Impact of Office-Based E-Prescribing on Prescribing Processes and Outcomes (Massachusetts)

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Impact of Office-Based E-Prescribing on Prescribing Processes and Outcomes - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017151
  • Project Period: 
    September 2007 - August 2011
  • AHRQ Funding Amount: 
    $1,199,007
  • PDF Version: 
    (PDF, 180.3 KB)

Summary: Suboptimal prescribing practices in outpatient settings can result in errors and excessive costs. Electronic prescribing (e-prescribing), which allows prescribers to write prescriptions electronically, is thought to be an important tool for meeting this challenge. The Medicare Modernization Act of 2003 set goals for the adoption of e-prescribing across the country, and private coalitions have used financial incentives to encourage its adoption. Effective e-prescribing systems must have utility for prescribers and must be integrated into routine medical practice workflow. If e-prescribing is to improve quality and safety, it must have valid and usable decision support capabilities and be available at the point of care.

The primary aim of this study was to evaluate the implementation of an e-prescribing system in ambulatory settings. The vendor ZixCorp's PocketScript system is currently used in a large number of practices in Massachusetts, New Jersey, Pennsylvania, New York, North Carolina, California, and Louisiana, providing a large study population with diverse practice types (e.g., pediatric, adult primary care, family practice, and specialty offices), locations (urban, suburban, and rural), and sizes (from singlephysician practices to groups of more than 20 providers). This study evaluated the use of alerts and drug history, and the impact of e-prescribing on workflow, patient safety, and patient adherence. The project staff partnered with the developers of the office-based e-prescribing system, and with multiple insurance companies and public programs that provided claims data.

The project was conducted in three phases. The first phase used data from the e-prescribing system to evaluate physician responses to decision-support interventions and alerts. In the second phase, the project team brought information technology experts and experienced survey researchers together to develop a qualitative study demonstrating the impact of e-prescribing on prescribing processes and outpatient workflow. The study included a large-scale survey to develop a detailed understanding of how e-prescribing can be integrated into medical practice. The third phase of the project drew on decades of project team experience in studying large medical databases to evaluate prescribing decisions and clinical outcomes when e-prescribing is initiated. The project linked patients' e-prescriptions with pharmacy claims and generated a comprehensive dataset to evaluate the true clinical impact of e-prescribing.

Specific Aims:

  • Measure physician use of two safety-related e-prescribing functions: safety alerts and dispensed drug history. (Achieved)
  • Measure the effect of e-prescribing on processes of prescribing for physicians to assess characteristics of successful and productive adoption.(Achieved)
  • Extend and expand ongoing research to assess whether the adoption of e-prescribing is associated with improved clinical outcomes for patients. (Achieved)

2011 Activities: The project collaborated with ZixCorps, an e-prescribing vendor, and two large insurance providers: Tufts Health Plan and Blue Cross Blue Shield of Massachusetts. Their data provided insights to the research questions. The data were prepared, and the analytic files and linkages across data sets were cleaned. A 1-year no-cost extension was used to complete all of the analyses for the project. The study team identified medications that generate alerts more frequently and the rates at which different medications are cancelled versus prescribed despite safety warnings. They characterized the rates at which physicians use e-prescribing and defined other metrics of how sophisticated is their use of the system. The team identified physician characteristics that may predict use of the system and developed models to evaluate these associations.

As last self-reported in the AHRQ Research Reporting System, project progress and activities were on track, and project budget spending was on target. Difficulties obtaining data from the collaborating organizations necessitated the 1-year no-cost extension. The project activities were completed when the project ended in August 2011.

Impact and Findings: Qualitative analyses identified seven themes, ranging from positive to negative, that affect how physicians adopt new technologies. Survey results indicated that physicians using e-prescribing systems that were part of an integrated electronic health record were more likely to use advanced e-prescribing features than were physicians using stand-alone e-prescribing systems. Quantitative analyses showed that physicians used e-prescribing systems more frequently, and they used more of the features over time. Of the 1,947 eligible respondents, 1,011 completed the survey, a response rate of 52 percent. Response rates by survey strata were almost equivalent: 51 percent for physicians in the regular-use stratum and 53 percent in the low-use stratum. Sixty percent of respondents reported having an integrated e-prescribing system; the rest had a stand-alone system. Those with integrated systems were more likely than those with stand-alone systems to be primary care physicians, to practice in larger groups and in a hospital or medical center, and to have practiced for fewer years. They were also more likely to be regular users of e-prescribing.

Ninety-seven percent of respondents reported that they were able to send prescriptions electronically. Eighty-seven percent had e-prescribing systems that included drug warnings or contraindications and the ability to manage refill authorizations.

Physicians with integrated systems were significantly more likely than those with stand-alone systems to report writing prescriptions electronically most or all of the time. At least half of physicians said that their use of e-prescribing made it easier for them to take care of prescription refills themselves, have staff take care of refills, batch process refills, write an initial prescription for a new patient, and prescribe within a patient's formulary. The majority (88 percent) of physicians were satisfied with their e-prescribing system. Overall, physicians reported that their use of e-prescribing had a positive effect on the safety of their prescribing practices. Sixty-eight percent of physicians reported that their system made it easier to reconcile a patient's medication list, and 57 percent reported a reduction in the number of calls the practice received from pharmacies about prescribing errors.

