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Mastering Big Data for Therapeutic Drug Monitoring

Rebecca Amen, PharmD, BCPS 

Clinical Pharmacy Specialist, Infectious Diseases
Benefis Health System

Julie Downen, PharmD, BCPS, BCIDP, CLSSBB

Antimicrobial Stewardship Coordinator
Springfield Memorial Hospital

Will Musick

Will Musick, PharmD, BCIDP

Infectious Diseases Clinical Specialist Houston Methodist Hospital

Data analytics is playing a critical role in the healthcare industry helping to optimize performance, improve efficiencies and patient outcomes. So when it comes to precision dosing of vancomycin, how can we leverage the data we are collecting to help inform better dosing decisions in real time?

A panel of experts discuss the benefits of using DoseMeRx’s EHR integrated solution and how the new analytics platform is a game-changer for clinical practice.

What you’ll learn

  • Discover how DoseMeRx’s EHR integrated solution has streamlined workflow and improved efficiencies for clinicians at the bedside
  • Learn how to leverage real-time clinical and usage data to track institutional goals, including patient risk indicators and reduction in AKI
  • Explore the platform’s new features and powerful embedded analytics dashboard

Content downloads

Webinar handout

Review further questions & answers

Dr. Sharmeen Roy moderates a Q&A with the panelists.
Have other questions? Get in touch with us today.

Rebecca Amen, PharmD, BCPS

Clinical Pharmacy Specialist, Infectious Diseases
Benefis Health System

Julie Downen, PharmD, BCPS, BCIDP, CLSSBB

Antimicrobial Stewardship Coordinator
Springfield Memorial Hospital

Will Musick

Will Musick, PharmD, BCIDP

Infectious Diseases Clinical Specialist Houston Methodist Hospital

How did DoseMeRx change your sampling practice when you moved to AUC based therapy? Are you still drawing trough only?

Dr. Rebecca Amen:
We primarily draw with morning labs. If there is a situation where there is risk of being drawn at the time of infusion, we time it as a trough prior to the AM dose (e.g. 0430 for an 0500 dose) or a random later in the day. In these circumstances lab/nursing try to move AM labs to the trough time if it is close for convenience of lab/nursing/patients. In the event of using 2 levels within the same dose interval, we try to make one of them at the time of am labs (super morbid obesity/quadriplegia). Generally our patient population is well represented by the calculator and re-measuring levels comes back as predicted. It is in a small minority we choose to use two levels.

Dr. Julie Downen:
We moved primarily to vancomycin randoms with AM labs, which really helps our lab colleagues. We do have carve outs or patient populations where we obtain troughs, but that is a minority of our vancomycin patients.

Dr. Will Musick:
Generally we do (and encourage) random’s only (with AM labs). However, we leave the final decision to the individual pharmacist managing the vancomycin for that patient.

What is your institution doing with organisms other than Staph. aureus, and meningitis patients? Are you targeting 400-600 for both of these scenarios as well?

Dr. Rebecca Amen:
AUC for all organisms (400-600). We exclude meningitis patients. However, it is very doable to hit a trough of 15 and an AUC of 400-600 by adjusting the frequency. We do not allow AUC > 600 just because we are targeting a desired trough.

Dr. Julie Downen:
We have included them thus far, but these groups would be interesting to further analyze.

Dr. Will Musick:
There is emerging (albeit small #s) literature in organisms other than SA. We encourage an AUC of 400-600 for all organisms. CNS infections are our only hard exclusion for AUC-guided dosing.

How can we use DoseMeRx for research purposes to convince higher administration in the value of precision dosing software?

Dr. Julie Downen:
The biggest value is in prevention of AKIs as well as to decrease overall gram utilization. Furthermore, if you have departments that are resource limited, such as lab, this helps them w/ efficiency (i.e. using AM lab draw times prevents another trip to the unit to obtain a trough and gives them more flexibility).

How accurate is the DoseMeRx when comes obese patients and patients with very high calculated CrCl >>>120?

Dr. Rebecca Amen:
I find that patients with super morbid obesity rarely calculate well with any calculator. I like the DoseMeRx model better than our previous trough estimations because you do not have to wait until steady state to draw levels. If someone is out of the population I would perceive as well represented like in your examples, I would draw 2 levels within the same dose interval around the 2nd-3rd dose. You will have a more accurate t1/2 and AUC for DoseMeRx to predict a regimen. Even though steady state has not been achieved, you can see the AUC’s that are predicted for the next few doses and if you have or will achieve therapeutic.

How do you interpret the Trough vs. AUC graph in DoseMe Analytics? Do you think this is the most impactful graph?

Dr. Rebecca Amen:
The time vs. AUC graph is helpful in the original implementation phase. I focus on the area where trough is 15-20 but AUC is > 600 to show patients with a high risk of AKI in the trough-based model. Also the area of patient with trough 15-20 but an AUC < 400 is an area that looked ok by surrogate marker but may actually fail therapy. It’s a good graph to explain the need for change.

Dr. Will Musick:
In terms of clinical outcomes, I think the Trough vs. AUC graph is most impactful. In terms of financial benefit/ROI, I think the AKI risk and AKI assessment graphs are most impactful, given a vancomycin-associated AKI “costs” about $40k.

