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)