Computer-Assisted Health
Care Quality Improvement 
Washington University Medical
Informatics Lab / BJC Health System 
MEDICINE
Computer-Assisted Health
Care Quality Improvement
Washington University Medical
Informatics Lab / BJC Health System
MEDICINE
Please describe your application and the information technology used in conjunction
with it. Please keep your language simple and your explanations non-technical.
The Medical Informatics Laboratory at Washington University Medical Center has one principal goal - to improve the quality of medical care by providing health care professionals with the right information at the right time. One of the principal activities of our group is to minimize the occurrence of complications from inappropriate medication administration. Because many different providers can prescribe medications without full knowledge of the consequences of interactions from medications already received, the Laboratory has developed a group of software systems that integrate pharmacy and clinical information. This new software provides pharmacists and clinicians with an additional "safety net" that assures a higher likelihood of safe prescriptions even in elderly patients receiving multiple medications.
Our group uses Sybase database technology to create a clinical data repository comprised of data integrated from disparate hospital-maintained information systems. We work with pharmacists and clinicians on a daily basis to ensure that we obtain all data necessary to improving the likelihood of identifying potential adverse medication orders. The collective knowledge about appropriate drug dosages and potentially dangerous drug interactions is encoded in two expert systems - DoseChecker and PharmADE. These systems are in daily use by Barnes-Jewish Hospital clinical pharmacists. Their use is being expanded to include clinicians ordering medications so that their overall knowledge of potential drug interactions is increased.
Each of our two systems helps patient care in different ways: >DoseChecker monitors the care of patients who receive potentially toxic drugs known to require careful dosing. It applies a set of dosing guidelines developed by local experts to determine if the dosing is appropriate. If the dosage does not fall within established guidelines, an alert is generated. Over a 6 month period, the system screened 28,528 drug orders and detected 2859 potential dosing errors. PharmADE monitors the care of patients by screening for medication orders that might interact with other medications already administered to the patient. Currently, over 120 contraindicated drug combinations are included in the system, and new contraindications can be added within days of their discovery. Reports and alerts are both printed and made available through a web-based interface developed using Sybase's WEB.SQL product. PharmADE detected 110 potentially lethal drug combinations over a 15 month period.
These programs are in daily use by pharmacists throughout our medical center and we believe they enhance patient care and possibly even save lives. Our experience suggests that appropriately applied information technology does not increase the cost of medical care - it lowers these costs and improves as well.
Has your application helped those it
was designed to help? How has it affected them? What are its most important benefits? What
positive impact will your application have beyond its immediate users? Will it change how
others live And / Or work? How will it impact society?
Our system has identified thousands of
potentially damaging drug dosage errors and over one hundred potentially lethal drug
interactions. Although we assume most of these errors would have been identified by
pharmacists and clinicians before harm is done, our providers are comforted by the
existence of another level of "safety net" technology that minimizes the chance
that harm will be done in the increasingly complex atmosphere of modern hospital care. It
can also become a learning tool and allow pharmacists to intervene where a fundamental
drug interaction does not seem to be understood by the practitioner. If the drug
interaction is understood and there is an exception, the exception can be incorporated
into the rule base and the quality of the program is improved.
How did information technology make
this application possible? Describe any new technology used and/or cite innovative uses of
existing technology. For example, did you adapt an old software program to solve a new
problem? Or did you define a problem and develop new technology to solve it?
This application would not be possible without a
set of sophisticated information technology tools that allow for the extraction of data
from stand-alone systems and the incorporation of these data into a single database
designed specifically for quality assurance use. The database design tools provided by
Sybase were especially useful here. Similarly, the technologies to extract data into HTML
format for secure delivery over our health system Intranet could be done with minimal
effort because of the quality of software available to facilitate interaction between
databases and world wide web servers
Is your application unique? Is it
original? How? Is it the first, the only, the best or most effective application of its
kind? How did your application evolve? What is its background?
Our application evolved from a simple graduate
school expert systems project initiated by one of our laboratory's principal programmers
while a graduate student. Her project quickly captured the imagination of a number of
physicians and information technology professionals and became a foundation for a
five-year series of expert systems projects that are contributing to the daily care of
patients in the Barnes-Jewish hospital. The work has been recognized through significant
funding from the National Institutes of Health and the nomination or receipt of several
quality awards. Although many pharmacy information systems allow for drug dosage checking
and drug interactions these systems often are limited in efficacy by their inability to
incorporate age, laboratory findings, and other clinical information that can
greatly affect the recommendation of an appropriate medication. Tightly integrated systems
contribute this information by recording all relevant data in a single, monolithic
architecture.
Our system is unique in that it allows information systems from multiple vendors to be integrated through a common database. The pharmaceutical and clinical knowledge is then represented in rule-based systems or database triggers that operate of this integrated database.
Has your application achieved or
exceeded its goals? It it fully operational? How many people benefit from it? Describe
future plans for the project.
Jim Gray, Director of Pharmacy at Barnes-Jewish
Hospital states , "the DoseChecker project is a model for multidisiplinary,
multi-institutional cooperation and teamwork resulting in measurable improvement to the
clinical care of our patients." Over the past two years, it has become a fully
functional system used by clinical pharmacists on a daily basis. It is withstanding the
evolution of new clinical laboratory and pharmacy systems and it has proven particularly
beneficial as new medications are introduced.
Specific benefits include:
Future plans include work with the Motorola Corporation and BJC system to extend the value of our software through real-time notification systems. Prototypes of these systems will be operational within the next six months and beta deployment will begin by the third quarter of 1998. Our Web-based systems will be extended to provide additional clinical support directly to physicians and other health care providers. We will also be migrating our systems to a real-time decision support mode for pharmacists in other hospitals within the BJC Health System.
What were the most important obstacles
that had to be overcome in order for your work to be successful? Technical problems?
Resources? Expertise? Organizational difficulties?
This project is unique in that most of the
challenges are technical and not organizational. Indeed, the demand among pharmacists and
other clinicians is very high. Our major problems have been maintaining communications
between legacy systems and our database as these legacy systems have evolved and migrated
to products from other vendors.
Other potential difficulties involve resources needed to support this type of system:
Perhaps the greatest reason for success with our project is the continued leadership provided by a tightly united team of physicians, pharmacists, and medical computer scientists. This group has formal meetings every week to review the status of the project and to discuss the addition of additional information concerning drug dosages and drug interactions. Senior leaders from pharmacy, informatics, and the medical service often attend these meetings.
Exhibits
For More Information:
Contact Thomas C. Bailey, MD
Washington University School of Medicine
314-454-8321
tbailey@im.wustl.edu
