TownHall: Transitioning from a Fragmented Pharmacy to Simple Semantic Data with Colin Banas, MD
Episode 824th June 2024 • This Week Health: Conference • This Week Health
00:00:00 00:16:39

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Today on Town Hall

I think a lot of us became complacent and it sort of became a check, the box phenomenon in this, new age of interoperability, that we're working on. This is too important to be complacent. This is how patients get hurt. Medications, medication errors, still the number one source of unintended consequences in the clinical setting by and far.

My name is Bill Russell. I'm a former CIO for a 16 hospital system and creator of This Week Health.

Where we are dedicated to transforming healthcare, one connection at a time. Our town hall show is designed to bring insights from practitioners and leaders. on the front lines of healthcare. Today's episode is sponsored by ARMIS, First Health Advisory, Meditech, Optimum Health IT, and uPerform. Alright, let's jump right into today's episode.

 Welcome to this episode of town hall. I am Dr. Mark Weissman, a CIO and CMIO. Today. I've got guest. We have Dr. Cohen bees from Dr. First. He's a chief medical officer. I've known Colin for couple years now, and he's really passionate about this topic of adverse drug events. And that's what we're gonna be talking about today.


Colin. Welcome to the show. Hey, thanks for having me mark.

So if you would give us a little bit about why you joined doctor first and what is you do for them?

Sure. So I joined Dr. First over three years ago as their chief medical officer. And that was after a really long stint, as a CMIO at a academic health system in the Mid-Atlantic.

I was there for over 17 years running the EMR more or less. And actually I was very passionate about medication safety during my tenure. As a hospitalist, as well as a chief medical information officer. And when that came to an end, I had an opportunity to join a pretty innovative company in doctor first that also had a passion in medication safety medication efficiency and data migration.

And so, it, was a natural, sort of next step for my career, if you will. And I haven't looked back ever since.

Fantastic. So as a disclaimer, my company uses the doctor first solution for medications and I didn't pick it actually. It was picked by our pharmacist, For the CIOs out there, they may not understand the extent of the problem here.

So just to put it in perspective, as a doctor, I'm coming into the ed, I'm gonna admit a patient and they've got their medication list. It's perfect. It's on an napkin. I just pick it up the napkin and I look at what they're on and I'm good to go. What could possibly go wrong? I don't have a lot of time cause I got a bunch of more patients that are coming in behind me.

So I'm gonna take a look at it. I'm gonna pick off really what I need and the 20,000 vitamins that they're on. I'm probably gonna skip that part. And I can't really tell if this dose is, are they really taking it twice a day? It says twice a day, but they told me it only taking it once a day. That's close enough.

I'm moving on, but helps you to be done. And what's the consequences of the way I do it.

Yeah. And this is, how patients get hurt. Right? This is sort of, the unintended consequences or the downstream consequences of not getting something as important as the med list or the med rec, correct.

Pretty much at every stage of transition. And so, maybe for that encounter, for the sprained foot or whatnot, maybe it's okay. But there's also the encounter where that patient then makes it upstairs to the inpatient side. And someone doesn't do a more complete medication history.

And, you know, these are real world stories, by the way, the, the anti seizure medication gets left off and now, four days later the patient sees and aspirates and spends two days in the ICU additional, excuse me, two weeks, I should say. . Yeah, the napkin is nice. I would argue that very, very often there is no napkin even.

And so what is wonderful and also a conundrum related to electronic medical records is data. We finally have access to data. I remember, converting to a major EMR in my former role, and finally having that little button off to the left that said, show me some of their fill history.

And that Phil history was a lot of claims data. Back then it was wonderful because, coming from paper, I remember not having any of it, but we quickly realized that that data was often incomplete and it was incomplete in really two ways. One medications could be flat out missing from it, whether it's your herbals or your vitamins that you mentioned before, or more importantly, medications that they didn't fill at a major pharmacy that didn't perhaps participate.

