Shareable Ink plus EHR equals interesting alternative

EMR Daily News: “Shareable Ink®, an enterprise cloud computing company that transforms paper documentation to structured data, today announced three new partnerships with leading EHR vendors that will further the company’s reach in delivering a reliable, portable and easy to implement electronic data capture solution that works with existing physician workflows. The agreements with Greenway Medical Technologies, Inc., NextEMR, VoiceHIT, and an existing partnership with Allscripts, signal the demand within the physician practice marketplace for a flexible technology that can be used in any care setting to help compliance with Meaningful Use (MU) requirements.”

I think highly of Shareable Ink. I like the concept and think it provides a nice bridge between where we are today and where we need to be. I first mentioned Shareable Ink back in November 2009. It was a good idea then, and it’s a good idea now.

Failure to use “low concentration” alerts properly leads to errors [ISMP Safety Alert]

When I read the headline in the most recent ISMP Medication Safety Alert!Smart pump custom concentrations without hard “low concentration” alerts I didn’t really get it. So what if a smart pump doesn’t stop you from programming “low concentrations”? Well after reading through the article, and the examples, it made perfect sense.

Failing to employ available dose error-reduction software (DERS) as intended and to heed important clinical alerts are common contributors to these errors. In particular, the misuse of custom concentration options (i.e., user must fill in the concentration) that do not employ a hard (requires reprogramming) minimum concentration limit is a prime example. This issue contributes largely to preventable errors with smart pumps given the counterintuitive, inverse relationship between concentration and volume. More concentrated drugs require less volume to deliver a specified dose; less concentrated drugs require more volume to deliver a specified dose. When using “fill-in-the-blank” custom concentrations, the concentration must be programmed into the pump so it can calculate the volume needed to deliver the prescribed dose. If the programmed concentration is lower than the actual concentration in the infusion bag or syringe, the pump will deliver an overdose. If the programmed concentration is higher than the actual concentration in the bag or syringe, the pump will deliver an underdose. Without a hard minimum concentration limit, the former scenario has led to life-threatening events, such as those described below.

Here’s a great example from the article that made the light bulb go off in my mind:

A physician prescribed IV HYDROmorphone 20 mg/100 mL (0.2 mg/mL) to infuse at 2.5 mg/hour. In this hospital, the standard concentration for this infusion was 0.1 mg/mL, so the custom concentration of 0.2 mg/mL had to be entered into the smart pump. The nurse selected the custom concentration option then mistakenly entered 2.5 mg/100 mL as the concentration instead of 20 mg/100 mL. Given the erroneously programmed concentration of 0.025 mg/mL, the pump issued a soft (can be overridden) low concentration alert. The nurse overrode the warning, mistakenly believing the warning was inconsequential. Based on the erroneous concentration, the smart pump infused the drug at a rate of 100 mL/hour, while the intended rate was 12.5 mL/hour. The pump delivered the entire bag of HYDROmorphone 20 mg to the patient in 1 hour.

#HIMSS12 Day 3

Actually Day 3 was yesterday, but I’m just now getting around to putting some thoughts on paper.

Best session I attended was Care Coordination in Practice: Managing Data Volume and Data
. 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.


#HIMSS12 Day 2

Today was the first real day of action for me at HIMSS12. I attended a couple of sessions and spent some time in the exhibitor area. The education sessions I attended were pretty vanilla. The most interesting of them was the first one I sat in on called “Got Smartphones? Leveraging Physician’s Smartphone Usage in HIT”. Rebecca Kennis and Dr. Afzal ur Rehman from UHS Hospitals described their journey toward building an iOS application for physicians to access clinical information from their HIS.

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

#HIMSS12 Day 1

The Healthcare Information and Management Systems Society Annual Conference & Exhibition, i.e. HIMSS12, started today in Las Vegas. Actually a lot of pre-conference stuff started today. I didn’t do much besides get situated, print my registration badge, figure out where everything was, visit the HIMSS bookstore and Social Media Pavilion, etc.

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).

“What’d I miss?” – Week of February February 12, 2011

I haven’t done one of these in quite a while, but thought I’d try to get back in the groove.

It’s been a pretty good week, and as usual there were a lot of things that happened during that time. Not all of it was pharmacy or technology related. Here’s a quick look at some of the stuff I found interesting.

  • The Vow was #1 at the box office last weekend. I haven’t seen it. Instead my wife and I went to see Safe House, which was pretty good. It’s no threat to the Bourne series, but I’d see it again. 
  • I thought this was pretty sticking funny. From Robot Chicken. Pay attention at 0:06 in the video. Quite the conundrum.


