Presented at Midwest HIMSS Fall Technology Conference - November 12, 2013 http://www.falltechnologyconference.org/

1. Medication Reconciliation
in electronic health information exchange
Presented by: Tomasz Adamusiak MD PhD (
Mary Shimoyama PhD
November 2013
Technology Innovations 1
@7omasz)

2. Conflict of Interest Disclosure
Tomasz Adamusiak
Mary Shimoyama
Have no real or apparent
conflicts of interest to report.
Slide 1

3. Using medication reconciliation to
prevent errors
The Joint Commission. Medication reconciliation. Sentinel event alert. Issue 35. 2006
The process of comparing a patient's
medication orders to all of the
medications that the patient
has been taking.
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4. Aim: avoid polypharmacy
Excessive or unnecessary medications acquired at interfaces of care—when a patient is
admitted to, transferred within, or discharged from a health care facility
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5. Aim: avoid adverse drug events
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6. More complex than it seems
~ 800 000 drug form names
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Acetaminophen with HYDROcodone
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acetaminophen with HYDROcodone
Acetaminophen (Tylenol)
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acetaminophen (Tylenol
Albuterol orders
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Al hydroxide/Mg hydroxide/ simethicone
Azithromycin (Zithromax) 250 mg IVPB daily X 4
(Mylanta)
days
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albuterol orders
List 1
List 2
Azithromycin (Zithromax) 500 mg IVPB once
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azithromycin (Zithromax) 250 mg daily X4 days
CefTRIAXone (Rocephin)
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azithromycin (Zithromax) 500mg once
Codeine
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cefTRIAXone (Rocephin)
Echinacea
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codeine
Furosemide (Lasix)
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echinacea
Ipratropium (Atrovent Neb)
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furosemide (Lasix)
Lisinopril
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ipratropium (Atrovent Neb)
MetFORMIN
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levofloxacin (Levaquin)
Oseltamivir (Tamiflu)
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lisinopril
Ranitidine (Zantac) 150mg
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metFORMIN
Reconcile
Sodium chloride
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oseltamivir (Tamiflu)
Zolpidem (Ambien 5 mg)
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famotadine (Ranitidine /Zantac 150mg)
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7. Meaningful Use Stage 2 Context
§ 170.314 2014 Edition electronic health record certification criteria
45 CFR Part 170, Federal Register/ Vol. 77, No. 171 / Tuesday, September 4, 2012
http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-20982.pdf
4. Clinical information reconciliation. Enable a user to electronically
reconcile the data that represent a patient’s active medication,
problem, and medication allergy list as follows. For each list type:
(i) Electronically and simultaneously display (i.e., in a single view)
the data from at least two list sources in a manner that allows a
user to view the data and their attributes, which must include, at a
minimum, the source and last modification date.
(ii) Enable a user to create a single reconciled list of medications,
medication allergies, or problems.
(iii) Enable a user to review and validate the accuracy of a final set of
data and, upon a user’s confirmation, automatically update the list.
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8. Improve care coordination
STAGE 2 OBJECTIVES AND MEASURES
42 CFR Parts 412, 413, and 495, Federal Register/ Vol. 77, No. 171
http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-21050.pdf
Stage 2 Measure
The EP, eligible hospital or CAH performs medication reconciliation
for more than 50 percent of transitions of care in which the patient is
transitioned into the care of the EP or admitted to the eligible hospital’s
or CAH’s inpatient or emergency department (POS 21 or 23).
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9. Medications will be encoded in a standard
uniform way across all certifed EHRs
§ 170.207 Vocabulary standards for representing electronic health information.
45 CFR Part 170, Federal Register/ Vol. 77, No. 171 / Tuesday, September 4, 2012
http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-20982.pdf
d) Medications.
(1)Standard. Any source vocabulary that is included in
RxNorm, a standardized nomenclature for clinical drugs
produced by the United States National Library of
Medicine.
(2)Standard. RxNorm, a standardized nomenclature for
clinical drugs produced by the United States National
Library of Medicine, August 6, 2012 Release
(incorporated by reference in § 170.299).
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10. Only structured information
allowed in MU 2 Transition of Care
Consolidated CDA
HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation
http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="310965"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"
displayName="Ibuprofen 200 MG Oral Tablet">
</code>
</manufacturedMaterial>
</manufacturedProduct>
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11. Only structured information
allowed in MU 2 Transition of Care
Consolidated CDA
HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation
http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
Medication
RXCUI
Information
<code code="310965"
Template
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"
