Health Information Technology and Improving Medication Use (Massachusetts)

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Summary:

The Centers for Education and Research on Therapeutics’ (CERT) program is a national initiative to increase awareness of the benefits and risks of new, existing, or combined uses of therapeutics through education and research. AHRQ funded the Brigham and Women’s Hospital (BWH) Health Information Technology (IT) CERT program to reduce medication errors and improve patient safety. The BWH CERT-Health IT team was comprised of a methodology and data resources core and a translation and dissemination core. These cross-disciplinary cores supported projects on soliciting information from patients on adverse medication events, using clinical-decision support (CDS), evaluating new processes for medication reconciliation post-discharge, and assessing the impact of regional health exchange on medication safety.

The specific objectives for this project were to:

  • Evaluate the impact of using telephony to ask outpatients identified from electronic health record (EHR) data if they are experiencing adverse effects related to specific medications.
  • Evaluate the impact of clinical decision support and automated telephone outreach on antihypertensive and lipid-lowering therapy in ambulatory care.
  • Evaluate errors arising from implementation of electronic prescribing.
  • Evaluate the impact of implementing a post-discharge ambulatory medication reconciliation intervention.
  • Evaluate effects of multiple vendor-based prescribing systems on medication safety among six Regional Health Information Organizations in New York and Massachusetts.

The BWH CERT funded six projects that focused on improved information sharing and efficacy and safety monitoring across settings; improved decision support; assessment of how patients are using medications; and how to educate and improve communication with patients. These projects and their findings follow.

e-Pharmaco-vigilance: Integrating Patient Reports of Side Effects with Electronic Health Records for Surveillance of Recently Approved Drugs. This project used an interactive voice recognition (IVR) system to call patients and ask them about their medication use and any negative experiences with medications. The team evaluated the accuracy of adverse drug events (ADE) determination in the ambulatory setting. The study found that the use of IVR in pharmoco-vigilance can provide important information about adherence to use of medications as well as estimates of possible ADEs in clinical practice. 

A Multimodal Intervention to Improve Antihypertensive and Lipid-lowering Therapy. This project evaluated the effectiveness of CDS compared to automated telephone outreach (ATO) when used to improve the use of antihypertensive and lipid-lowering medications in community-based primary care practices. The study was both qualitative, in which the challenges faced by clinicians to manage hypertension and hypercholesterolemia were studied; and quantitative, in which a CDS intervention was implemented and evaluated. The qualitative study revealed that about half of the study clinicians found hypertension goals more difficult to reach, while half felt that hyperlipidemia goals were more difficult. Physicians felt that, rather than how they managed patients’ care, it was the patients themselves who had more impact on their success in reaching treatment goals. Barriers were similar for both conditions including patient attitudes, motivation, knowledge, and resources. Important to overcoming barriers was having good relationships and additional time with patients. The qualitative studies are pending. 

Unintended Consequences of Electronic Prescribing. This project examined the consequences of electronic prescribing (e-Prescribing) in the community setting using a mixed-methodology approach. The project team reviewed approximately 4,000 prescriptions in three States. They noted an average of 1.03 errors per prescription, of which 35 percent were classified as ADEs. Of the ADEs, 58 percent were significant and 42 percent were serious. The errors were in four main areas: 1) omitted information (61 percent); unclear information (16 percent); conflicting information (16 percent); and clinically incorrect (8 percent). Different e-Prescribing systems were associated with different types of errors, suggesting that these systems are associated with unique patterns of errors. Five themes emerged from the qualitative analysis: 1) communication issues; 2) workflow issues; 3) opportunities for new errors; 4) cost issues; and 5) technical system issues.

Ambulatory Medication Reconciliation Following Hospital Discharge. This project used a cluster-randomized controlled trial to examine the impact of a post-discharge medication reconciliation tool on medication errors. The team found that the accuracy of documented medication regimens 30 days after discharge was around 22 percent. The use of the tool was low, but did lead to a small improvement in documented regimens and to a modest decrease in serious medication errors.  