  • HIIMSS12 is next week in Las Vegas. This is the first year I’ve been able to attend and I’m excited. This is the most excited I’ve been about attending a conference in a long, long time. I can’t wait to get there. I’m looking forward to meeting some folks that I’ve only talked to virtually. In addition I’ll be attending my first ever HIMSS 2012 Tweetup with HP on Tuesday, February 21. Details can be found here. Cool stuff, dude.
  • It looks like infant Tylenol oral suspension is on the hook again. More than 500,000 bottles have been recalled. It has to do with the flow restrictor. You can read more about it the ASHP News Site. Infant Tylenol suspension has taken a beating over the years. It begs two questions: 1) why can’t people get this right?, and 2) what do we do in the long run if people can never figure it out? Check the video below for instructions on using Infants Tylenol suspension. It’s not that hard people!
  • How far have we really come with smartphone technology? Actually we’ve come a long way, but have you ever gone back and looked at handheld technology over the years? If you have, you’ll know that it’s basically the same. Take a look at this user guide for one of the Sony Clie PDAs (PEG-NZ90). Yes, yes, it’s quite ugly, but look at the manual and evaluate what it can do. Crud, throw in a faster processor, a little more memory and a 4G antenna and I’d use it. The PEG-NZ90 was introduced by Sony in 2003.
  • imageI don’t pay much attention to retail pharmacy, but have you ever seen the ClearRx bottle and labeling system from Target? Brilliant, simply brilliant. Pharmacy bottles have been the same basic design for a long, long time. I applaud Target for doing something different. I still don’t like retail pharmacy, but I think their bottle design is cool.
  • I started using the Cloudring service. I use a lot of cloud-based storage solutions and Cloudring helps me keep certain files synched up between them. It also allows me to easily see all my cloud storage solutions at the same time and move files back and forth. So far I’ve experimented with Dropbox, Google Docs, Box and Evernote. It’s very cool.
  • The Barcode News: “Imagine, instead of a cashier having to handle every item in your cart, or you having to play spin the bottle with your ketchup at the self-checkout, you simply place your items on a conveyor belt where they are automatically scanned by the time they get to the bagging station. This is possible with 360 scanners. As the name denotes, 360 scanners are capable of scanning a product bar code from 360 degrees.” – Yeah, now instead of thinking of these things in grocery stores, think of using them in healthcare so people don’t have to actively scan things.
  • EHR Bloggers: “As part of the treatment plan for a patient who has a critical need to take one or more pills at or very near specified times throughout the day a physician, nurse or perhaps a new kind of specialist will develop a tracking plan.” – Stalker anyone? Just sayin’.
  • I read a lot of articles at the sciencebase website. They make reading about science fun and interesting. Even though it’s not from this week, I love the blurb they did on the shape of snowflakes. “Snowflakes have at their heart a minute grain of dust that was once floating in a cloud, this speck of dust is the nucleation centre around which water vapour from the atmosphere can condense and if it is cold enough crystallise as ice. As with any crystallisation process it follows a symmetry intrinsic to the atoms or molecules from which the crystal is formed. In the case of water, the underlying symmetry is hexagonal symmetry.” Be sure to watch the video on the site that shows some great snowflake images. Beautiful stuff.
  • How much work goes into movie poster design? Too much. Fast Company has an interesting article on The Psychology Behind Movie Poster Designs. It’s interesting to note that I never see a movie based on the poster design. Do you? I typically watch a movie based on whether or not I think it will entertain me. I don’t see a movie for artistic value, or views on “reality”, or political statements, etc. I go to be entertained. I go to escape reality for a couple of hours.
  • Snowboarding at night wearing an LED suite. Quite beautiful.


  • AJHP March 1, 2012 vol. 69 no. 5 405-421 “ Projecting future drug expenditures – 2012”: “For 2012, we project a 3–5% increase in total drug expenditures across all settings, a 5–7% increase in expenditures for clinic-administered drugs, and a 0–2% increase in hospital drug expenditures.” – Why is this important? Because acute care pharmacy budgets can run over $100 Million a year, that’s why.
  • Scientists have conducted the first successful human test with a drug delivery chip. The article appeared in Science Translational Medicine where the authors describes the successful use of a programmable chip loaded with medication and injected into a person. The chip holds several doses of the drug in place until an electrical current is applied, then the drug is released in the quantity specified. I worked on something like this when I was an undergraduate studying chemistry. Of course it was only in a beaker and not using drugs, but I used polyaniline to carry specific molecular entities and release them when current was applied. In our case, it was all or none, but it was cool. I still have my lab books from the experiments. 
  • Picked up a Samsung Galaxy Player 5.0 this week. I love the screen on this thing. Yeah, it’s big, but it’s beautiful. I already synched it with my Google account, which means I instantly had access to all my documents, my music, and of course my email. I also took some time to watch a little Netflix on it and listen to some music via it’s build in FM radio. I plan to take it with me to HIMSS12 along with all my other tech “stuff”. Deciding which of my toys to take on trips is becoming more difficult by the day. 