Has having access to DoseMe Analytics improved compliance and protocols?

Dr. Rebecca Amen:
I have plans to target education based on information from the usage dashboard (specific users) as well as clinical dashboard (specific patient populations). One example is that our time to therapeutic is lower in obese patients. Of course, they have a larger Vd, but we can adjust our practice to try to obtain therapeutic within 48 hours. We would not have known this without the dashboard.

Another example is that many pharmacists were targeting an AUC of 500 rather than letting AUCs in the lower 400s continue. I changed the DoseMeRx default AUC target from 500 to 450 for calculations. After this change the graphs clearly show a decrease in our average daily dose amounts as well as AUC24 outcomes > 600. So we are easily able to monitor the efficacy of what seem like minor changes.


Dr. Sharmeen Roy – Good afternoon, everyone. We’re very excited to have you join us today. For all the pharmacists, first of all, I want to start by wishing you happy Pharmacists‘ Month! This is always a fun time of day to see all the creative activities that pharmacy departments all over the country are doing. As a treat from us we’re here with a great panel today to discuss “Mastering Big Data for Therapeutic Drug Monitoring: an effortless data-driven approach to vancomycin AUC dosing.” My name is Sharmeen Roy, and I am the Senior Director of Pharmacy solutions at DoseMeRx.

Before we get started, let’s just get through some housekeeping rules. The webinar will be recorded, and a link will be e-mailed afterwards. You all are on listen-only mode for the presentation. There is a handout available if you’d like to access it through the document icon. And please feel free to submit your questions anytime throughout the webinar, we’ll be answering those with our panelists in the Q and A session.

We will be here today discussing a few topics, streamlining workflow and improving efficiency with our updated DoseMeRx interface. And also talking about practical utilization of real-time clinical and usage data. We will be followed by a live demo and then wrapping it up with a Q&A with our panelists.

Let’s get right into it. Why are we talking about big data today? I think everyone would agree that from a pharmacist perspective, we are in a unique position in health systems. I think we are all serving in a very central role. We interact with all health care professionals and are poised to really leverage data that helps patient care and medication safety, as well as improving patient outcomes.

So, why “big data”? Traditionally, it’s been categorized by the three Bs: volume, velocity, and variety, and the definition now has expanded to five needs to address value. What does all that mean? Essentially, it means that there’s more data than ever, and it’s being collected from multiple sources at a very fast rate. And we need to leverage that data by ensuring that it’s quality data, as well as using it in a meaningful way to show valuable patient outcomes. And that’s what we’ve been trying to do here, at those things.

We’ve been on a journey with our clinicians, as you’ll hear today, providing you a platform to help implement the new vancomycin dosing guidelines, and now we’re ready to measure those successes.

Today, we have probably a lot of clinicians [listening in to the webinar] who use this platform daily. And it’s with their feedback, we’re able to make our platform more robust and measure those successes with our embedded analytics. We had to make some upgrades along the way which my colleague MJ will be showing us a little bit later today.

Our panelists here today were kind enough to volunteer their time out of their busy schedule today, so we really appreciate that they’re able to join us. I’m really looking forward to hearing from all of them. We have a nice mix of large academic centers, as well as community hospital, who recently implemented [DoseMeRx].

So, without further delay, I’d like to turn it over to our panel to do a brief introduction about themselves. We’ll start with Becca.

Dr. Becca Amen – Hey, my name is Becca, Amen. I’m from Benefits Hospital in Great Falls, Montana, it’s considered a mid-size hospital. We have about 350 licensed inpatient beds, and we take patients from up to a third of the area of Montana. So we’ve been using DoseMeRx for about a year now and so we’re ready to see some data about what we’ve done.

Dr. Julie Downen – Good afternoon, I’m Julie Downen and I work at Springfield Memorial Hospital located in Springfield, Illinois. We are a 521 bed teaching hospital, part of a five hospital health system memorial health. And we started using DoseMeRx this past spring.

Dr. Will Musick – Hi. My name is William Music and I work at Houston Methodist Hospital in Houston, Texas. The central hub hospital of our system is a 1250 bed academic teaching hospital, and Texas Medical Center, and we are an eight hospital system across the Houston metro area. We’ve been using and working collaboratively with DoseMeRx for a long time, since around about 2015.

Dr. Sharmeen Roy – Thanks. Will, you forgot to mention, you’re also part of our Clinical Advisory Board!Thank you all for being here today. So, we’ll start with our discussion. But I want you all to think about this statement: Good big data makes big decisions easy. Now, I know you want to comment on this, but we’ll wait until that until the end. And I promise, we’ll circle back to it. I’m really looking forward to hearing your thoughts on it.

So let’s, let’s get started. Will, I know you mentioned that you’ve probably been using [DoseMeRx] the longest. So how long? Can you tell us about your journey with DoseMeRx, if you’ve been using it for all patient populations, just a little bit about your experience.

Dr. Will Musick: Absolutely. We started circa 2015, I was looking for tools to help implement the changes I knew that were coming down the pike from the change to AUC-based dosing and monitoring. I knew we were going to need some IT support for that and started surveying available options and landed on this website called DoseMeRx and requested more info. And we’ve been working with DoseMeRx ever since.

