Electronic Prescribing and Decision Support to Improve Rural Primary Care Quality (South Dakota)

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Electronic Prescribing and Decision Support to Improve Rural Primary Care Quality - 2011

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017149
  • Project Period: 
    September 2007 - August 2011
  • AHRQ Funding Amount: 
    $1,181,866
  • PDF Version: 
    (PDF, 194.54 KB)

Summary: Poor patient compliance with prescribed medications can adversely affect treatment outcomes. The compliance rate for patients receiving long-term treatment for chronic conditions, such as hypertension, is estimated to be as low as 50 percent. The introduction of electronic prescribing (e-prescribing) systems has the potential to greatly improve the accuracy and efficiency of pharmaceutical treatments. This project examined whether, in rural ambulatory care settings, the use of an e-prescribing system with clinical decision support for medication management increases patient prescription adherence, improves the medication management process, and improves health outcomes in hypertensive patients. As part of its overall Avera HealtheCARE TM Initiative, the South Dakota-based health system worked with 28 hospitals and 116 clinics to implement a regional electronic medical record (EMR). The technology package included advanced e-prescribing software, DrFirst Rcopia, that enables physicians to track the fill status of prescribed medications, and provides interaction alerts, formulary listings, dosing options, patient medication history, and printed wallet-size medication lists. The research team examined the impact of the technology on the medication management for patients with hypertension in nine rural or frontier primary care facilities. The project focused on two health information technology (IT) systems: 1) DrFirst Rcopia electronic prescription management system as a stand-alone product; and 2) DrFirst Rcopia integrated within the Meditech/LSS Data Systems Medical EMR and Practice Management Suite, the EMR system being implemented by Avera Health in the ambulatory setting. This EMR includes Zynx Health decision support technology.

The project took advantage of staged implementation, first gathering baseline measures and then tracking clinics that are using e-prescribing as a stand-alone tool before moving to an EMR, and clinics that are moving directly to an EMR with integrated e-prescribing.  Medical claims data and the e-prescribing patient-fill histories were used to determine whether patient prescription adherence improved, as measured by blood pressure levels and changes in treatment for patients with blood pressure higher than one hundred forty over ninety. This study was based on the observation of a "natural" process of disseminating and implementing a set of health IT innovations. As such, the experiment can be characterized as a quasi-experimental design with opportunistic, nonrandom assignment of clinics to the experimental condition.

Specific Aims:

  • Improve the rate of adherence to prescribed medications among patients with hypertension in rural communities. (Achieved)
  • Improve adherence to prescribed medications among patients with hypertension through use of e-prescribing tools in rural care settings. (Achieved)
  • Improve health outcomes for patients with hypertension in rural communities through the use of e-prescribing and associated clinical decision support tools. (Achieved)
  • Enhance patient and provider satisfaction with the e-prescribing tool. (Achieved)
  • Overcome barriers to successful adoption of e-prescribing. (Achieved)

2011 Activities: A 1-year no-cost extension provided time for the project team to complete data collection activities and the program evaluator and biostatistician to complete the analysis. The team administered the second round of provider satisfaction interviews and patient satisfaction with care surveys. As last self-reported in the AHRQ Research Reporting System, project progress was on track and project budget spending was on target. All activities were completed when the project ended in August 2011.

Impact and Findings: The results did not indicate that the implementation of stand-alone e-prescribing had an effect on the control of hypertension since the proportion of patients with control of blood pressure dropped slightly after implementation. However, after the EMR implementation occurred, there was an increase in the proportion of patients with control of hypertension compared with stand-alone e-prescribing. In addition, the proportion of patients with control of hypertension after EMR implementation was higher than at the baseline, prior to e-prescribing. There were a similar number of prescriptions in both the stand-alone system and after compliance and adherence messaging were added. The first-fill rates in these first two implementations were substantially higher than during the EMR implementation.

The patient survey results were similar across the three study phases. There was a slight downward trend in the level of satisfaction on hypertension treatment after implementation of the stand-alone e-prescribing system and after implementation of the EMR. However, there was an increased level of satisfaction with hypertension medications after both implementations.

A total of 149 educational interventions were recorded for patients with hypertension. A total of 26 patients were identified with hypertension pre- and post-intervention. There did not appear to be a significant effect on blood pressure control, although data on educational interventions and the number of blood pressure readings pre- and post-intervention were limited.

