AHRQ 2007 Conference September 27, 2007
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Transcript of AHRQ 2007 Conference September 27, 2007
Maximizing the Effectiveness of E-Prescribing Between Physicians and Community Pharmacies:Implementation
AHRQ 2007 Conference September 27, 2007
Principal Investigator:Kate Lapane, PhD
Project Manager:Ken Whittemore, MBA
Co-Investigators:Catherine Dubé, EdDMike Rupp, PhDTerri Jackson, PhD
OVERVIEW
Testing of interoperability of the standards; certification processes and pilot testing
Evaluation of the implementation of the standards from multiple perspectives using mixed-method approach
BREADTH: geography, e-prescribing technologies, practice settings, perspectives 6 states, 6 vendors, ~275 docs in ~88 practices , 276 retail pharmacy stores, ~1100 patients
OBJECTIVES OF THE PROJECT
The Perspectives
Evaluation Strategies:
• Mixed-method approach– Qualitative methods:
• Focus groups
• Performance analyses (on-site observation) – physician practice only
– Quantitative• Survey
– Providers (physicians and other prescribers, pharmacists and pharmacy techs)
– Patients• Documentation of interventions (pharmacy)
Clinician perspectives
Just because a practice has e-Rx capabilities….
• Not all clinicians within the practice e-rx– Training issues– Lack of understanding of benefits
• Not all clinicians use e-rx with all patients
• Not with all prescriptions– Regulations (scheduled drugs)
• Not all functionalities of e-Rx
Frequency of reviewing patient PBM med history
0% 50% 100%
F
E
D
C
B
A
OVERALL
Always Most of time Sometimes Never
Phys
icia
n So
ftwar
e Ve
ndor
Non-clinician use of review of medication history
0 20 40 60 80 100
C
A
OVERALL
Yes No
• Users of two vendors reported significant use of functionality among non-clinicians.
0 10 20 30 40 50 60 70
C
A
OVERALL
Most/All of the time Sometimes Never
Review patient medication history? Frequency of use of functionality?
• If workflow structured to permit it, non-clinicians use functionality frequently.
Vend
or
Vend
or
Variation in frequency of updating medication list with patient
0% 20% 40% 60% 80% 100%
F
E
D
C
B
A
OVERALL
Always Most of time Sometimes Never
Phys
icia
n So
ftwar
e Ve
ndor
0% 20% 40% 60% 80% 100%
F
E - State 2
E - State 1
D
C
A
OVERALL
Vend
or
Very useful Somewhat useful Not useful
Usefulness of patient’s medication history provided through your e-prescribing software in reconciling the active medication list?
Med history – missed opportunities?
• Data may not be displayed optimally• Used mostly if there is a problem–
– drill back down to learn more• Need to harness the power of med history
and train clinicians to use data prospectively to prevent medication issues
Patient perceptions regarding frequency of discussion with clinician
0 20 40 60 80
Never
Sometimes
Often/Always
Percentage
E-Rx No E-Rx
Adherence Accuracy of Medication List
0 20 40 60 80 100
Never
Sometimes
Often/Always
Percentage
E-Rx No E-Rx
ALERT FATIGUE…….
0% 20% 40% 60% 80% 100%
F
E
D
C
B
A
OVERALL
Never Sometimes Most/Always
Phys
icia
n So
ftwar
e Ve
ndor
0% 20% 40% 60% 80% 100%
F
E
D
C
B
A
OVERALL
Never Sometimes Most/Always
DOSE CHECKS DRUG-DRUG INTERACTIONS
Pharmacy perspective
Distribution of personnel survey responses by pharmacy chain organization
7 36 42
813
12965
2
c d f h i j k
Pharmacy chain organizations
Note: Respondents from 276 stores with minimum e-Rx activity (5 per day).
RUPP, JACKSON.
Pharmacy perspective
Satisfaction with e-Prescribing
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Pharmacist
Technician
Intern
Very DissatisfiedModerately DissatisfiedSomewhat Dissatisfied
Somewhat SatisfiedModerately SatisfiedVery Satisfied
Very Satisfied 18.7% 19.0% 14.3%
Moderately Satisfied 33.9% 34.2% 48.6%
Somewhat Satisfied 28.8% 28.3% 28.6%
Somewhat Dissatisfied 11.5% 10.6% 5.7%
Moderately Dissatisfied 5.2% 5.1% 2.9%
Very Dissatisfied 2.0% 2.8% 0.0%
Pharmacist Technician Intern
RUPP M, JACKSON T.
