Safety Through Enhanced e-PreScribing Tools (STEPStools): Developing Web Services for Safe Pediatric Dosing (Tennessee)

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Summary:

Prescribing medications for children has more complexity than prescribing medications for adults because of the variability in development and physical ability of children. As such, medication errors are a leading reason for childhood iatrogenic morbidity and mortality, in which the medical treatment given is the cause of harm to the child. Current e-prescribing systems have two important gaps which need to be filled to ensure safe prescribing of medications to children: 1) they are unable to automatically round doses, and 2) they do not apply compounded medication knowledge to prescribing. These gaps may inadvertently lead users of e-prescribing systems to under or over dose a given medication, depending on its particular properties. This project sought to create tools to overcome these gaps, and to disseminate those tools once created. The objectives of the project were to:

  • Convene a panel of American Academy of Pediatrics (AAP) and American Medical Informatics Association experts to construct a knowledgebase of actionable data to guide e-prescribing systems in the appropriate rounding of calculated doses and selection of extemporaneous medication formulations.
  • Develop Web services and Web browser client to allow browsing this knowledgebase.
  • Evaluate the usability and content validity of these Web services through a series of pediatric prescribing use-cases, site visits to pilot users, and an examination of the error rate of prescriptions generated with and without the use of these Web services.

The project team successfully developed a knowledgebase specific to medication management for children. The tools created included an algorithm for rounding of medication doses and a compounded medication knowledgebase. The result, called STEPSTools, was integrated into an existing e-prescribing system. Web services were developed so that others could have access to the knowledgebase and to allow distribution of the tools. In the future, the team plans to disseminate the tool and make it publicly available without cost to pediatricians via coordination with the AAP.

Safety Through Enhanced e-PreScribing Tools (STEPStools): Developing Web Services for Safe Pediatric Dosing - 2011

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health IT (IQHIT)
  • Grant Number: 
    R18 HS 017216
  • Project Period: 
    September 2007 - February 2011
  • AHRQ Funding Amount: 
    $1,157,753
  • PDF Version: 
    (PDF, 207.87 KB)

Summary: The Safety Through Enhanced e-PreScribing Tools (STEPStools) project assessed a generally-available knowledgebase for pediatric medication management's impact on quality and safety. STEPStools constructed, pilot tested, and evaluated available tools that provide medication-specific knowledge about dose rounding and extemporaneous formulations necessary for small children. The project also evaluated the effectiveness of using a service-oriented architecture to distribute knowledge, which is an emerging method for knowledge management and dissemination.

The project committed to releasing this database as a toolkit, initially as a dataset available publicly through the Agency for Healthcare Research and Quality, and ultimately through the National Library of Medicine and RxNorm, the drug nomenclature for standardizing the representation of clinical drugs. The project informs the vendor community and general public about the utility of Web services as a tool for knowledge dissemination, and is specifically proposed as a method to distribute clinical decision support. In addition, the American Academy of Pediatrics (AAP) has contributed to this knowledgebase and will enable its availability to e-prescribing developers for many years.

Specific Aims:

  • Convene a panel of AAP and American Medical Informatics Association experts to construct a knowledgebase of actionable data to guide e-prescribing systems in the appropriate rounding of calculated doses and selection of extemporaneous medication formulations. (Achieved)
  • Develop Web services and Web browser client to allow browsing this knowledgebase. (Achieved)
  • Evaluate the usability and content validity of these Web services through a series of pediatric prescribing use-cases, site visits to pilot users, and an examination of the error rate of prescriptions generated with and without the use of these Web services. (Achieved)

2011 Activities: The team completed the analysis of the validity of the rounding tolerances and the degree to which STEPStools recommendations were in agreement with the prescribing practices of practitioners. Due to delays in collaborations with vendors, Dr. Johnson used a 6-month no-cost extension to continue the evaluation through February 2011.