Provider perceptions were more positive when compared to the baseline pre-implementation for both the stand-alone e-prescribing and the EMR implementations. Patient adherence increased, as reflected in the medication possession ratios.

There was a small but consistent pattern across the three study phases, which showed reduced use of brand-name medications and increased use of multisource or generic medications. Changes in medication availability during the time period of the study from additional multisource medication options for prescribers may have influenced the results.

The clinic operating costs trended down for the first three phases, with an increase in cost for phase four during the EMR implementation at most of the clinical sites.

Target Population: Adults, Chronic Care*, Hypertension, Rural Health*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions and the electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

Electronic Prescribing and Decision Support to Improve Rural Primary Care Quality - 2010

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017149
  • Project Period: 
    September 2007 – August 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,181,866
  • PDF Version: 
    (PDF, 371.46 KB)


Target Population: Adults, Chronic Care*, Hypertension, Rural Health*

Summary: For many chronic conditions, poor patient compliance with prescribed medications can adversely affect treatment outcomes. It is estimated that the compliance rate for patients receiving long-term treatment for chronic conditions, such as hypertension, can be as low as 50 percent. The introduction of electronic prescribing (e-prescribing) systems has the potential to greatly improve the accuracy and efficiency of pharmaceutical treatments. The purpose of this project is to examine whether, in rural ambulatory care settings, the use of an e-prescribing system with clinical decision support related to medication management increases patient prescription adherence, improves the medication management process, and improves health outcomes in hypertensive patients. As part of its overall Avera HealtheCARE™ Initiative, the South Dakota-based health system is working with 28 hospitals and 116 clinics to implement a regional electronic medical record (EMR). The technology package will include advanced e-prescribing software (DrFirst Rcopia) that provides physicians the capability to track the fill status of prescribed medications, and provides interaction alerts, formulary listings, dosing options, patient medication history, and printed wallet-size medication lists. The study examines the impact of the technology on the medication management for patients with hypertension in nine rural or frontier primary care facilities. The project will focus on the following health information technology (IT) systems:

  • DrFirst Rcopia electronic prescription management system as a stand-alone product.
  • DrFirst Rcopia integrated within the Meditech/LSS Data Systems Medical EMR and Practice Management Suite, the EMR system being implemented by Avera Health in the ambulatory setting. This EMR includes Zynx Health decision support technology and is Certification Commission for Health Information Technology-certified.

The project takes advantage of a staged implementation, first gathering baseline measures and then tracking clinics that are using e-prescribing as a stand-alone tool before moving to an EMR, and clinics that are moving directly to an EMR with integrated e-prescribing. To examine whether patient prescription adherence improves, medical claims data and the e-prescribing patient-fill histories will be used. Improved outcomes will be measured in blood pressure levels and changes in treatment for patients with blood pressure higher than 140/90.

This study is based on the observation of a “natural” process of disseminating and implementing a set of health IT innovations. As such, the experiment can be characterized as a quasi-experimental design with opportunistic, nonrandom assignment of clinics to the experimental condition.

Specific Aims:

  • Improve the rate of adherence to prescribed medications among patients with hypertension in rural communities. (Ongoing)
  • Improve adherence to prescribed medications among patients with hypertension through use of e-prescribing tools in rural care settings. (Ongoing)
  • Improve health outcomes for patients with hypertension in rural communities through the use of e-prescribing and associated clinical decision support tools. (Ongoing)
  • Enhance patient and provider satisfaction with the e-prescribing tool. (Ongoing)
  • Overcome barriers to successful adoption of e-prescribing. (Ongoing)

2010 Activities: Data collection characterizes the main work of the study team during this period. The project team is collecting data, and the program evaluator and biostatistician have begun analysis. The team will be administering the second round of provider satisfaction interviews and patient satisfaction with care surveys for both the Avera United Medical Clinic and Avera Hand County Medical Clinic just prior to the clinics transitioning from DrFirst Rcopia stand-alone e-prescribing to e-prescribing integrated within the LSS EMR in the first quarter of 2011. Five clinics now use e-prescribing through the LSS EMR.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): Project progress is mostly on track, meeting most milestones on time. Project spending is roughly on target. The current focus of the project is on sustaining the intervention, and collecting and analyzing data.

