Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
E-prescribing in communitybased practices: successes and barriers Michael A Fischer, M.D., M.S. Division of Pharmacoepidemiology and Pharmacoeconomics Department of Medicine Brigham and Women’s Hospital Harvard Medical School Research team • Co-authors Ritu Agarwal, PhD U Maryland Corey Angst, PhD Notre Dame Cate Desroches, PhD MGH • BCBSMA – Megan Bell – Adrienne Cyrulik, MPH • Tufts Health Plan – Julie Newton • Zix Corporation – Angus MacDonald – Scott Plunkett Background • Promise of e-prescribing – Improved safety – Value – Efficiency • Slow spread to community-based practices – Uncertain what drives successful e-prescribing uptake in community setting Study setting • Initiated by BCBSMA and Tufts Health Plan • Partnered with ZixCorp, providing physicians with PocketScript system • Program began in early 2004 Prior studies – erx adoption Fischer et al, JGIM, 2008 Prior studies – e-rx and costs 64% Start of e-prescribing 62% Percent Tier 1 60% 58% 56% Control prescribers 54% Intervention prescribers, eprescriptions Intervention prescribers, non-eprescriptions 52% 50% -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 Month relative to 1st e-prescription Fischer et al, Arch Int Med, 2008, in press 11 Prior studies – e-rx and safety • Most alerts over-ridden by prescribers – Weingart et al. Arch Int Med, 2003 • Reviews suggest reduced ADEs, but inadequate studies in outpatient setting – Ammenwerth et al. JAMIA, 2008 Study questions • What is the experience of communitybased practices that adopt electronic prescribing systems? • What barriers remain to successful adoption and use of e-prescribing? • Where has e-prescribing succeeded; has it created new problems? Study design • Focus groups – Conducted spring 2008 – Prescribers and office staff • Internal medicine, pediatrics, FP, cardiology, nephrology – Both current and former users • High/low volume, abandoned, transitioned to EMR • Interviews – Detailed discussions with prescribers Findings • E-prescribing positives • Ongoing challenges/barriers E-prescribing positives • • • • • • Prescription security Financial gain Office efficiency Medication safety Insurance issues Communication with pharmacy E-prescribing positives • Prescription security – Less people touch the actual prescription – Patients cannot lose the prescription – Patients cannot tamper with prescription E-prescribing positives • Financial gain – Direct incentives a major factor • Initial adoption subsidized • Later incentives for ongoing use – Potential gains in patient satisfaction • “if we can reduce wait times, we’ve succeeded” • Unclear of RoI in terms of practice billing E-prescribing positives • Office efficiency – Major changes in practice workflow • Less calls for front-end staff • Refills and other non-critical medication issues can be batched for MD review – Frees staff time and attention • Less interruption of work • Pharmacy information is updated and accurate • Perceived ROI, but hard to quantify E-prescribing positives • Medication safety – Quick review of patient medication history • Available round the clock, out of office – Alerts about drug-drug interactions • Office staff appreciated reminders • Physicians less certain, many alerts dismissed – Ability to identify patients on a specific drug • Especially useful for recalls – “I can identify all the patients on..” E-prescribing positives • Insurance issues – Can see if a drug is not covered • Avoids callbacks, increased patient satisfaction – Ability to identify patients on a specific drug • Also useful for prescribing incentive programs E-prescribing positives • Communication with pharmacy – Timely flow of information – Ability to send specific messages • e.g.: “no more refills until patient sees doctor” Ongoing challenges/barriers • • • • • • Learning curve Usability Reliability Safety concerns Patient resistance Data security Ongoing challenges/barriers • Learning curve – New skill: “not covered in medical school” – Difficult for older prescribers – High burden on champions/superusers – New tasks for some personnel – source of resistance – Lack of support – “Locked in” with initial vendor choice Ongoing challenges/barriers • Usability – Types of devices/interfaces – Problems with some pharmacies – Inability to transmit to PBMs • Reliability – Connectivity/network problems, loss of productivity – Resistance for sick patients or weekends Ongoing challenges/barriers • Safety concerns – Selecting wrong patient – Selecting wrong drug (Cipro/Cialis) – Some doses/formulations not in system – Drug alerts not perceived as helpful: “ignore almost all” – Some alerts may be handled by nonprescribers in the process of queuing Ongoing challenges/barriers • Patient resistance – Wanting something in hand (older pts) – Bad experiences with failed transmissions – Inability to transmit to PBMs • Data security – Concern about whether transmitting patient data creates liability exposure – Concern about prescribing data and tracking/profiling – Who owns the data: cost of changing Summary observations • Overall positive experience – almost none would “turn back the clock” • Successes: office efficiency, pharmacy communication, formulary information, prescription security • Barriers/challenges: Learning curve, reliability, questionable safety impact Summary observations • Benefits more apparent in larger practices with high volume of chronic mediations – More opportunities to streamline workflow – Prescription volume/management is seen as a major issue at baseline – Possible financial gains easier to perceive Next steps • On-site visits to observe system use, validate focus group observations • Large-sample survey to test generalizability of initial findings • Quantitative studies of e-rx impact on cost, safety, adherence, clinical outcomes