STFM MSE Conference 2012 An Electronic Prescribing Curriculum

STFM MSE Conference 2012 An Electronic Prescribing Curriculum: Integrating Clinical Informatics with Basic Science to Promote Chronic Disease Management Steven M. Schwartz, MD sms 4@georgetown. edu Jeffrey M. Weinfeld, MD weinfelj@georgetown. edu Yvonne M. Hernandez, Ph. D hernandy@georgetown. edu Joshua M. Berglund, MBA, jb 838@georgetown. edu Georgetown University School of Medicine

Educational Goals By the end of the Workshop Learners will: § Experience an e-prescribing “case” § Identify the elements of an electronic prescribing curriculum. • • • Curricular objectives Opportunities for curricular integration e. Rx training environment Case creation/implementation Evaluation §Create an e-prescribing “case” and test it in an e-prescribing training environment. § Assess peer cases attributes and limitations. Georgetown University School of Medicine § Recognize opportunities and challenges to implementing such a curriculum at their home institution. 2

Part I: Experiencing a Case Georgetown University School of Medicine

Activity 1: Practice Case § § § Georgetown University School of Medicine Divide into solo/pairs Training video (7 min) Login card / case script Complete sample case (10 min) Feedback 4

http: //www. screencast. com/t/rjj. W 0 OBL TRAINING VIDEO Georgetown University School of Medicine 5

Feedback? § § Georgetown University School of Medicine How was the experience? Was the video helpful? What prescriptions did you write? Should a second or third year student be able to do this on their own? 6

Part II: Presentation of our e. Prescribing Curriculum Georgetown University School of Medicine

Georgetown University School of Medicine GR Evidence-Based Medicine (EBM) Ambulatory Care II Physical Diagnosis (Sm Groups) Health Care Ethics PD (Hospital) Grand Rounds APR GR OSCE Pediatrics/Geriatrics MAR Ortho, Rheum, Derm Endocrine Gastrointestinal /Hepatic FEB SPRING BREAK Reproduction JAN Disorders CNS II: Psychiatric DEC Disorders CNS I: Neurologic NOV Renal /Genitourinary OCT HOLDIAY BREAK ID II: Bacteriology & Mycology SEPT Upper Respiratory & Pulmonary Cardiovascular Immune Regulation AUG SHELF ID I: Virology Hematology/ Oncology Fundamentals Georgetown University School of Medicine M 2 Academic Year 2010 -2011 MAY JUNE JUL 8

Georgetown University School of Medicine M 2 Academic Year 2010 -2011 MAR APR Gastrointestinal /Hepatic JUNE JUL Longitudinal Courses Pharmacology Pathology Microbiology & Immunology Laboratory Medicine Clinical Skills Primer Physical Diagnosis Evidence-Based Medicine Ortho, Rheum, Derm Endocrine SPRING BREAK Reproduction MAY Other Courses in Modules Human Sexuality Psychiatry Pediatrics/Geriatrics FEB Disorders HOLDIAY BREAK CNS I: Neurologic JAN Disorders DEC CNS II: Psychiatric ID I: Virology Upper Respiratory & Pulmonary Cardiovascular Immune Regulation Hematology/ Oncology Georgetown University School of Medicine NOV Renal /Genitourinary OCT ID II: Bacteriology & Mycology SEPT Fundamentals AUG 9

M 2 MODULES Quarter 1 Fundamentals Immune Regulation Hematology Infectious Diseases I: Virology Georgetown University School of Medicine Quarter 3 • • CNS I: Neurological Disorders • • Renal/Genitourinary • • Reproduction • • CNS II: Psychiatric Disorders Quarter 4 Quarter 2 • Gastrointestinal/Hepatic • Infectious Diseases II: Bacteriology & Mycology • Endocrine • Ortho/Rheum/Derm • Cardiovascular • Pediatrics/Geriatrics • Respiratory 10

e. Prescribing Curriculum and LCME Standards § ED-5 -A. The educational program must include instructional opportunities for active learning and independent study to foster the skills necessary for lifelong learning. § ED-6. The curriculum must incorporate the fundamental principles of medicine and its underlying scientific concepts; allow students to acquire skills of critical judgment based on evidence and experience; and develop students’ ability to use principles and skills wisely in solving problems of health and disease. Georgetown University School of Medicine § ED-28. There must be evaluation of problem solving, clinical reasoning, and communication skills. 11

Goals of our 2 nd Year e. RX Curriculum § Self-directed learning – tutorials and exercises § Integration • Modular (interdisciplinary)/System integration • Clinically anchored in the context of patients with multiple illness § Problem solving Georgetown University School of Medicine • Apply knowledge learned in basic science and clinical lectures • Utilize POC resource materials § Build chronic disease management skills § Exposure to informatics skills 12

What is Informatics? "The scientific field that deals with biomedical information, data, and knowledge - their storage, retrieval, and optimal use for problem-solving and decision-making. ” Georgetown University School of Medicine Shortliffe and Blois in Medical Informatics 2 nd ed. , 2001 13

e. Prescribing Learner Centered Objectives § Understand use eprescribing • • Georgetown University School of Medicine Meaningful Use objective Key function of certified EHRs An area nobody was teaching No student experience with topic 14

Clinical Decision Support § Understand respond to Clinical Decision Support (CDS) § CDS improves outcomes and practitioner performance (Garg JAMA, 2005) § A part of meaningful use § Alerts can be confusing and "alert fatigue" can reduce their effectiveness (van der Sijs JAMIA, 2006) Georgetown University School of Medicine 15

