Design and Testing of an EHR-Integrated, Busulfan Pharmacokinetic Decision Support Tool for the Point-of-Care Clinician.

Introduction:

The article written by Susan M. Abdel-Rahman and her colleagues developed a Pharmacokinetic Decision Support Tool (DST) for Therapeutic drug monitoring (TDM) that can be integrated within an EHR.

In the discipline of Therapeutic drug monitoring, drug dosing is payed close attention as underdosing and overdosing to medication with a very narrow therapeutic range.

The software is designed to be throughout the TDM process for the clinical practioners such as physicians, clinical physicians, clinical pharmacologists, clinical pharmacists, nurses, medical laboratory scientists, ect.  Because it is a multi-disciplinary process, an EHR with decision support capabilities can help monitor, capture results, and facilitate the safety and care of patients undergoing TDM.

In addition in recording observation, the DST have predicative capabilities where as with patient vitals and lab results are able to form a good fit model that is matched against the actual lab results.

Discussion:

Integration with EHR using Cerner which encourages different add ons and Apps onto the EHR via “software as link within the EHR.” Since the user never leaves the EHR, the transition from dose simulation to order entry is seamless.  The developers would like to employ a Computerized Physician Order Entry (CPOE), but elected not to until software validation.

The researchers focused on the drug, Busulfan, as it is a commonly used as an “antineoplastic agent commonly used …  to prepare patients for bone marrow transplantation (BMT).” With a narrow therapetuic window, following recommended guidelines are not usually enough to ensure safety and efficacy for the individual patients, which is why TDM is implemented.

“With early and broad stake-holder engagement we developed a clinical DST for the non-pharmacologist. This tools affords our clinicians the ability to seamlessly transition from patient assessment, to pharmacokinetic modeling and simulation, and subsequent prescription order entry”

The paper mentioned that providing training and access to external TDM software was not practical and would also interrupt physician workflow which is why the developers chose to create a DST aimed towards the point-of-care clinician within the EHR.  This would also improve the continuity of care when embedded with an EHR as information is inside a patient’s record.  This would most likely not be the case if they chose to develop a separate application or if providers use a separate software to perform these TDM tasks.

The developers emphasized stakeholder engagement while developing this tool to communicate with care providers to “to draw perspectives from the various providers that are (or would soon be) involved in the TDM process.”

The challenge of their DST is to market and increase usability of such a product outside the “academic center at which the software was developed. As a result, many of these systems have failed to reach a broader audience and, thus, have failed to demonstrate improvements in the process of care or in patient outcomes.” Part of that includes the high technical knowledge in performing TDM, however, it is noted that attempts to “integrate TDM into the clinical care work flow have been pursued for over three decades.”

For a successful TDM Decision Support Tool requires:

1. Knowledge of the Patient

2. A thorough understanding of the pharmacologic principles that drive the relationship between dose-exposure-response

3. Expertise in mathematical and pharmacoknetic modeling and simulations

4. Precise and accurately recorded specimen collection

Implications

“Importantly, Clinical Pharmacologists familiar with pharmacokinetic modeling and simulation remain accessible to the BMT team by pager; however, the clinical team members for whom the patient is their primary responsibility are now the drivers of the TDM activities.”

“The effective TDM-based DST should be designed and vetted by a multi-disciplinary team to ensure that it performs optimally and supports the needs of the end-users. It should also integrate directly into the EHR and intelligently filter, organize, and deliver user-specific information at appropriate times to maximize the efficiency and quality of care that the patient receives (Fuchs et al., 2013).”

The goal of this tool was to increase quality of patient care and to increase collaboration among the care team.  As health care is heading towards that direction where primary care doctors communicate and collaborate with specialists and other care providers.  It was intentional that the development of the tool was focused at the point-of-care and implemented within the EHR because as the primary care doctor would be the one to help coordinate the patient’s healthcare.

Although in its early stages, the developers and collaborators of the TDM DST would want to perform quality assurance and refine the back-end algorithm in accuracy and predictions.

References:

Abdel-Rahman, Susan M., Matthew L. Breitkreutz, Charlie Bi, Brett J. Matzuka, K. Leigh Casey, Uttam Garg, Sara Winkle, J. Steven Leeder, Jeanann , and Brian Rivera. “Design and Testing of an EHR-Integrated, Busulfan Decision Support Tool for the Point-of-Care Clinician.” Frontiers in Pharmacology Front. Pharmacol. 7 (2016): n. pag. PubMed. Web.

Definitions:

Point-of-Care Clinician: Clinical point of care is when clinicians deliver healthcare products and services to patients at the time of care.

Decision Support Tool (DST): Computer-based tools (simulation models, and/or techniques and methods) developed to support decision analysis and participatory processes.

Electronic Health Record (EHR): An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.

Therapeutic Drug Monitoring (TDM): Therapeutic drug monitoring (TDM) is a branch of clinical chemistry and clinical pharmacology that specializes in the measurement of medication concentrations in blood. Its main focus is on drugs with a narrow therapeutic range