APM Final PDF

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Final exam of fifth year apm fall ...

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Marketing (4-5 Questions) 

Marketing: o Social process, where individuals/groups obtain what they need & want through creating/exchanging products/value w/ each other o Selling & advertising is only a piece of big pic  Think beyond this... think about satisfying customer needs o Social Media Marketing o Marketing Mix (4 P’s)  Product:  Different varieties of product  Design, brand, package (Style, name, quality, usefulness)  Reason your customer would want to purchase  Price  Retail price, discount, bonus, Payment Plan, credit Terms  Place/Distribution  Delivery, Retail location, Download, Logistics  Cost-Based Pricing o Cost plus pricing add a mark-up to cost of product  Value-Based Pricing o Based on perceived value of consumer (eg: iphone)  Competition-Based Pricing (Eg: generic medications)  Look out for deceptive practice known as downsizing Promotion  Ads (newspaper, e-magazines, tv), Sales promotions, Public relations, Personal Selling, Sponsorship, Brochure, Emails, Sales call  Strategies: o Push Promotion o Pull Promotion o Market Analysis:  Market Definition 

First step in any market analysisWho are you selling to?  A specific grp of consumers a company aims its products & services  Determines which customers are most likely to buy from you Market Segmentation  Target Marketselect groups w/in the overall market  A strategy where a broad market is divided into specific categories & these categories are separated by common needs, interests, or priorities  include Consumers, Businesses, Countries  Once separated, unique market strategies are designed to target each category Customer Profile/characteristics  Geographic  Demographic  Psychographic characteristics  Socioeconomic factors (income, occupation, & education) SWOT Analysis  Outlines major strengths+weaknesses of proposed business/program & explains opportunities+ threats  Evaluate the internal Strength & Weaknesses o These come from within your company o Even if your business’ market was devoid of competitors, these strengths and weaknesses would still exist  Evaluate the external Opportunities & Threats o These sources originate from outside your company o Even if your business worked perfectly, these opportunities and threats would still exist in the marketplace Competitor Analysis  Understand the characteristics of competitors o Their market share (percentage of the market) o Years in business o Number of customers o Product or niche  Strengths and weaknesses of each competitor 

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o Quality of service o Credentials o Customers service, etc. Marketing Plan  Marketing Strategy o Based on information collected in previous steps of the business planning process you identify the target market and build a plan to capture that market  2 Parts: o Initial Marketing Plan  Promotional activities and market goals for the period right before and immediately after launching the new business o Ongoing Marketing Plan  Long-term plan to address potential market opportunities Sales Strategy  Product, Price, Promotion, Place (distribution channels)

Clinical Informatics in Pharmacy (3-4 Questions) 

Objectives: o Define clinical informatics, including basic theories and principles; o Outline the importance of interoperability and the role of data standards in data sharing; o Summarize some benefits and challenges of using Electronic Medical Records (EMR); o Describe the logic, limitations, and best practices associated with clinical decision support (CDS);

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o Describe various clinical informatics applications, including benefits and unintended consequences of health technologies and workflows; o Summarize various roles of technology solutions, including benefits and limitations, and the importance of design/configuration decisions 

The highest attainable standard of health is one of the fundamental rights of every human being.

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Informatics: o Biomedical informatics is the study of information as it flows through healthcare environments 

Information is a resource you must actively manage, not just a tool you use to complete other tasks

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Not just “computers,” but systems that include people, policies, and culture!

o Clinical informatics emphasis is on the use of information to:

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Improve patient safety

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improve care quality

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(ideally in the most Cost-effective way).

Informatics Theory: o Ackhoff’s DIKW Model  Data(Organization)  Information(Interpretation)  Knowledge(Understanding)Wisdom  Foundation of Evidence Based Medicine o Cognitive Science: Memory  Long-Term Memory: everything you know (Conceptual and Procedural)  Working Memory: what you need to accomplish an immediate task  You can only hold between 5-10 “chunks” of info in Working Memory at any given time. 

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MULTI-TASKING is inefficient, b/ for each task, at least one “chunk” must be devoted to remembering what is needed to complete it!