So we use DoseMeRx in all of our populations here. We don’t really do pediatrics at the central referral hospital where I work. But I know our community hospitals do use it in pediatrics as well. About the only population that right now we exclude from DoseMeRx is our neuro critical care patients. And there’s just some entrenched ideas about dosing antibiotics on those neuro infection cases. But other than that, everybody’s pretty much a candidate at Houston Methodist.

Dr. Sharmeen Roy – Becca, I’d love to hear your experience. You’ve been using for about a year now?

Dr. Rebecca Amen – Yes, about a year. And it really was very well accepted, especially by nephrology when we showed them all the data. So we went live, we’ve been using in pediatrics, we do have a NICU pediatric program. So they both do use DoseMeRx there. We’ve been using it in adults. And, like you said, we do exclude neuro infections, but otherwise, it’s pretty much most of our patients.

Dr. Sharmeen Roy – And last, but not least, Julie.

Dr. Julie Downen – So we actually just recently implemented DoseMeRx this past spring. And we actually took a phased approach because we were actually going to transition to dosing all vancomycin, which was not our previous practice. So we’ve actually, just as of a couple of weeks ago, we’re now dosing all vancomycin for our patients. And we primarily see an adult patient population. We do get a few peds, but we have a few hospital down the street. So pretty much, we focus on those adult patients.

Dr. Sharmeen Roy – So, it sounds like DoseMeRx may help to implement that new protocol, so to speak or new service taking over all of the vancomycin patients. And with DACA, you mentioned pediatrics. So was that something that was doable because of DoseMeRx platform being available, or how did that come about?

Dr. Rebecca Amen – So we’ve been dosing all of our adults for quite some time, historically trough-based dosing and then switching the AUC with DoseMeRx. But that was all pretty smooth. What changed was in pediatrics we had previously we’d given recommendations on vancomycin dosing changes, but really we hadn’t done it taking it on as the pharmacist dosing it, and when they heard that we could do AUC dosing, the pediatricians were just on board. They wanted us. They had seen the data. They wanted to do it, but didn’t have a way to do it. So as soon as that came live in pediatrics they’re all ours. So we’ve been doing most to all of our pediatric vancomycin dosing since DoseMeRx. So that was a huge change for us. A really good change for us.

Dr. Sharmeen Roy – Awesome. Will, were there any new protocols, or anything that DoseMeRx was able to help you implement? I know you’ve been using it for some time now.

Dr. Will Musick – Our protocols really haven’t changed. We’ve had a pharmacy, vancomycin dosing protocol at all of our hospitals and various different forms for a long time, as long as I’ve been with the organization, which is about 18 years now. It has expanded. We have worked on unifying those protocols. But really, the push to a tool like DoseMeRx, was to allow the conversion of targets and AUC-targeted dosing, as opposed to historical, trough-based methodologies. And the other thing it facilitates is there’s multiple ways to do AUC dosing. But if you want to keep it at a low-level burden, then you need IT support for that.

Dr. Sharmeen Roy – That sounds like a lot of what I hear from other institutions as well. As a company, we really look for feedback from our customers. People who are using it day in and day out. Can you elaborate on a feature that maybe your team was able to request from us, and now you’ve seen it come live?

Dr. Rebecca Amen – One of the things that originally when it came out, when we got it, was that the intervals we put in what our normal standard interval was, and that was Q12 for us. And so every patient, when it started recommending doses, they always came up as Q12 and one of the recent updates was they changed it to really be more patient-specific, it can take into account the patient’s clearance and the patient’s half-life and so, now, it’s more specific to the patient. So, we actually had pharmacists using the Q12 like, oh, it’s recommending this. And so it’s really helped us that the platform was able to make that adjustment and change the way we see it or are initially when we go in.

Dr. Sharmeen Roy – I think you’re referring to the intuitive interval. I know that was something that we received requests for that quite often and I’m glad that’s helpful from your standpoint. And Will, I know you’ve seen the platform go through a lot of changes. So I’d love to hear what feature that you saw and had requested.

Dr. Will Musick – We’ve used DoseMeRx in a number of fashions. We started with standalone, non-integrated cloud based, enter all your own data. And then we went to a third-party integration through clinical decision support software, which is what we use now. But then there are some delays as with any IT interface, and sometimes things will get miss keyed in the EMR and then go through and fudge up the data in the system and the ability to actually go in and edit the data inside the DoseMeRx platform, e.g. change the time so it’s not at the same time as the level because you talked to the nurse, and you knew the dose was not actually given after the level was drawn. So to be able to troubleshoot those things, in the moment, was a really big change for us in terms of efficiency and user satisfaction.

Dr. Sharmeen Roy – All right, I know we’ve made a lot of changes and added lot of features. How would you say, Becca, that it’s improved? Maybe your workflow, or your team’s workflow, based on what you’ve heard from your team.

Dr. Rebecca Amen – Sure, and this goes back to that editing data thing. We requested that, also we have a lot of issues with transitions of care, because we take patients from all these little, tiny, small hospitals around Montana and so they’ve gotten one or two doses of vancomycin prior to coming to us. So using that edit, you can add in those previous doses and get your calculator to use those for your calculations. So that’s really helped with our transitions of care to inpatient, but also facilitated them going back outpatient, should you be on long-term vancomycin they can continue to use the platform and add in doses into the account as an outpatient and use the dosing outpatient as well. So it’s really helped us with transitions of care, and I think that that’s been a great change for our patients.