Impact and Findings: The team conducted a concordance analysis using a 24-item survey of test cases to assess the validity of the rounding tolerances and the degree to which STEPStools recommendations were in agreement with the prescribing practices of practitioners. The survey was piloted with 10 subjects and then distributed to a total of 172 pediatricians. Eighty test cases were compared. Of these, there was complete concordance between the recommended dose/formulation and the prescribed dose/formulation for 31, or 39 percent of the cases. Forty-four complete responses were received after six reminders over the course of 3 months, for an overall response rate of 26 percent.

When combined with the data from all test cases, STEPStools either matched or exceeded the performance of the test cases in 46 (84 percent) of the cases where it was able to provide a recommendation. Results confirm that Web services are a feasible knowledge and tool distribution method. Some of the initial findings include the types of information that providers find useful in the tool. For example, the tool scores a variety of answers, starting from the top-choice medication, to one that would not be recommended. The team also learned what information providers think are extraneous.

Interviews were conducted before STEPStools' implementation (environmental scan) and after implementation (summative evaluation) with 11 subjects. The sample of prescribers and prescribing agents consisted of physicians and nurses representing general pediatrics, and three different pediatric specialties who regularly use the e-prescribing system RxStar to generate prescriptions. Users see potential for a tool to assist with rounding, however they would like more flexibility in recommendations, e.g., specific medication schedules and high-dose Amoxicillin. Certain subspecialties prescribe compounded medications more frequently than others; these prescribers found the added compounded medications in the list to be useful.

The project team also increased its understanding of how to link knowledgebases when working with vendors. RxNorm is used as a link between the rounding knowledgebase and the vendor-supplied knowledgebase. The RxNorm creates unique identifiers for the medication name (i.e., Amoxicillin), the routed form of the medication (Amoxocillin Oral), and the dispensable form of medication (Amoxicillin 400 mg/5mL Oral Suspension). Although the unique identifiers were expected to link with other knowledgebases, a number of unanticipated barriers arose. Another finding was that inactive ingredients in compounds are not typically included in RxNorm and are not coded in many vendor systems. Therefore, inactive ingredients are not included in the knowledgebase. Additional work should improve the performance of the rounding algorithm and the number of medications it is able to round.

Target Population: Pediatric*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies. 

Business Goal: Synthesis and Dissemination

* This target population is one of AHRQ's priority populations.

Safety Through Enhanced e-PreScribing Tools (STEPStools): Developing Web Services for Safe Pediatric Dosing - 2010

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health IT (IQHIT)
  • Grant Number: 
    R18 HS 017216
  • Project Period: 
    September 2007 – February 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,157,753
  • PDF Version: 
    (PDF, 408.84 KB)


Target Population: Pediatric*

Summary: The Safety Through Enhanced e-PreScribing Tools (STEPStools) project assesses a generally-available knowledgebase for pediatric medication management’s impact on quality and safety. STEPStools is constructing, pilot testing, and evaluating available tools that provide medication-specific knowledge about dose rounding and extemporaneous formulations necessary for small children. The project also evaluates the effectiveness of using a service-oriented architecture to distribute knowledge, which is an emerging method for knowledge management and dissemination.

The project is committed to releasing this database as a toolkit, initially as a dataset available publicly through the Agency for Healthcare Research and Quality, and ultimately through the National Library of Medicine and RxNorm, the drug nomenclature for standardizing the representation of clinical drugs. The project will inform the vendor community and general public about the utility of Web services as a tool for knowledge dissemination, as proposed in places such as the clinical decision support roadmap. In addition, the American Academy of Pediatrics (AAP) will contribute to this knowledgebase and will enable its availability to e-prescribing developers for many years.

