Thursday, 26 June 2008

DLM260 and Prescribing Safety

This DLM contains a lot of stuff. We do not yet have it in Glenburn, but given the upset I am not so sure I am looking forward to it!

The 'Prescribing Safety' implementation aspect has come from the Scottish Enhanced Functionality programme - essentially a method the Scottish NHS employs to ensure certain requirements are met by system suppliers or else the Scottish NHS will not pay for their systems. The main aspects of the Prescribing Safety SEF that have caused controversy amongst users are the appearance of a new dialogue asking for a 'Reason for Override' essentially, this against all 'High' level warnings. This is probably dangerous as it risks alert fatigue.

There are some other aspects of the DLM which have led to confusion so I will attempt here to explain medication decision support options to let you, the happy users, tweak the settings for your continued enjoyment and benefit. ;-)


Before we go any further, if you have never discovered the Consultation Manager, Options, Setup screen (accessed with ALT - C - O -S from the keyboard) then now is the time.
Which gets:
And you want to click on the 'Drug Check' tab which, for me (because we have not got DLM 260 yet) looks like this:
But with DLM 260 it is this:
The above screen lifted from the DLM 260 help file, which is available from here.

What has Changed?

Minimum Number of Days for Drug Check

There used to be two options here, as you can see from the original Drug Check form above. The first was for which Clinical Data to use for therapy decision support ('drug check'), and the second for which therapy records to use. They have removed the 'Clinical Data for Drug Checks' option entirely. Previously you could use an option of 'Currently Relevant' clinical data, but I am not sure (and few people seem to be!) what this meant. Now the system will check on all medical history, regardless of whether it is flagged in the system in some way as 'active'. (The only way I can see to flag a medical history item as 'active' is by using problems).

This change may have impacted on what you now see in your drug check warnings, as the system will now be including clinical data in its therapy decision support that it was not doing previously. To be clear, the clinical data checks apply only to Contraindications, Precautions and Prescriber Warnings - this is usefully referred to as 'Condition Checking' in FDB documentation. We have had some e-mail correspondence with clinicians affected by this. This screen shot:
was supplied, the patient being a fit young man. Why the warning? Well, because now ALL medical history is being queried and this man must have something in his history that is triggering the alert. But how do you find that out?? Click on the warning line itself, and it will expand to show you the triggering history.
Now you and I might think that 'Renal Calculus' is a different thing from 'Severe Renal Impairment' and I am sure that people at INPS think this also. I am also fairly sure that First Data Bank (FDB) who supply the drug dictionary and decision support think this is not a great alert either, but right now this is what it does. The other change here is the 'Therapy Data' for drug checks which has had the 'Currently Relevant' option removed and a default time period added. The help file says this:
'We recommend that all users set the date offset to 1 year. On receipt of DLM 260, all users who have an offset date of less than 30 days will be automatically changed to the minimum 30 days offset. For new users, the default Therapy drug check offset date is set to 1 year.'
In Vision 4 I am hoping to use 'Current Medication' as the driver for decision support, because 'Current Medication' is better modelled in V4 than V3 partly due to the different implementation of medication types. For the time being, however, in V3 (and V4) we are using a date offset. So for interactions and drug doubling warnings, Vision 3 will look back at the 'Date' of therapy items and check your newly added item against all items that come within that date range. I do not know at present which 'Date' it looks at, whether that is Date Prescribed, Date Issued, Date Authorised, but hopefully it is taking into account all 3. This screenshot:
shows an alert triggered for drug doubling although the patient last had a co-codamol prescription issued 4 months ago. This is doing what it should, and it is querying all therapy data in the past 1 year for checking for interactions and drug doubling. Again, you can click on the warning line to show the triggering medications:

Contraindications, Precautions, Prescriber Warnings

You can no longer turn these off, and if you had them off then Vision DLM260 will turn them back on for you at the level of 'Patient Specific'. 'Patient Specific' means the system will check all medical history for the patient and see if there are any relevant warnings, like the 'Renal Calculus' one above. The specificity of these warnings is being worked on by FDB (we hope!) so one day soon it will be better. Deciding if a patient has a thing is not as easy as you would think, in computable terms at any rate! You can set these to 'General' and 'all' also.
though I remain unclear as to what a 'general' warning is and still need to see if I can identify in FDB what exactly is going on there. I set mine to 'Patient Specific' and this is fine for me.