In the data feed. And then the second is the instructions, as you alluded to before, two times a day, or how to take this correctly, the instructions can be missing from claims data because really the claims only care about the NDC number of the drug and the number of pills that went out the door.

So it doesn't have that full set of instructions. So what's so important about MedRec and med history is getting the most complete data that you can and making sure that data lands in the electronic record. Appropriately in the correct format. So that things like drug interaction, drug, allergy, et cetera, and mere can proceed.

And so, your example maybe nine out of 10 times nothing happens, but all it takes is that Swiss cheese, the one med or the one patient or the one error to slip through and it compounds. And this is how people get heard.

I think what I saw when this was done really, really well was when we put pharmacy techs in the ed, no offense to the doctors in the room. And I saw think being, one of them, we can do a great job at this. We usually don't have time to, and there are others who can do it better and probably at a more cost effective rate.

And they're trained to do just this, the pharmacy techs. I think every ed in the world should have pharmacy techs in it for this exact reason, for the complex patients that are gonna be admitted. You need a good, accurate medication history. Is that the best way to do it? Is that what leading organizations are doing?

I just found it to be useful, but is that, what's the standard you're seeing

It is undoubtedly one of the best practices. The problem is it comes , at a cost, , you're effectively throwing FTEs at a really important problem. Now the literature supports you. There are great researchers like Dr.

Jeffrey sniper out of mass general or his partner Dr. Ick out at Cedar Sinai, they study the impact of pharmacy tech or pharmacists on med rec. And undoubtedly, it makes the process safer. Still not perfect, of course nothing is, but, I think a lot of problems you've seen, now that we're coming, hopefully out.

The pandemic is we're still strapped for funds. And a lot of times, especially in academic health systems, as you would know, it's a lot easier to say, we can't get to that right now, but don't worry. We have interns, we have residents, we have nurses, a lot of that stuff continues to fall back.

Downstream , for that really important role, but to your original point. Yeah. There's no doubt that it is best practice to involve pharmacy talent in this process.

So regardless of who's doing it, let's just talk about the data for a second. So the HIE can have some of the data sometimes depending upon your state you may find your electronic health record has pulled it in from some different areas.

You can pick up the phone and call the local pharmacy that the patient uses perhaps, and get some information there. You may have some stuff coming in from some other EHRs that perhaps you have connections with. So I'm find that there's not one place in the chart that I go to and I get my answer.

We've got data. We don't have interoperability by any means. So how's this supposed to work?

There's a couple things and this is really what I, I get really passionate about because I think you're spot on. And you've been doing this just as long, if not longer than I have.

You I'm just, I'm marking that for the record, but that's

We remember not having any semblance of, interoperability. I remember breaking into record rooms as an intern so that I could have the echo for cardiology rounds so that I didn't look like I, didn't know what was going on with my paper, because it was all paper, or calling and getting faxes, which unfortunately still exists a lot of times, but.

We have gotten better as an industry in moving data from a to B it's not perfect by any means. We have a long way to go, but at least there's something, you know, a lot of times, your major EMRs probably have some semblance of CCDs coming in from somewhere or , semblance of interoperability.

The problem that you alluded to is that we still don't have semantic interoperability. So we're really good at moving blob, text or blob information from a to B. But we still haven't sort of figured out how to make sure that the receiving system is getting it the way they need to get it in the format that they can consume it so that the semantics or the context is preserved.

And so, a lot of this is manifest in duplicates. I hear time and time again. I went from having not enough or any data coming over to almost having too much. And a lot of it is junk. A lot of it is duplicates. A lot of it is unstructured. It's almost not even worth it for me to go look at that tab because it's too overwhelming.

I'd rather just start from scratch. And that's, terrible. And so one of our passions at DrFirst and one of the things that we're working on with our AI is removing the duplicates, filling in the gaps of the data when it is missing, but also making darn sure that it is semantically interoperable when you're receiving it so that it comes, you know, if your organization is expecting oral, instead of PO.

It sounds easy, but it's actually, it's not quite, sorted out at the national level. And so that's where solutions like ours can really fit in. So the other thing you pointed out is. Where am I going to get the data? And you're right. There's no one stop shopping for this.

