Project motivation and technological challenge
The economic and human costs associated with adverse drug effects are one of the major challenges for hospital pharmacies. More than 197,000 deaths are caused in the European Union each year by the misuse of medicines, more than 4% of patients are affected by the misuse of medicines and in 34.8% of cases these problems could have been avoided1.
Caduceus participated in an innovative project for the development and evaluation of a Clinical Decision Support System (CDS) to address these problems by reducing the incidence of adverse effects in hospital pharmacy. The project was carried out by:
- The hospital pharmacy of the Gregorio Marañón Hospital as a clinical part.
- Yerbabuena Software as developers of the clinical decision support system.
- Caduceus Software as interoperability and clinical informatics consultants and integrators of the different systems of the solution.
To be functional, this CDS system required information from multiple hospital information systems, such as
- Hospital Information System (HIS): to obtain patient demographic information.
- Pharmacy Information System (PIS): to obtain information on pharmacy prescriptions.
- Laboratory Information System (LIMS): to obtain information on the results of tests performed on the patient.
The messaging of all these systems had to be received, processed and used for applying specific rules to detect potential risks from adverse effects.
These risks raised alerts in the CDS system that indicated to pharmacy staff about situations that could worsen the patient’s condition, lengthen hospitalization or endanger their life. Such actions can save lives, so the quality and availability of data is very important.
Technical aspects
The integrated systems were:
- HIS provider of information from the census of patients: HP-HIS.
- LIMS provider of test results information: Modulab Gold from Izasa Scientific-WerfenLife for analytical results and Servolab from Siemens for microbiology.
- PIS provider of information on pharmaceutical prescriptions: FARHOS from Visual Limes.
- CDS system as a consumer of the information processed by the integration engine.
Technical information on the messaging involved:
- Patient discharge:
ADT_A28 - Patient modification:
ADT_A08 - Merge of patient EHR:
ADT_A34 - Cancellation of merge of patient EHR:
ADT_A37 - Laboratory results (analytics and microbiology):
ORU_R01 - New pharmaceutical prescription, modification of prescription and cancellation of prescription:
OMP_O09
This messaging made up a volume of about half a million messages per month.
Solution Implementation
The interoperability solution developed by Caduceus consisted of an integration engine based on Mirth Connect. This integration engine had multiple phases for message reception, validation and processing.
For the development of this integration engine was used:
- Mirth Connect version 2.2.2
- PostgreSQL database for messaging tables (tables to store the traceability of integrations), business tables (master tables, patients, clinical records, analytics and prescriptions) and views that provided the information as the CDS system required.
- Integration monitoring system to control the integration activity and alert of possible errors.
Gregorio Marañón University General Hospital
The Gregorio Marañón University General Hospital is a public hospital belonging to the Madrid Health Service, distributed in several buildings. It stands out for its technological equipment and its teaching and research capacity, as well as the high training and qualification of its professionals, being a national and international reference in several specialties.
It is an organization with more than four hundred years of history. It is currently composed of more than 7,500 professionals distributed in a hospital complex with more than 20 buildings, including several health care centers as well as two specialty centers and several other mental health centers.
The high degree of specialization of its professionals, its renowned teaching and research capacity, in addition to its high technological resources, consolidate it as a first-class hospital at national and international level, where a large volume of healthcare activity is carried out.
Source: Hospital Gregorio Marañón website
The integration included a large number of configurable alerts and checks to ensure compliance with information security and quality requirements. Among others, alerts were triggered due to:
- Inactivity for accepted and processed messages.
- Rejected messages (for example, repeated messages).
- Reception of old messaging.
- Messaging with blocked processing.
- Failure to comply with the message processing order.
- Patient census errors.
Conclusions
As a sample of the actual activity of the CDS, the January 2015 statistics are compiled. During this month, 79 interventions were performed due to warnings about adverse drug effects using actual information from laboratory and pharmacy systems.
Of these 79 warnings, 60 were significant, 14 were significant and 2 were for potentially lethal adverse effects. This is a good example of the usefulness of this system in a real environment.