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Chapter 1  -  Approaching Clinical Decision Support in Medication Management

The following outlines tasks in the medication management cycle and related CDS opportunities; typical parties responsible for each step in the cycle are listed in parentheses. This outline underpins further discussion on applying CDS to improving medication use and outcomes in this and subsequent chapters.

Medication Selection/Reconciliation (prescriber, nurse, pharmacist)
• Select, for a clinical condition, a medication that is safe and effective, appropriate for a specific patient and circumstance, and available within an organizational formulary. The selection should be based on clinical evidence, best practice, patient characteristics, and cost-effectiveness. ^[2]  The selection process requires access to pertinent patient information (such as clinical history, weight, height and age), as well as pertinent disease management knowledge (for example, evidence-based best practice treatment approaches) and drug information (addressing dosing, side effects, costs, interactions, contraindications and the like).
• Support medication reconciliation with an accurate list of the patient’s medications, along with medication identification and therapeutic use information.

Ordering (prescriber)

• Create a medication order/prescription (ideally linked to the indication) for the patient to take a drug or for the drug to be administered.
• Provide dosing recommendations, ideally specific to patient and clinical condition.
• Conduct automatic checks (or at least communicate reference information when appropriate) for contraindications, duplications, DDIs, drug-lab interactions, clinically significant allergies, right dose/route/frequency.

Verification/Dispensing (pharmacist, pharmacy staff)

• Double check for interactions, appropriateness/contraindications, right dose/route/frequency/timing.
• Match prescription/order to correct dose and dose form.
• Check for proper concentration and volume to minimize pump programming errors, incompatibilities, and dispensing waste — important especially in pediatrics (for example, using 500-mL instead of 1000-mL bags when appropriate, and the like).

Administration (patient or caretaker, nurse, and/or other clinician)

• Make positive medication and patient identification.
• Assess patient and document pertinent parameters (such as blood pressure, heart rate, blood glucose, pain level) prior to administration.
• Check for incompatibilities/interactions, such as between parenteral medications, between medications and foods, etc.
• Recheck right dose/route/frequency, administration technique and timing, monitoring guidelines.
• Provide reminder/guidance when medications are not administered at the appropriate time or are delayed or missed.

Education (patient or caretaker, pharmacist, nurse, prescriber, other clinicians)

• Engage patient in effective medication use; help patient understand how and why to properly take medications (including indication, administration, and desired effects), how to appropriately store and handle medications, and potential adverse effects to be vigilant for and how to address them; ensure patient understanding of information (whether communicated via discussion, handouts, patient portals/kiosks, PHRs, and/or audio/video material and other media). Engage caregiver/parent when needed to support patient.

Monitoring (patient or caregiver, nurse, other clinicians, pharmacist, prescriber, health system)

• Verify proper patient adherence to the medication regimen.
• Anticipate and monitor individual desired and adverse effects, for example, through history/symptoms, examination, and check of appropriate labs with notification of critical labs/adverse effects.
• Track adverse events across populations, for example, (ideally) via robust structured data-reporting system that incorporates medication error taxonomy standards, and updating the patient record with any new allergy/side effect/interaction.
• Provide feedback and input about patient medication use — across care settings — into the medication reconciliation/selection step, and thus help close the medication management loop.

Figure 1-1 illustrates how all the individuals and components of the medication management cycle are connected. It is important to remember these connections going forward to avoid the tendency to isolate key tasks in silos; this approach plagues the traditional medication management process and supports errors and inefficiency. You do not want to create or continue an environment in which people take a narrow view of this interdependent process and respond with, "That’s not my job", or, "The pharmacist or nurse will take care of that", thereby creating a breeding ground for poor outcomes. As we will show in this chapter and in Chapters 3 through 5, well-executed CDS can support knowledge and data flows that help optimize care quality and efficiency throughout this cycle.

Figure 1-1: Medication Management Cycle

© 2009 Healthcare Information Management Systems Society (HIMSS)