Specific Aims:
  • Convene a panel of AAP and American Medical Informatics Association experts to construct a knowledgebase of actionable data to guide e-prescribing systems in the appropriate rounding of calculated doses and selection of extemporaneous medication formulations. (Achieved)
  • Develop Web services and Web browser client to allow browsing this knowledgebase. (Achieved)
  • Evaluate the usability and content validity of these Web services through a series of pediatric prescribing use-cases, site visits to pilot users, and an examination of the error rate of prescriptions generated with and without the use of these Web services. (Ongoing)

2010 Activities: The validation of the rounding knowledgebase, which provides age-specific dosages for commonly-prescribed medications, continued through 2010. Dr. Johnson and his team created rounding recommendations and presented these recommendations to the AAP. Rounding consensus was reached on approximately 20 medications, after which the rounding knowledgebase was completed.

In order to test the knowledge and rounding algorithm, the team added another testing phase of the knowledge database. The evaluation was not part of the initial proposal but became necessary as the research team realized the challenges associated with selecting a formulation and ideal dose for each patient request. The knowledge and rounding algorithm was tested with a dataset of thousands of completed prescriptions, and the variability between the rounding algorithm recommendation and the approach used by the pediatrician was quantified. Analysis of these differences provided additional information to improve the algorithm. A survey of pediatric providers was completed and providers were presented with a series of case studies to show the results of medication rounding through STEPStools. The providers were asked to agree or disagree with the suggested dose, and to explain why if they disagreed. Each instance of disagreement was reviewed by the project expert panel and resolved.

The ecological survey conducted early in the project informed the process of incorporating STEPStools into the e-prescribing workflow. Throughout the year the research team worked with vendors to tailor the database and integrate its contents into the e-prescribing workflow. Two groups, Office Practicum and Vanderbilt, are contributing to the evaluation of STEPStools. NextGen was originally planned as a partner, but they were not able to collaborate on the required timeline. STEPStools is now live with the Office Practicum and Vanderbilt sites and both vendors are working with multiple practices. Due to delays in collaborations with vendors, the grant received a no-cost extension to continue the evaluation through February 2011.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): The project is on track with 80-to-99 percent of milestones and the budget spending is roughly on target.

Preliminary Impact and Findings: The project team is working on several manuscripts that describe the project findings. These include a manuscript on the rounding knowledgebase and another on the rounding algorithm. A third paper will describe the team’s approach to developing Web services. In addition, several posters are planned.

Some of the initial findings are about the types of information that providers find useful in the tool. For example, the tool scores a variety of answers, starting from the top-choice medication, down to one that would not be recommended. The team learned what information providers find useful, and what is extraneous.

The project team also increased its understanding of how to link knowledgebases when working with vendors. RxNorm is used as a link between the rounding knowledgebase and the vendor-supplied knowledgebase. The RxNorm creates unique identifiers for the medication name (i.e., Amoxicillin), the routed form of the medication (Amoxocillin Oral), and the dispensable form of medication (Amoxicillin 400 mg/5mL Oral Suspension). Although the unique identifiers were expected to link with other knowledgebases, a number of unanticipated barriers have arisen and will be outlined in a planned manuscript. Another finding was that inactive ingredients in compounds are not typically included in RxNorm and are not coded in many vendor systems. Therefore, inactive ingredients will not be included in the knowledgebase.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Synthesis and Dissemination

*AHRQ Priority Population.

STEPStools: Developing Web Services for Safe Pediatric Dosing - Final Report

Citation:
Johnson KB, Gadd Cynthia, Weinberg Stuart, et. al. STEPStools: Developing Web Services for Safe Pediatric Dosing - Final Report. (Prepared by Vanderbilt University Medical Center under Grant No. R18 HS017216). Rockville, MD: Agency for Healthcare Research and Quality, 2011. (PDF, 2.34 MB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
Document Type: 
Population: 

Ensuring Safer Prescribing for Children: AAP Members Funded to Launch the STEPStools Project

PDF: Ensuring Safer Prescribing for Children: AAP Members Funded to Launch the STEPStools Project (PDF, 71.81 KB)
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