They have taken away the option of turning off interaction warnings completely so you must see some of them. In Scotland you cannot only show 'High' warnings in interactions, you must show 'High and Medium'. These are actually level 3 and 4 FDB warnings.
"For Scottish practices, you can select High/Medium/Low, or High/Medium, to display drug to drug interactions, but you cannot select High."
You can in England, you lucky people :) So now we get all the 2 and 3 bar FDB Interaction warnings all the time, and cannot stop them. This is probably not so good, I think.

Drug Doubling

Drug doubling also has had the 'Suppress all levels' option removed, which is OK. You can still set it to Same Action group which is what most clinicians use IME (when they know it is there!).

The Override Confirmation Required Problem

So this setting makes Vision 3 give you an additional screen before being able to add the drug. In Scotland (again, for we are truly blessed) we are not allowed to turn this down to only High warnings. Which I think is the biggest safety risk of all.

We now have logging of overrides, so presumably if the prescriber duly gets into the habit of doing ALT+P for bypassing the warning reason (as they will have to to make the system usable), this is audited. And if it harms a patient, the clinician will carry the responsibility for this but NHS Scotland can state 'We made sure they saw the warnings, so it ain't our fault'.

The paradoxical nature of presenting every warning to busy clinicians who work using heuristic thought processes is that over warning them is dangerous, because it is only when something breaks the pattern that it stands out.

So, I would think that Level 4 FDB warnings and Allergies should require a reason and that should be the interruption to your usual, every day prescribing process that stops you killing folk. This is (almost) what you can set it up for in England. But not in Scotland. So, what shall we do here? I think this is a question we need to take back to NSS / SEF / INPS / FDBE and probably other vendors.

Anyway, the point I am trying to get across to those of you in England is that you do not need to see this 'Add reason' form every time because you can change it in Setup to 'Only High'. Which is quite good, really. You can bypass the override reason with ALT+P or clicking on Proceed. But I think getting into the habit of hitting ALT+P is the way to go. If it is just for high level warnings then entering a reason might even be clinically prudent!

I would be pleased to have Scottish user's comments on the Prescribing Safety SEF (e-mail me), whether good or bad, and I will feed them back via SCIMP to NSS.


There are other aspect to Prescribing Safety that I am not going to discuss here just now, largely because I have to get some paperwork done and have a surgery to do! Download the Help file, it is pretty comprehensive. I am away on holiday for the next 2 weeks so no post to the blog. I am always hopeful that someone else might want to contribute to the site, so please contact me if so and I'll set you up access.


Thursday, 12 June 2008

Consultation Management

This form:

lets you define the attributes of the consultation. If you change the date here then every entry you make will carry that date. Similarly for the selection of a clinician.

Most importantly it also allows you to change and select an appropriate consultation type. This can be done quickly with the keyboard by pressing, repeatedly id needs be, the first letter of the Consultation Type.

Thus, 'S' for 'Surgery Consultation' or 'M, M, M' for 'Medicine Management'. It is good practice to use these types as best you can.

If you don;t want to start a Consultation with the patient, you just want a look at their records, then you can click on 'Cancel' here, which will display the record but not record a consultation against it. Pressing 'Esc' on the keyboard does the same thing.

You decide whether the Consultation Form appears at the end or the beginning of a consultation in Con Man Setup here:

So you can have it on open, close, both or not at all. Which is a matter of choice really, some find it easier at the start and some at the end. Unless you are doing exactly the same task every day with the record, I would recommend you have it appear at least once.

You can also bring the form back up to Update it by double clicking on the status bar on the bottom right of the Patient Record view here:

so if you need to change anything, you can!


Tuesday, 3 June 2008

RHS Advice

Using the Right Hand Side of the prescription for an additional text advice is very useful but has no expiry date, which means it persists for ever more. I always start such advice notes with the Date on which they were added. Then, at least, it becomes apparant that it is out of date or no longer applies when you see it appearing 6 prescriptions later or, worse, copied to the repeat master text.

Expiry date on advice notes would be a good thing IMHO.