Section 23.4: Clinical Surveillance and Interventions

23.4.1 The “Why”: The Great Practice Shift from Reactive to Proactive

For decades, the practice of hospital pharmacy has been defined by a fundamentally reactive workflow. An order is written by a provider. It appears in a queue. A pharmacist reviews that single order for that single patient, verifies it, and the process moves on. While your clinical judgment during that verification is critical, the workflow itself is passive. You are waiting for the work to come to you. You are a highly skilled gatekeeper, but a gatekeeper nonetheless. This model, while essential, is inherently limited. It only allows you to find problems that have already manifested as a formal medication order. You might catch an incorrect dose, but you have no systematic way of finding the patient whose declining renal function now makes their existing dose incorrect.

The modern EHR, and specifically the toolsets within a platform like MEDITECH Expanse, enables a revolutionary transformation in this practice model. It allows for the shift from a reactive stance to a proactive, population-based approach. This is the single most significant evolution in clinical pharmacy practice in the last fifty years. Instead of waiting for problems to arrive in your queue, you are now empowered to go hunting for them across the entire patient population, using the EHR as your digital hunting ground.

This is the concept of Clinical Surveillance. It is the digital equivalent of rounding on every single patient in the hospital simultaneously. The system’s tools allow you to build electronic “nets” that are cast across the sea of patient data. These nets are designed to catch specific, pre-defined clinical scenarios that indicate a potential medication-related problem or an opportunity for optimization. When a patient’s data matches the criteria of your rule, the system alerts you. It brings the potential problem directly to your attention, often hours or even days before it would have manifested as an adverse event or a problematic order.

As a Pharmacy Informatics Analyst, you are the architect of this proactive safety engine. You will work with clinical leaders to identify the highest-risk scenarios in your hospital and then translate that clinical logic into the language of the EHR, building the rules and alerts that drive this new model of care. Mastering these tools is not just about learning to use a new feature; it’s about fundamentally redesigning the work of a clinical pharmacist. You are building the infrastructure that allows your pharmacy department to move beyond simply processing orders and to begin truly managing the medication-related outcomes of the entire patient population.

23.4.2 The Surveillance Engine: Deconstructing the MEDITECH Toolset

MEDITECH Expanse provides a powerful, integrated suite of tools designed to facilitate clinical surveillance. While they all work together, it’s important to understand the distinct purpose of each component. At its core, the system is a classic rules engine. It constantly scans a universe of patient data points (“Attributes”) and compares them against a set of logical conditions you have written (“Rules”). When a condition is met, it performs a pre-defined action (“Alerts” or “Triggers”). Your job is to become an expert in defining each of these components to build clinically meaningful surveillance.

Mastery Deep Dive: Attributes – The Building Blocks

Before you can write a single rule, you must understand your building materials. Attributes are pointers to specific fields within the MEDITECH database. The system comes with thousands of standard attributes, but you will often need to create custom ones for pharmacy-specific needs. The key is to know what data is available and where to find it.

Attribute Category	Examples of Standard Attributes	Common Pharmacy Use Case
Pharmacy (PHA)	Active Medication, Dispense Drug Mnemonic, Order Start/Stop Date, IV Rate, Therapeutic Class	Identifying all patients currently on a specific medication (e.g., any IV antibiotic) or from a specific class (e.g., any DOAC).
Laboratory (LAB)	Result Value (e.g., 5.3), Result High/Low Flag, Collection Date/Time, Test Mnemonic (e.g., K, CRE)	Finding all patients with a potassium level above 5.0, or whose creatinine has increased by more than 0.3 in the last 48 hours.
Admissions (ADM)	Patient Location, Patient Age, Patient Weight, Admitting Provider, Length of Stay	Targeting patients on a specific unit (e.g., ICU), or creating age-specific rules (e.g., patients > 65 on the Beers list).
Microbiology (MIC)	Organism Identified, Organism Susceptibilities (S, I, R), Specimen Source	Alerting a pharmacist when a blood culture grows a resistant organism (like MRSA or VRE) so they can recommend an appropriate antibiotic change. This is a core antimicrobial stewardship function.

23.4.3 Masterclass: Building a Surveillance Rule from Scratch

Let’s move from theory to practice. We will now walk through the end-to-end process of building one of the most common and valuable pharmacy surveillance rules: “Identify Patients with Acute Kidney Injury (AKI) on High-Risk Nephrotoxic Medications.” This rule demonstrates the power of combining lab data with medication data to find patients at risk before severe harm occurs.