Dr. Sharmeen Roy – That’s great to hear because I know that one of the nice features is that notes and communication tool within DoseMeRx, which helps talk through, from a handoff perspective, from one pharmacist to another. It’s really nice to get that. Julie, would you say there have been any improvements in workflow or anything that’s helped with the new features?

Dr. Julie Downen – Yes, actually, the progress notes have helped us with standardizing our documentation. And it’s so much easier than our previous method for leaving progress notes within the chart; [now] were much more efficient. I think one of the great recent updates that’s been super helpful is within the clinical notes. That information that we customize within the progress notes pulls into the notes and activities login. We’ve found that really helpful and gained some additional efficiencies from that.

Dr. Sharmeen Roy – I know that your institution recently implemented, this spring is when it started, and now recently you’ve taken over all of vancomycin dosing. What would you say is the most impactful feature in helping you accomplish that goal as it relates to DoseMeRx?

Dr. Julie Downen – I think one of the things that made this easy to do, if you will, was the EHR integration. When I first started looking at this product, I was able to use the web-based version and really liked that. But with our volumes of vancomycin, and just the amount of work that we do each day with managing and monitoring, we would not have been able to survive on the web-based to be quite honest. The EHR integration was key in our transition from trough-based monitoring to AUC-based monitoring.

Dr. Sharmeen Roy – Will, what about you? What do you think is most impactful for your institution?

Dr. Will Musick – I’ll absolutely second that. To a large degree, we used the web-based version, and all our own data points, and all our own doses, and there were a lot of improvements made over the years that we were using that platform and ease of use for entering data points. But nothing compares to the efficiency of data just flying in from either your EMR, or a clinical decision support tool, the kind of embedded format that we use. That’s been a huge time savings, a huge boost in efficiency and a huge boost in user satisfaction for the platform.

Dr. Sharmeen Roy – As pharmacists, we love integration, right? Anything that can automatically be populated to make our life easier, since we’re toggling between so many different programs and addressing so many different aspects of patient care. So it’s good to hear that that was a move that your institutions made, and something that was very beneficial.

I’m going to switch gears a little bit and start talking about embedded analytics. I know that there are many more aspects of the new features [in DoseMeRx] that we can probably have a whole session about, and you’ll see that in the demo. But, let’s transition to embedded analytics.

We have two dashboards, a clinical one, and a usage one. We’ll talk about both. I know all of you had the opportunity to look at it, and the audience will get a chance to see that today live. But as you think through when you started using it and playing around with the clinical dashboard, when you reviewed it, I want to ask, were there any surprises Becca?

Dr. Rebecca Amen – Overall, it almost surprised us that we were doing really good for what we were expecting, or I guess we weren’t expecting anything, so it looks really good! One population that really stuck out to us was that our obese patients or those that we were using the obesity calculator on, we weren’t doing as well at getting them to therapeutic within that 48 hours. And so it really helped us target what are we doing there, and what can we do to improve.

Dr. Sharmeen Roy – What about you Julie? Any surprises for you so far?

Dr. Julie Downen – What I focused in on is our time to therapeutic targets. Really, we’ve been doing well so far. But this also offers us an opportunity for growth for our pharmacists and for our department to improve in that area. And then the other area, which is really important measurement for our leaders here is AKI. And so, I’m really watching that, and looking for opportunities to improve or educate our staff from there.

Dr. Sharmeen Roy – And Will, any surprises for you?

Dr. Will Musick – It’s really pretty! In all seriousness, it’s a very succinct analytics dashboard. Everything is right there, front-facing. You can drill down into it a bit, there’s some ability to customize at the institution level as you’re going through data. It’s just nicely packaged.
We come from the experience and in previous iterations, where we would contact customer support, say, “hey, can we have some use metrics?” And we’d get a report, and we’d mess with it ourselves. But now it’s there, and it’s anytime you want it.

Dr. Sharmeen Roy – So it’s interactive, and it’s real-time, so you can change whatever you need to, right at your fingertips.

So talking about the clinical metrics, have any of them resulted in changes at your institution that you want to talk about?

Dr. Rebecca Amen – We’ve been looking at obesity, and we do have a population of morbidly obese patients that it’s recommended to do two levels in and that’s one of the things that we’re trying to target, which people are appropriate for two levels? Because not everyone is, and I don’t want to avoid extra levels if you don’t have to. If we can help get those people to therapeutic more quickly and have them in line with the rest of the patients, I think that’s our goal, so we’ve started education in that area.

Dr. Sharmeen Roy – So it really helped to focus on that patient population and also target your education. And Julie, it helped you take over all the dosing for your team or pharmacy to dose. What kind of metrics have changed practice or resulted in any other changes?

Dr. Julie Downen – Well at this point, since we actually just started taking over all vancomycin dosing just a few weeks ago, we have big plans for the analytics tool. This tool, once you see it, you’ll see, we are going to be able to share this information internally. Share that with our pharmacy staff and our department as they’re eager to see the outcomes and what we’re doing with DoseMeRx. And then we have a pretty active stewardship committee here at Springfield Memorial so I will provide updates to our providers and as well as our senior leaders and other physicians throughout the hospital. So, I can’t say that we’ve done anything yet, but we have really big plans for the future!

