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Administrator
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Registered: ‎02-22-2010
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DDI Alerting Webinar

[ Edited ]

Thanks for joining our webinar with John Horn and Andrew Seger on "Alert Fatigue with Drug-Drug Interaction Software: The Way Forward."

View the on-demand recording or download the slides.

Steve Sklar, PharmD, clinical manager of drug interaction and allergy databases for Wolters Kluwer’s Medi-Span drug information database, will be answering questions on drug-drug interactions for a limited period of time. Have a question for Steve? Post it here and he will do his best to answer your question.

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Posts: 578
Registered: ‎02-22-2010
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Re: DDI Alerting Webinar

[ Edited ]

Here are questions from our live presentation:

 

Q: How is the customized DI database affected when a drug file is imported (ie:FDB; Medispan)?

Q: It seems wrong to expect every individual hospital to create their own set of drug pairs that should alert. Couldn't there be a consensus process of physicians and pharmacists from a variety of institutions to create a "best practice" for alerting in hospitals? Also, I believe that the need for alerts in hospitals (where patients may be monitored differently) should be different than for alerts needed in a community e-Prescribing setting. Your thoughts?

Q: Most of the studies on alert fatigue zero in on the severity parameter; however other filters and attributes are generally available such as levels of evidence/documentation, route specificity, etc. Could you address the importance of implementation of these types of attributes in reducing the alert burden... Why are these attributes generally ignored in the research arena?

Q: You continue to reference customization of the DDI database/alerts.  From a regulatory stand, as relates to HT Meaningful Use, is customization acceptable, if it has been reviewed by an approving body at the specific facility including medical staff buy in?

Q: How do you deal with USPI CrCl data use for DDIs and dosing versus GFR reporting by hospitals.  When will someone agree or consolidate labeling/reporting?

Expert
Posts: 1
Registered: ‎06-22-2011
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Re: DDI Alerting Webinar

Thank you to everyone who has posted questions related to the DDI Alerting Webinar, and thank you to our presenters for their excellent insight on a difficult and complicated topic. I have posted comments below to each of the questions that have been posed thus far on the topic. Each question is noted below, followed by my comments. Thanks again to all who participated in the webinar.

 

Q: How is the customized DI database affected when a drug file is imported (ie:FDB; Medispan)?

 

I can speak to the Medi-Span data and say that each drug interaction (which is maintained at a class level with the capability of including and excluding members) in our newer product offering for DDI screening is based on a static identifier. Incremental data updates to the information would not affect customizations that have already been put into place. Additions of drugs to basic drug files and into drug interaction classes would not affect customizations. One other important aspect related to customization that was not discussed during the webinar is the ability for the data provider to have a method to override a customization when a significant change has occurred in the clinical literature. By a simple change in the data, we can cause a interaction that was previously suppressed, for example, to fire again so that the clinician is made aware of a significant clinical change in the information. At that time, the user can determine again whether the interaction should be suppressed. There are specific criteria which would cause us to override a previous suppression.



Q: It seems wrong to expect every individual hospital to create their own set of drug pairs that should alert. Couldn't there be a consensus process of physicians and pharmacists from a variety of institutions to create a "best practice" for alerting in hospitals? Also, I believe that the need for alerts in hospitals (where patients may be monitored differently) should be different than for alerts needed in a community e-Prescribing setting. Your thoughts?

 

The concept of hospitals creating their own sets of alert pairs is obviously fraught with the issues of time consumption, human resource availability and money. To that end, there have been a number of groups that have attempted to come to a best practices list of interactions, but it is a significantly difficult task in that the needs of users even within the same institution are so variable that it takes significant resources to come to conclusions. Unfortunately, picking important interactions by consensus may be effective in reaching an endpoint, but it also may introduce non-scientific and non-evidentiary aspects such as anecdote and ‘in my experience’ into the equation. Therefore, our approach to the issue is to provide solid clinical data and develop the tools for customization that will help most users or institutions to fine tune their interaction output. Solid clinical data provision rests on solid critical review of the literature, appropriate assignment of available filters and attributes such as severity, documentation level, route, schedule, correct inclusion and exclusion of drugs from interaction classes for specific interactions, etc.