Impact of Vendor Systems on Ambulatory Medication Safety. This project evaluated the effects of e-Prescribing on medication safety in the ambulatory setting, including medication errors, near misses and preventable ADEs. In particular the team looked at the impact of these systems on ambulatory medication safety over time, comparing medication safety among recent adopters, those who adopted electronic prescribing less than 6 months prior, to experienced users, those who have been using e-Prescribing for more than 1 year. Low rates of errors were noted during implementation and after sustained use. The team concluded that extensive support for implementation and training minimizes patient safety threats early after transitioning to a new e-Prescribing system, and leads to sustained low error rates in the long term. 

Identification of a Common Set of Clinical Decision Support Rules. This project developed a starter set of clinically significant rules on medication-related CDS that could be implemented into other clinical information systems across health care settings. Best-practice recommendations were developed including usability designs, an implementation guide, and educational programs for the American Medical Informatics Association 10X10 program. The starter set and associated recommendations have been widely disseminated through published articles in Health Affairs, BMJ Quality & Safety, the Journal of the American Medical Informatics Association, and the Journal of Patient Safety (see publications below).

Health Information Technology and Improving Medication Use - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-004: Centers for Education and Research on Therapeutics (CERTs) (U18)
  • Grant Number: 
    U18 HS 016970
  • Project Period: 
    September 2007 – August 2012
  • AHRQ Funding Amount: 
    $1,999,073
  • PDF Version: 
    (PDF, 271.29 KB)

Summary: The Centers for Education and Research on Therapeutics (CERTs) program is a national initiative that uses education and research to increase awareness of the benefits and risks of new, existing, or combined uses of therapeutics. Each CERT supports multiple research projects under the direction of a lead principal investigator.

In 2007, recognizing that health information technology (IT) has great potential to reduce medication errors and improve patient safety, the Agency for Healthcare Research and Quality funded the Brigham and Women’s Hospital Health IT CERT program. The CERT-Health IT team is comprised of a methodology and data resources core and a translation and dissemination core. These cross-disciplinary cores supported projects soliciting information from patients about adverse medication events, using clinical decision support (CDS), evaluating new processes for medication reconciliation post- hospital discharge, and assessing the impact of regional health information exchange on medication safety.

Specific Aims:

  • Evaluate the impact of using telephony to ask outpatients identified from electronic health record (EHR) data if they are experiencing adverse effects related to specific medications. (Achieved)
  • Evaluate the impact of clinical decision support and automated telephone outreach on antihypertensive and lipid-lowering therapy in ambulatory care. (Achieved)
  • Evaluate errors arising from implementation of electronic prescribing. (Achieved)
  • Evaluate the impact of implementing a post-discharge ambulatory medication reconciliation intervention. (Achieved)
  • Evaluate effects of multiple vendor-based prescribing systems on medication safety among six Regional Health Information Organizations in New York and Massachusetts. (Achieved)
  • Development of a Clinical Decision Support Roadmap with identification of a set clinical decision support rules that can be used in multiple settings. (Achieved)

2012 Activities: Project 1: e-Pharmaco-vigilance: Integrating Patient Reports of Side Effects with Electronic Health Records for Surveillance of Recently Approved Drugs. The goal of this project was to increase surveillance evidence for recently-released Food and Drug Administration-approved drugs. Interactive voice response is linked to a patient EHR to monitor patients taking these medications by calling and asking them about their progress using a medication and if they are having any problems. The project team completed the project in 2011, and in 2012 focused on project results dissemination.

Project 2: A Multi-Modal Intervention to Improve Antihypertensive and Lipid-Lowering Therapy. This project compares the impact of CDS with and without automated telephone outreach to patients on the use of antihypertensive and lipid-lowering medications. The team recruited one intervention site in Brockton, MA, which received EHR-based alerts, and two control sites in New York where patients received generic automated telephone interactive voice response (ATIVR) messages. The project completed the intervention of EHR hypertension alerts in 2012 and data analysis continued past the end of the grant period.

Project 3: Unintended Consequences of e-Prescribing. This project focused on identifying unintended consequences of electronic prescribing (e-prescribing) and developing recommendations to prevent them. Prescriptions from commercial pharmacies were reviewed to identify the frequency and character of errors in e-prescribing. An expert panel reviewed unintended consequences and evaluated their impact on pharmacy workflow. A qualitative study of the unintended consequences in the outpatient pharmacy setting, including workflow implications, was conducted. Recommendations for minimizing e-prescribing errors and their unintended consequences were developed. In 2012, the project focused on disseminating its findings and recommendations.

