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Welcome to St. Abrutis Healthcare *

Welcome to St. Abrutis Healthcare *. A proposed Clinical Decision Support System to improve management o f prescription medications among our elderly patients. * St. Abrutis Healthcare is a wholly owned subsidiary of the MDM- VanHalen International Corporation.

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Welcome to St. Abrutis Healthcare *

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  1. Welcome to St. Abrutis Healthcare* Aproposed Clinical Decision Support System to improve management of prescription medicationsamong our elderly patients * St. Abrutis Healthcare is a wholly owned subsidiary of the MDM-VanHalenInternational Corporation

  2. St. Abrutis Healthcare Catchment area: 241,820 5 rural counties 41,300 Medicare Acute Hospitals: 200 bed 75 bed 30 bed CAH LTC/SNF: 2 >100 bed 3 <50 bed Providers: 64% Primary Care 41% Specialty Care St. Abrutis Healthcare

  3. Elders andADEs Sedation falls Coagulation problems Kidney damage Increased susceptibility to … Leading to … Unnecessary hospitalization Re-hospitalization St. Abrutis Healthcare

  4. Elders andADEs Beers Criteria Potentially Inappropriate Medicataions(PIMs) 1 in 20 adults1 59% of hospitalized patients2 85% discharged from ICU3 In NH, the risk: - HospitalizationOR=1.274 - Death OR=1.464 St. Abrutis Healthcare 1- Bourgeois 2010; 2- Fleming 2008; 3- Morandi 2013; 4- Dedhiya 2010

  5. Elders andADEs At St. Abrutis Healthcare 41,300x13.81ADE /1000 … 569ADEs per year! $1,9831per ADE … $1,130,191 per year! St. Abrutis Healthcare 1- Field 2005

  6. Elders andADEs Using Beers Criteria works … Education  24 – 31% reduction in PIM1,2 Baseline 2% reduction2 Only 2% d/c’ed meds resumed3 St. Abrutis Healthcare 1- Keith 2013; 2- Monane 1998; 3- Garfinkle 2013

  7. CDS toreduce PIMs? Med Rec module Incorporate multiple Med lists Alerting to PIMs Post d/c follow-up visits Improve provider workflow Infuse evidence about Meds St. Abrutis Healthcare

  8. Proposed System Specification St. Abrutis Healthcare

  9. Knowledge Source/ Acquisition/ Representation Beers Criteria Encoded into rules Represented in XML documents Using RxNorm terms St. Abrutis Healthcare

  10. System Architecture St. Abrutis Healthcare

  11. Workflow Integration

  12. Demo Use Case Mary, 72yo with mild dementia, moved to assisted living Slipped, fell last week, was in pain so went to hospital Diagnosed with back strain and spasm, discharged Vicodin 10/500 mg tabs, 1 po q4-6 hr pain Meloxicam 15mg tabs, 1 poqday Cyclobenzeprine 10mg tabs, 1 po TID Mary is back at the office today for her hospital follow-up visit St. Abrutis Healthcare

  13. St. Abrutis Healthcare wishes to thank… The board of MDM-VanHalen International Jenny Alderden Mohammad Aljouaid Justin Clutter Chad Hodge Casey Rommel Teresa Taft

  14. St. Abrutis Healthcare No, really, it’s over, Even the Aclepius fell off - You can stop now.

  15. St. Abrutis Healthcare* Aproposed Clinical Decision Support System to improve management of prescription medicationsamong our elderly patients Handout * St. Abrutis Healthcare is a wholly owned subsidiary of the MDM-VanHalenInternational Corporation