 

I would agree with the overall concept related to the second part of your question that the current state of the art in interaction screening is to use the same basic clinical data for ‘multiple masters’. A good example is a scenario in which a potential absorption interaction might be in play. This information would be important to pharmacists and nursing (via electronic drug administration records) but is of no major concern to the prescriber, thus an interruptive alert for the prescriber would not be needed. A new Medi-Span drug interaction offering allows us to preferentially place (or not place) interactions into the output files that would be incorporated into products with potential use by very different market segments (e.g. CPOE vs retail pharmacy segment) with very different perceived needs. Thus we are effectively suppressing the hit to prescribers but could output the information to pharmacy, for example.

 


Q: Most of the studies on alert fatigue zero in on the severity parameter; however other filters and attributes are generally available such as levels of evidence/documentation, route specificity, etc. Could you address the importance of implementation of these types of attributes in reducing the alert burden. Why are these attributes generally ignored in the research arena?

 

The use of additional filters and parameters for screening beyond the basic data are extremely important in helping to reduce alert fatigue. Examples of these would be levels of documentation as a companion parameter to severity, appropriate setting of thresholds below which the user would not see an interaction hit, use of other attributes such as route and schedule specificity, etc. Unfortunately, implementation features that are important beyond the actual ‘severity’ of the clinical data but that can assist in reduction of the number of alerts are rarely considered. It is my belief, albeit unsubstantiated, that the volume of alerts reported in various publications related to alert fatigue may be artificially elevated because the sole view is placed on the assigned severity of the interaction, when other factors which might be put into play to reduce the volume of alerts have been poorly deployed (or worse yet, not deployed at all). The difficulty in the research environment is that while researchers may be aware that parameters such as documentation level or level of evidence exist, systems need be compared for research purposes in an 'apples to apples' environment, thus other useful parameters that might actually reduce output volume are not considered in data that is gathered for comparison purposes.

 

 

Q: You continue to reference customization of the DDI database/alerts.  From a regulatory stand, as relates to HT Meaningful Use, is customization acceptable, if it has been reviewed by an approving body at the specific facility including medical staff buy in?

 

In the context of “meaningful use,” certified healthcare technology must demonstrate the capability for “those with administrator rights” to “adjust notifications provided for drug-drug and drug-allergy interaction checks”.  As far as I know, the Office of the National Coordinator for HIT (ONC) remains silent in regards to governance and review procedures that should be in place to guide policy decisions made by an enterprise to enact the customization of default DDI content.

 

The following link provides the test procedure as authored by the National Institute of Standards and Technology:  http://healthcare.nist.gov/docs/170.302.a_DrugDrugDrugAllergy_v1.1.pdf

 

 

Q: How do you deal with USPI CrCl data use for DDIs and dosing versus GFR reporting by hospitals.  When will someone agree or consolidate labeling/reporting?

 

With regard to drug interaction screening, we don’t currently use measures of renal function as an input property in our Drug-Drug Interaction checking algorithm. This is a concept that we are actively reviewing at this time along with other physiologic parameters and pharmacogenomic concepts.

 

Dosing in the presence of decreased renal function is based on the renal function parameter reported in the literature or package insert, whether it is creatinine clearance or serum creatinine.  If a hospital or institution prefers to use a different measurement, it is up to that institution to convert the unit of measure using whichever method/formula they have identified as their standard.

 

Within our Medi-Span advanced dosing databases, we typically use creatinine clearance based thresholds as a measure of renal function in the context of screening high or maximum dosages or as a filter when providing applicable order strings for a given mediation.  Use of CrCl for this purpose is done in a manner consistent with drug labeling, consensus guidelines, peer-reviewed literature and applicable references.  We are not aware of standard development organization or regulatory discussion related to conformance standards in regards to the use of CrCl or GFR in the context of clinical decision support rules.

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Re: DDI Alerting Webinar

I am an Independent Pharmacy Consultant and do a lot of MTM out of my own home.  What sources of DDIs are there available on line and which do you recommend?