patient and clinician reported and actual adherence. Agreement between adherence measures was calculated using intraclass correlation coefficients (95% CI), and disagreements for individuals were displayed using Bland-Altman plots.

Results: Patient-identified prescriptions matched the medical record prescription. Median self-reported adherence was 80% (interquartile range, 60%-95%), whereas median adherence measured by nebulizer download was 36% (interquartile range, 5%-84.5%). Nine participants overmedicated and underreported adherence. Median clinician report ranged from 50% to 60%, depending on profession. Extensive discrepancies between self-report and clinician report compared with nebulizer download were identified for individuals.

Conclusions: Self- and clinician-reporting of adherence does not provide accurate measurement of adherence when compared with electronic monitoring. Using inaccurate measures has implications for treatment burden, clinician prescribing practices, cost, and accuracy of trial data.

1. CHEST August 2011 vol. 140 no. 2 425-432
2. Detailed information on the I-neb AAD System.

More and more studies are questioning the efficacy of electronic health records, and the U.S. Food and Drug Administration has begun collecting reports involving electronic health and IT errors, some of which have resulted in death…

“The thing about these systems is that it doesn’t really look like they’re getting any cheaper,” he said. “And the upgrades and the upkeep represents a very significant cost, especially in outpatient clinics.”

Of those, 163 contained mistakes that could have led to “adverse drug events.” Most errors were mistakes of omission — a doctor left out an important piece of data.

Notably, this “is consistent with the literature on manual handwritten prescription error rates,” the report said. But the larger point is computerized systems do not automatically outperform paper ones. [referring to: Errors associated with outpatient computerized prescribing systems. JAMIA, 2011; DOI: 10.1136/amiajnl-2011-000205]

For an industry that relies on data and evidence-based measurements to make decisions on the clinical and pharmaceutical side, there isn’t a lot of evidence supporting the notion that electronic health records produce cheaper care or better outcomes.

I think the article outlines some of the significant problems that need to be addressed before a truly effective EHR system can be utilized. We’re forcing the healthcare industry to implement a technology that they’re simply not ready for. The IT infrastructure in healthcare is built on marbles and is still years behind the consumer market in all but the most advanced facilities. In addition we continue to struggle to standardize information. We first need to understand what the information will look like before we begin forcing everyone to use it.

There’s no question in my mind that sharing information across the healthcare continuum is paramount to providing safe, efficient, cost effective healthcare. However, there are some key pieces of the puzzle missing. Without those pieces we’re not going to get the whole picture, and that’s a problem.

• 80% were concerned with stolen personal information
• 64% were concerned with lost, damaged or corrupted files
• 62% were concerned with the misuse of information”

I’m not surprised by the numbers. In general people are afraid of change and the unknown. With that said, I think all you need to do is walk a patient through the paper processes that we use now to give them some insight into how bad things really are. Stolen and lost personal and medical information is a major problem within the current healthcare system. It’s not uncommon in any given week to hear about patient records that have been lost or stolen. And as far as misuse of information, well lets just say that’s all too common as well.

The advantages to an EHR outweigh the concerns listed above. Just sayin’.

I think this background is why I found the Shareable Ink approach to documentation so fascinating. I really see it as an interesting way to try and capture the benefits of granular data elements and electronic capture of the data while still enjoying the benefits of paper.

My simplified explanation of the Shareable Ink technology is as follows. You print out a form that you want to use for the patient visit. Each page that’s printed out has a unique background (although it just looks like a colored page to the naked eye). When you use the Shareable Ink pen to write on the printed out page, the pen uses a camera to record what you wrote on that page and where you wrote it. Then, once you sync the pen it recreates the document you wrote on in the system.”

I featured Shareable Ink as my Cool Technology for Pharmacy back in November 2009. I always thought a product like this would find a home among pharmacists. It offers the familiarity of pen and paper while giving pharmacists the opportunity to contribute to the electronic record at the same time. Pharmacy practice is rooted in a tradition of using paper to record information. Paper is terribly unreliable when it comes to searching for information or collecting data. I can’t tell you the number of times I’ve gone to a stack of patient “kinetics cards” to look for a piece of information only to find that the card was missing or simply misfiled. And because pharmacists are slow to adopt new technology it makes sense that something like Shareable Ink might offer a nice transitional technology as we move closer to a complete electronic health record.

EHR Bloggers: “We’re excited to bring you a major new feature for your EHR account today: drug-drug and drug-allergy interaction alerts. It’s a frequently requested enhancement and also a big step towards Meaningful Use. And, like all our features, this clinical decision support system (CDSS) is entirely free.