  16. Figure 1 – System Architecture

  17. Figure 2 – Large-scale Workflow Integration

  18. Figure 3 – Outpatient Workflow Integration

  19. References - p1 Bates, D. W., Kuperman, G. J., Wang, S., Gandhi, T., Kittler, A., Volk, L., …Middleton, B. (2003.). Ten commandments for effective clinical decision support: Making the practice of evidence-based medicine a reality. Journal of the American Medical Informatics Association : JAMIA, 10(6), 523–30. Beers, M. H., Ouslander, J., Rollingher, I., Brooks, J., & Beck, J. C. (1991). Explicit criteria for determining inappropriate medication use in nursing home residents. Archives of Internal Medicine; 151(9), 1825-32. Borgeois, F.T., Shannon, M.W., Valim, C, & Mandl, K.D. (2010). Adverse drug events in the outpatient setting: An 11-year national analysis. Pharmacoepidemiology & Drug Safety, 19(9), 901-910. Campanelli, C. M. (2012). American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults: The American Geriatrics Society 2012 Beers criteria update expert panel. Journal of American Geriatrics Society, 60(4), 616–631. doi:10.1111/j.1532-5415.2012.03923.x.American Dedhiya, S. D., Hancock, E., Craig, B. A., Doebbeling, C. C., & Thomas, J. (2010). Incidence, use, and outcomes associated with potentially inappropriate medication use in older adults. The American Journal of Geriatric Pharmacotherapy, 8(6), 562–70. doi:10.1016/S1543-5946(10)80005-4 Field, T. S., Gilman, B. H., Subramanian, S., Fuller, J. C., David, W., Gurwitz, J. H., & Bates, D. W. (2005). The costs associated with adverse drug events among older adults in the ambulatory setting. Medical Care, 43(12), 1171–1176. Hale, L.S., GRifin, A.E., Cartwright, O.M., Moulin, J, Alford, S.J., & Fleming, R.M.. (2008). Potentially inappropriate medication use in hospitalized older adults : A DUE using the full Beers criteria. Formulary, 43(9), 326. Garfinkel, D., & Mangin, D. (2013). Feasibility study of a systematic approach for discontinuation of multiple medications in older adults. Archives of Internal Medicine, 170(18), 1648–1654. Gurwitz, J. H., Field, T. S., Rochon, P., Judge, J., Harrold, L. R., Bell, C. M., … Bates, D. W. (2008). Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting. Journal of the American Geriatrics Society, 56(12), 2225–33. doi:10.1111/j.1532-5415.2008.02004.x Hustey, F. M., Wallis, N., & Miller, J. (2007). Inappropriate prescribing in an older ED population. The American Journal of Emergency Medicine, 25(7), 804–7. doi:10.1016/j.ajem.2007.01.018 Keith, S. W., Maio, V., Dudash, K., Templin, M., & Del Canale, S. (2013). A physician-focused intervention to reduce potentially inappropriate medication prescribing in older people: a 3-year, Italian, prospective, proof-of-concept study. Drugs & Aging, 30(2), 119–27. doi:10.1007/s40266-012-0043-y Kawamoto, K., & Lobach, D. F. (2006). Design, implementation, use, and preliminary evaluation of an UMLS-enabled terminology Web service for clinical decision support. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium, 979. doi:86251 [pii]

  20. References - p2 Lattanzio, F., Laino, I., Pedone, C., Corica, F., Maltese, G., Salerno, G., … Incalzi, R. A. (2012). Geriatric conditions and adverse drug reactions in elderly hospitalized patients. Journal of the American Medical Directors Association, 13(2), 96–9. doi:10.1016/j.jamda.2011.04.006 Monane, M., Matthias, D. M., Nagle, B. A., & Kelly, M. A. (1998). Improving prescribing patterns for the elderly through an online drug utilization review intervention: a system linking the physician, pharmacist, and computer. JAMA : The Journal of the American Medical Association, 280(14), 1249–52. Morandi, A., Vasilevskis, E., Pandharipande, P., Girard, T., Solberg, L., & Neal, E. (2013). Inappropriate medications in elderly ICU survivors: Where to intervene? Archives of Internal Medicine, 171(11), 2011–2013. Nixdorff, N., Hustey, F. M., Brady, A. K., Vaji, K., Leonard, M., & Messinger-Rapport, B. J. (2008). Potentially inappropriate medications and adverse drug effects in elders in the ED. The American Journal of Emergency Medicine, 26(6), 697–700. doi:10.1016/j.ajem.2007.12.007 O’Connor, M. N., Gallagher, P., Byrne, S., & O’Mahony, D. (2012). Adverse drug reactions in older patients during hospitalisation: are they predictable? Age and Ageing, 41(6), 771–6. doi:10.1093/ageing/afs046 Terrell, K. M., Heard, K., & Miller, D. K. (2006). Prescribing to older ED patients. The American Journal of Emergency Medicine, 24(4), 468–78. doi:10.1016/j.ajem.2006.01.016 Terrell, K. M., Perkins, A. J., Dexter, P. R., Hui, S. L., Callahan, C. M., & Miller, D. K. (2009). Computerized decision support to reduce potentially inappropriate prescribing to older emergency department patients: a randomized, controlled trial. Journal of the American Geriatrics Society, 57(8), 1388–94. doi:10.1111/j.1532-5415.2009.02352.x Teymoorian, S. (2011). Association between postdischarge adverse drug reactions and 30-day hospital readmission in patients aged 80 and older. Journal of the American Geriatrics Society, 59(5), 948–950. Yourman, L., Concato, J., & Agostini, J. V. (2008). Use of computer decision support interventions to improve medication prescribing in older adults: a systematic review. The American Journal of Geriatric Pharmacotherapy, 6(2), 119–29. doi:10.1016/j.amjopharm.2008.06.001

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