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Rheumatology Medication Safety App
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The goal of the Rheumatology Medication Safety App is to improve safe prescribing of medications used in rheumatology. The App is comprised of four dashboards adopted across 120 VA facilities:
1) The DMARD Latent Infections Dashboard focuses on screening for latent infections (tuberculosis (TB), hepatitis B virus (HBV), and hepatitis C virus (HCV)) prior to starting new immunosuppressants.
2) The Hydroxychloroquine Dashboard focuses on weight-based dosing of hydroxychloroquine.
3) The Gout Dashboard focuses on serum urate levels for patients on urate lowering therapies, as well as HLA-B*58:01 genetic allele testing for high-risk patients on allopurinol.
4) The Shingrix Dashboard focuses on shingles vaccination for patients receiving chronic immunosuppression.
Origin:
October 2020, San Francisco VA Medical Center
Adoptions:
110 in-progress
Partners:
Quality Enhancement Research Initiative
Recent Updates
Overview
Problem
The rapid proliferation of specialty medications including biologics and targeted synthetic disease-modifying agents (DMARDs) has dramatically expanded the treatment options available to patients with auto-immune conditions. However, health-system innovations to ensure safe prescribing of these medications have not kept pace. These drugs are known to increas
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The rapid proliferation of specialty medications including biologics and targeted synthetic disease-modifying agents (DMARDs) has dramatically expanded the treatment options available to patients with auto-immune conditions. However, health-system innovations to ensure safe prescribing of these medications have not kept pace. These drugs are known to increase the risk of reactivation of life-threatening infections, including HBV, HCV, and latent TB. Despite recommendations endorsed by the National Quality Forum (NQF), a large fraction of patients receiving these medications nationwide are missing screening tests for TB, HBV, and HCV.
Hydroxychloroquine (HCQ) is a conventional DMARD commonly used for patients with rheumatoid arthritis or systemic lupus erythematous. Although long-term use of HCQ can cause retinal toxicity, this risk can be reduced if high doses of the drug are avoided. Studies suggest that many patients are receiving higher than recommended doses of this drug.
The 2020 guidelines for gout management emphasize a treat-to-target approach, focusing on achieving and maintaining a serum urate level of ≤6.0 mg/dL which can reduce risk of flares and reduce gouty tophi. Studies have shown that a significant proportion of patients fail to reach this serum urate target.
Veterans who carry the HLA-B*58:01 allele are at risk for significant toxicity if they receive allopurinol for management of their gout. Genetic testing is recommended for South Asian and Black patients receiving allopurinol to reduce the risk of severe cutaneous adverse events.
Shingrix is a recombinant zoster vaccine (RZV) recommended for the prevention of shingles for immunocompromised individuals to reduce the risk of shingles. Despite its strong safety and efficacy profile, vaccination rates among these high-risk groups remain suboptimal. See more
Hydroxychloroquine (HCQ) is a conventional DMARD commonly used for patients with rheumatoid arthritis or systemic lupus erythematous. Although long-term use of HCQ can cause retinal toxicity, this risk can be reduced if high doses of the drug are avoided. Studies suggest that many patients are receiving higher than recommended doses of this drug.
The 2020 guidelines for gout management emphasize a treat-to-target approach, focusing on achieving and maintaining a serum urate level of ≤6.0 mg/dL which can reduce risk of flares and reduce gouty tophi. Studies have shown that a significant proportion of patients fail to reach this serum urate target.
Veterans who carry the HLA-B*58:01 allele are at risk for significant toxicity if they receive allopurinol for management of their gout. Genetic testing is recommended for South Asian and Black patients receiving allopurinol to reduce the risk of severe cutaneous adverse events.
Shingrix is a recombinant zoster vaccine (RZV) recommended for the prevention of shingles for immunocompromised individuals to reduce the risk of shingles. Despite its strong safety and efficacy profile, vaccination rates among these high-risk groups remain suboptimal. See more
- Study: Hydroxychloroquine dosing in immune-mediated diseases: implications for patient safety. Hydroxychloroquine dosing in immune-mediated diseases: implications for patient safety
- Study: RISE registry reveals potential gaps in medication safety for new users of biologics and targeted synthetic DMARDs. RISE registry reveals potential gaps in medication safety for new users of biologics and targeted synthetic DMARDs
- Study: VHA data shows low HLA-B*58:01 testing in high-risk allopurinol users; reveals wide variation across facilities. Facility Variation in HLA-B*58:01 Allele Testing for Asian and Black Patients Receiving Allopurinol in the Veterans Affairs Healthcare System
- Study: VHA data shows low RZV vaccination rates among immunosuppressed veterans. Recombinant Zoster Vaccination Among U.S. Veterans Receiving Immunosuppressive Medications 2017-2023
Files
Solution
We developed the Rheumatology Medication Safety App (Microsoft PowerBI) to improve the safe prescribing of medications used in rheumatology. This App pulls data from CDW to create a report of patients who have and have not received appropriate screening tests (among biologic/targeted small molecule users), drug dose (among hydroxychloroquine users), not-to-t
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We developed the Rheumatology Medication Safety App (Microsoft PowerBI) to improve the safe prescribing of medications used in rheumatology. This App pulls data from CDW to create a report of patients who have and have not received appropriate screening tests (among biologic/targeted small molecule users), drug dose (among hydroxychloroquine users), not-to-target serum urate levels (among those on urate lowering therapies), missing HLA-B*58:01 genetic allele tests (among Black and Asian allopurinol users), and missing or incomplete Shingrix vaccination (among chronic immunosuppression medication users).