That’s it folks. I think I’ll keep it short and sweet this week. Enjoy your weekend everyone, and remember “one of the symptoms of an approaching nervous breakdown is the belief that one’s work is terribly important” (Bertrand Russell).

Pharmaceuticals from crab shells

This is pretty cool stuff.

Vienna University of Technology: “Fungi with additional foreign genes have been created at the Vienna University of Technology. They can now turn chitin into pharmaceuticals.

Usually, mould fungi are nothing to cheer about – but now they can be used as “chemical factories”. Scientists at the Vienna University of Technology have succeeded in introducing bacterial genes into the fungus Trichoderma, so that the fungus can now produce important chemicals for the pharmaceutical industry. The raw material used by the fungus is abundant – it is chitin, which makes up the shells of crustaceans."

N-Acetylneuraminic acid (sialic acid or Neu5Ac) is a naturally widespread carbohydrate with several biological functions, including blood protein half-life regulation, variety of toxin neutralization, cellular adhesion and glycoprotein lytic protection. Neu5Ac is also the starting reagent of biochemical derivatives for the synthesis of pharmaceuticals, including antivirals. Basically it’s pretty important, but it’s also very expensive, running about $2600 per gram.

Fortunately the team at Vienna UT uses a genetically altered form of the fungus Trichoderma to help create Neu5Ac from Chitin, which is readily and abundantly available, thus making it a much more cost effective pharmaceutical substrate. Ta-da!

ADR death statistics for the US, 1999-2006 [article]

Here’s an interesting article from the February 2012 issue of The Annals of Pharmacotherpy [Adverse Drug Reaction Deaths Reported in United States Vital Statistics, 1999-2006].1 The most commonly involved drug classes are no big surprise, but it was interesting to note that the incidence of ADR death changed with age, race, and urbanization. I suppose the increase in death rate for ADR with increased age and rural living isn’t that big of a surprise, but the differences among sex and race was unexpected. 


Current Issue Cover

Background: Adverse drug reactions (ADRs) are an important source of morbidity and mortality during medical care.
Objective: To examine the trends in mortality related to ADRs reported through the US vital statistics system since January 1999.
Methods: Demographic characteristics of people reported as dying as a result of ADRs from 1999 to 2006 were evaluated. The National Mortality Statistics database was queried for International Classification of Diseases, Tenth Revision, codes Y40-Y59, which are specific for deaths due to adverse effects of drugs in therapeutic use. The data were subgrouped based on demographic factors to identify important trends. Crude rates were calculated based on incidents per 100,000 population. Odds ratios and 95% confidence intervals for subgroups were calculated by logistical regression.
Results: During the 8-year study period 2,313,902,748 person years were evaluated and 2341 ADR-related deaths were identified. Annual rates ranged from 0.08/100,000 to 0.12/100,000, and rates increased significantly over time at a rate of 0.0058 per year. ADR deaths were significantly more likely in persons older than 55 years. The risk was greatest in those aged 75 years or older (OR 6.96, 95% CI 6.30 to 7.69). ADR deaths were higher among men than women. Rates varied by race and ethnicity and were highest among blacks (OR 1.38, 95% CI 1.23 to 1.54). Geographically, rates varied widely between states. Based on urbanization, rates were highest in extremely rural (non-core) areas (OR 2.05, 95% CI 1.76 to 2.38). The most common drug classes associated with death were anticoagulants, opioids, and immunosuppressants.
CONCLUSIONS: ADR death rates have a clear association with age, race, and urbanization subgroups. Older individuals, males, blacks, and individuals residing in extremely rural areas experienced higher ADR death rates; these findings warrant further study to develop prevention strategies.

  1. Ann Pharmacother February 2012 vol. 46 no. 2 169-175

We’re asking the wrong questions

thoughtful_monkeyA couple of weeks ago I spent the morning with a friend of mine. He also happens to be a pharmacist and the director of a pharmacy IT group for a medium-sized healthcare system. As one might imagine we have similar interests, which means we spend most of our time together talking about pharmacy; where we’ve been, where we’re going, how to make it better, and so on. We both think that pharmacy is moving at a glacial pace when it comes to making important changes and any real change will likely occur long after we’re both retired.

One thing that occurred to us during the conversation was that we always seem to ask the same questions, which always results in the same answers.

  • How do make a process faster [to free up pharmacist’s time]?
  • How do we make a process more efficient [to free up pharmacist’s time]?
  • How do we make a process better [to free up pharmacist’s time]?
  • Etcetera

Continue reading We’re asking the wrong questions