Dr. Sharmeen Roy – That’s good that you’re already seeing the potential of it, and planning for how you may be able to utilize it in the future, which is nice to hear all different perspectives, because, Rebecca, you have been utilizing it. Will, you’ve been utilizing it. So now what changes can be made, and to that effect have you been able to have any discussions with the pharmacists about the data that you’ve seen? What are the committees that you’re presenting to?

Dr. Rebecca Amen – We do have a council of pharmacists that guide our clinical interventions and metrics. So we’ve presented to clinical counsel, to the Antimicrobial Stewardship Committee, to P and T. And then our director presents to senior leadership. She has me put together a couple of slides to add into her presentation of all the things we’re doing. And so, this has been great. I can just slide it right over instead of creating things manually so that’s beautiful.

Dr. Sharmeen Roy – And have you been able to talk to your pharmacist at all about any changes you have made as a result already?

Dr. Rebecca Amen – So one of the things that we did, and this is even before this dashboard came out, was a pharmacist had a hard time with the mentality change of AUC dosing. Wanting to be like, well, maybe we should be 500 to 600, instead of 400 to 500. So originally, we had in the calculator the pre-determined AUC target was 500 and you start to see the pharmacists are like I’m going to be over 500, and so I dropped that down to 450. When this dashboard came out, it’s beautiful to see when we made that change, how our AUC changed with that, with that we did. It’s really nice to see that, if we make another change going forward, that we’ll be able to see that come out right away and see these measurements. So, that was really cool, that we’ve already been able to see things that we’ve done historically.

Dr. Sharmeen Roy – And that’s really what we were trying to accomplish, right? You have that real-time access and data, and you can make those changes based on what you’re seeing happening, so you don’t have to wait. I know Will talked about the metrics we would send out, those static reports; it’s hard to intervene on that at the end of the quarter, so to speak. So it’s nice to see that real time where you can make that change and then monitor, whether it’s a week later or a month later, and really see the impact of those changes.

I know, Julie, you talked about how you’re planning on using it, so are you planning on presenting to any committees or how do you anticipate using utilizing this dashboard?

Dr. Julie Downen – We will share it, pretty scheduled. We do a data review, just with antimicrobial utilization and days of therapy. So we’ll roll that in at our Antimicrobial Stewardship Committee and report on it quarterly, just like we do all those other pieces. But again, our leadership team is really focused on safety, and AKI, so when I go to Clinical Performance Committee, and for my annual update, I’ll definitely be sharing this information and comparing it to our baseline data that we’ve collected.

Dr. Sharmeen Roy – Great. Will, has it allowed you to have any discussions with your pharmacy team or maybe hospital wide committees?

Dr. Will Musick – We’ve started discussions and we definitely have plans to integrate it into our stewardship committee, on a regular review in the future. Being such a large organization, these logistic changes take some time to filter from availability to in-use, and so we’re in that process right now, but we definitely plan to use it to provide some summary numbers to our stewardship committees, as well as start to drill in, to look at outlier populations and areas for improvement.

Dr. Sharmeen Roy – So now looking, thinking through that dashboard and looking at that time to therapeutic or the therapeutic target goals graph, when you take a look at that, are you meeting your target goals? Becca, we’ll start with you.

Dr. Rebecca Amen – Well, like I said, we just started doing NICU Peds with this calculator and the Peds pharmacists are really killing it, and our time to therapeutic is 100%, 0 to 24 hours. And so, I think that that’s the goal, right? So, I think that we can try to push that in some of our other populations and in our adult population and see if we can do as good as the Peds people are doing.

Dr. Sharmeen Roy – How about you, Will, have you had a chance to review the dashboard? Are you meeting your goals?

Dr. Will Musick – We’ve got a decent baseline. We look really good at the 48 hour mark. We’re definitely going to have to drill into the 0 to 24 hours and try to stress that within our end user pharmacists, the clinical pharmacy group. So, we’re just dipping a toe into that, but we will definitely be used in that going forward, to give people feedback on their day-to-day performance.

Dr. Sharmeen Roy – What do you think our approach will be? How are you going to be able to meet those goals? Are you targeting education? Or what’s the plan?

Dr. Will Musick – We hope to use it to identify specific subpopulations or outliers. We’ve done CE on changing to AUC dosing, we’ve done special population CEs, we have general education planned on estimating renal function. These are big things, and we’ve done some big updates to the medical staff, as well to provide them with information, but that gets repetitive and it’s very resource intensive to put those kind of things together. And really, now we hope to be able to fine tune our interventions and fine tune our targets and fine tune our re-education now to specific subpopulations.

Dr. Sharmeen Roy – Right, so I’ve heard you all mentioned AKI and your subpopulation with looking at the renal function. Our patient risk indicator graph looks at specifically that, it looks at the patient risk indicator, indicates tracking of AKI, also different definitions. Becca, do you want to talk about how you’ve been able to utilize that?