Project 4: Ambulatory Medication Reconciliation Following Hospital Discharge. The objective of this research was to assess the use of a medication reconciliation module in ambulatory EHRs to reduce postdischarge medication discrepancies and adverse drug events (ADEs). The use of the reconciliation module was low when it was first made available in the EHR, so the project team created an active reminder (“pop up”) in the EHR medication screen and a passive reminder in the EHR summary screen. The team compared use of the reconciliation module before and after the reminders were developed. During the enrollment and followup period, the project team monitored the uptake of the medication reconciliation module and observed an increase in its use over time. The project team conducted a secondary analysis of the accuracy of medication lists 1 month after discharge compared with patient-reported lists. The project team completed a manuscript describing their findings on the impact of the post-discharge ambulatory medication reconciliation intervention.

Project 5: Impact of Vendor Systems on Ambulatory Medication Safety. This project compared the impact of different vendor-based e-prescribing systems on medication safety. It also compared the impact of e-prescribing by users in the short term (less than 6 months) and the longer term (greater than 1 year). Enrollment of 20 providers was completed in rural Hudson Valley, New York, and 17 providers in New York City. The team finished two manuscripts of their findings and focused on project dissemination.

Project 6: Identification of a Common Set of Clinical Decision Support Rules. This project convened a panel of expert clinical informaticians, providers, and regulatory agencies to identify high-value CDS rules. The review team assessed a list of “best practices” decision rules in the areas of preventive care reminders and medication decision-support rules related to drug-drug interactions and therapeutic duplications. Criteria for review of the rules was based on the Institute of Medicine’s Crossing the Quality Chasm report improving quality features including safety, timeliness, patient-centeredness, effectiveness, efficiency, and equity.

A 1-year no-cost extension was used to analyze data and develop manuscripts for five of the six projects. Project 2, A Multi-Modal Intervention to Improve Antihypertensive and Lipid-Lowering Therapy continued its intervention through 2012. The original practice sites identified changed their organizational affiliation, which delayed identification of participating practice sites.

Impact and Findings: Findings for each project are described below.

Project 1: Pharmacovigilance provides important information related to the patient perspective on ADEs. Significant differences in medication cessation were reported by patients when compared with documentation in the EHR. The project tracked the percentage of calls that triggered an email response to the provider and, for those emails, the percentage that resulted in direct followup through a phone call, office visit, or discontinuation of the medication. Of participants, 50.2 percent reported greater than one symptom; of these, 22.0 percent thought the symptom was medication-related. Analysis identified that pharmacovigilence is associated with increased use of specialty services but is not associated with EHR-documented medication cessation, use of acute services, death, or use of primary care services. The results indicate the value of innovative ways to collect information on ADEs from patients.

Project 2: Interviews with physicians found that they have different perspectives on reaching the treatment goals from recognized evidenced-based guidelines for hypertension and hyperlipidemia. Some physicians thought that it was critical to reach the treatment goals while others felt that the unique circumstances of the patient determined the importance of reaching them. The analysis of the intervention to improve treatment through CDS compared to automated telephone outreach will be completed in 2013.

Project 3: Prescribing errors vary significantly depending on the computerized prescribing system used, indicating that most errors are amenable to modification of systems. Informatics strategies can be used to minimize errors, including the following: 1) CDS with maximum dose checkers; 2) automating amount to be dispensed to prevent inconsistent quantity errors by eliminating the redundant entry of the final medication quantity; and 3) use of dispense forcing functions, which create constraints in data entry to prevent errors such as structured data entry with mandatory data fields to prevent omitted information. The findings will inform the design and implementation of e-prescribing systems within retail pharmacies.

Project 4: This study found the accuracy of documented medication regimens 30 days after hospital discharge is, at 22 percent, poor. Although primary care providers are in the best position to identify and correct errors, the results on use of the medication reconciliation module found a modest impact on patient safety. This project found that active use of the reconciliation module was low without additional support such as provider education and electronic reminders to use the module. The tool led to small improvements in documentation of medications as compared to usual care practices, and a modest decrease in serious medication errors. The project identified several recommended improvements to increase the usability of the tool and improve patient safety in the future.