Drug Interaction Alerts
You will now be automatically alerted when a drug you are adding, prescribing or refilling interacts with another drug or with an allergy listed in the patient’s chart. The following video shows you how to set permissions, heed alerts and override alerts. “

To gain access and begin using the Practice Fusion EHR simply sign up for a free account here. I would encourage any practitioner that needs a robust, easy to use EHR system to give Practice Fusion a look. It’s a solid application.

I was going to try the new feature for myself, but forgot my credentials; how embarrassing.

Integration of medical device data into EMRs is highly desireable, and many vendors have broached the subject. The reality, however, is that few vendors have been able to create a reliable way of pulling that data into an usable EMR format in real-time. During this years Siemens Innovations conference, I received a private showing of Siemens EMR, i.e. Soarian, and its ability to pull data from several medical devices. As impressive as the display was it still required quite a bit of manual manipulation by the end user to be useful.

The sticking point in all this data collection appears to be the inability of all the different vendors to get on the same page. I spent some time last year speaking with one particular vendor about the issue and they agreed that the difficulty wasn’t necessarily the data, but gaining access to it.

From a pharmacists perspective data from vital sign monitors, ventilators, infusion pumps and blood glucose monitors would be of particular interest as this information is often collected manually and used to make decisions regarding patient care and medication use.

Instead of creating another third party solution to collect and manage all this information, maybe it’s time for vendors to sit down and find a common ground on which to build. I’m just sayin’.

The new Intelligent Medical Devices HIMSS Analytics white  paper referred to in the EMR Daily News article can be found here.

Abstract:

This paper discusses how to share medical information between heterogeneous applications via web services. Our design theory is based on a real-options framework, performance analysis and experience building iRevive, a working web-services-enabled pre-hospital documentation application. The trade-offs between efficiency and flexibility are examined in the context of exchanging information based on emerging standards in the healthcare world. These trade-offs are quantified using a real-options approach. We illustrate the importance of uncertainty in deciding the architecture enabling an application to access medical information from Electronic Medical Records (EMRs).

The article goes into quite a bit of detail in describing the trade-offs between getting access to all the information necessary to perform your job and the need for usability and speed in a data driven system. The article centered on building an integrated hospital EMR system designed to collect data via web services instead of the “every day” desktop applications typically seen in a hospital.

Some of the key points from the article include:

• Web services are a good choice for promoting the exchange of information among various systems.
• As uncertainty in data requirements goes up, so does the need for flexibility in the system. Unfortunately the same uncertainty that requires flexibility also creates inefficiency and complexity in design, i.e. how can a developer build software to capture and use data when the end user is uncertain about what data needs to be collected and how they’re going to use it.
• Modularity in EMR data design can be good or bad depending on the needs of the end user and the money available to design the system. However, increased modularity doesn’t necessarily equal increased integration or performance. It has the potential, however to create standardization and simplification.
• There are many different architectures to consider when designing an EMR capable of sharing data, but the design must balance efficiency and flexibility with usability.

The article offers an interesting perspective on system design as the authors delve into the trade-off between flexibility and efficiency in any system. According to the authors “when the designer understands users’ needs, then a focus on efficient web services makes sense”; that about sums it up for me. Anytime someone wants to get away from the desktop I consider it a positive.

The article uses an application called iRevive to illustrate several points. iRevive is a mobile data collection system for use by healthcare professionals in the field. I don’t think the product still exists as the company website looks like it’s been neglected for quite some time.

1. Gaynor, M., Myung, D., Restuccia, J. and Moulton, S. (2010) ‘Designing infrastructure to exchange Electronic Medical Records with web services’, Int J. Biomedical Engineering and Technology, Vol. 3, Nos. ¾, pp. 393-412

- Ai, Shrek Forever After remained #1 at the boxoffice last weekend with Sex in the City 2 coming in second. The Prince of Persia, the movie my family and I decided to see last weekend, was a close third. It was good.

- For anyone that really cares, the NBA finals started this week with the Lakers putting the hurt on the Celtics. I’m not a big fan of professional basketball, but at least it’s not baseball.

- The 2010 ASHP Summer Meeting is getting underway in Tampa. The meeting will officially run from June 6-9, but there’s already quite a bit going on. I was at the Summer Meeting last year in Chicago. It’s not nearly as big as Midyear, but it’s still worth the trip if you’re able to attend. I will be sitting this one out. To make sure you don’t miss anything important be sure to follow the action on Twitter by using #ashpsm10.

- Speaking of #ashpsm10, Brent Fox Tweeted this question earlier today: how many pharmacist are aware of “meaningful use”?. My answer is not many. Besides the pharmacists that are involved in informatics, the number that know anything about meaningful use is small. None of the pharmacists I work with know anything about it.

