An Exclusive Interview with Dewey Howell, Design Clinicals President and CEO

Meeting JCAHO's medication reconciliation requirement is a pain for most hospitals. A few weeks ago, a reader e-mailed me asking about it, so I did a quick Google search and listed a handful of companies offering software to help comply. One of them was Design Clinicals. My link to their site sent lots of hits their way, which got the attention of president and CEO Dewey Howell, MD, PhD, who e-mailed me offering to write something for HIStalk if I thought readers would be interested.

I did. We decided that an interview might be a better format since I also wanted to know more about the company and Dewey himself. He agreed. With that, thanks to Dewey for joining me by telephone from his first site's go-live in Seattle.

Give me some background on the company and you.

I started out as a physician. I went to a school in Texas in a combined MD-PhD program, with the PhD in immunology. Most people who get the dual degree go into research in a subspecialty. My path took a turn when I decided to go into a family medicine. I like general medicine more than the subspecialties.

I’ve always been a techie. When I was a resident, I start developing software because I was frustrated with the software available to me as a physician.

In our residency, like most, we do our patient management and communication using 5x7 cards with notes scribbled on them, passing them back and forth trying to communicate the plan of care. I wasn’t on the job more than week or two until I decided I couldn’t do those orange cards. I knew what we could do with technology and medicine.

I developed a hand-held application that enabled us to maintain our patient panel – the patient list, problem list, and to-do list. In the three years of residency, I got involved in consulting, helping our IT department with the physician parts of rollouts.

I founded Design Clinicals to develop a suite of products that are clinician-centric, for physicians, nurses, and pharmacists.

For those not familiar with medication reconciliation, can you give a description of what it involves, the clinical problems it addresses, and where it started?

In my capacity as a consultant to the IT department, I got asked to come to a medication reconciliation committee meeting, which was the first I’d heard of it. They asked me to hear what they were trying to do and see if I had thoughts on how to get it done.

Medication reconciliation was spurred on by a JCAHO mandate that was put out towards the end of 2005. It became a National Patient Safety Goal in 2006 and hospitals were required to be compliant starting January 2006. They’re still struggling.

Healthcare organizations, both inpatient and outpatient, need to have a process for maintaining a complete list of meds a patient takes. That list needs to be available for any provider who needs it for making decisions about further prescribing. Any time the patient’s status changes, like going from a medical floor to an intensive care floor or transferring out of organization, the providers need to review the list and make sure no mistakes happen.

All clinicians I talk to say, “This is nothing new, we’ve been doing this all along – we just don’t call it medication reconciliation.” We were always supposed to be reviewing home meds and basing prescribing on what the patient was taking and what they need to take. There just wasn’t a formal process to create the list, manage it, and communicate with the patient.

A variety of patient safety reports have described the errors that happen at transition points. Mismanagement of medications can happen at admitting, transfer, and discharge. There’s not a clinician I’ve talked to who doesn’t understand the importance of the mandate.

We all have personal examples of Patient X who came in, and two days into the stay, I discovered they he or she was taking something at home that I should have continued. Or, they go home and take duplicate therapy or forget to take therapy because I wasn’t clear in communicating what I wanted them to do. The importance of the mandate is undeniable, unlike some things that JCAHO or other regulatory organizations make us do.

One organization is a good example. They had a paper process, a yellow form for home meds filled out on admission that traveled with the patient. Changes were scribbled on. The form was illegible and hard to maintain. You can’t design an ideal form that works well for a patient with two meds vs. those that have 40. Having multiple forms is impractical. Paper forms are a challenge. When the patient leaves and comes back a couple of days later, you start all over with a new piece of paper.

Hospitals say medication reconciliation takes 25 to 45 minutes per patient discharge in nurse and physician time. It’s a time drain for something that doesn’t have to be. I thought this was a great idea, right in line with what I wanted to do with my company. I wanted to develop products that really help physicians get the job done efficiently and in a safe way. We prototyped an application and they loved it. We developed it over the next 12 months and are rolling it out now in a medium-sized community hospital in the Seattle area.

With all the challenges there are with paper in getting the mandate met, designing an electronic solution is still a problem. In most organizations, there are multiple sources of medication orders They can come from the patient, the inpatient pharmacy, an outpatient EMR, or a CPOE system. Trying to get all of those into one language so you can reconcile them is quite a challenge.

I started from the beginning building around an interface engine and First DataBank’s suite of products. You have to have a detailed, insider understanding of a clinician’s workflow. The management of medications is so central that it touches everything we do. It was very important that this wasn’t just another mandate, but a chance to help us do our jobs faster and better.

A GI colleague of mine says it takes eight forms to do a colonoscopy in the hospital. The sentiment of docs is that everything is a form, a requirement, or something that gets in the way of taking care of a patient. Our MedsTracker application helps them in ways they haven’t seen. I think we’ve gotten there.

