Medicines Management

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Medicines Management
Guideline Management
Rob Brenninkmeijer, pharmacist Digitalis Rx bv,
Amsterdam
Two systems, one approach
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Digitalis started 20 years ago in the Netherlands
as an enterprise

• for digital pharmaceutical care and medicines
  management by ways of
• Publishing, content management distribution of
  electronic prescription guidelines
• Implementation of electronic guidelines and
  integration in GP prescribing practice
  (Electronic Prescribing System, Prescriptor)
• Production, content management, desk editing
  publication of interactive web workshoptools
  for the rational and transparent selection of
  medicines

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Prescriptor

• e-Prescribing system (EPS) for applying therapy
  guidelines
• Software component bolt on to electronic patient
  record (ePR) systems
• First module ready 1988
• Rudimentary techniques and systems
• Not the end
• Not even the beginning of the end
• Getting doctors to agree (motto when two
  doctors agree, one is not a doctor.)

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Prescriptor

• e-Prescribing system (EPS) for applying therapy
  guidelines
• Software component bolt on to electronic patient
  record (ePR) systems
• First module ready 1988
• Rudimentary techniques and systems
• Not the end.
• Not even the beginning of the end
• Getting doctors to agree (motto when two
  doctors agree, one is not a doctor.)

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Prescriptor-EPS why?

• Development of a road atlas versus a navigation
  system
• Therapeutic network has vastly expanded in the
  last 20 years.
• Printed guidelines not effective, and hard to
  manage
• Digital guidelines flexible and easy to
  maintain higher level of integration in the care
  process
• Autonomy prescriber as the driving force is
  guaranteed
• Regional and/or national implementation of
  electronic medication record of the patient
• Facilitating exchange of medication history of
  the patient between care providers
• GP and pharmacist share a higher level of mutual
  responsibility to prevent medication-conflicts
  and adverse reactions
• GP can process online notifications of traffic
  incidents more efficiently with an EPS!

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First NL article published in 1988
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Prescriptor UK publications
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First introduction in the UK 1993 Prodigy
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Prescriptor revisited

• First phase sponsored by the NHS, however not
  much direct involvement
• Therapy decision tree linked to READ diagnostic
  codes
• Based on translated Dutch Guidelines (Nijmegen
  regional formulary)
• Reasonable balance between technical brilliance
  and daily practice

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NHS takes over..

• Renames Prescriptor UK to Prodigy
• Prescribing RatiOnally with Decision support In
  General practice studY
• Rolled out 1996 1997
• Prescriptor was used as a reference model and
  integrated in three GP-systems
• Pilot worked in a way

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BMJ 1996
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Prodigy Phase II

• Rebuild from scratch in 1997
• Launched around 2000
• Bad, reasonable and good implementations in many
  different GP systems
• Part success - part failure too much top down
• Too little effort in making it work in the field
  not enough bottum up
• Phase III never left the drawing board!
• NHS kept on developing Prodigy guidelines until
  2007
• NHS should have focused on a more bottum up
  implementation instead

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In the meantime.Prescriptor NL

• National sponsored project on national Electronic
  Prescribing System started in 1998
• Prescriptor initially left out of it
• Eventually part of EPS project thanks to active
  lobby of GP user groups
• Connected to 6 major GP-systems and installed
  base of 70 of all GP practices in NL
• Also implemented in combination with all 3 out of
  hours call management systems
• In use in all medical departments of penitentiary
  institutions and within the military services
• Some implementations in large nursing homes

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• Demo

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Anatomy of a Prescriptor Guideline

• The tree

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The IndicationClinical Recommendation
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Connected to a classificatione.g. Read, ICPC,
ICD, SNOMED the trunk
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Therapy SchemeClinical Scenarios the branches
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Therapy Cluster
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Prescription
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FiltersSelection criteria
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EPS-Pyramid
Local
Regional / Transmural formularies STEPSelect
National formulary (e.g. derived from national
guidelines)
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Summary Prescriptor

• Supports goal oriented therapeutic navigation
  within prescribing process from complaint or
  disease to treatment.
• GP is driving force and is responsible for minor
  adjustments
• Supports multisource national, regional and/or
  local prescription formularies
• National guidelines and Patient information
  leaflets
• Integration of a national Drug Dictionary
• Prospective Medication Surveillance is integrated