- There is a great article on “Fanboyism” at the You Are Not So Smart website. “On the other hand, if the product is unnecessary, like an iPad, there is a great chance the customer will become a fanboy because they had to choose to spend a big chunk of money on it. It’s the choosing one thing over another which leads to narratives about why you did it.” Yep, I couldn’t agree more.

- Speaking of the iPad, here’s a useful article on tips for Keynote presentations on the iPad. I’ve been looking at Keynote for the iPad as I’ve started to enjoy doing a few presentations over the past couple of months. My other big hurdle with the iPad is viewing Microsoft Office documents on the device. Fortunately Documents To Go is now available on the iPad. Sweet.

- Have you seen the video of surgeons in Japan using an iPad during surgery? If not just take a look at the video below. I don’t know whether to be amazed or appalled.

- Just in case you missed it, AT&T announced this week that they were doing away with their unlimited data plans. Just when I thought AT&T couldn’t do anything worse they turn around and make it difficult for future iPhone and iPad users to really enjoy the capability of those devices. I’ve said it before and I’ll say it again, as long as AT&T is as pathetic as they are I will not use their service for any of my personal mobile needs. Yes I have an iPhone, but it is provided to me as an electronic leash by my hospital. My personal device of choice is the Motorola DROID running on the Verizon network.

- Lately I’ve been interested in rugged laptops and tablet PCs. The Gertac V100 definitely qualifies as the latter. The thing is pretty much indestructible. The only downside is the cost of this tough little dude, which starts at a cool $3500. Ouch!

- Yesterday I posted my thoughts on the Practice Fusion EMR. I noted a couple of concerns regarding lack of access on my mobile devices and lack of clinical checking with medications. Well, Dr. Glenn Laffel from Practice Fusion left a comment on my post letting me know that Practice Fusion will offer drug-drug and drug-allergy checking “shortly“. In addition Emily from Practice Fusion commented that Practice Fusion was “also working on a mobile strategy this year.” I guess you can scratch those concerns off my list.

- I’ve talked about using a hi-tech Bluetooth scanner with the iPad before. Well how about a low-tech scanner. Here’s an interesting setup that does the same thing as the hi-tech scanner, but costs a whole lot less. The solution consists of an iPad, a CueCat USB scanner and a camera connection kit. Pretty nifty, huh?

- CMIO: “A password-protected laptop computer containing information about 61,027 Cincinnati Children’s Hospital Medical Center patients from multiple states and several foreign countries has been stolen.” How many time do I need to say this: never, ever store patient information on a laptop or any other form of portable storage solution. Mobile devices should only be used to gain access to centrally housed, secure cloud repositories. Enough said.

- A couple of articles you might find interesting:

CPOE system design aspects and their qualitative effect on usability. Stud Health Technol Inform. 2008;136:309-14

This article looks at the configuration of alerts in a CPOE system and how poorly designed implementation strategies can leave a bad taste in the mouth of those using the system. “Published studies reported that alerts which show up too early or too late in the workflow of CPOE users ordering medication can lead to errors from which users cannot recover.” It’s not only about how robust the clinical decision support is, but how it’s strategically integrated into the system as well.

Example of a Human Factors Engineering approach to a medication administration work system: potential impact on patient safety. Int J Med Inform. 2010 Apr;79(4):e43-57. Epub 2009 Sep 8.

This article gives a very interesting overview of Human Factors Engineering (HFE) and how it was applied in the face of CPOE. Interesting stuff.

- GottaBeMobile: “The Dell Streak is going on sale this weekend in Europe and will be available in the U.S. starting next month direct from Dell for $499.” I am actually excited to see this device up close and personal. Check out the gorilla glass demonstration over at Engadget. Like I said before, anything that has the descriptor “gorilla” in it has to be cool.

- The HTC EVO has been getting a lot of press this week. What a great looking Android device. A couple of long time Apple fanboys (Scoble and Gray) have given the EVO serious consideration this week, which I find encouraging. It will be interesting to see what Apple has up its sleeve with the next iPhone release rumored to be hitting the streets next month.  I have been impressed with my DROID over the past several months and believe that the Android operating system is still very immature. I can’t wait to see what it has to offer over the next several months. I’ll be looking for a new smartphone sometime before Christmas and think the timing should be right for something new and exciting.  Unfortunately my hopes of purchasing the Notion Ink Adam Adroid tablet sometime this summer went up in flames with the announcement that the device will be delayed until November. Booooooo!

- I use WordPress to write and manage this blog. It offers an incredible array of tools that makes it easy to use and more robust than anything else I’ve toyed with. One of the things that makes WordPress so interesting is the number of plugins that allow you to do anything from collect stats to autopost to the social media of choice. Socialmediatoday has a nice list of the “18 Must Have WordPress Plugins for Your Blog.” I even use a few of them.