Dr. Rebecca Amen – Historically, of course, this has all been manually. And I had a student, look through all of patients, run a report of all the patients, and look up AKIs. We did have him do a study of trough vs. AUC. And the AUC looking better than, than what we were doing with trough in AKIs. This is just a timesaver; instead of having to wait for you to have a student and pull manual charts. I think that this is a great way going forward to have the data at your fingertips and be able to do things with it that you weren’t able to do historically, just because of time.

Dr. Sharmeen Roy – This has been great, Julie, I know it’s a little bit new in the process, but I’d love to hear your thoughts on that.

Dr. Julie Downen – Just like Becca, we used residents to comb through charts, to find these AKI events. But, this dashboard makes it so easy. And so, we’ve really aligned our definition of API with the KDIGO guidelines, which you guys cite that within your patient risk factor indicators graph. And so then we can really translate our baseline data and then share the data that we have through analytics, to further make improvements down the line and see where we can improve patient care.

Dr. Sharmeen Roy – And Will I know you mentioned subpopulation looking at it, what would you find the most useful with the patient risk indicators?

Dr. Will Musick – We’ve done analyzes in the past with AKI and risk, and patients receiving vancomycin, if nobody on the call’s ever done it, go do it. You will then understand how big a lift that is, from a manual collection perspective. Even if you can get all the data electronically out of your EMR, or third party, then cleaning it, and applying definitions and weeding out trash data that’s in the set. To be able to do that on the fly, is a big game changer, because it’s a huge lift. We’ve done small quality projects. We’ve got a paper we’re trying to get imprint right now from a residents project last year that looks at AKI, not from a specific methodology or outcomes perspective, but just implementing AUC guidelines, you can see a difference. But getting that data to prove to someone there’s a difference is, is a huge lift.

Dr. Sharmeen Roy – Yes. Having been the student and the resident had to do all these reviews and had to assign it to people. I know what that looks like and the time that it takes to do the manual collections, I totally relate to that one.

So, if we look at this part of the dashboard, the risk indicators, what would you like to see in the future iteration? What would you like to be added, Becca, if you are looking at the risk indicators?

Dr. Rebecca Amen – So one of the things is you see your rates, but then how do you fix it? So, for me, I’d like to see, what’s the timeframe to AKI, are we having them within a couple of days? Are we having them at seven days? Is it a timeframe thing? Is it specific populations? So can we sort out are they diabetics, are they elderly? Is it our young people? Actually, one of the groups that we found we were having more AKIs and are 20- to 40-year-olds who have other comorbidities or IV drug use. So that was a group for us. So is there are ways to split it out with groups?

Dr. Sharmeen Roy – That definitely sounds like something that will make it more robust and useful. So we’ll definitely be talking soon to come up with all the different ideas you have. As I mentioned earlier, we really rely on the feedback from the user. So it’s awesome to hear that.
Will, what about yourself? I know you talked about subpopulations, anything else, anything specific you’d want to see added?

Dr. Will Musick – Yeah, I think really getting into the weeds of subpopulations would be the cherry on the top for us as well. You get into data use agreements and things like that, and embedded platforms and whatnot. But in theory, it shouldn’t be such a herculean lift to look at concomitant nephro toxins, patients who got [inaudible] and separate them out as opposed to normal population patients with known history of CKD or admission serum creatinine and being able to tease these subpopulations out with, would a welcome innovation.

Dr. Sharmeen Roy – All great ideas, and I’m making notes, will definitely be chatting.
Let’s move on to the usage dashboard, I know it’s a little bit different. But it has very good information. I’d love to hear how you’re utilizing the usage dashboard. Becca, can you talk about how you’ve been using it with your team?

Dr. Rebecca Amen – It’s really interesting to see, because you can look through users and see some people are dosing based on default dose. Some people are dosing based on a custom dose. Some are doing a custom target. So it’s of interesting to see what different people are doing, and then you can shape your overarching education. But you can also go talk to those specific people and say, show me what you’re doing, and then see is this something that we should adopt? Or is this something that we should change? So, it’s been really interesting to see how people are doing things differently, and everyone came from a different background. So it’s fun to get those little nuances and try to create a global approach.

Dr. Sharmeen Roy – I think as a pharmacist whose utilizing it, that’s probably good feedback to receive as well, right? Like, am I doing this correctly? There’s data to show either way, if it is or not. I think it just creates that dialog that’s very open and transparent. And we’re looking at this together, we want to reach our goal together ourselves. I think it’s very helpful from that perspective as well. Julie, how about yourself? Any surprises from the usage dashboards? What are the plans?

Dr. Julie Downen – From the usage dashboard, that’s really going to help us hone in and refine our practice here. It’ll help us ensure consistency and compliance. Just highlighting those various different doses like Becca did and making sure that we’re following our protocol. So that’ll be helpful, especially in these early stages. And another piece that I found really helpful as we expanded to dosing all vancomycin, this usage dashboard also breaks down when you’re the busiest, in terms of how frequently DoseMeRx has been launched, and you get either like an hourly breakdown or a daily breakdown. And so, for us, as we’re trying to manage an increased workload on the weekend, that’s really helpful for us to see those numbers. It’s a lot easier than pulling your report, and counting up all these different, various numbers. So that’s also helping us as we’ve expanded our practice, here.

