Table of Contents
Description of the clinical issue involving metformin medication
In amongst the patients newly diagnosed with type-2 diabetes, the first line therapy is always metformin. According to DeFronzo et al. (2016), the drug is regarded as safe, but there are some of the most frequent adverse cases that are gastrointestinal in nature. These cases include diarrhea, vomiting, and nausea. The drug is specifically less tolerated by individuals or patients with historical or pre-existing gastrointestinal conditions. In addition, the drug is also contraindicated in those patients diagnosed with hepatic insufficiency and renal disorder. The category of patients mainly affected by the adverse effects of the drugs are elderly persons over the age of 65 because it is a population segment mainly characterized by circulatory dysfunction as a result of an increased lactic acidosis. The lactic acidosis condition is rarely reported. However, over the past few years, the condition is associated with over 50% of the mortality cases in elderly persons.
Metformin-associated lactic acidosis may be triggered by the accumulation of drugs in elderly patients with newly diagnosed renal failure or even insufficiency. This is mainly contradicted by the overproduction of lactate, commonly resulting from the hypoxic tissues in the failure of the circulatory and the respiratory system of the human body (Suh, 2015). Inhibition of gluconeogenesis as a result of liver damage may also be one feature of the disorder in patients over the age of 60. This has been the reason why in most of the labels on the metformin drug package, there is a label warning of lactic acidosis. Nevertheless, there is also a need to have a system embedded in the Electronic Health Record (HER) system that would aid in the decision making process during metformin therapy.
Thus, the RRMC health facility requires a well-designed system implanted in the HER system. In this approach, the proposed system will utilize the computerized provider order entry system (CPOE) to design a Clinical despising support system (CDSS) rooted in the EHR system for the betterment of the metformin therapy within the facility. Metformin-associated lactic acidosis is a serious case that results from medication errors, and as such, the approach is aimed at significantly addressing the issue at the facility.
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The Rationale behind Design Development
The CPOE usage (a type of digital transformation of medicine) has rapidly increased with almost all the health facilities of the United States adopting it. The main aim of the adoption of the system is that it improves the safety of medication orders as well as the electronic ordering of tests which has been the most recent developments in the same line (Green et al., 2015). The digitalization of healthcare processes may have both positive and negative consequences, and thus, there is a need to design another system from the CPOE. The design that would allow for improved patient safety and experience is the designing of CDSS in line with the CPOE system in the electronic health record system.
During the metformin therapy, the crucial steps involved are ordering, transcribing, dispensing, and finally administration. According to the study by Pasquel et al. (2015), inpatient medication errors mainly occur at the ordering step or the transcribing stage. The ordering stage is the stage in which the nurse or a clinician selects the appropriate medication and dosage as well as the frequency at which the drug will be administered. Moreover, the transcribing stage is the time when the clinician writes the description for the patient concerning the metformin medication. The errors at this stage involve poor handwriting, ambiguous abbreviation, and most often, little knowledge with regards to ordering.
The CPOE system can help in preventing such errors happening at the ordering phase and transcribing stage by standardizing and ensuring complete orders. However, with the linking of the CPOE with the CDSS, all the errors in the ordering and dispensing phases are eliminated, unlike when using the CPOE alone. The usefulness of the designing of the CDSS using the CPOE is that when the CPOE has helped the clinician in ordering, transcribing and dispensing, the errors can be detected by the CDSS. The CDSS can detect drug allergies as well as certain patient’s preexisting conditions that may cause obstacles when administering metformin therapy. Thus, the CDSS can be designed with the CPOE and embedded in the EHR.
The metformin therapy requires a clear inquiry on the patient allergies, historical medical data, as well as preexisting conditions. The metformin-associated lactic acidosis may be witnessed when the patient is administered with the metformin drug without consideration of certain clinical factors (Pasquel et al., 2015). Thus, with the help of the CDSS, the clinical decision making is made easier with the ordering, dispensing, and the administration of the drug made safer and easier.
Implementation of the CDSS in the RRMC facility and the measure of its effectiveness
The implementation of the proposed CDSS designed with the CPOE embed in the EHR system may not be immediate. Nonetheless, the gradual implementation of the process would be the best approach. According to the study by Elenko et al. (2015), the implementation of the digital transformation of medicine is costly, gradual, and challenging. Thus, with the adoption of the new system, the medical staff will first be trained and introduced to the new changes proposed to take place at the RRMC facility. Training and orientation of clinical staff would be the initial stage of the adoption of the new digital medication system. The targeted group will be those at the Diabetes Management Department.
The patient outcomes subsequent to the implementation of the new digital system would be done through an overview of the patient experience, outcomes and the rates of medication errors. The data from the previous interventions without the use of CDSS will be likened with the data collected after the implementation of the system. Cases of metformin-associated lactic acidosis in diabetes type two patients who visited the facility before and after the implementation of the system will be compared. A reduction in the medication errors would mean that there is a significant reduction of metformin-associated lactic acidosis.
Assessment of the challenges and proposed solutions that might apply to the implementation of the system
The challenge of the implementation of the digital medication system is the financial constraints and effectiveness. The implementation of the digital medication system may require time and resources, which may not be within reach of the RRMC facility. Furthermore, the effectiveness of the system would be achieved if the clinicians have gained enough skills and expertise in the use of the system. The proposed solution is that the system will be gradually implemented through phases. The division of the implementation of the system would allow for the RRMC facility to adequately address the financial obligations.
- DeFronzo, R., Fleming, G. A., Chen, K., & Bicsak, T. A. (2016). Metformin-associated lactic acidosis: current perspectives on causes and risk. Metabolism-Clinical and Experimental, 65(2), 20-29.
- Elenko, E., Underwood, L., & Zohar, D. (2015). Defining digital medicine. Nature biotechnology, 33(5), 456.
- Green, R. A., Hripcsak, G., Salmasian, H., Lazar, E. J., Bostwick, S. B., Bakken, S. R., & Vawdrey, D. K. (2015). Intercepting wrong-patient orders in a computerized provider order entry system. Annals of emergency medicine, 65(6), 679-686.
- Pasquel, F. J., Hinedi, Z., Umpierrez, G. E., Klein, R., Adigweme, A., Coralli, R., … & Lopez, F. A. (2015). Metformin-associated lactic acidosis. The American journal of the medical sciences, 349(3), 263-267.
- Suh, S. (2015). Metformin-associated lactic acidosis. Endocrinology and Metabolism, 30(1), 45-46.