What is your sense of where most hospitals are with this process?

Most hospitals have a fully paper system that is incomplete. It allows them to check off the JCAHO box, but they know it really hasn’t made a difference in providing safe medication use. Part of that is because compliance with forms is 50% at best.

Other folks have a combination of electronic and paper, where you start out by entering meds in a system, print forms that allow you to do editing like “Continue Y or N”, and print paper that floats through the hospital. At the end, you’re stuck with 4-5 pieces of paper that a nurse has to translate and get back into the computer.

These are some of the big vendors’ solutions for med rec. At HIMSS, one of the systems that was highlighted was just like this – pieces of paper printed out at various times and re-entered into longitudinal data. The hospital might make it through the JCAHO survey, but they’re introducing transcription and other errors that don’t serve the spirit of what the mandate is all about.

An ISMP report describes hospitals’ efforts in medication reconciliation. I was shocked with how they described the role of the pharmacist, nurse, and physician. In 60% of hospitals, med rec is being done by the nurse. As an MD, I think, that’s my job, not the nurse’s job. It’s being put on the nurse’s plate because it doesn’t fit into the workflow of the physician.

Several companies have announced medication reconciliation software. How does a prospective customer decide how to approach possible technology solutions?

Understand how medications flow through your organizations and where the handoff and communications points are. Ensure that the product facilitates the workflows around those handoff points. An example is verbal orders. There always will be cases where the patient needs to get started on meds and reconciliation needs to happen while the physician is in the car or at home. The process needs to support medication reconciliation by the nurse that is verified by the physician later.

There is no one–size-fits-all approach. A product shouldn’t tell you how to do medication reconciliation – you should tell the product.

How does MedsTracker work at a high level?

It pulls medication orders from any data source, like an outpatient EMR or inpatient pharmacy. It allows keeping a longitudinal record of the patient’s medication history. It serves as source material for physician ordering at admission, discharge, and transfer. At admission, it pulls in the home meds. For inpatients, it pulls in the inpatient information. At discharge, it pulls both. It’s integrated for both ordering and discharge prescription writing.

What are the most valuable lessons you’ve learned from your initial development and implementation work with MedsTracker?

I’ve been consulting in IT for 2 ½ years, but I’ve learned that nurses, physicians, and pharmacists know they want something out of IT, but they don’t know how to communicate what they want or don’t know what they want. Organizations go into an IT project not really understanding what the goal is, so they come out on the other end with something that doesn’t fit. For this project, we started by saying, “What are your needs?”

I heard a lot of buzz at HIMSS about medication reconciliation, including a multidisciplinary session among nurses, pharmacists, and physicians in the Sunday tracks. What was your impression of the interest there?

I think there as a lot of interest. The large, multidisciplinary session showed a clear interest. It was a great session. Throughout many of the other education sessions, there was a lot of buzz about medication reconciliation. It was used as an example of workflow challenges or solutions that are needed. I heard it lots of places.

Our presentations in the FDB booth were very well attended and the people were engaged. I would have liked to have seen more formal attention to med rec instead of just an undercurrent, but that may be a reflection of the struggling of the industry to solve the problem.

In Washington, an organization put together a statewide conference on medication reconciliation and how it's being done. They had to pull teeth to get people to come and talk about their successes because they didn’t see them as successes.

Design Clinicals offers other software.

We have Patient Pilot, which is a patient tracking, Palm-based application. We’re moving to Web-based to integrate with medication reconciliation and management, which is also Web-based. It does workflow-oriented tracking of patients and handoffs from one doctor to another.

You hear a lot about handoff communication. There’s a JCAHO mandate there, too. Hospitalist medicine has grown over the past 15 years. The doctor taking care of complex patients in the hospital doesn’t know them at the outset. They need tools to help with that.

OB Tracker is along same lines for obstetrical patients. It tracks OB patients, assuring that appropriate things are done over the nine months and that billing is captured, which is important to OBs because of how billing is done.

These three make up a foundation for a series of tracking applications we’re developing to help physicians track patients. It’s the population-based model of care.

What other opportunities do you see for the company?

Full computerized order entry. For medication reconciliation to work, it has to be integrated in the order process. Otherwise, the work is duplicative. MedsTracker is a natural stepping stone to CPOE. That already has some big players and I’m just a little fish, but I think there’s an opportunity to do CPOE right. We want the industry to be better.

Who do you admire in the industry?

I have to say I’m fairly new it, with only a couple of years on the IT side. I admire a lot of people I see who are speaking up about the low standards and the improvements that need to be made. That’s what will bring about change.

My relationship with FDB has been a wonderful one. They’ve been a great partner in terms of their content. We use Order View, which facilitates physician order entry and order sets. Their commitment to physicians – I’ve been really impressed.

Do you read HIStalk?

Of course! I’m on the notification list when there’s a new post. I got my button from the Medicity booth at HIMSS and wore it.