Dr. Sharmeen Roy – I love hearing that, because that’s the big thing with big data, right? If it’s not usable, there’s data everywhere. I’m really glad to hear that you’re able to make those assessments of workload between the days of the week and make the appropriate changes, which is very helpful when your pharmacists have so many things they’re juggling now, during any given shift.

Moving on to opportunities for retraining. I know Becca that you touched on the use of the obesity model and potentially doing re-education that’s targeted for that. What about you Will? Has there been any identifying of opportunities for your staff using the usage dashboard?

Dr. Will Musick – I think the biggest thing for us really has been the fact that it’s real-time and it’s easily accessible, and we can get feedback to our end users quickly as opposed to, here’s the end of last year or the last two quarters data. We have done some slash e-mails and clinical meeting, like top user stuff to create some competition in a very competitive group of people, anyway. So because the paradigm shift was mentioned earlier and for some pharmacists, it truly is like winning over the adoption of this newfangled thing.

Dr. Sharmeen Roy – Are you giving out prizes for that competition?

Dr. Will Musick – Pats on the back.

Dr. Sharmeen Roy – All right. So this is really great to hear how you’re using it on a day-to-day basis and real time. Overall, I would just love to hear, how much time is this saving you?

Dr. Julie Downen – A ton. I can’t even put an amount of time on it. Just to paint you a picture: our baseline data that we collected, we had to do a sample. We couldn’t look at all patients. And even since we’ve gone live, we’ve done a few small samples. But this captures all of your patients. So it really paints you a much better, more complete picture than doing these random audits that are so time-consuming.

And then the best part is, is then it’s all wrapped up and presented in a ready-to-use, beautiful dashboard, so that’s also a timesaver as well. I can’t put an amount [of time], but it’s very easy to use and really helps us provide good quality care and lets us do other things instead of manually looking at a handful of charts, and now we have that complete picture, because of these analytics.

Dr. Sharmeen Roy – We can all use a little bit of extra time in our day. What about you Becca, how much time does it save you?

Dr. Rebecca Amen – I agree with Julie that we were doing samples. Honestly, I don’t know how much time it would’ve taken, because we never would have had the time to do it. And so would just be doing your dosing as you were doing it because that’s all you know. And now we have data to say, hey, we should target and improve. So we just have data that we never would have had, that we can now have actual patient outcome improvements because we had the data to make changes. So, it’s not measurable. I agree.

Dr. Sharmeen Roy – I’d say Will can put a time frame to it. How about you as well?

Dr. Will Musick – The analytics platform is weeks‘ worth of work. Just to get general summary numbers is weeks’ worth of work and scrubbing, and if you want any kind of specific endpoints. This was a major research project for PGY2 ID Resident two years ago, just to get the data points out of it, the analytics platform can show you anytime you want it.

Dr. Sharmeen Roy – That’s great. Again, always good to save some time, right? So, let’s just circle back to that initial statement; I had mentioned that “good big data makes big decisions easy.” Really quickly, what does the embedded analytics help you make? We’ll start with you, Will.

Dr. Will Musick – We’re definitely young in the process. We have plans to get the analytics data back as feedback to our end users to increase adoption rates for the platform. But honestly, the biggest thing is efficiency. We are early in discussions about putting together a data dump into a database, to be analyzed in a Tableau platform, to try to get some ongoing quality metrics out of it. And now, for the most part, they all exist in the analytics platform and DoseMeRx. And so that’s just been a huge benefit for us.

Dr. Sharmeen Roy – Becca, what about you?

Dr. Rebecca Amen – Our goal is always to improve patient outcomes. So, if you have good big data, you can make the decision where to target education, how to make changes, and how to improve outcomes. So I think that’s going to help us achieve our goals.

Dr. Sharmeen Roy – And Julie, I know you have plans.

Dr. Julie Downen – We’re really going to focus on the improvement of patient care. We want to get our targeted AUC within 48 hours, and we really want to minimize that risk for AKI. So, those are going to be our targets initially.

Dr. Sharmeen Roy – All right, I want to be sensitive to the time here. We’re going to transition to our live demo. I’m going to turn it over to MJ so you can have a visual of all these great features and the analytics we’ll be talking about. MJ I’m going to hand it over to you, it’s all yours.

[For access to the live demo recording and/or transcript, contact us]

Dr. Sharmeen Roy –Thanks MJ, thank you for showing all the features and the analytics. We’re now at the Q and A section, and we have lots of questions [from the audience]. I’m not sure we’re going get to all of them, but definitely be reaching out to you and sending you our responses. So, we’ll go ahead and get right into it. You have some questions regarding the analytics portion, as well as some clinical questions.

Let’s start with the first question we had, is “how can DoseMeRx be used for research purposes to convince higher administration, and the value of DoseMeRx?” I believe, Becca and Will you both referred to some research projects of how you’re able to utilize it. I’ll turn it over to you to answer that question.

Dr. Rebecca Amen – We just had a student do a baseline from our previous model of trough-based dosing and then our AKI rates from DoseMeRx and showed a decrease in AKI, and our nephrology team was really excited to see that. So I think that’s something, I mean, even if you can prevent one AKI a quarter, that’s still a huge cost burden. So anything that shows decrease in AKIs is a big deal.

Dr. Sharmeen Roy – And Will?

