Funding for Health IT is at an all-time high and new “experiments” are announced almost daily. Just in March, Microsoft sold Watson Health “assets”, which included Micromedex, to Francisco Partners and acquired Nuance. And Google announced a new partnership between Google Health and Meditech to “jointly work on an integrated clinical solution.” Some may recall that in 2008, the main objective and raison d’être for Google Health was to “unite digital health records and data.” This was dropped four years later.
Is it time to invest in clinical-centric approaches from organizations that have a proven commitment to improving healthcare decisions and patient outcomes?
The principles of clinical-centric IT approaches
When it comes to drug reference and clinical decision support (CDS) technology, clinicians should be able to trust the solutions they refer to every day and see the value they’re getting right away, without further burdening their workflow. If you ask them what the standard should be for these solutions, they almost invariably come back to the same four global principles: accuracy, applicability, accessibility, and interoperability.
For healthcare leaders, IT and technology solutions are very expensive. But not getting the right information at the point of care is a major safety risk and can mean life or death for patients. Investing in clinical-centric IT approaches that rely on stakeholders with a proven commitment to better care decisions can make all the difference.
New evidence is constantly published, but it’s not all equal, meaningful, or applicable. And, just like healthcare data, the clinical evidence and guidelines that underpin the practice of evidence-based medicine change over time.
In July 2021, researchers at the Jameel Clinic at the Massachusetts Institute of Technology worked with Stat News to understand if popular algorithms for sepsis detection held up over time. Three algorithms were tested at three-year intervals on a database of 40,000 patients admitted to intensive care units at Beth Israel Deaconess Medical Center between 2008 and 2019.
The result? According to the Stat article, “Instead of transforming care, the algorithms withered in the face of fast-moving clinical conditions — unable to keep up with the pace of change. Their frailty exposes gaping holes in the governance of products whose quiet deterioration in hospitals around the country threatens to mislead doctors and undermine patient safety.”
This means that the content in these solutions should be subjected to a rigorous development and maintenance process for accuracy and reliability over time. That process can only be done by medical and pharmacy doctors who:
- Have a firsthand experience in clinical practice
- Are trained to understand the different types and quality of evidence
- Are trained to write clinical recommendations that can then be vetted by independent experts
- Are supported by medical writers trained for digital publication
Nada Al-Qadheeb, PharmD, BCCCP, FCCP, FCCM, is a Clinical Pharmacy Consultant in Critical Care, the Chief of Pharmaceutical Care and Formulary Management Affairs for the Eastern Health Cluster (EHC), which includes 22 hospitals and was the first one organized in the Kingdom of Saudi Arabia as part of the national Vision 2030 plan.
Dr. Al-Qadheeb has also been a consultant for the Lexicomp® editorial team for almost 10 years. She is one of more than 300 expert consultants, many leading specialists and sub-specialists in and outside the U.S., who are regularly called upon by the editors to check on new drug additions and updates from new evidence to existing monographs. These requests are categorized as either urgent or non-urgent.
Of the editorial process, she says, “I know the detail that goes into publishing a monograph. I know the rigor that's behind the content. There are always several internal pharmacy specialists and external consultants reviewing my input, and other specialists focusing on sections like adverse drug events (ADEs) or dosing fields. For us, we’re fighting for Lexicomp.”
The content in Health IT solutions must be contextualized and organized in ways that clinicians know and understand for caregiving, and that goes far beyond publishing drug labels or the evidence.
Nada was first introduced to Lexicomp in 2011, when she was doing her Fellowship in Critical Care Pharmacy at Tufts Medical Center and Northeastern University. Back then, editors were starting to build the Lexi-Drugs Multinational drug database and looking for consultants outside the U.S.
“As a consultant on the Lexicomp content, I’m asked specific questions on the practice for specific medications in Saudi Arabia, what I’d like to add to monographs to reflect current best practices and regional perspective, and what is the underlying evidence for these. The editors then discuss and decide if there is enough to support the addition of new local guidance in the monograph.”
But context is more than localization. When asked the specific types of information her pharmacists need, Dr. Al-Qadheeb cites dosing, renal insufficiency, pediatric dosing, off-label indications, cancer medications, antimicrobial stewardship, IV compatibility, trauma care, and the list goes on.
This level of information is also essential to expanding services and for quality initiatives. For EHC, international accreditations are very important and drug reference content that aligns with these standards are a must-have.
“International accreditations mean that institutions like ours meet or exceed specific quality and safety standards that are globally recognized by our profession. It also brings comfort and confidence to our clinicians and to our patients. Everyone feels safer.”
Having accreditations also help scale research, for example being able to get more clinical trials approved and enroll more patients in, and become affiliated with other hospitals, academic, and research centers.
One year ago, as the Covid-19 pandemic was raging, the King Fahad Specialist Hospital-Dammam (KFSHD) earned the coveted Magnet recognition from the American Nurses Credentialing Center. This came on top of accreditations from the Joint Commission International and others earned by hospitals in the cluster.
To be impactful, drug reference solutions must be used by clinicians at the decision-making time, which varies enormously amongst members of the care team and between different types of organizations. This means that they must be available, within reach (both physically and from a language perspective), and easy to use anytime and anywhere. The full content should be viewable on mobile devices, and available right from the EHRs or other information systems when applicable. Content should be responsive and written for digital and with the mindset of clinicians.
For the past two years, accessibility has been essential. Teams had to adapt to new environments and take on new roles. Dr. Al-Qadheeb recalls, “we had to shift a lot of pharmacists from hospital pharmacies to the Covid centers or to cover the primary health clinics where people with Covid symptoms would go to. We also had many pharmacy technicians help at the vaccination centers, and I worked with other hospital pharmacy directors to make sure we had coverage when staff was sick.”
At a baseline, interoperability is about using solutions that adhere to HL7 and other internationally and locally accepted standards by which they can connect, exchange data, and operate together in one IT ecosystem.
But interoperability is still too often the sole concern of IT leaders, and without clear directives and buy-in at the C-suite level, it sometimes falls off the radar. It’s especially true in the context of limited financial resources, which most hospitals struggle with. This limitation is often exacerbated by misaligned and rigid budgets and IT infrastructure, and a lack of planning based on measurable objectives. Health IT ecosystems and solutions must be planned for measurable quality and operational improvements.
When asked about technology, Dr. Al-Qadheeb echoes what most healthcare leaders go through. “We just hired a new IT lead for the entire cluster for a comprehensive look and coordination of our technology ecosystem. We believe in technology, but it's very expensive and we have competing priorities. And technology needs vary across the cluster.”
Again, she cites the example of KFSHD, the largest of the 22 hospitals in the cluster. There, teams have access to a lot of technology, like the Pyxis™ automated medication dispensing system, which is connected to the information system, Health Information System technology, infusion pumps, barcoding, etc.
Essential drug and clinical decision technology
The first driver for technology planning is safety. And because budgets are strained and priorities are changing, drug reference and CDS technology is sometimes be relegated to the “nice to have” list, and choosing the most affordable option, instead of the proven one, becomes acceptable.
But in Dr. Al-Qadheeb’s mind, there is no doubt. “I know the detail and precision that is put into developing the evidence-based content and guidance in Lexicomp. Every statement is verified. Other drug information tools are not as detailed-oriented. It’s a lot of work and my teams really appreciate and trust that. Practicing without Lexicomp is unsafe and dangerous.”