Preliminary Impact and Findings: A significant degree of variation exists across pharmacy software systems relative to e-prescribing capability and processing. The more sophisticated systems typically found in large chain pharmacies are capable of systematically processing prescription data entry with limited manual entry. Some older, more antiquated systems found in small independent pharmacies offer little automation, requiring the pharmacist to enter nearly all elements of the prescription. The receiving pharmacists most often use SureScripts. Upon further investigation, the project director discovered that the pharmacy certification process essentially certifies that pharmacy software is capable of receiving electronic prescriptions from SureScripts in a standard format. SureScripts certification does not address how the pharmacy software processes electronic prescriptions after receipt. As such, the pharmacists who are required to perform minimal prescription data entry perceive a greater efficiency gain than those required to perform more data entry when processing new electronic prescriptions.

All pharmacists reported the greatest workflow efficiency gains are associated with processing provider responses to pharmacy-initiated renewal requests and a decrease in telephone and facsimile interruptions. Pharmacy-initiated prescription renewal requests are sent electronically to e-prescribing providers with the prescription data elements as they exist in the pharmacy software. Therefore, the responses that come back to the pharmacies are easily accepted by the pharmacy software, requiring limited data entry. Also, telephone calls and facsimile interruptions have decreased as more prescriptions are delivered to the pharmacies by electronic transmission. Pharmacists believe the decrease in interruptions allows them to spend more time providing better quality service to their patients.

Finally, pharmacists were asked to rate their level of satisfaction with e-prescribing on a scale of 1 to 10, with 10 being the most satisfied. Eight of the nine pharmacists reported a satisfaction level of 7, while one pharmacist reported an 8. In general, it appears as though the pharmacist community is relatively satisfied with electronic prescribing.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions and the electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

*AHRQ Priority Population.

Project Details - Ended

Project Categories

Summary:

 

The purpose of this research was to examine whether, in rural ambulatory care settings, the use of an e-prescribing system with clinical decision support related to medication management increases patient prescription adherence, improves health outcomes in hypertensive patients, and improves the medication management process. The aims of the study were to:

  • Improve the rate of adherence to prescribed medications among patients with hypertension in rural communities. 
  • Improve adherence to prescribed medications among patients with hypertension through use of e-prescribing tools in rural care settings. 
  • Improve health outcomes for patients with hypertension in rural communities through the use of e-prescribing and associated clinical decision support tools.
  • Enhance patient and provider satisfaction with the e-prescribing tool.
  • Overcome barriers to successful adoption of e-prescribing. 
The project implemented e-prescribing extensively in nine rural ambulatory care clinic settings within the Avera Health System service area; particularly eastern South Dakota, southwest Minnesota, and northwest Iowa. The research focused on blood pressure management of hypertensive patients who were 18 years of age or older. The study model was a staged implementation, first gathering baseline measures, then tracking clinics using e-prescribing as a stand-alone tool, and moving to an integrated electronic medical record (EMR) with e-prescribing. Medical claims data and the e-prescribing patient-fill histories were used to examine whether patient prescription adherence improved. Improved outcomes were measured in blood pressure readings, and changes in treatment for patients with blood pressure higher than 140/90.  Additionally, provider interviews and patient surveys assessed the perception of e-prescribing.
Based on a  population analysis, the implementation of e-prescribing did not appear to have a significant effect on hypertension control. Compared to the baseline pre-implementation, provider perceptions were more positive for both the stand-alone electronic prescribing and the EMR implementations. There did appear to be an increase in patient adherence and an upward trend in the prescribing of generic anti-hypertensive medications.

Electronic Prescribing and Decision Support to Improve Rural Primary Care Quality - Final Report

Citation:
Veline J. Electronic Prescribing and Decision Support to Improve Rural Primary Care Quality - Final Report. (Prepared by Avera Health under Grant No. R18 HS017149). Rockville, MD: Agency for Healthcare Research and Quality, 2011. (PDF, 275.07 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
Document Type: 
Population: 
Medical Condition: 

Medication Adherence and Compliance Patient Letter

PDF: Medication Adherence and Compliance Patient Letter (PDF, 18.06 KB)
This project does not have any related survey.
This project does not have any related story.
This project does not have any related emerging lesson.