Pharmacist perceptionsHow eRxs Compare: Pharmacists (n=446)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Safety
Effectiveness
Efficiency
Pt Communication
MD Communication
Pt Relations
MD Relations
Much WorseSomewhat WorseNo ChangeSomewhat BetterMuch Better
Much Better 31.4% 23.1% 28.0% 11.7% 18.3% 11.0% 13.7%
Somewhat Better 41.5% 47.4% 47.0% 23.6% 30.2% 33.6% 27.7%
No Change 16.0% 20.9% 14.1% 52.3% 25.7% 43.5% 40.3%
Somewhat Worse 9.3% 7.7% 9.1% 10.4% 21.4% 10.4% 15.1%
Much Worse 1.8% 0.9% 1.8% 2.0% 4.3% 1.6% 3.2%
Safety Effectiveness Efficiency
Pt Communicati
on
MD Communicati
on Pt Relations MD
Relations
RUPP M, JACKSON T.
Variation in how e-RX processed
• Most chains drop e-Rx into the store fill queue• Some print e-RX and then process (phasing out, short
term transition issue)• Most auto populate fields• Images of e-RX available on some systems• Some chains treat e-Rx with lower response urgency
than:– Customers waiting in line– Clinicians on the phone– Faxes on the printer
• Other chains grant e-RX the highest fill priority
Medication history for pharmacists?
• Currently not available to pharmacists– Some chain wide – Some store only
• No sharing across pharmacies
Patient Perspectives
Does E-Rx offer potential?
Geriatric patient perspective on e-Rx
0
10
20
30
40
50
60
70
Stonglypreferpaper
Stronglyprefer e-
rx
E-RxNo E-rx
Notes of caution Q&A:
When do you expect your Rx to be ready?
Paper RX helps me remember to pick up my RX?
18% IMMEDIATELY!
57% - 74% agree!
Geriatric patient perspective
• Mismatch in perceptions– Clinicians think that discussions are occurring
more frequently than patients report• Med history and formulary/benefits:
– Potential to increase the frequency of medication discussions
– Change in quality of discussions unknown– Missed opportunities for improvement?
• Engaging the patient in the process
Summary
• Less than optimal use of functionality
• How do we build it to make them come?2nd generation issues
• Who should come?– Engaging:
• Pharmacists – med history at point of dispensing?• Physicians – using med history in practice• Patients – tools for them?
BibliographyLapane KL, Quilliam, Dore. Roadblock on the Health IT Superhighway: E-prescribing and the
Controlled Substances Act. J Opioid Management 2007; 3(4):xxx-xxx.Lapane KL, Dube C, Schneider K, Quilliam BJ. Patient Perceptions Regarding E-prescriptions:
Is the Geriatric Patient Ready? J Am Geriatr Soc. 2007 Aug;55(8):1254-9.Dube C, Lapane KL, Rosen R. The business case for e-prescribing (in preparation)Goldman R, Dube C, Lapane KL. The status of electronic processing of refills (in preparation)Lapane KL, Waring ME, Schneider KL, Quilliam BJ, Dube C. A mixed-method Study Of The
Value Of Drug Alerts At Point Of E-Prescribing In Primary Care (in revision, JGIM)Dube C, Lapane KL. Medication history at the point of prescribing: changing clinical practice (in
preparation)Lapane KL, Dube C, Schneider K, Quilliam BJ. (Mis)Perceptions of Patients and Providers
Regarding Medication Issues, In revision, Am J Managed Care Lapane KL, Waring ME, Dube C, Schneider KL, Whittemore K. E-prescribing as an agent of
patient safety: A mixed-method study. (under review AHRQ)Rupp M, Jackson T. Pharmacy personnel attitudes towards e-prescribing. (in preparation)Jackson T, Rupp M. Medication therapy interventions on e-prescriptions. (in preparation) Lapane KL, Waring ME. Medicare Part D implementation: Lessons learned (in preparation)