Australasian Medical Journal:
analysis of Medscope's decision support system
An investigation into drug-related problems identifiable by commercial medication review software
Accredited pharmacists conduct home medicines reviews (HMRs) to detect and resolve potential drug-related problems (DRPs). A commercial expert system, Medscope Review Mentor (MRM), has been developed to assist pharmacists in the detection and resolution of potential DRPs. ... read AMJ article
Medication Review Manager Decision Support.A number of resources exist to assist the pharmacist in the assessment of medication reviews, including various drug monographs (eg AMH, MIMs, AusDI) and therapeutic references (eg Theraputic Guidelines, Epocrates).
Medication Review Manager (MRM) is one reference that should be included in every accredited pharmacist's resources.
MRM decision support is fundamentally different from other resources. The difference is due to its innovative use of expert system technology to identify issues that are specific to the particular case being reviewed.
Unlike other commercial reference systems, MRM decision support is NOT available to GPs. Information sourced from MRM's expert system adds value to the GP's assessment of their patients. Information sourced from other commercial systems just regurgitates information that the GP already has access to (and has most likely already reviewed). Medscope recommends that MRM form part of an accredited pharmacist's library. MRM identifies adverse medication related issues that other systems cannot.
MRM decision support is different.MRM is fundamentally different to all other forms of decision support.
MRM identifies issues that matter, including missing drugs, and presents the issues in a well worded medication review format. It is the only system, specifically designed for medication reviews.
Issues that Matter.
MRM takes into account the patient's entire profile and identifies the issues that matter.
Static drug information resources and texts provide monographs for drugs that list adverse effects, contraindications, interactions and so on. The onus is on the pharmacist to investigate pages of material to determine the relevance and likelihood of the various possibilities. Static disease related texts and guidelines are similar in that the information needs to be evaluated to determine whether its relevant to the case being reviewed. Many of the static reference tools used by accredited pharmacists are now available electronically (online and stand-alone), but are effectively a searchable version of the hard copy. Some "smart" electronic systems include drug interaction databases that fire alerts based on absolute interactions between the entered drugs. These alerts occur regardless of the context of the patient's medical profile and whether symptoms consistent with the interaction are present. Time lost investigating false leads contributes significantly to the time taken to complete medication reviews, and including information for irrelevant issues in reports is a commonly reported flaw identified by GPs receiving the reviews.
MRM, on the other hand, assesses the patient's medical profile (drugs and doses, pathology, signs and symptoms, and diseases) to determine relevance. MRM, by design, does not create false positives as issues are alerted specifically only if particular parameters are satisfied.
Missing Medications are Identified.
MRM's expert system design enables it to alert on medications missing from a patient's regimen.
Traditional drug information tools do not deal well with missing medications and, again, the onus is on the pharmacist, who has to be aware of or examine the literature to determine if a patient's medication regimen needs to be supplemented. Issues relating to the addition of (missing) drugs in medication reviews are common and can have a big impact on patients' symptoms and prognosis.
Issues are Report-Ready.
One of the most common complaints voiced by GPs concerning medication reviews is that report content tends to be cut/paste copies of material from drug information sources, some of which are linked to their clinical systems.
MRM is not available to GPs. Alerts identified by MRM are worded in such a way that is specific to the case in question and use a format that GPs recognize. Issues will not be "cut and paste" and won't be from sources the GP has access to.
The Only System Specific to Medication Reviews.
Getting the right wording is one of the common frustrations voiced by accredited pharmacists when writing a medication review report.
Traditional drug databases are generic in nature and have been designed to cater for all drug information applications and often do not provide appropriately structured issue descriptions.
MRM's knowledge base is specific to medication reviews and its alert rules have been compiled from assessment of thousands of real medication review cases (HMRs and RMMRs) by some of Australia's most recognised accredited pharmacists. Alerts identified by MRM are written and formatted for medication review use following the medically accepted SOAP format (see below). The alert text can be further customised to suit individual pharmacist's reporting style.
How is decision support used in MRM?The MRM system can be used to support decisions before the interview, as well as after the interview, when additional information is available. MRM behaves as a useful quality assurance tool, often reminding the pharmacist of issues that may have been overlooked. Finally, the issues in MRM are medication review specific and worded as such in a fully flexible format.
To help prepare for the interview, MRM decision support is used to analyse the patient profile to identify issues that the pharmacist should investigate during the interview. A template is generated by MRM that the pharmacist uses to guide them through the interview.
Pre-interview analysis and interview templates are particularly useful in cases where the interviewing pharmacist may not be the accredited pharmacist reviewing the HMR/RMMR.
Traditional drug information decision support tools can assist the accredited pharmacist in identifying issues related with a patient's medication regimen when properly utilised. Unlike other decision support tools, however, MRM is able to identify issues that are specific to the case being reviewed and reduces time spent looking up "false positives". It is also able to identify medications that may be missing from the patient's treatment.
The decision support mechanism in MRM assists pharmacists to identify issues more efficiently and effectively.
Quality Assurance (QA).
Regardless of a pharmacist's medication review proficiency, there is always a need to QA findings. When following an investigative thread, it is possible for a pharmacist to be so focused on a topic, that other issues are not considered.
MRM decision support is useful for double checking reviews, and ensuring consistency in identification and reporting of issues. MRM identifies the same problem in the same circumstances, every time.
Significant time writing the HMR/RMMR report is spent wording identified issues to clearly communicate your findings to the GP.
MRM's decision support is medication review specific. Findings are worded for direct use in reports, using a modified SOAP (subjective, objective, assessment, plan) format. MRM's wording, however, can be customised and personalised to suit individuals' reporting styles.
Personalising involves replacing references to patient, with the patient's name. A report preference set via the My Account menu controls this behavior.
Customising involves editing the MRM finding to your own wording. Options exist to apply the wording change only to the current case, or every time the alert is activated.
MRM decision support: The only System that Grows it Knowledge with regular use.MRM is an "expert system". This means that it draws upon thousands of existing cases for knowledge on how to deal with the presented case. However, if an issue is presented for the first time, MRM will be unable to identify it. This is where the enormous advantage of the expert system technology used by MRM comes in. Pharmacists using the system can add new issues, and these are included in the knowledge base after being assessed by Medscope's clinical team. MRM, by design, grows in knowledge every time it is used.
MRM's knowledgebase already contains thousands of rules and is able to assess hundreds of thousands of cases, due to the large number of rule permutations. MRM's ability to identify the less common issues encountered in medication reviews increases every day, with every use. The benefits of the increases are instantly available to all users as the system is based on the internet.
MRM can form an invaluable part of an accredited pharmacist's toolkit
What MRM decision support cannot do.MRM is an expert system that draws upon thousands of existing cases for knowledge on how to deal with the presented case. If an issue is presented for the first time, MRM will be unable to identify it.
MRM, however, allows pharmacists to add new issues, which are included in the knowledge base after being assessed by Medscope's clinical team. MRM by design grows in knowledge every time it is used.
MRM's knowledgebase already contains thousands of rules is able to asses hundreds of thousands cases, due to the large number of rule permutations. MRM's ability to identify the obscure fringes of the HMR/RMMR spread increases every day with every use.