Title: Medicines Management
1Medicines Management
Guideline Management
Rob Brenninkmeijer, pharmacist Digitalis Rx bv,
Amsterdam
Two systems, one approach
2Digitalis 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
3Prescriptor
- 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.)
4Prescriptor
- 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.)
5Prescriptor-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!
6First NL article published in 1988
7Prescriptor UK publications
8First introduction in the UK 1993 Prodigy
9Prescriptor 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
10NHS 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
11BMJ 1996
12Prodigy 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
13In 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
14 15Anatomy of a Prescriptor Guideline
16The IndicationClinical Recommendation
17Connected to a classificatione.g. Read, ICPC,
ICD, SNOMED the trunk
18Therapy SchemeClinical Scenarios the branches
19Therapy Cluster
20Prescription
21FiltersSelection criteria
22EPS-Pyramid
Local
Regional / Transmural formularies STEPSelect
National formulary (e.g. derived from national
guidelines)
23Summary 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
24Consequences 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
25Guidelines and medicines
- root clinical evidence experience
- trunk, branches guideline
- leaves precriptions, medicines
26Medicines 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!
27Medicines 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.
28Lack 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
29STEPSelect Northern IrishDutch collaboration
- Incorporated in several approaches
- Medicines governance (policy)
- Integrated Medicines management (prescribing,
dispensing, procurement) - Guideline Management
30STEPSelect 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.
31STEPSelect 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)..
32www.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
33STEPSelect 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!!!
34The 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.