Have a great weekend everyone.

Following my blog post last Friday where I threatened to take a drive to San Francisco for a demo of their software, Emily from Practice Fusion left this comment:

“No need for the road trip. You can get your own free EMR account with Practice Fusion in just a few seconds online here – https://pfws.practicefusion.com/apps/ehr/main.html?signup=true
Have fun testing it out. Feel free to reach out if you want more details.“

So I followed the link. The Practice Fusion site claims that any new user can be up and running within five minutes, i.e. “Live in Five”. They weren’t kidding. It only took me couple of minutes to get my login and password, and I off to the races.

The setup was incredibly simple and I found the user interface to be intuative and easy to use. It only took me a moment to get a new patient in the system and start creating a medical history. The Practice Fusion EMR uses a tabbed interface with clearly marked headers for Home, Schedule, Charts, e-Scripts, Messages, Documents, Reports and Admin. Below the primary tabs is a secondary set of tabs that gives the user access to online help videos, the recent activity of users, a “Community” area for additional information and a Marketplace where you can access consultants. However, once you enter the patient information area the secondary tabs disappear and you’re presented with nothing but a clean, unhindered user interface with easy access to your patients.

The medication section is pretty nice as you can easily search for a drug by simply typing in a few letters of the drug name and hitting ‘Enter’. The search works for both brand and generic name. The application even offers the ability to generate and send electronic prescriptions. This is a great feature. Electronic prescribing is a much better way of doing things as paper scripts often get lost, torn or forgotten.

As a pharmacist there are a couple of things I would like to see added to the medication area in Practice Fusion. First, there appears to be no cross checking between allergies and newly entered medications. I added a penicillin allergy to my patient and had no trouble ordering amoxicillin without any warnings. Second, I would like to see some clinical decision support around medication entry. There appears to be no clinical checking against coded diagnosis or the patients active medications. I was able to enter an amiodarone prescription on top of a warfarin prescription without warning. I assume that Practice Fusion expects individual pharmacies to police patient allergies and drug-drug interactions. While that is a reasonable assumption, it would be nice to see some kind of clinical chekcing in the application. Finally, I would like to see a more robust sig area within the prescription writer. I created some cool sigs while playing around with the app. I should say cool for me, but not for the pharmacist receiving them. I would have definitely received a phone call for clarification. With all that said, it is important to remember that the Practice Fusion application is not a pharmacy order entry system, is very robust and is available completely free of charge.

There are other modules available inside the Practice Fusion application, but I didn’t play with those as they had to do with insurances, billing, etc. Just not my cup of tea.

Pharmacists should take note of applications like the Practice Fusion EMR because it is clearly in their best interest. As pharmacists move into the medical home or into clinics to manage anticoagulation, hypertension, heart failure, weight loss and diabetes they will be exposed to EHR/EMR systems like Practice Fusion. They offer several advantages over legacy software systems and paper charting. Web-based medical records are the future of healthcare, so it’s best to just get used to the idea.

Oh, one other thing of note. I couldn’t view the Practice Fusion EMR on either my DROID or my iPhone; Flash issues. The application is easy to use from a desktop computer or a laptop, but it would be nice to use a smartphone to access your patient’s information in a pinch. Froyo, a.k.a. Andorid 2.2, is supposed to rectify issues with Flash. I’m looking forward to giving it another try once I update my DROID.

Throw in all the information above along with the fact that Dell and Practice Fusion have partnered to provide a ready made hardware solution to go with their EMR, and you’ve got a nice setup.

According to the Practice Fusion site:

The 1st Edition of Keys to EMR Success, was the HIMSS Book of the Year Award winner. In this revised Edition, nationally recognized expert Ron Sterling has included new chapters on EHR and Malpractice Risk, ARRA and Meaningful Use as well as detailed coverage of conversion issues for practices that have an old EMR.

“There is no question,” says Sterling, “that the selection and implementation of an EHR is a ‘bet-the-practice’ proposition. If you fail, you end up with more costs and greater frustration. Yet, few practices will be able to avoid implementing EHRs.”

I looked for the book in the usual places, i.e. Amazon, Barnes and Noble, etc. I found the first addition, but no luck on the second. I even had hopes of finding it in electronic format for the Nook, Kindle or even the iPad. Nope. So if you want to purchase the book you’ll need to go directly to the Greenbranch Publishing website.

While contemplating purchasing this book something occured to me. With the length of time it takes to publish a book, how relative would this material be to the current state of EHR/EMR implementation? Technology is moving at lightning speed. Maybe it’s time to consider a new way of disseminating information like this. Just a thought.