Health Information Technology and Improving Medication Use

• 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).