PillHarmonics: An Orchestrated Medication Clinical Decision Support Service

项目摘要 与药物有关的不良事件导致200多万人住院，350万名医生 每年的办公室访问。药物决策支持，如果实施得当，可以产生重大影响 在这些数字上，增强了患者的安全性，提高了药物疗效。但虽然药物决策支持是 现在电子健康记录(EHR)中司空见惯，许多问题仍然存在，临床医生通常 对缺乏患者特异性和不适当的用药警报环境感到不满。 除此之外，药物基因警报正变得越来越重要。研究表明，超过 一半的初级保健患者接触到药物基因组学(PGx)相关药物；7%的FDA- 批准的药物和美国每年开出的40亿张处方中的18%受到影响 通过PGx交互作用；到目前为止，近98%的人至少有一个可操作的变体 指导方针。 PGx调查结果最常作为不可操作的PDF报告集成到EHR中。结构化 特定于EHR的解决方案正在出现，几个小组正在试验HL7 FHIR和CDS挂钩 标准。这些工作的一个共同主题是，PGx的实现与其他类型的 用药决策支持，导致警报脱节。多年来，团体一直建议 需要将PGx与其他类型的已识别药物相互作用相结合。有证据表明，这样一种 整体方法可以解决患者的安全问题(例如，通过并列相互冲突的药物建议) 和警报疲劳(例如，通过更高的警报精确度)。 然而，将PGx合并到一个已经存在许多可用性挑战的环境中可能会模糊风险 这类警报的好处。作为回应，该项目旨在开发一种药物决策支持服务， PillHarmonics，将药物-基因相互作用检查与其他类型的药物无缝集成 警示(如药物-药物、药物过敏和药物状况)，从而通过 通过更精确地显示相关警报，最大限度地减少不良药物事件并减少警报疲劳。 在计划中的原型中，PillHarmonics将从模拟的EHR收集FHIR格式的临床数据 通过Hapi FHIR服务器；FHIR格式的基因组数据，在这种情况下来自Elimu的基因组数据服务器；以及药物 知识，在这种情况下，来自第一数据库和PharmGKB。该服务将标识的交互转换为 作为结构化FHIR检测问题公开的标准化数据元素，每个问题一个检测问题 互动。PillHarmonics服务将通过CDS Hooks应用程序进行演示，该应用程序生成 在患者现有药物中添加他克莫司或氯吡格雷时的综合警报 养生法。目标2评估将需要对PillHarmonics算法使用 一种既定的评估工具。

Project Summary Medication related adverse events account for over 2 million hospital stays and 3.5 million physician office visits per year. Medication decision support, when implemented correctly, can have a significant impact on these numbers, enhancing patient safety and improving drug efficacy. But while drug decision support is now commonplace in Electronic Health Records (EHRs), many issues remain, and clinicians are generally unsatisfied with the lack of patient specificity and inappropriate context of medication alerts. Add to this the fact that drug-gene alerts are becoming increasingly important. Studies show that over half of all primary care patients are exposed to pharmacogenomics (PGx) relevant drugs; that 7% of FDA- approved medications and 18% of the 4 billion prescriptions written in the United States per year are affected by PGx interactions; and that nearly 98% of individuals have at least one actionable variant by current guidelines. PGx findings are most commonly integrated into the EHR as non-actionable PDF reports. Structured EHR-specific solutions are emerging, and several groups are experimenting with HL7 FHIR and CDS Hooks standards. A common theme across these efforts is that PGx is implemented apart from other types of medication decision support, leading to disjointedness of alerts. For many years, groups have suggested the need to integrate PGx with other types of identified medication interactions. Evidence suggests that such a holistic approach can address patient safety issues (e.g., by juxtaposing conflicting drug recommendations) and alert fatigue (e.g., through greater alert precision). However, merging PGx into an environment that already has many usability challenges risks obscuring the benefits of such alerts. In response, this project aims to develop a medication decision support service, ‘PillHarmonics’, that seamlessly integrates drug-gene interaction checking with other types of medication alerting (such as drug-drug, drug-allergy, and drug-condition), thereby enhancing patient safety through minimization of adverse drug events and decreasing alert fatigue via more precise surfacing of relevant alerts. In the planned prototype, PillHarmonics will gather FHIR-formatted clinical data from an EHR, simulated by a HAPI FHIR server; FHIR-formatted genomic data, in this case from Elimu’s genomic data server; and drug knowledge, in this case from First DataBank and PharmGKB. The service translates identified interactions into normalized data elements which are exposed as structured FHIR DetectedIssues, one DetectedIssue per interaction. The PillHarmonics service will be demonstrated via a CDS Hooks application that generates integrated alerts in response to the addition of tacrolimus or clopidogrel to a patient's existing medication regimen. AIM 2 evaluation will entail a ‘perceived usefulness’ assessment of the PillHarmonics algorithm using an established evaluation instrument.