Interruptions of any kind—including multitasking —disrupt working memory and substantially increase the risk of error. Cognitive Load: measure of how much information is competing for space in your (limited!) Working Memory. 

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Conceptual Knowledge o Internal mental models of the world around you  Information about a domain/topic (like pharmacy) o “How you think the world works”  Procedural Knowledge o How to carry out a process (use a spoon, check your email, prepare chemo)  Note that neither type of knowledge is necessarily “true” or “correct” o Objective, factual knowledge is often used to create both types o "Factual knowledge” is not itself a way that humans arrange information in their brains!  We store things as conceptual and procedural knowledge  Also includes stimuli from the environment (interruptions, alarms, phone calls, physical contact)  Multitasking threatens patient safety  Mental Models o Human Factors  Systems design for human needs, capabilities, and limitations  “Systems” includes computers, environments, policies, and people  Focus is on:  Preventing errors  Recovering from errors when they happen  The right thing should be easy and intuitive  The wrong thing should be difficult  Applied Human Factors Research:  Black Box Warning  Tallman Lettering o Dopamine o Dobutamine  Colored Text 

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In EMR, critical information “face up” o On main screen, not in hover display or mouse click away Medical Records Then and Now o Then:  Single Physician’s Use/Teaching  Legal  Billing  Patient Care o Now:  Patient Care  Billing/Legal  Clinician use/Teaching  Communication across disciplines, practices, facilities 

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Definitions: o CPOE: Computerize Provider (or Physician, or Prescriber) Order Entry system  Advantages:  Reduced Prescribing Errors  Free of handwriting identification problems  Orders reach pharmacy more quickly  Less Look alike sound alike (LASA) errors  Integrated into medical records and decisionsupport systems  Interfaced vs Integrated  Avoid unwanted abbreviation  More likely to identify the prescribing physician  Available for immediate data analysis, including post marketing reporting  Generate significant economic savings  Able to link to ADE reporting systems  Patient specific therapeutic profiles integrated into order entry screens.  Drug interaction warnings  All patient information on every order  Decrease patient identification error  CPOE Effects upon Pharmacy  Rph spend more time thinking clinically o Prescriber calls take longer o Clinical concern vs illegibility  But…

o Same error repeated o Too much info  CPOE: Unintended Consequences:  Error Categories o Used CPOE to determine low/starting dose  Medical residents don’t know how to dose heparin o Used CPOE to determine the range of doses Gaps in antibiotic therapy  Delay in re-approval of antibiotics when only ID prescribers could order/approve o Procedure-linked medications not D/C when procedures are canceled. o Over-dependence on technology  People tend to trust computer instead of “common sense”  Decreased communication  “Stealth Orders”  Most Common Ambulatory Errors facilitated by use of CPOE o Order not routed/received o Wrong dose ordered o Duplicate Orders  E-Prescribing benefits beyond CPO  Prescribers o Eligibility o Electronic delivery to pharmacies o Prescription filling history  Pharmacies o Paperless transactions (no transcription) o Eligibility o Aware of other pharmacy dispense histories  Prescription Monitoring Program (PMP)  Different platform  Limited to controls in Massachusetts for opioid addicts  Pharmacy dispenses: o Paper prescription o ePrescribed prescription o Electronic transmission to pharmacies decreased pharmacy vs. prescriber record discrepancies by about 50% o EHR/EMR  Electronic Health Record/Electronic Medical Record

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Often used interchangeably, although the EHR can contain non-clinical information  System Policies:  o eMAR: Electronic Medication Administration Record o Alert: A system message generated by an EHR, that either warns a provider about a proposed action or suggests a course of action the provider has not yet done  Alerts may “fire” either at time of prescribing or periodically to encourage longitudinal monitoring  Purpose of longitudinal Alerts: Focus limited RPh clincal resources where most needed  Common Drug-related Rule Types that generate alerts  Specific Drug  Drug-Drug  Drug–Allergy  Drug–Lab(microorchemistry)  Drug-Disease  Alerting for Omission of Therapy:  Pay for performance o Incentives if decrease negative outcomes  Accountable Care Organizations (ACO) o Capitation: Fixed payment for patient population  Reimbursement based upon quality of care (metrics, outcomes) o If you don’t document, it didn’t happen  However… diagnosis related alerts often fail 

