INTEROPen & FHIR
Rose is an 84-year-old woman with hypertension and rheumatoid arthritis. She lives at home on her own and has weekly visits from her daughter, who lives 35 miles away. Rose also receives daily support from a care worker to help with everyday activities.
On Sunday, her care worker becomes concerned because Rose has been feeling unwell, is getting worse, and is now nauseous and confused. The caregiver calls an ambulance, and Rose is admitted to the hospital.
The ED doctor diagnoses a urinary tract infection and prescribes trimethoprim, 200 mg, twice daily for three days. Rose is transferred to an elderly care ward for further observation. Her care worker has confirmed that she takes daily medications but doesn’t have them in her possession. The hospital team has no further clinical information at this time.
While on the ward, Rose further deteriorates, requiring additional clinical intervention. Her general practitioner (GP) confirms that she is taking the following medications:
- Bendroflumethiazide, 2.5 mg, daily
- Lisinopril, 10 mg, daily
- Simvastatin, 40 mg, at night
- Methotrexate, 20 mg, once every Wednesday
- Folic acid, 5 mg, daily except Wednesday
- Paracetamol, 1 g, four times daily when needed
Methotrexate interacts with trimethoprim. Rose’s antibiotic medication is adjusted accordingly, and daily medications for symptomatic control are continued. Rose makes a full recovery in the hospital, but she requires an extended stay due to admission complications resulting from a lack of visibility into the medications she takes at home.
Such scenarios are common. They frequently result in delayed treatment, clinical complications, and extended stays in hospital.
Now, replay this scenario but imagine the patient’s home medications being readily accessible by clinical teams within their TrakCare EPR, on demand and at the point of care, regardless of the time or day of the week. The prescribing error would have been avoided, resulting in a shorter stay in the hospital and with less discomfort experienced by the patient.
England’s National Health Service (NHS) has defined a set of open FHIR APIs for use in all GP Systems, so they can serve up structured and coded medication and allergy data, using Dictionary of Medicines and Devices (DM+D) codes and SNOMED, through identical APIs. The requirement is complicated by the fact that some medications and allergies may not be included, as they are not retrospectively coded, so any consumer of these APIs must handle both coded and uncoded data in a clinically safe way.
In England, InterSystems is a founding member and vendor co-chair of INTEROPen, which includes vendors, NHS provider organizations, social care, central NHS organizations, and standards bodies, who define and drive adoption of open interoperability standards based on HL7 FHIR. INTEROPen runs between four to six hackathons per year, empowering developers from member organizations to test out standards and APIs, which they then use to connect systems based on real clinical scenarios. At the most recent hackathon in July, InterSystems successfully leveraged identical GP Connect FHIR APIs and NHS Spine to integrate TrakCare with two GP systems. NHS Spine serves as a backbone, providing patient demographics and record location. If you provide a patient’s NHS number, for example, NHS Spine will direct you to the GP System that houses the patient’s record.
Using the “Patient Medicines On Admission” data entry screen and the NHS number to connect to the Spine, InterSystems built and demonstrated the ability to automatically find the correct GP record, access the FHIR APIs, retrieve the FHIR data, and use that data to populate the patient’s record in TrakCare. We validated coded medication data and recorded it as a DM+D coded medication with associated display data for the clinician. For uncoded medication and allergy data, we showed we could store this information as free text in the patient record and then allow the clinician to enter it as structured and coded data in TrakCare. A TrakCare Visual Rule, meanwhile, alerted prescribers when an unstructured allergy record was present at the point of prescribing. This ensured that prescribers were fully aware that the usual real-time decision support was provided against this unstructured allergy record.
We are now normalizing this as a product within TrakCare and expect to have it available for our TrakCare 2020 customers in early 2021. England is the first country in the world to have implemented this capability, and TrakCare is, we believe, the first acute EMR to support this.
When customers use this capability, they will be able to achieve the following benefits:
- Timely and precise clerking of medications (and allergies) on admission (MOA)
- Clarity of primary care medications and allergy records
- Removal of transcribing steps
- Actionable MOA that can be continued for Inpatient electronic prescribing and medication administration (ePMA) and medication reconciliation
We are starting to plan the rollout of this capability to our customer base and look forward to providing details of benefits obtained from the key piece of interoperability.
This story originally appeared the November 6, 2020- OnTrak News Flash No.6