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Consequences of decision support e-Prescribing

• Prescribing less experience/intuition driven
• Prescribing less spinal driven, adhoc,
  soloistic, but is more conditioned, based on
  mutual professional agreements
• Consensus on therapy guidelines and selection
  procedures of medicines become more rational
  group processes
• The dynamics to issue, maintain, distribute and
  implement guidelines AND to enhance appropriate
  prescribing will increase
• Improved infrastructure / communication chain
  within the domain of pharmacotherapy

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Guidelines and medicines

• root clinical evidence experience
• trunk, branches guideline
• leaves precriptions, medicines

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Medicines Management

• Encompassing the entire way that medicines are
  selected, procured, delivered, prescribed,
  administered and reviewed to optimise the
  contribution that medicines make to producing
  informed and desired outcomes of patient care
• Medicines Management and Guideline Management are
  complimentary!

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Medicines management why

• The present healthcare system faces great
  challenges
• increasing numbers of adverse events
• poor adherence
• increasing numbers of medication incidents
• inadequate communication across the
  primary/secondary care interface.
• Furthermore, expenditure on medicines is one of
  the major cost elements in healthcare.

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Lack of integrated Product Use

• This is identified as a significant element in
  inefficiency of the current medicines management
  system.
• fragmented and dispersed application and use of
  agents within a therapeutic class
• different generics being used
• discontinuity between primary and secondary care
• use of parallel imports in primary care
• confusion for patients, particularly the elderly
• avoidable drug-related hospital admissions

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STEPSelect Northern IrishDutch collaboration

• Incorporated in several approaches
• Medicines governance (policy)
• Integrated Medicines management (prescribing,
  dispensing, procurement)
• Guideline Management

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STEPSelect 4 stages

• STEP I clinical evaluation Evaluation and
  continuous updating of all available evidence
  relating to efficacy, evidence, safety,
  tolerability, ease of use, medical interactions
  and experience is carried out. This pre-selection
  of medicines within a therapeutic class is purely
  based on clinical criteria.
• STEP II risk assessment This phase focuses on
  factors that impact upon the safe use of the
  various products during routine use by patients.
  This assessment is carried out on both the
  packaging and instructions, to minimise
  difficulties for patients and help them safely
  and optimally use their medicines.

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STEPSelect 4 stages

• STEP III budgetary impact analysis This phase
  entails looking at the impact of the use of the
  agents in a therapeutic class on the complete
  healthcare economy, in both primary and secondary
  care.
• STEP IV final procurement The
  procurement model also allows for a radical
  redesign of the medicine tariff based upon
  safety, efficacy and economy. Flexibility is
  built into the process as it does not demand 100
  compliance with the product selections, but
  rather, only requires a reasonable percentage
  compliance (70 80 depending on the group)..

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www.stepselect.com

• Facilitates clinical fase I of STEPSelect
• Online matrix modules by which rational
  considerations are made using review criteria to
  select preferred medicines.
• Process
• collection of literature data
• production of matrix, article and scores
• review by experts, industry and patient groups
• (virtual) workshops with prescribers

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STEPSelect in N-I outcomes

• quality(Q) and safety(S) result in both health
  improvement(I) and better efficiency(E) QSIE
• effectively linking clinical evidence with the
  procurement process resulting in a much more
  integrated, less fragmented approach to medicines
  management that exists in the field of
  communication and decision-making within primary
  and secondary care chains of prescribers,
  suppliers and procurers of pharmaceutical care (Q
  and E).
• evidence based reduction in the incidence of
  hospitalisation due to the inappropriate use of
  medicines (S and I)
• Cost reduction by efficiency improvement that can
  (also) make room for innovative new drugs all in
  all.investments outweighted the costs involved
  (E but.Q, S and I first!!!

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The guideline is patient but the doctor is
not....)

• Lessons learned.
• Allow multisource national and/or regional
  FLEXIBLE implementation of guidelines
• Minimize distance between guideline management
  and medicines management ownership practitioners
• Correct focus, less technique, more
  implementation
• Teaching doctors how to improved use of
  electronic medical records and better ways to
  share information
• Shift from professional-centric towards a more
  interdisciplinary approach
• See the little picture, dont create ONE BIG
  UNIVERSE or pursue a BIG BANG

) free after Joseph Joubert (1754-1824) the
paper is patient but the reader is not.