About a year ago, I posted a blog on how we create data silos. As I perused that blog, I realized that had omitted a significant way in which we create data silos, local data encoding. That is, we use non-standard data identifiers for our drug concepts, often using codes that are derived from a local charge description master or re-imagined at each health-system; sometimes at each facility! So the identifier assigned to, let's say, an Ibuprofen 200 mg tablet, is not only different at each facility, but may wind up pointing to an entirely different drug at a different organization.
One of the benefits from having worked both as a provider and within industry is the opportunity to see practice across a broad swath of organizations across the county, and my long-standing experience has been that this is true.
The funny thing is, I could stand up in a room full of 500 pharmacists and hold up a little green capsule and say "this is an Ibuprofen 200 mg gel cap" and nobody in the room would be confused what I was talking about. Sadly, our automated systems are not quite so erudite, and we require that these drug concepts be encoded in order to be certain that any conversation between two computer systems can reliably identify the drug being referenced.
Having been at this now for 50 years, I have seen how this came about. Our original computer systems were not all that capable, interfaces were primarily for billing, and we really had no other option. We had to work with what we had at the time.
The impact has been, however, that there winds up being an immense amount of time and effort spent generating drug databases for our use, and that sheer effort has become a barrier to our adoption of new technologies, since each such adoption creates the need to populate yet another database that other automated systems at our organizations have to talk to. Even replacing, say. an automated dispensing cabinet system can generate months of effort to get an organization's current formulary properly instantiated, even though the underlying data concepts are well-known and well-understood.
Why do we permit this to exist? What if there were a national encoding system that everyone used? If that were true, all automation systems that relate to medications could come pre-loaded with formularies that were already encoded with that standard set of codes. Purchasing new, or replacement, systems would not involve having to type in and verify the assignment of current local codes. Sites would still have to customize how those concepts operated in technology, but I will bet even that could be standardized over time. But that standardization would save person-months of effort when purchasing or replacing a system.
There is such an encoding system. It is published by the National Library of Medicine under the name RxNorm. It even has codes for the volume information required for liquid drug products. There are probably concepts it lacks, but those could be identified and added. And even if its encoding could be applied to 80 or 90% of the items in a formulary that had to be encoded, it would save an immense amount of time.
Note that I am only talking about the encoding. We all seem to love our particular choice of name formatting, but that would not have to change (although it could). We would just suddenly all be using the exact same codes to describe concepts we all understand.
This is a reversal on my part, because, until recently, there were some distinct handicaps in its structure; specifically, the lack of encoding for different volumes of pharmaceutical liquid drug packing. That quantification has addressed what I consider to be the most significant barrier to its use. For example, for irinotecan hydrochloride, it has separate codes (RxCUIs) for:
- irinotecan hydrochloride 20 mg/mL, 2 mL (17216319)
- irinotecan hydrochloride 20 mg/mL, 5 mL (17216324)
- irinotecan hydrochloride 20 mg/mL, 10 mL (1719772)
- irinotecan hydrochloride 20 mg/mL, 15 mL (17216333)
- irinotecan hydrochloride 20 mg/mL, 25 mL (17216492)
One of the barriers to adopting this as a standard encoding system is that the initial lift for adoption would be quite heavy in established health-systems. Adoption would be required within the our EMR systems, our billing systems, and all our automated systems that deal with drugs (such as our pharmacy inventory and dispensing systems).
But just imagine what a huge difference it would eventually make. Replacing an EMR systems sounds like an ideal time to make such a change happen. What would do to installation time for an automated dispensing system, for example, if all a site had to do was to configure the drug items to their preference? The lift just might be worth it.
Dennis A. Tribble, PharmD, FASHP
Retired
Ormond Beach, FL
The ideas expressed herein are my own, and not necessarily those of ASHP.