MEDICATION RECONCILIATION Using PH-Doc June 12, 2012 Presented by Daniel Jensen, Associate Director of Public Health, Olmsted County Deb Castellanos, Technical Manager/Project Manager, Xerox Corporation

Powerpoint and Demo of the “PH-Doc” software Intellectual property of MCCC, powered by Xerox Corp.

Software installed in 28 local public health agencies in South East Minnesota What is local public health in MINNESOTA?

Public Health Documentation System Software application owned and managed by the users long-standing relationship with the developers First program written in 1984 “Re-engineered” several times over 28 years Electronic Chart and Practice Management System

Years “re-engineering for interoperability” when along came the SE Minnesota Beacon Project Community of hospitals, clinics, counties and schools sharing clinical health information Mayo Clinic – GE’s EMR Mayo Health Systems – Cerner’s EMR Olmsted Medical Center – Med3000’s EMR Winona Health – Cerner’s EMR Allina Health – Epic’s EMR 11 counties in SE MN – PH-Doc Health Record 46 school districts in SE MN - PH-Doc Portal

These clinics, hospitals and counties are exchanging clinical data using the National Health Information “NwHIN” specifications and open source software; GATEWAY at each site with the ability to perform peer-to-peer communications Uses SOAP webservices over HTTPS Wraps payload in SAML assertions Includes auditing and logging Enables the exchange of CDA Documents SE Minnesota Beacon Project April 2010 – April 2013

What is a CDA Document? Structured XML document based on the HL7 V3 RIM activities, entities, participants, roles, moods Standard HEADER section patient information, title, date, author, custodian, authenticator Sections of clinical content – preferably structured and coded medications, allergies, problems, immunizations, vital signs, procedures, advance directives, payers, results, plan of care, family history, social history, pregnancy, visit notes, comments

Under the Beacon project … several enhancements were made to PH-Doc o structured medications and allergies RXNORM, UNI, NUI, Snomed o structured CDA documents Summary of Care, Laboratory Studies, Asthma Action Plans Public Health CDA (environmental, social factors, behavioral factors) o live feeds to Regenstrief Institute patient visits and quality of life indicators

Under the Beacon project … infrastructure was added to each county to host its gateway An appliance (from Mirth corporation) was ordered for each of the 11 counties

Mirth Appliance The appliance hosts communication services; SFTP, HTTP, WebServices, LLP … … and includes the Aurion Gateway … ‘open source’ with support

14 Public Health Nurse DMZ PH-Doc Application Server Internet Connect Gateway Patient Correlation Security and Authentication Audits and Logs MIRTH Mayo Clinic Mayo Health Olmsted Medical Winona Health Allina Health

Outgoing REQUEST – one per patient Patient Demographics – used to match at destination site Requestor – name and Role Purpose for request Destination Gateway(s) – based on Release of Information Type of document(s)

Each request becomes a thread Don’t want to tie up the nurse. Depending on number of documents and gateways, could take a few minutes ALERT when the request has finished processing Status of documents that have been pulled Each document stored as XML with stylesheet Each document rendered/stored as PDF Each document parsed for structured data

Parsing the Coded Data.NET shop Used C# and XPATH Specifications from HITSP C32 C83 C80 C154

Parsing the CCD Details from HITSP C80/C83 Structured data elements & code tables To develop our parsing rules 21 Mayo

Parsing the CCD Details from HITSP C80/C83 Structured data elements & code tables To develop our parsing rules 22

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Now that we have parsed data… able to tackle “reconciliation” As defined by the JACHO, medication reconciliation is "the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner or level of care. “

… we’ve done it before … Designed as an INTERACTIVE process nurses working with the patient in the home/school/jail Our first reconciliation screen dealt with IMMUNIZATION data coming from the state of Minnesota’s IMMUNIZATION registry Used a secure webservice to request data. We used the codes we received from the state and mapped to CPT/CVX codes.

Design Standards Side by side presentation of two lists Pink coding identifies information missing from PH-Doc Easy drag and drop (or click multiples and press ARROW) LEFT – incoming dataRIGHT – PH-Doc Chart

Medication Reconciliation Even better …. RXNORM codes Multiple sources More data – dosing, physician, reaction, text Current and History

Medication Reconciliation Nurse works with the patient to reconcile the two lists Sometime multiple sources - pull most recent and show others Pull to current vs pull to history “History” – requires REASON – only text today. Hope to make this more robust, able to share these reasons with clinicians “Too expensive” “Upsets my stomach” “Heard rumors about possible side effects”

Once an accurate medication list has been documented … hopefully all associated with RXNORM codes Time for DRUG-TO-DRUG interactions check

Allergy Reconciliation Same concept for reconciling allergies Request external documents Parse data and store in ‘auxiliary tables’ Present side-by-side Allow external data to be merged with existing data