Dr. Will Musick – Research opportunities definitely exists, I really see it more, as a quality assurance, quality improvement kind of thing, and a return-on-investment argument. We have done the internal data lift using our residents and some students helped to show that, without getting into too much of the weeds, that just implementing AUC guidance and AUC decision making definitely improves renal related outcomes in these populations. And I think, as Becca mentioned, that actually adds up quickly if you look at the pharmaco and medical economics data how much an AKI costs.

Dr. Sharmeen Roy – The next question is regarding the most popular graph, is that Trough vs. AUC in our clinical dashboard. So the question is, can you walk through the Trough vs. AUC visual and describe how you had interpreted it? How you are able to utilize that and interpret it to the teams that you presented to. Julie, you haven’t had a chance to present it, but I know you reviewed it! Do you want to start by commenting on that?

Dr. Julie Downen – Absolutely. I think one of the great features of the analytics tool is it allows you really to hone in on certain areas and ranges. At first, you look at it and there’s a whole lot of information there, different AUCs, different trough ranges. What I plan to share with our providers is to then take that graph as it is and then hone in on that 400 to 600 range and really show how these lower troughs are truly getting us to those therapeutic AUCs. And then, I would take it a step further and then share our AKI data because we know that those troughs are supra therapeutic troughs have been really what’s associated with that nephrotoxicity. So I would couple that together and share that with the group and really show that this dosing is effective in that manner.

Dr. Will Musick – I was going to say there’s two things I usually call out when we’re looking at a graph like that, number one there’s obviously a relationship, it does correlate, but the correlation is not perfect and there are outliers and it is a wide blob on the map. And you definitely see those patients in whom trough would work just fine to get you to 4 to 6. But on either ends of the spectrum, you have patients who it just doesn’t work that way. And you definitively, that the danger patients are those patients that have therapeutic troughs but their AUCs are way over 600 and those are your AKI patients.

Dr. Rebecca Amen – I keep going back to the pediatric population because we had such great success there, but look at those little tiny purple guys on the bottom. You can see that with pediatrics; they need really low troughs to hit that AUC. That’s something that we’ve been overdosing Peds for how many years and that’s something our providers were really, really excited about. So if you want someone that’s an exaggerated group to really show this on, look at Peds.

Dr. Sharmeen Roy – I know you all know this, but trained in Peds, so that’s near and dear to my heart. I know it takes a while for a Peds infectious disease groups to convert, so definitely a good visual if you are trying to convince them to transition over.

So, our next question, I believe it’s actually for Will, I think all of you can probably answer this, are the panelists using it for chronic kidney disease and dialysis patients as well? I know I heard about neuro patients being excluded, but what about the dialysis patients?

Dr. Will Musick – They’re the only population that we’ve called out specifically that, let’s not go there yet. We do within our education and within our clinical competencies, we definitely talk about patient populations and whose creatinine measurements don’t necessarily line up with their actual renal function. And so to be leery of these populations, be leery of populations who have exaggerated volumes of distributions compared to the population. But the beauty of the platform is, is that have to think about that upfront but then once you get into actually dosing the patient and providing feedback to DoseMeRx, i.e. levels, the patient’s levels will take over. So if you provide a level or two, maybe three, and a very off-the-wall out in left field type of patient, from a pharmacokinetics perspective, you can still be confident that you are where you need to be.

Dr. Sharmeen Roy – Becca, do you have anything to add to that?

Dr. Rebecca Amen – You were talking about those people that you are leery of, or the quadriplegic patient, or whatever their SCr is 0.2 and you know that’s not real. So, just knowing who are your people that you need two levels within the same interval? Get it early and then you have patient specific data and you can go forward dosing. So the platform is perfectly setup, as long as you have the clinical judgement to capture those patients you can use the platform perfectly to have good outcomes with them.

Dr. Sharmeen Roy – I know we’re over our time. But I think we can squeeze in one more question. So how did DoseMeRx change your sampling practice when you moved to AUC based therapy? Are you still drawing top levels? Are you switched over?

Dr. Rebecca Amen – We love it. We only send our lab team up once a day with their morning drop, with the exception of those people I just said I got two levels on. But you can time one of them with an AM lab. Our lab team is a huge, huge fan of us right now!

Dr. Will Musick – That’s really one of the beauties of moving to a Bayesian level analysis, and using a computer to do math, is that it doesn’t care if you’re at steady state, it doesn’t care if it’s a trough. It doesn’t care, it just does the math.

Dr. Julie Downen – I would just echo that we moved to random levels with AM labs, as well. And one of the nice things about DoseMeRx is that we’ve been able to use, there’s a dosing date and time to start your doses. So, for us, are AM lab times varies amongst our units throughout the hospital, so we actually also use that to also avoid AM lab draw times. So we have found that helpful, as well, when we’re trying to not interfere with our AM labs.

Dr. Sharmeen Roy – That’s great to hear. I’m sure your lab colleagues are all giving you presents and candies for making their life a lot simpler because I know how chasing levels can be.

Dr. Rebecca Amen – Our patients do too!

Dr. Sharmeen Roy – That’s true! Well, thank you so much for all of your time. I know that you all have a lot going on and you all are very, very busy, and I really appreciate you being on here. I hope this was very insightful for our audience. And just want to thank all our panelists today, for your time. Thanks everyone for joining.

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