Project 5: This project found no difference in prescription error rates 3 months after implementation of the e-prescribing system compared to prescriptions made 1 year after implementation. Relatively low error rates were found, both during implementation and during sustained use among practices with support for use of a new e-prescribing system. Support for providers before, during, and after implementation may help mitigate potential safety threats resulting from implementation of an e-prescribing system and might lead to sustained safety benefits over the long term.

Project 6: This project developed a starter set of clinically significant rules on medication-related decision support that could be implemented in clinical information systems across health care settings. These findings have been disseminated in articles in Health Affairs, BMJ Quality & Safety, the Journal of the American Informatics Association, and the Journal of Patient Safety.

Target Population: General

Strategic Goal: Develop and disseminate health information technology (IT) evidence and evidencebased tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Knowledge Creation

Health Information Technology and Improving Medication Use - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-004: Centers for Education and Research on Therapeutics (CERTs) (U18)
  • Grant Number: 
    U18 HS 016970
  • Project Period: 
    September 2007 - August 2012
  • AHRQ Funding Amount: 
    $1,999,073
  • PDF Version: 
    (PDF, 241.89 KB)

Summary: The Centers for Education and Research on Therapeutics (CERTs) program is a national initiative to increase awareness of the benefits and risks of new, existing, or combined uses of therapeutics through education and research. Each CERT supports multiple research projects under the direction of a lead principal investigator.

In 2007, recognizing that health information technology (IT) has great potential to reduce medication errors and improve patient safety, the Agency for Healthcare Research and Quality funded the Brigham and Women's Hospital Health IT CERT program. The Brigham and Women's Hospital CERT-Health IT team is comprised of a methodology and data resources core and a translation and dissemination core. These cross-disciplinary cores currently support projects on soliciting information from patients on adverse medication events, using clinical decision support (CDS), evaluating new processes for medication reconciliation post-discharge, and assessing the impact of regional health information exchange on medication safety.

Results from the six CERT projects described below will break new ground in determining how current health IT-related interventions can be broadly disseminated. In addition, the Brigham and Women's Hospital CERT-Health IT team will build and bolster educational tools and programs to assist with therapeutics and health IT.

Specific Aims:

  • Evaluate the impact of using telephony to ask outpatients identified from electronic health record (EHR) data if they are experiencing adverse effects related to specific medications. (Achieved)
  • Evaluate the impact of clinical decision support and automated telephone outreach on antihypertensive and lipid-lowering therapy in ambulatory care. (Ongoing)
  • Evaluate errors arising from implementation of electronic prescribing. (Achieved)
  • Evaluate the impact of implementing a post-discharge ambulatory medication reconciliation intervention. (Achieved)
  • Evaluate effects of multiple vendor-based prescribing systems on medication safety among six Regional Health Information Organizations in New York and Massachusetts. (Achieved)

2011 Activities: The focus of activity for each project is described below.

Project 1: e-Pharmaco-vigilance: Integrating Patient Reports of Side Effects with Electronic Health Records for Surveillance of Recently Approved Drugs. The goal of this project is to increase surveillance evidence for recently-released Food and Drug Administration-approved drugs. Interactive voice response is linked to a patient EHR to monitor patients taking these medications by calling and asking them about their progress using a medication and if they are having any problems. The project team completed the intervention in 2010 and in 2011 focused on data analysis, manuscript preparation, and dissemination.

Project 2: A Multi-Modal Intervention to Improve Antihypertensive and Lipid-Lowering Therapy. This project compares the impact of CDS with and without automated telephone outreach to patients on the use of antihypertensive and lipid-lowering medications. The team recruited one intervention site in Brockton, MA, that received EHR-based alerts, and two control sites in New York where patients will receive generic automated telephone interactive voice response (ATIVR) messages. The project conducted semi-structured informational interviews using an interview script with primary care physicians to understand care gaps in the treatment of hypertension and hyperlipidemia. The project director worked with the EHR vendor to map the CDS rules at the intervention practices, and developed a method for patient identification in a paper-based chart system at the control sites.

