AHRQ Annual Conference September 27, 2007 Presenter – Michael Bordelon
Maximizing the Effectiveness of E-Prescribing Between Physicians and Community Pharmacies:...
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Transcript of Maximizing the Effectiveness of E-Prescribing Between Physicians and Community Pharmacies:...
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
Ph
ysic
ian
So
ftw
are
Ven
do
r
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.
Ven
do
r
Ven
do
r
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
Ph
ysic
ian
So
ftw
are
Ven
do
r
0% 20% 40% 60% 80% 100%
F
E - State 2
E - State 1
D
C
A
OVERALL
Ve
nd
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
Ph
ysic
ian
So
ftw
are
Ven
do
r
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 Dissatisfied
Moderately Dissatisfied
Somewhat Dissatisfied
Somewhat Satisfied
Moderately Satisfied
Very 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 Worse
Somewhat Worse
No Change
Somewhat Better
Much 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-Rx
No 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)