Step 1: Define the Clinical Question and Scope

First, we collaborate with our clinical pharmacy specialists. The goal is not just “find AKI.” We need to be specific. After discussion, we define the clinical intent:

“We want to be alerted to any adult patient who meets the KDIGO criteria for Stage 1 AKI (an increase in serum creatinine of ≥0.3 mg/dL within 48 hours) AND who has an active order for one of the following high-risk nephrotoxic drugs: Vancomycin, Piperacillin-Tazobactam, or an Aminoglycoside.”

Step 2: Identify and Build the Necessary Attributes

Now we translate the clinical question into data points the system can understand.

Clinical Concept	Required Attribute(s) in MEDITECH	Build Action Needed
Adult Patient	ADM Patient Age	Standard attribute, no build needed. We will set the condition to `Age >= 18`.
AKI Criteria (SCr increase ≥0.3 in 48h)	LAB Serum Creatinine Result Value	This requires a more complex, calculated attribute. We need the system to look at the most recent creatinine and compare it to any creatinine values from the previous 48 hours and find the difference. MEDITECH has tools for this kind of time-based comparison logic.
Active High-Risk Nephrotoxic Meds	PHA Active Medication	This requires a custom attribute. We must create a “Query” (a list) named `NEPHROTOXIC_DRUGS` that contains the PHA mnemonics for every single Vancomycin, Pip-Tazo, Gentamicin, Tobramycin, and Amikacin product in our formulary.

Step 3: Construct the Rule’s Logic

Now we assemble our attributes into a formal rule using Boolean logic. The Surveillance tool provides a user interface for this, but thinking in terms of pseudo-code is the clearest way to design it.

Step 4: Define the Trigger and Alert

What should the system do when all three conditions are met for a patient? We have several options, and we can even choose more than one.

• Primary Action: Add to a Patient List. This is the most common and effective action. We will create a custom Patient List (sometimes called a “worklist”) named “Pharmacy – AKI Monitoring.” When the rule fires, the patient automatically appears on this list. This creates a centralized to-do list for the clinical pharmacy team to work from.
• Secondary Action: Send a Notification. For very high-risk alerts, we could configure the system to also send a priority message directly to the inbox of the pharmacist assigned to that patient’s unit. This is more “in your face” and should be used judiciously to avoid alert fatigue.

Step 5: Test, Validate, and Deploy

You can never, ever build a rule and move it directly into the LIVE environment. It must be rigorously tested in a test environment using fake patients. You would create a test patient, give them a starting creatinine of 0.8, then result a new creatinine of 1.2. You would place an order for Vancomycin. Then you would run the rule and confirm that your test patient, and only your test patient, appears on the AKI Monitoring list. Once you are 100% confident the logic is sound, you can schedule the move into your production environment.

23.4.4 Documenting Your Value: The Pharmacist Intervention

Detecting a potential problem with a surveillance rule is only half the battle. The true value of a clinical pharmacist is in the action they take based on that information. That action, or intervention, must be documented. Without documentation, from a data and quality perspective, the work was never done. This is not just about justifying your job; it’s about creating a legal record of the care provided, communicating your actions to the rest of the healthcare team, and generating the data needed to track clinical outcomes and measure the pharmacy department’s impact.

MEDITECH provides a dedicated tool for this: the Pharmacist Intervention module. As an analyst, you are responsible for building the dictionary of available intervention types that pharmacists can choose from. The goal is to create a list that is comprehensive enough to capture the wide variety of clinical activities a pharmacist performs, yet structured enough to allow for meaningful data analysis.

Masterclass Table: Building an Intervention Dictionary

Category of Intervention	Specific, Actionable Intervention Types to Build	Rationale
Dose Optimization	Renal Dose Adjustment Hepatic Dose Adjustment Indication-Specific Dosing Supratherapeutic Dose Corrected Subtherapeutic Dose Corrected	These are the most common pharmacist interventions. They need to be specific to allow for targeted analysis (e.g., how many of our dose adjustments are due to renal vs. hepatic impairment?).
IV to PO Conversion	IV to PO Conversion – Therapeutic Interchange IV to PO Conversion – Same Drug	Separating these two is important. Converting from IV Levaquin to PO Levaquin is a simple switch. Converting from IV Zosyn to PO Augmentin is a therapeutic interchange that requires different clinical consideration.
Safety & Allergy	Allergy Clarification / Correction Drug Interaction – Recommendation Made Therapeutic Duplication Corrected High-Risk Medication Monitored	These directly capture the pharmacist’s role as a safety net. Tracking these interventions is crucial for quality and safety committees.
Antimicrobial Stewardship	Antibiotic De-escalation Recommended Bug-Drug Mismatch Corrected Redundant/Anaerobic Coverage Discontinued Antibiotic Timeout Performed	These are essential for any hospital’s stewardship program and are often required for regulatory compliance (e.g., by The Joint Commission).