Project 3: Unintended Consequences of ePrescribing. This project reviewed prescriptions from commercial pharmacies to identify electronic prescription (e-prescribing) errors. The prescriptions were analyzed to determine the frequency and character of errors, and develop recommendations for preventing these errors and other unintended consequences. The team prepared for an expert panel to review unintended consequences of e-prescribing and evaluate its impact on pharmacy workflow. This panel developed a list of recommendations for preventing unintended consequences of e-prescribing. The team conducted a qualitative study of the unintended consequences of e-prescribing in the outpatient pharmacy setting, including workflow implications. A manuscript is currently being prepared.

Project 4: Ambulatory Medication Reconciliation Following Hospital Discharge. In 2007, a post-discharge medication reconciliation module was created within the ambulatory EHR to reduce medication errors. When the trial began in 2008, use of the module was low, so the project team created an active reminder ("pop up") in the EHR medication screen and a passive reminder in the EHR summary screen. The team compared use of the reconciliation module before and after the reminders were developed. By the end of 2010, more than 1,000 clinical providers were enrolled. During the enrollment and follow-up period, the project team monitored the uptake of the medication reconciliation module and observed an increase in module use over time. The project team conducted a secondary analysis of the accuracy of medication lists one month after discharge compared with patient report. A manuscript describing their findings on the impact of the post-discharge ambulatory medication reconciliation intervention is being written.

Project 5: Impact of Vendor Systems on Ambulatory Medication Safety. This project compared the impact of e-prescribing by users in the short term (less than 6 months) and the longer term (greater than 1 year). The project completed enrollment of 20 providers in rural Hudson Valley, New York, and 17 providers in New York City. The team met with the commercial e-prescribing vendor to ensure that the prescription data could be captured for the time periods of interest. The team obtained electronic prescription downloads of the data from the e-prescribing vendor, and completed prescription review and data analysis. One manuscript draft has already been completed and is undergoing internal review. A second manuscript draft is being prepared.

Project 6: Identification of Decision Support Rules for Dissemination in EHRs. This project developed medication-related CDS rules for EHRs in inpatient and outpatient settings. The team reviewed a large dataset of adverse drug events involving multiple drugs in community hospitals to build on previous research and develop recommendations to prevent adverse drug events. As the second component of the project, seven sites were visited to assess the EHR and computerized physician order entry system alerts for compliance with human factors principles. The team analyzed the data collected during the seven site visits using ATLAS.ti software to identify the constructs that determine successful implementation of medication-related CDS and assessment of human factors principles. The human factors principles were developed by the research team and are established for use in other systems with visual alerts. They have not yet been applied to clinical information systems.

A 1-year no-cost extension is being used to analyze data and develop manuscripts. The project will end in August 2012.

Preliminary Impact and Findings: Preliminary findings for each project are described below.

Project 1: Pharmacovigilance provides important information related to the patient perspective. Significant differences in medication cessation were reported by patients when compared with documentation in the EHR. The project tracked the percentage of calls that triggered an email response to the provider and, for those emails, the percentage that resulted in direct follow-up through a phone call, office visit, or discontinuation of the medication. Analysis identified that pharmacovigilence is associated with increased use of specialty services but is not associated with EHR-documented medication cessation, use of acute services, death, or use of primary care services.

Project 2: An article detailing the qualitative assessment component of the study is in the final stages of manuscript preparation. Available tools from this project include an ATIVR guide and script, Achieving Benchmarks in Treating Hypertension and Hyperlipidemia: Barriers and Best Practices, and a detailed description and specification of quality measures and the corresponding alert triggers for the EHR alerts implemented in the intervention practice.

Project 3: Informatics strategies can be used to minimize errors, including the following: 1) CDS with maximum dose checkers; 2) automating amount to be dispensed to prevent inconsistent quantity errors by eliminating the redundant entry of the final medication quantity; and 3) use of dispense forcing functions, which create constraints in data entry to prevent errors such as structured data entry with mandatory data fields to prevent omitted information.

