The role of Medi-Span Clinical in international accreditation
“The introduction of Medi-Span Clinical improved our closed-loop medication management, thus assisting us to achieve HISSS EMRAM Level 7 certification,” Dr Pai Peiying of China Medical University Hospital (CMUH) said affirmatively.
To ride on the digitalisation trend, raise the level of medical care and connect with the international community, in April 2017 CMUH accepted HIMSS’ (the Healthcare Information Management and Systems Society) assessment for Electronic Medical Record Adoption Model (EMRAM) and obtained level 6 certification.
At the direction of CMUH Director Zhou Deyang, Dr Pai played a key role in facilitating the assessment process. Dr Pai is the hospital’s Director of General Internal Medicine, Chairman of the Medical Committee and Deputy Director of the Teaching Department. Dr Pai is also responsible for projects such as structuring of hospital medical records and system optimisation.
In early December 2019, after another three-day intensive evaluation, CMUH became the second medical centre in Taiwan and the first in central Taiwan to achieve the highest level 7 of HIMSS EMRAM certification. This certified that CMUH has reached the highest level in information security, closed-loop management of medical operations, smart management and clinical decision-making system, which can safeguard patient safety.
“After passing HISSS EMRAM level 6, the assessment report identified areas that needed to be improved, which were mainly system-related issues,” said Dr Pai. “By “system-related issues”, they generally refer to establishment and optimisation of digital information-based systems. But HIMSS’ focus is actually on how the hospital can improve the flow of information and cut staff workload to reduce human error, improve the quality of care and patient safety.”
Therefore, after referencing proposals from different vendors, CMUH decided to adopt Medi-Span Clinical after considering that Medi-Span Clinical is data-rich, fully functional, and meets HIMSS requirements as well as those of the hospital for system optimisation.
Considerations for adopting Medi-Span Clinical
Of course, “hospitals would have built their own information systems,” recalled Dr Pai. “Just that at the beginning, everything was relatively simple: medical units will explain their requirements to the IT team, who will build the corresponding system. But as the system became more complex, functionalities began to overlap. Subsequent requirements were sometimes not met so as not to conflict with existing functionalities. Coupled with the shortage of IT staff, and busy clinician schedules, issues began to occur with in-house development.”
To construct a complete drug warning system, warning mechanisms including drug interaction, drug allergy, drug-food interaction, dosing range, prescription duplication, cumulative dose, etc. have been planned. However, it was hard to manage with existing manpower. After considering many different solutions, the final decision was made to introduce Medi-Span Clinical.
“Medi-Span Clinical is the best solution to meet the original plan framework,” Dr Pai pointed out, “Including the between drug-to-drug, allergies or food interactions, Medi-Span Clinical’s global database is very exhaustive, and a dedicated editorial team responsible for data collection, organisation and review, as well as system updates. These are features that local hospitals, with relatively limited IT staff and busy pharmacists, cannot match.”
“After passing HISSS EMRAM level 6, we realised the need to look externally, and found Medi-Span Clinical through the pharmacy department. We spent a lot of time evaluating it, and another year to fully integrate it with our existing system. After achieving HIMSS EMRAM level 7, we continuously worked with the Wolters Kluwer team to enhance and optimise the system. Firstly, we integrated the original hospital database with that of Medi-Span Clinical, to compare the hospital’s existing domestic drug information with Medi-Span Clinical’s database. This allows us to obtain more complete information and further reduce risk.”
Reducing Alert Fatigue
“Secondly, and more importantly, we simplified the alert system, to reduce the more general and less serious drug warnings, so as to prevent alert fatigue from affecting clinicians’ work.”
Many new medical devices, such as computerised physician order entry (CPOEs), smart intravenous pumps or heart monitoring devices, now provide clinicians with auditory or visual warnings to prevent and respond to safety risks. However, a 2014 study showed that in a university hospital, physiology monitors in 66 adult intensive care units generated more than 2 million alerts in a month, equivalent to 187 warnings per patient per day. Medical personnel are constantly receiving a large number of alerts, unintentionally leading to the issue of “alert fatigue” and desensitising them to safety alerts.
While it is true that some warnings are clinically insignificant, medical personnel are likely to ignore both informational alerts and emergency alerts that might prevent patient harm. This conversely increases the likelihood of patient harm.
Therefore, it is important that advanced clinical systems can flexibly adapt to the needs of clinicians .
As the Medi-Span Clinical database contains a comprehensive set of medication scenarios, there’s a potential of frequent medication alerts, something that pharmacists found distracting.
CMUH’s IT team and pharmacists then actively communicated with the Wolters Kluwer team, adjusting and simplifying the system adjustments to leave only the more severe and fatal drug reactions and cut down the frequency of warnings. This reduced the clinicians’ alert fatigue.
At the same time, we stepped up efforts to communicate the benefits of Medispan Clinical in reducing medication risks, and assuring clinicians that only highly relevant alerts are given. The efforts paid off and clinicians gradually trusted the system and adapted to the new workflow.
