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Tuesday, September 25, 2018

Clinical Workflow Integration (part 2)

Continuing from my last post, let's look at the various technologies that need to be integrated for medication ordering workflows.
Workflow
  1. The EHR / CPOE System
  2. Clinical Decision Support for
    1. Drug Interactions
    2. Allergies
    3. Problems
  3. BPM drug formulary
  4. Medication vocabulary
  5. ePrescribing
  6. Prescription Drug Monitoring Program portal
  7. the provider's Local formulary
  8. Prior Authorization (for drugs which require it)
  9. Signature Capture (and other components needed for eRX of controlled substances)
Add to that:
  1. Custom Forms
  2. A Workflow Engine (props to @wareFLO)
  3. Integration with drug pricing information
  4. Medication history
Each of these 13 technologies potentially comes from a different supplier. I can count at least a baker's dozen different standards (n.b., If I went to all of the meetings for the SDOs publishing those standards I could do NOTHING else).  Some of these components want to control the user interface.  Nobody supplies all the pieces in a unified whole.  Then as you probably already understand, some of the same technology is also applicable to other workflows: refills, medication reconciliation, medication review, et cetera.  And many of these technologies are also applicable inside information systems used by other stakeholders (pharmacists, payers/PBMs, public health ...).

Many physicians ePrescribing workflows look like the starter house on a quarter acre lot, that then got a garage, and hot tub, a later addition to have more room for the kids, a pool, and then a mother-in-law suite.  There's precious little room for anything else.  That's because, like the starter house, it grew over time without appreciable planning put into all the eventual users and uses in which it is used.

Paper based PDMPs have been around for a long time, electronically for more than a decade, but real time integration into medication workflows didn't really start to occur until about 4-5 years ago, and only in the last few have they become prevalent.  Legislation now requires integration into the physician workflow in several states (with more mandates coming).

ePrescribing of Controlled Substances has been around for a lot less time (first authorized federally in 2010 regulation), but electronic integrations started a bit sooner in many markets than did integration with PDMPs.

Many physicians ePrescribing workflows look like the starter house on a quarter acre lot, that then got a garage, and hot tub, a later addition to have more room for the kids, a pool, and then a mother-in-law suite.  There's precious little room for anything else.

It's time to rethink medication workflows, and rethink the standards.  Just about everyone in the list of stakeholders in the previous post wants to make recommendations, limit choices, get exceptions acknowledged, get reasons for exceptions, et cetera.  And everyone wants to do it in a different (even if standard) way, and to make it easier, just about everyone supplies proprietary data and APIs.

We need to unify the components so that they can work in a common way. We need to standardize the data AND the APIs.  We need to have these things take on a common shape that can be stacked and hooked together like LEGO® blocks*, and run in parallel, and aggregated.  We need to stop building things that only experts can understand, and build them in a way that we can explain it to our kids.

   -- Keith

* Yes, I know it's a tired metaphor, but it still works, and you understood me, and so would a
   six-year-old, making my last point.


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