Project 4: If the post-discharge medication regimen is not correct in the outpatient medical record, it perpetuates the cycle of medication discrepancies. Primary care providers (PCPs) are in the best position to identify and correct errors of inpatient medication reconciliation. The electronic medication reconciliation system creates a seamless transition by explicitly involving the PCP in the post-discharge medication process.

Project 5: Support for providers before, during, and after implementation may help mitigate potential safety threats from implementation of an EHR system and result in sustained safety benefits over the long term. Relatively low error rates were found, both during implementation and during sustained use among practices with support for use of a new e-prescribing system.

Project 6: The CERT-Health IT CDS project has focused on the development of a starter set of clinically significant rules on medication-related decision support that could be implemented in clinical information systems across health care settings. These findings have been disseminated through published articles in Health Affairs, BMJ Quality & Safety, the Journal of the American Informatics Association, and the Journal of Patient Safety.

Target Population: General

Strategic Goal: Develop and disseminate health information technology (IT) evidence and evidence- based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Knowledge Creation

Health Information Technology and Improving Medication Use - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-004: Centers for Education and Research on Therapeutics (CERTs) (U18)
  • Grant Number: 
    U18 HS 016970
  • Project Period: 
    September 2007 – August 2011
  • AHRQ Funding Amount: 
    $1,999,073
  • PDF Version: 
    (PDF, 449 KB)


Target Population: General

Summary: The Centers for Education and Research on Therapeutics (CERTs) program is a national initiative to increase awareness of the benefits and risks of new, existing, or combined uses of therapeutics through education and research. Each CERT supports multiple research projects under the direction of a lead principal investigator.

In 2007, recognizing that information technology (IT) has great potential to reduce medication errors and improve patient safety, the Agency for Healthcare Research and Quality funded the Brigham and Women’s Hospital Health IT CERT program. The Brigham and Women’s Hospital CERT-Health IT team is organized into two “cores”: the Methodology and Data Resources Core, and the Translation and Dissemination Core. These cross-disciplinary cores currently support projects on soliciting information from patients on adverse medication events, using clinical decision support (CDS), evaluating new processes for medication reconciliation post-discharge, and assessing the impact of regional health exchange on medication safety.

Results from these projects will break new ground in determining how current health IT-related interventions can be broadly disseminated. In addition, the Brigham and Women’s Hospital CERT-Health IT team will build and bolster educational tools and programs to assist with therapeutics and health IT.

Specific Aims:

  • Evaluate the impact of using telephony to ask outpatients identified from electronic health record (EHR) data if they are experiencing adverse effects related to specific medications. (Ongoing)
  • Evaluate the impact of clinical decision support and automated telephone outreach on antihypertensive and lipid-lowering therapy in ambulatory care. (Ongoing)
  • Evaluate errors arising from implementation of electronic prescribing. (Ongoing)
  • Evaluate the impact of implementing a post-discharge ambulatory medication reconciliation intervention. (Ongoing)
  • Evaluate effects of multiple vendor-based prescribing systems on medication safety among six Regional Health Information Organizations in New York and Massachusetts. (Ongoing)

2010 Activities: The focus of activity for each project is described below.

Project 1: e-Pharmaco-vigilance: Integrating Patient Reports of Side Effects with Electronic Health Records for Surveillance of Recently Approved Drugs. The goal of this project is to increase surveillance evidence for recently released Food and Drug Administration-approved drugs. Interactive voice response is linked to a patient EHR to actively monitor patients taking these medications by calling and asking them about their progress using a medication and if they are having any problems. The system is programmed with electronic triggers to e-mail corresponding messages to the physician. The project enrolled approximately 300 to 400 patients per month for a total of 7,755 patients over two years (August 2008 – February 2010). The response rate for followup calls was 70 percent for patients actively taking the targeted medications and with working telephone numbers.

Project 2: A Multi-Modal Intervention to Improve Antihypertensive and Lipid-Lowering Therapy. This project compares the impact of CDS with and without automated telephone outreach (ATO) to patients on the use of antihypertensive and lipid-lowering medications. The project conducted semi-structured informational interviews with primary care physicians to understand care gaps in the treatment of hypertension and hyperlipidemia. A manuscript detailing the qualitative results of the interviews is in final stages of preparation. The team received institutional review board approval and developed the automated telephone script for CDS-supported patient outreach for one arm of the evaluation. Vendor agreements were finalized to begin the ATO outreach. Parallel efforts were employed to identify community practices to engage in this effort.

