Internal Med? There's an app for that!
I have dropped off the face of the internet for the past 2 weeks.
As the PGY-1 year winds down, I am 2 weeks into one of the last rotations of the year: internal medicine. Being one of the most intense rotations, I am pretty much devoting ~13 of the 24 hours each day at the hospital. During one of my sleep deprived deliriums, I began to think how healthcare IT/informatics could alleviate or perhaps automate part of my time consuming daily routine.
To put it in perspective, my hospital is certainly not IT-deprived. EHR, CPOE, CDS, BCMA, eMARs, ADHD, ROFL; we have all of those wonderful acronyms available. Everything is electronic. If something has to be written on a piece of paper, that piece of paper will be scanned and made available in the EHR. In addition, we provide comprehensive inpatient and outpatient primary care services. Our outpatient pharmacy uses the same system, so all records regarding the patient are available to everyone involved in their care. So, this pretty much sounds like the technological healthcare utopia we all dream of, right? Not quite...
At 0600 everyday, I come in and do three things first. I check the medicine team roster for patients on our service (usually ~15-20), print their outpatient and inpatient medication profile, a consolidated lab value sheet with a 7 day history, and their microbiology cultures for the past 30 days. Then, I proceed to do a medication reconciliation for every patient. I'll note what meds were new, held, or continued prior to admission or from the previous day. I'll also see if there were dosage changes. As the pharmacist, I am also responsible for all antibiotic stewardship and anticoagulation monitoring (warfarin, etc.).
With this daily routine in mind, here are the major areas where I think informatics can really help streamline the process:
1.) Medication reconciliation
Don't get me wrong, I'm ecstatic that a majority of our patients utilize our outpatient pharmacy, making med rec a lot easier. Medication reconciliation by pharmacists on admission and discharge is a struggle (borderline impossibility) for most hospitals to implement due the variety of sources where patients fill their scripts vs the credibility of their oral history. Even though I don't have that problem, med rec is still ultra time consuming. It takes me about 5-10 minutes/patient to compare the the outpt/intpt lists, note what was new/held/continued/changed, check the doses and adjust them based on renal fx/other lab parameters, and check the appropriateness of each medication (this is a teaching hospital afterall...). For about 15 patients on the daily census, each averaging 15 meds onboard, the entire process can be 75-150 minutes. Obviously, the entire purpose of med rec is to make sure all patients are on the appropriate meds with the correct doses and indication, but the actual comparing between lists can be completed by a detail oriented monkey.
Before my mailbox explodes with hatemail, think about it. All you need are a set of eyeballs to spot differences between the outpt/inpt list. Before we consider hiring the monkey, can't we make the computer do this? Isn't the record electronic?
Let me introduce you to our friend RxNorm. RxNorm, for those unfamiliar, is a standardized nomenclature for characterizing clinical drugs. It is produced and developed by the US National Library of Medicine. Think of it as an NDC, but so much better. It uses semantics and relational tables to describe what a drug consists of, is an ingredient of, has a dosage of, dosage form of, and trade name of, etc. Essentially, it seeks to help achieve interoperability across computerized drug information systems and records. Work at a VA hospital? Don't worry, they got you covered too. Since I'm pretty sure our system already uses this nomenclature, it shouldn't be hard to code a simple program that compares the two medication lists and prints a result of what exactly was new/held/continued/changed. From there, the pharmacist could immediately go into the clinical aspect of the process. This sounds like a much more elegant solution than me having to work with the monkey everyday.
2.) Our hospital is all electronic, why am I printing out all this stuff?! Dashboards and mobile IT.
Our integrated EHR certainly produces a large amount of useful raw data, but it isn't organized very well in the graphic user interface (GUI). As I mentioned earlier, I need to print ~4-5 pages for each patient everyday. After a month of doing this, I think I'll have earned myself a spot on Greenpeace's hit list. The need to print stems from the fact that pertinent lab values are scattered all across many different tabs in the software, and the only way to organize them on one page is to print it. Also, I do not have a mobile-computing-thing (laptop, tablet, etc.) to bring with me on rounds. The entire process can be better streamlined through the use of clinical dashboards. The data is already there; a dashboard is a way to visually aggregate all interested parameters onto one screen. Ideally, each patient would have their own dashboard customized for rounding purposes. It would display their inpt and outpt med lists, cc/hpi, pertinent labs, and recent culture results. An excellent way to display this dashboard would be on a mobile tablet. Perphaps the dashboard could be displayed as HTML on a secure webpage so the output could be standardized on all platforms as long as a browser is available. Of course, HIPAA is always a concern with wireless mobile devices. However, the hospital already has a solution in the form of FIPS 140-2 encryption through supported programs like GuardianEdge. Problem solved.
Dashboards:
Current: a shared .xls to monitor patient data vs. Future: what a clinical dashboard should look like
So there you have it. Between the last two points, the non-clinical time I have to devote to preparing for rounds can be cut down drastically and I'll probably save the lives of about half a dozen trees. The backbone for the implementation of automated medication reconciliation and clinical dashboards is already there; we'd just have to go one step further.
* The above pictures are photoshopped stock photos from http://www.sxc.hu/. We don't actually have a med rec monkey...yet.
*EDIT: I just got an e-mail from someone saying there is indeed an app for internal medicine; it's UpToDate(R). Sadly, I'd have to agree from observing some PGY-1 medicine interns...