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Alert Fatigue:  Usually the result of too many inappropriate alerts o WHY? Alerts are constructed using rule-based, programmed Procedural Knowledge as a way to mimic Conceptual Knowledge!  After receiving too many alerts, the provider ignores and/or overrides them. o WHY? Because they create excess Cognitive Load!  Decreases and possibly eliminates the safety gains expected from use of technology o WHY? Because interruptions (alerts are interruptions!) add to Cognitive Load by disrupting the 5-10 chunks of information held in Working Memory!  Managing Human Factors: Avoid Alert Fatigue

o Inhibiting alert fatigue o Turn off insignificant alert  Drug/Drug  Increase trigger values o Make alerts smarter  Add logic about diagnosis  Remember alert was overridden in future (pt specific) o Graded Alerts:  Some alerts are passive, others require a response o Regular monitoring of alert rates with rule adjustments 

Interoperability: o How do you transmit information between different systems/ users? o The Ideal: Integrated Pharmacy/Medication Management o Standards: the key to interoperability  Data Standards for Different Functions:  HL7  Standards for the exchange of clinical data (information transmission standard)  SNOMED-CT  Clinical terminology standard used for patient care  ICD-10  Clinical terminology standard most frequently used for billing  NCPDP (National Council for Prescription Drug Programs)  Specific data interchange standards for pharmacy, including ePrescribing and reimbursement  RxNorm  Ingredient-based naming standard for branded and generic U.S. Drug Products

o Interfaced:  Data shared between two independent systems

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Best functionality/user interface for needs of each group of users aka “Best of Breed”  Limited by interoperability constraints; may require reentering data in multiple places  Data might only flow one way (in or out)  Multiple log-ins to different systems  Changing one system may break the interface to other systems  If one system crashes or has a downtime, usually not all systems are down.  Individual systems can function independently Integrated:  One total system with subsystems (CPOE, pharmacy, eMAR, lab, etc.)  Easier viewing of information across disciplines  Often give up advantages for primary users that you could have had with “Best of Breed”  Everything writes to one database  Single log-in  Changes in one part of the system may affect other areas of the same system  If one sub-system crashes, often everything crashes  Down time planning is more important What’s Stopping us?  Resources  People/Databases store information differently  Everyone’s got an opinion! Informatics Technologies in Pharmacy Barcodes  Are They Replacing RPh Check? ~No  Dispensing from carousels to pyxis to nurse to patient  Kiosk dispensing machines  allowed some small hospitals to dispense drugs without Rph o Not always refilled by RPh  Barcoding won’t prevent errors if not used correctly o Lesson learned from BWH – technicians would manually enter NDC o Unreadable bar codes undermine confidence in BCMA  Ultimately provoke high-risk workarounds  Should barcoding replace RPh check for noncompounded doses?  Barcoding and the 5 Rights:  Correct PT  Correct Drug (dosage form) 

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Key o

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Correct Time Correct Dose: It helps Correct Route: It helps

o eMAR  Electronic Medication Administration Record (or the system that manages them)  Allows for billing at point of administration, not at the point of dispensing  MAR charting in real time  Workflow Problems:  Inflexibility o Orders discontinued but administered  Earlier eMARs won’t allow documentation of dose o Can configure such that rescheduling done only by pharmacy  Qualify Multiple doses or orders o If older dose not charted, scanning may link to older dose or not link to a dose  Urgency o Medication given prior to order written  Can’t be documented  Workflow vs.Policy  Workarounds • “clever, alternative approaches” • Alerts can’t fire if documentation is done later o (ADMs) Automated Dispensing Machines  Cabinets  ATM like convenience and security o Improved “honor system” narcotic boxes o Improve billing accuracy for doses dispensed o Improve pharmacy turn-around time  Drug instantly available to nursing if loaded  Standalone systems o Own medication dictionary  Two Main Settings o Non-profiled machines  All medications available for all patients o Profiled  Choose from a list of drugs active for that patient