Medi-Span Clinical completes closed-loop medication management
“Most importantly, Medi-Span Clinical assisted us in completing close-loop medication management. HIMSS’s assessment for closed-loop medication management requires the use of automation throughout the process, from the doctor’s prescription, pharmacist’s validation and finally nurse’s issuance of drugs, which will eliminate the possibility of errors in any of those steps,” said Dr Bai solemnly. “The role of Medi-Span Clinical, in addition to issuing alerts to the relevant medical personnel at any step of the process, was also to allow personnel to communicate with each other online with records of multi-party communications captured.”
This is important as sometimes there is inevitably contention between the doctor’s prescription and the pharmacist’s review. In general, doctors should be alert when they write a prescription and Medi-Span Clinical warns of a potential issue. But apart from the most fatal drug conflicts that should never be prescribed, the system will not prevent doctors from prescribing drugs in general. Therefore, if the physician insists, the prescription will be filled and sent for review. The prescriptions will then be sent to the reviewing pharmacist, who will also receive the warning.
Although pharmacists are medication professionals, they are not specialists and are not necessarily familiar with all medications. So when they receive a prescription with a warning, they need to communicate with the doctors. At this point, there are two scenarios: in most cases, Medi-Span Clinical allows pharmacists to respond directly via the system to the doctor. However, if the situation is urgent, the pharmacist may also call the doctor directly to communicate, and note down the call outcomes in the system.
“If phone calls are used frequently to communicate, on one hand it will interfere with physicians’ work, while on the other there is no record of the communications. There will be a lack of clarity if we were to seek accountability in the future. Therefore, in accordance with HIMSS assessment, we encourage colleagues to communicate through the online system as default, so it is easy to track the whole medication process and ensure accountability,” said Dr Pai.
Introduction of advanced systems helps to raise medical personnel capabilities
Besides assisting with closed-loop medication management, the introduction of Medi-Span Clinical has an unexpected but important benefit for hospitals, which is in raising the capabilities of medical personnel.
There are simply too many kinds of drugs on the market today, with countless interactions between them. For young clinicians, there will definitely be drugs that are unfamiliar to them. In the past, clinicians would often refer to the pharmacopeia while prescribing, which took time and effort. However, after the introduction of Medi-Span Clinical, in addition to medication alerts, the system provides certain medication information such as the recommended dose. As a result, besides significantly lowering the barrier to entry for new clinicians, the system allows them to learn medical knowledge through various situations on-the-job.
Also, as compared to the past, there were not as many diseases and knowledge had not progressed as fast. But today, doctors may not necessarily be aware of some new treatment methods and drug knowledge, and thus it is important to have a database which is easy accessible. But it is impossible to build a complete database with the hospital’s existing manpower alone. Compared to other vendors, Medi-Span Clinical’s drug database is not only very complete, but also continuously acquires new databases and updated. Medi-Span Clinical’s data is also reviewed simultaneously by 7,300 clinical experts to ensure data confidence. This is one of the important considerations for the introduction of Medi-Span Clinical by CMUH.
“During this year’s contract renewal process, we decided to introduce the Lexicomp clinical pharmacy database as well, with the main aim for clinicians to further learn about drug prescriptions through more case studies,” said Dr Pai. “Besides searching for knowledge, Lexicomp also support decision-making, through which clinicians can learn how to make decisions. With a knowledge base that exceeds those of teachers, it will be very helpful for students who are keen to self-study.”
“Of course, knowledge is useless without the ability to use it flexibly and correctly, and that depends on the users’ own judgment. This aspect will be complemented by trainings from senior physicians. However, the database will be a great help for students who are willing to self-learn even after they leave class. So the hospital is pleased to purchase such materials to raise the standard of its medical staff.”
Dr Pai also raised that there are in fact many good systems overseas. Although importing them requires a certain cost, he felt that making good use of these advanced and sound database systems will be very beneficial to the growth of Taiwan’s medical institutions and talent capabilities. It would be difficult to reduce the various clinical errors through one’s own strength; it is still necessary to at times learn from others’ best practices to be able to break through restrictions and blind spots.
Overall areas for future system optimisation
Touching on the direction and vision of future hospital system optimisation, Dr Pai said: “Most of the systems introduced now provide information for medical staff to refer to. But we hope that in the future we can strengthen the systems to provide treatment advice proactively.” Some advanced clinical decision support systems used overseas automatically capture medical reports written by physicians, and then based on algorithms, suggest possible causes and the next examination or treatment to be done. Rather than playing a leading role, the system provides physicians with more comprehensive considerations.
For example, in the case of myocardial infarction, when symptoms are in line with typical performance, cardiac catheterisation is usually performed directly. However, there have also been atypical symptoms noted clinically, such as upper abdominal pain or back pain. It may be difficult to detect a link to myocardial infarction just based on the physician’s judgment alone. But backed by a huge database and algorithms, with a machine’s supercomputing power to analyse atypical symptoms and present the probability percentages of the various possible diagnosis, physicians may detect the actual diagnosis earlier.
But of course, even the more advanced systems currently can only manage one or two simple disease diagnosis, and are unable to simultaneously take into account the possibility of a variety of diseases like a physician. However, under the spirit of caring for patients as if they are family, Dr Pai stressed that the direction of system optimisation is based on maximising well-being of patients. He looks forward to a breakthrough in the near future which will bring a new dawn to the medical field.
Photo by ijeab – freepik