Project 3: Unintended Consequences of ePrescribing. This project reviewed prescriptions from commercial pharmacies to identify e-prescription errors. The reviews were analyzed to determine the frequency and character of errors and develop recommendations for preventing these errors and other unintended consequences. Investigators also began work on the second aim of the project, studying the impact of ePrescribing on pharmacy workflow.

Project 4: Ambulatory Medication Reconciliation Following Hospital Discharge. In 2007, a post-discharge medication reconciliation module was created within the ambulatory EHR to reduce medication errors. When the trial began in 2008, use of the module was low, so the project team created an active reminder (“pop up”) in the EHR medication screen and a passive reminder in the EHR summary screen. The team compared use of the reconciliation module before and after the reminders were developed. By the end of 2010, over 1,000 clinical providers were enrolled. During the enrollment and followup period, the project team monitored the uptake of the medication reconciliation module and observed an increase in module use over time.

Project 5: Impact of Vendor Systems on Ambulatory Medication Safety. This project compares the impact of electronic prescribing by users in the short term (less than six months) to longer-term users (greater than one year). The project is enrolling providers in rural Hudson Valley, New York and New York City. Provider enrollment was completed in Hudson Valley and five providers in New York City were recruited. The team met with the commercial electronic prescribing vendor to ensure that the prescription data can be captured for the two time periods of interest. The team spent 2010 collecting data.

Project 6: Identification of Decision Support Rules for Dissemination in EHRs. This project is developing medication-related CDS rules for EHRs in inpatient and outpatient settings. The team reviewed a large dataset of adverse drug events involving multiple drugs in community hospitals to build on previous research and develop recommendations to prevent adverse drug events. As the second component of the project, seven sites were visited to assess the EHR and computerized physician order entry system alerts for compliance with human factors principles. Analysis of the data collected during the seven site visits began in 2010. The human factors principles were developed by the research team and are established for use in other systems with visual alerts. They have not yet been applied to clinical information systems.

Preliminary Impact and Findings: Preliminary findings for each project are described below.

Project 1: The project is tracking the percentage of calls that trigger an e-mail response to the provider and, for those e-mails, the percentage that result in direct followup through a phone call, office visit, or discontinuation of the medication. A manuscript describing the system’s design, implementation, and challenges is in press at Pharmacoepidemiology and Drug Safety.

Project 2: An article detailing the qualitative assessment component of the study is in the final stages of manuscript preparation.

Project 3: Preliminary results have characterized the types of errors, error rates across different e-prescribing systems, differences in errors between systems, and range in error rates in areas such as inappropriate abbreviations and omitted duration. Initial findings were presented at the American Medical Informatics Association Annual Meeting in November of 2010 and a manuscript has been submitted for publication.

Project 4: The project team began analyzing the outcomes of using the post-discharge medication reconciliation module by adjudicating medication discrepancies and reviewing potential adverse outcomes. The analysis is pending and a manuscript is in preparation for publication in 2011.

Project 5: The project is completing data collection activities and will perform analysis in 2011. A manuscript detailing the study findings is expected late 2011.

Project 6: A manuscript was recently published in the Journal of the American Medical Informatics Association describing the key human factors principles for consideration in the design and implementation of medication-related decision support systems. Dr. Bates and Dr. Phansalkar discussed their findings on the CERT-Health IT CDS project at the 2010 Med Info meeting. This discussion described the development of content and evaluation criteria for implementing medication-related decision support at various institutions in the United States. The CERT-Health IT CDS project has focused on the development of a starter set of clinically significant rules on medication-related decision support that could be implemented in clinical information systems across health care settings.

Strategic Goal: Develop and disseminate health information technology (IT) evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Knowledge Creation

Health Information Technology and Improving Medication Use - Final Report

Citation:
Bates D. Health Information Technology and Improving Medication Use - Final Report. (Prepared by Brigham and Women's Hospital under Grant No. U18 HS016970). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 368.03 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.
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