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Other drugs unavailable unless on “override list”  Improve safety by limiting access to medications  Profiles based on HL7 interface messages o “Cubie” drawers preferred over matrix drawers  Carousels o Decrease physical space required for storage and access o Improve inventory tracking o Automated ordering o Improve accuracy and speed of drug retrieval  Antidote retrieval o Improve security o Store fastmovers on same shelf  Decrease time spinning o Automated Medication Storage and Retrieval Systems ("pickers")  Box Picker  Pill Picker o Unit Dosing Systems  Unit Dose bulk bottles into patient specific packs  Single Tablet Packs  Individual “dose” packs o Automated IV workflow manager  Creates workflow queues and workload awareness (status board)  Guide the technician through making a dose  Barcode verification of products used and reconstitution diluents  Automated compounding process including calculation (techs don’t have to do calculations)  Require technician to capture images of preparation steps  Supports remote pharmacist verification o “Smart IV Pumps”  Infusion Pumps w/ alerts for abnormally high or low doses/rates  Some studies show that the default setting was it to be “dumb” caused it to be ineffective  Needs to be configured to be “smart” Administrative Applications: o Analytics for Population Health & Business Intelligence 

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Clinical informatics emphasis is on the use of information to 

Improve patient safety

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Improve care quality (in most Cost-effective way)

Information on populations (patients, customers, clinician habits) can be studied in aggregate to improve processes (and, we hope, outcomes). o Population Health:  Every step in every process can (theoretically) be analyzed  Financial incentives tied to documenting measurable impact on populations  Accountable Care Organizations  MACRA (replaces Meaningful Use)reimbursement  Hospitals are being held to prescribing standards per disease 

Medication Safety & Continuous Quality Improvement (4-6 Questions) 

Quality Related Event: o The incorrect dispensing of a prescribed medication that is received by a patient o A variation from the prescriber’s order o A failure to identify & manage

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Types of Errors: o Actual errors o Potential Errors 

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Under staffing fatigued nurse (vague communication) medication error (similar medication bottle)

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Classification of Dispensing Errors o Mechanical: Take place during the processing of a prescription o Judgmental/Cognitive: Missed DUR review or failure to properly counsel patient are just two examples

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Contributing factors for Med errors o Failed communication 

Illegible handwriting

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Misplaced zeroes or decimal points 

Trailing zero, misplaced decimal point, always use leading zero

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Abbreviations

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Look-A-Like Sound-A-Like drugs

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Auditory mistakes: Echo, clarify

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Confusing or incomplete orders

o Drug-related or device-related problems 

Bar codes can help but pharmacist should still physically check product

o Poor drug distribution practices o Distracting Work environment o Lack of patient information or education o Dose miscalculations o Incorrect drug administration o E prescribing is not bullet proof 

What if an error occurs? o Fill out a QAR report 

Part of each pharmacy’s Continuous quality improvement program

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247 CMR 15.02 *** on exam 

Each pharmacy shall establish a Continuous Quality Improvement Program for the purpose of detecting, documenting, assessing and preventing Quality Related Events (QREs)

o Notify the patient or patient's representative, the prescriber (if indicated in the professional judgment of the pharmacist) and other members of the healthcare team

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Sincere apology

o Directions for correcting the error o Instructions for minimizing the negative impact on the patient o Requirements for Pharmacists who are notified of a QRE 

The pharmacist who has discovered or been informed of a QRE shall immediately provide: 

Notification to the patient or patient's representative, the prescriber (if indicated in the professional judgment of the pharmacist) and other members of the healthcare team

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Directions for correcting the error

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Instructions for minimizing the negative impact on the patient

o Reporting Mechanism 

Identify problem areas so appropriate measures may be implemented

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Provides a detailed report for further review by legal department, pharmacy manager/supervisor, and the Board of Pharmacy

o QAR: 

Demographics

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Prescription Information

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Type of incident

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Who notified you of the incident
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