And pharm techs are great, but pharmacy and farm techs, they need access to other data sources as well. And that's why it behooves you to get solutions that can actually amalgamate and combine multiple sources together. Whether it's claims data versus individual pharmacy data versus HIE data, you wanna get all that data together, then you want to de-duplicate it and then get the semantics out of.


 So what does the pharmacy data event work look like? Can a doctor first or any of the companies that are out there, can they get a comprehensive view of the patient? Are we still living in a fragmented world where that little mom and pop pharmacy that's out there may or may not play? How common is that?

What percent of the market can you guys touch, I guess is the best way to ask.

Yeah. And it depends on geography. What in some of the areas that we go touch, they'll get maybe. 70 to 80% of the data, or at least some data on a patient that presents to their organization. And because of the, efforts that we make to combine multiple data sources, especially the mom and pop pharmacies, we actually go out of our way to make those connections.

We can sometimes augment that by up to 20%. So, and that 20% can be patients that you didn't get any data on before. Or it can be portions of medications or even medications themselves that you weren't previously seeing. So your question is, is it still fragmented?

Absolutely. It's still fragmented, unfortunately. And that's where the promise of interoperability and solutions like AI and semantic interoperability really hopefully have a sweet spot to solving this problem.

So, I love to look at the future here and all I want is a medication list as a doctor, right?

It's all the clinicians want, give me a nice clean medication list and then give me off to the side. Say, Hey, here's some things we think they might be on or double check the dose on this one. focus my attention on these three things and I'm outta that med list and able to move on to my next task.

Are we there yet? Are we close to there yet? Where are we at?

I'd say we're getting closer. I think, and I alluded to this earlier. I think the biggest problem now is getting the garbage out of your view whether that's duplicates, whether that's the ZPAC from three years ago, because the problem that we've seen with the quote garbage is that a clinician who is not necessarily really focused in, might add those medication.

Back to the active med list. So, you're actively working against your clinical team because, maybe they stopped the Coumadin a month ago and now you've just added it back in and, fast forward through the admission and discharge. And now the patient's back on a blood thinner that they should have been stopped before.

So I think the promise of interoperability, semantic, interoperability, and data cleansing. Really holds the secret to solving this problem and to giving you the view that you need clinically so that you can sort of do this fast, do this safely and then get along your about your day.

All right.

So Colin, I, I like to end to make sure we keep this somewhat tactical for those practicing CMIOs CIOs. What's the point that you'd wanna get across in terms of this topic? Yeah, I, and yeah. What makes it so important for us?

Well, there's really two things one we've been talking about med rec probably, ever since the joint commission.

So this is pushing 15 years and I think a lot of us myself included became complacent and it sort of became a check, the box phenomenon, like, are we doing med rec on our admissions? Are we doing them in discharge? We put rules in place that make it virtually impossible. to Send a patient out of the hospital or the clinic without proving that you've done a med rec, but it doesn't actually speak to the quality of it.

We have, again, I think complacent is the right word. We, think we've hit a wall from a technical perspective or technology perspective. And so those organizations that can afford it. Taking the next step by throwing FTEs at it that we, so we talked about that pharmacy tax pharma, pharmacy talent, I guess my point is that in this, new age of interoperability, that we're working on.

This is too important to be complacent. This is how patients get hurt. Medications, medication errors, still the number one source of unintended consequences in the clinical setting by and far. And so what I would say to folks out there is don't be complacent on med histories and med rec And don't think that your current solutions are all that is out there. There are actually other sources of data, other ways to skin this cat, if you will. And so it's really too important not to take a look and I'd leave it at that.

Awesome Colin. Hey, thanks for your time today. I really I'd love to connect again with previous CMIOs and, and see where they're at in life.

And now, now a chief medical officer, clearly thriving here. So great to see you again, Colin. Appreciate your time,

mark. Anytime you know me.

Awesome. All have a good one.

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