Chronic Disease Management § Chronic Disease management skills § Chronic Care Model - Informatics is central § Few curricular opportunities § Grant* objectives *This research is supported by the Health Resources and Services Administration (HRSA) (D 56 HP 00085 -07 -00), 2009 -2012. Georgetown University School of Medicine 16

Implementation § § e. Rx Basics Online Tutorial Live lecture on e. Rx Launched 2 -3 cases per quarter Short video tutorials on select topics • • • Georgetown University School of Medicine Step by step Hands-on Instruction Demo Responding to CDS alerts Medication history and reconciliation Pediatric prescribing and dosing Considering cost and formulary alerts § Cases with a variety of objectives 17

Sample Cases Georgetown University School of Medicine § Pt with moderate persistent asthma - controller and rescue medication § Pain meds for pt with metastatic cancer – long-acting opioid and short-acting opioid for breakthrough; Rx to prevent/treat side effect (constipation); e. Rx rules on scheduled Rx § Woman with Bipolar Dis on oral contraceptive requires treatment with antiepileptic meds; manage interaction § Pt on metformin for Type 2 DM now has renal insufficiency and pre-hypertension; chronic disease progression § HIV regimen for woman with HIV/Hep B and unreliable use of birth control- chronic dz, multi system (ID, Repro) § Pt with diabetic neuropathy will take pain meds only if covered by insurance (considering cost, formulary alert) 18

Sample Case: Patient with DVT and DM needs TB Treatment Self-directed CDS tutorial Integration of CV and ID lecture info Patient with multiple illnesses Application of knowledge learned in Pharmacology, LM, Microbiology lectures § Interpretation of labs - INR values § Use of resource - warfarin dosing calculator § Chronic disease management 19 § § Georgetown University School of Medicine

Curricular Partners and Calendar § Collaborative process • Pharmacology • Informatics • Contributions from content experts (lecturers) and module directors § Timeline Georgetown University School of Medicine • 4 week prep • 1 week to complete assignment • 1 month to return grades 20

Ingredients for an e. Rx Curriculum § § § § Georgetown University School of Medicine Courseware system (Blackboard) Tutorials e. RX training environment (Rcopia) Cases and solutions Handheld computing references/resources Patient profile for Rcopia Discussion board (Blackboard) Grading rubric 21

e. RX System Issues § Differing needs of clinical vs. educational setting and use § Good for clinical practice • Reliability • Real world § Not ideal for education • Security restrictions (group practice vs students can see each others data) – Prescription memory Georgetown University School of Medicine • Licensing models – Per user 22

Choosing a System § System related • Test/training environment instead of production environment • EHR training environment vs. e. RX stand-alone training environment - Institutional systems in place? • Vendor customer service • Cost § Administrative related Georgetown University School of Medicine • • Password management Preferences/Optional settings Bulk upload/Duplication of patient profile Reporting 23

Case Technical Checklist § Before the first case • Create & distribute student accounts • Ask students to log in and verify they can access the system § For each case • Create and replicate patient profile for each student • Note beginning and end date of case • Assist students with technical issues (password reset, etc) • Monitor Blackboard site Discussion Board § After the case Georgetown University School of Medicine • Create a report with student submissions (for grading) 24

Sample Grading Rubric To receive credit for Part B you needed to: 1. Stop the TB meds. 2. Write two warfarin prescriptions and associate the DVT with the prescriptions: a) b) Warfarin 6 mg on M, W, F, Sun, plus Warfarin 5 mg on Tue, Thurs, and Sat. Alternative warfarin regimens: 5 mg daily plus 1 mg on M, W, F, Sun. OR 5 mg daily with a notation to take an extra ½ tablet (2. 5 mg) one day per week will be accepted. 3. RX must be sent to Rite-Aid on Lee Hwy, Arlington, VA Georgetown University School of Medicine 25

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Evaluation § Students receive a detailed solution § Rcopia produces a submission report - grade each student individually § Follow a grading rubric provided to students § All or none scoring – credit given only if all elements are met § Feedback to students on common errors § 5% of Pharmacology grade Georgetown University School of Medicine 27

Beyond the paper case § Does 2 nd year training in an e. RX system prepare students to use it with a live Standardized Patient? § What other informatics or clinical skills are needed? § Adaption and integration into 3 rd year OSCE Georgetown University School of Medicine 28

Break (5 min) Georgetown University School of Medicine 29

Part III: Creating a Case Georgetown University School of Medicine

Activity 2: Create Case Objectives (10 min) Worksheet 1: 1. Learner objectives a) Who is the learner? b) What is the context/course/curriculum placement? c) Choose a topic 2. Placement into groups 3. Define the case objectives Georgetown University School of Medicine 31

Activity 2: Create a Case (20 min) Worksheet 2: 1. Identify challenges students should face. 2. Write a script and case elements. 3. Create a “digital patient profile”. Georgetown University School of Medicine 32

Activity 2: Demo Sample Cases Created by Group (15 min) 1. Test the system for generation of the required elements. 2. Identify and troubleshoot problems that students might encounter. 3. Establish a method for student assessment. Georgetown University School of Medicine 33

DISCUSSION Georgetown University School of Medicine 34

Wrap –up questions § Questions about q Curriculum? q Process q Tech? q Support cost? § How do I apply this at home? Georgetown University School of Medicine 35

Conclusion § An ERX curriculum can: q q q Georgetown University School of Medicine Create opportunity for integration, higher order thinking and decision making Teach modern clinical skills Is adaptable to different training levels § You may already have what you need to adapt at home 36