These dashboards can be used for population health management to identify patients who are missing critical labs, who are receiving hydroxychloroquine at high doses, who have high, missing, or outdated serum urate levels, who have missing or positive HLA-B*58:01 allele results while being treated with allopurinol, and who have incomplete or missing Shingrix vaccinations while on chronic immunosuppression. See more
These dashboards can be used for population health management to identify patients who are missing critical labs, who are receiving hydroxychloroquine at high doses, who have high, missing, or outdated serum urate levels, who have missing or positive HLA-B*58:01 allele results while being treated with allopurinol, and who have incomplete or missing Shingrix vaccinations while on chronic immunosuppression. See more
Links
- Introduction video reviewing the aspects of each dashboard on the Rheumatology Medication Safety App. Introduction to the Rheumatology Medication Safety App
Results
Pilot testing of the App began in October 2020 and national rollout began in January 2022. As new dashboards are developed, they are similarly pilot tested prior to national rollout.
- Study: Time series analysis examining the effectiveness of the Hydroxychloroquine Patient Safety Dashboard among VA pilot sites. HCQ Dashboard time series analysis manuscript
Files
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Multimedia
Images
Results from a pragmatic trial of the VA Rheumatology Medication Safety App's HCQ Dashboard: Interrupted time series analysis shows that the proportion of patients receiving high doses of hydroxychloroquine decreased over time among pilot facilities compared to controls.
Implementation
Timeline
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Spring 2022
The Rheumatology Medication Safety App is available to all VA personnel with access to CPRS.
Departments
- Dermatology
- Gastroenterology
- Hematology/Oncology
- Pharmacy
- Rheumatology
Core Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
|
PROCESSES |
|
TOOLS |
|
Links
- Rheumatology Medication Safety App Landing Page Rheumatology Medication Safety App
- This toolkit is to support the Rheumatology Medication Safety App's DMARD and HCQ dashboards by providing presentations, slide decks, email templates, and other resources to aid efforts to increase pre-screenings and safe prescribing for Veteran patients on high-risk immunotherapies. DMARD Patient Safety Toolkit
- This toolkit is to support the Rheumatology Medication Safety App's Gout Dashboard by providing presentations, slide decks, email/letter templates, educational materials, patient-facing materials, and other resources to support caring for Veteran patients with gout. Gout Patient Safety Toolkit
- This searchable Knowledge Base houses frequently asked questions about our dashboards and provides resources (e.g. workflows) for effective utilization of the App. Knowledge Base (FAQs)
- Information and instructions for each of the App's dashboards, including the purpose, recommended use, actionable items (including criteria and definitions), data source, data frequency, and drill-through features. Dashboard Information and Instructions
Risks and mitigations
| Risk | Mitigation |
|---|---|
| Disclaimers for the Rheumatology Medication Safety App |
1) Do not rely solely on the information in this report for clinical decision-making. Data are not yet widely validated. Omission and/or false positives are possible. Use CPRS to ensure the information is correct before taking action with a patient. 2) Do not use these data for research. It is against the VA CDW terms of use and VA policy. |
| Disclaimers for the DMARD Latent Infections Dashboard |
1) Providers that are *Unknown at this time* may be non-VA providers via the community care program. 2) TB testing information comes from lab tests, clinical note title, or health factors, but not clinical note narratives; therefore, TB tests for some patients may not be captured here. |
| Disclaimers for the Hydroxychloroquine Dashboard | 1) For orders with complex medication instructions or those that do not match the quantity dispensed, the calculated dose in mg/kg/day may be inaccurate. |
| Disclaimers for the Gout Dashboard |
1) Providers that are *Unknown at this time* may be non-VA providers via the community care program. 2) HLA-B*58:01 labs on the dashboard are extracted from structured lab fields only; therefore, HLA-B*58:01 labs for some patients may not be captured here. |
| Disclaimers for the Shingrix Dashboard |
1) Shingrix information on the dashboard are extracted from structured lab fields only; Shingrix given outside the VHA may not be captured here. 2) For orders with complex medication instructions, the calculated glucocorticoids (prednisone) dose in mgs/day may be inaccurate. |
About
Origin story
Dr. Schmajuk is a rheumatologist who has studied quality of care and medication safety. She helped develop the American College of Rheumatology’s RISE registry and thought that the VA could use similar dashboards to drive patient safety and quality improvement for Veterans. This application was developed as part of the Measurement Science QUERI at the SFVAMC
...
Dr. Schmajuk is a rheumatologist who has studied quality of care and medication safety. She helped develop the American College of Rheumatology’s RISE registry and thought that the VA could use similar dashboards to drive patient safety and quality improvement for Veterans. This application was developed as part of the Measurement Science QUERI at the SFVAMC, funded by HSR&D.
Original team
Gabriela Schmajuk
Project Primary Investigator, Rheumatologist
Cherish Wilson
Program Manager
Gary Tarasovsky
Data Manager, Data Analyst
Comment
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