displayName="Ibuprofen 200 MG Oral Tablet">
</code>
</manufacturedMaterial>
Normalized
</manufacturedProduct>
Drug Name
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12. RxNorm
http://www.nlm.nih.gov/research/umls/rxnorm/overview.html
• Normalized naming system for generic and
branded drugs
• Semantic integration of 12 drug
vocabularies
• Strength + Ingredient + Dose Form
+ Brand name
• FDA Unique Ingredient Identifiers (UNIIs)
• 11-digit HIPAA format National Drug Codes
(NDCs)
© 2013 Medical College of Wisconsin
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13. 12+1 RxNorm sources
http://www.nlm.nih.gov/research/umls/rxnorm/overview.html
1. Anatomical Therapeutic Chemical Classification System
Since 8/13
2. Gold Standard Drug Database
3. Medi-Span Master Drug Data Base
4. Medical Subject Headings (MeSH)
5. Multum MediSource Lexicon
6. Micromedex RED BOOK
7. FDA National Drug Code Directory
8. FDA Structured Product Labels
9. FDB MedKnowledge (formerly NDDF Plus)
10.Veterans Health Administration National Drug File - Reference
Terminology
11.US Edition of SNOMED CT (drug information)
12.Veterans Health Administration National Drug File
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14. RxNorm as its own source
SAB=RXNORM
Normalized drug names, e.g.,
Warfarin Sodium 1 MG Oral Tablet
• Generic drugs
 Ingredient Strength Dose Form
• Branded drugs
 Ingredient Strength Dose Form [Brand Name]
• Generic drug packs
 {# (Ingredient Strength Dose Form) / # (Ingredient Strength Dose Form)} Pack
• Branded drug packs
 {# (Ingredient Strength Dose Form) / # (Ingredient Strength Dose Form)} Pack
[Brand Name]
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15. RxNorm relations
Link concepts that contain the same ingredient or dose form.
You can navigate between an ingredient and a fully-specified drug.
String
Relationship Attribute
String
Acetaminophen 325 MG Oral Tablet
has_tradename
Acetaminophen 325 MG Oral Tablet
[Tylenol]
part_of
Acetaminophen / Diphenhydramine
Acetaminophen
Acetaminophen 325 MG Oral Tablet
[Tylenol]
Oral Tablet
has_dose_form
dose_form_of
Oral Tablet
Acetaminophen 325 MG Oral Tablet
[Tylenol]
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16. The Anatomical Therapeutic Chemical
Classification System with Defined Daily Doses
(ATC/DDD)
http://www.whocc.no/atc/structure_and_principles/
Furosemide
RXCUI: 4603
ATC: C03CA01
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17. RxNorm translation between
American and European standards
Winnenburg R, Bodenreider O. Stud Health Technol Inform. 2013;192:827-31.
Exploring pharmacoepidemiologic groupings of drugs from a clinical perspective.
• Not all drugs in ATC available in US
• Only about half of the ATC drugs can be associated with
drug properties in NDF-RT
• Many drugs not associated with therapeutic intent,
mechanism of action or physiologic effect properties in
NDF-RT
• Not a complete mapping
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18. RxNorm and UMLS release cycles
RxNorm 1+3 weeks
UMLS 6 months
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19. RxNorm reconciliation scenario:
patient on multiple painkillers
200 mg ibuprofen q.d.s.
550 mg naproxen sodium b.i.d.
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20. RxNorm reconciliation scenario:
patient on multiple painkillers
Anti-Inflammatory Agents, Non-Steroidal
N0000175722
200 mg ibuprofen q.d.s.
Ibuprofen 200 MG Oral Tablet
RxCUI: 310965
1036 NDCs
34 branded drugs, e.g., Advil
6 contraindications, e.g.,
asthma
550 mg naproxen sodium b.i.d.
Naproxen sodium 550 MG
Oral Tablet
RxCUI: 849431
225 NDCs
2 branded drugs, e.g.,
Alfaxen
2 contraindications, e.g.,
Pregnancy Third Trimester
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21. Twinlist
Human-Computer Interaction Lab, University of Maryland
User Interface and Visualization for Medication Reconciliation
http://www.cs.umd.edu/hcil/sharp/twinlist/
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22. RxNorm support provided by NLM
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23. MyMedicationList beta
http://mml.nlm.nih.gov/
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24. RxNav – visualizing RxNorm
http://rxnav.nlm.nih.gov/
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25. The Computational Photography
Project for Pill Identification C3PI
http://rximage.nlm.nih.gov/
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26. Our experience at MCW
https://clinminer.hmgc.mcw.edu
user: himssdemo password: himssdemo
Pilot: 1300 patients
31% codes
unable to map
4% unmapped
observations
120k codes total (Epic/MediSpan)
600k Rx entries total
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27. 4% FDA-supplied NDCs
not in RxNorm scope (July 2013)
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28. Practical reconciliation via RxNorm
Part 1 – NDC search
https://clinminer.hmgc.mcw.edu/clinminer#ontology/search/0573-0150-48
user: himssdemo password: himssdemo
NDC: 0573-0150-48
325 TABLET, COATED
in 1 BOTTLE
Pfizer Consumer
Healthcare
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29. Practical reconciliation via RxNorm
Part 2 – Exploration
https://clinminer.hmgc.mcw.edu/clinminer#ontology/term/C0593505
user: himssdemo password: himssdemo
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30. Thank you
This project was funded in part by the Advancing a
Healthier Wisconsin endowment at the Medical College of
Wisconsin and the National Center for Research
Resources and the National Center for Advancing
Translational Sciences, National Institutes of Health,
through grant UL1 RR031973. The content is solely the
responsibility of the authors and does not necessarily
represent the official views of the NIH.
We thank Stacy Zacher, Glenn Bushee, and Bradley
Taylor for their help.
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