Use of the e-prescribing system increased with duration of experience with the system. While physicians who had been using the system for less than one year averaged less than five e-prescriptions per week, those using e-prescribing for more than one year averaged 17 e-prescriptions per week, and those using e-prescribing for more than three years averaged 33 e-prescriptions per week.

Target Population: General

Strategic Goal: Develop and disseminate health 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: Synthesis and Dissemination

Impact of Office-Based E-Prescribing on Prescribing Processes and Outcomes - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017151
  • Project Period: 
    September 2007 – August 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,199,007
  • PDF Version: 
    (PDF, 364.16 KB)


Target Population: General

Summary: Suboptimal prescribing practices in current systems of care delivery in outpatient settings can result in errors and excessive costs. Electronic prescribing (e-prescribing) is a technology that allows prescribers to write prescriptions electronically. The Medicare Modernization Act set goals for the adoption of e-prescribing across the country, and private coalitions have stepped forward to encourage the adoption of e-prescribing through the use of financial incentives. Effective e-prescribing systems must have utility for prescribers and must be integrated into the workflow of routine medical practice; for e-prescribing to improve quality and safety, it must have valid and usable decision support capabilities and be available at the point of care.

The primary aim of this study is to evaluate the implementation of an e-prescribing system in ambulatory settings. ZixCorp’s PocketScript system is currently used in a large number of practices in Massachusetts, New Jersey, Pennsylvania, New York, North Carolina, California, and Louisiana, providing a large study population with diverse practice types (e.g., pediatric, adult primary care, family practice, and specialty offices), locations (urban, suburban, and rural), and sizes (from single-physician practices to groups of more than 20 providers). This study will evaluate the full spectrum of e-prescribing. The project has an active partnership with the developers of the office-based e-prescribing system, and with multiple insurance companies and public programs that will provide claims data.

The project is being conducted in three phases. The first phase uses data from the e-prescribing system to evaluate physician responses to decision support interventions and alerts. In the second phase, the project brings together experts on information technology and experienced survey researchers to develop a qualitative study demonstrating the impact of e-prescribing on prescribing processes and outpatient workflow, including a large-scale survey to develop a detailed understanding of how e-prescribing can be integrated into medical practice. The third phase of the project will draw on decades of experience by the project team studying large medical databases to evaluate prescribing decisions and clinical outcomes when e-prescribing is initiated. The project will link patients’ e-prescriptions with pharmacy claims and will generate a comprehensive dataset to evaluate the true clinical impact of e-prescribing.

Specific Aims:

  • Measure physician use of two safety-related e-prescribing functions: safety alerts and dispensed drug history. (Ongoing)
  • Measure the effect of e-prescribing on processes of prescribing for physicians to assess characteristics of successful and productive adoption. (Ongoing)
  • Extend and expand ongoing research to assess whether the adoption of e-prescribing is associated with improved clinical outcomes for patients. (Ongoing)

2010 Activities: Data use agreements were executed between the e-prescribing company and the research institution. The dataset was received, uploaded, cleaned, and verified. The study team has begun to define the variables and cohorts for the analyses, and project programmers have begun integrating the datasets. The key challenge in preparing the datasets has been linking events and individuals from the e-prescription files to the insurance claims files. Linkage of providers went smoothly for one health plan’s data (Tufts) and has been more challenging for another (Blue Cross Blue Shield of Massachusetts) due to a need to reconcile identifiers of providers who practice in a variety of locations. The final step will be linking e-prescriptions to filled claims.

Four focus groups were conducted during this period, two each with doctors and nurses and office managers, which explored a variety of topics that were used in developing the large sample survey. The resulting manuscript was published in the Journal of the American Medical Informatics Association. The large sample survey was closed to enrollment in fall of 2009. Over 1,000 survey responses were included in the final sample. During this period the data were prepared for analysis and initial analyses have focused on the comparison of stand-alone e-prescribing to integrated systems. The resulting manuscript was accepted by Health Affairs and published in December 2010.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): The project progress is mostly on track with the team reporting that they are meeting 80 to 99 percent of their milestones. Project spending is roughly on target.

Preliminary Impact and Findings: Focus group participants identified a range of issues associated with the current use of e-prescribing in their practices, including benefits derived and perceived, challenges in using the technology, and workflow issues caused by the technology. Positive responses toward e-prescribing focused on efficiency, a reduction in medical errors, patient satisfaction, and ease of use. Negative responses focused on technological problems, medical errors, trust of technology, the learning curve for using the software, and surveillance and liability issues. There were different reactions and changes to the e-prescribing workflow based on which functions were completed by physicians versus office staff. Physicians entered prescriptions while seeing patients or immediately thereafter, whereas the office staff usually handled refills. By splitting the tasks, significant workflow efficiency was gained.

In regard to e-prescription adoption, the focus groups found that the attitude of the doctors played a major role in the perceived usefulness of the technology. Some practices that adopted the technology have found that it has been completely integrated into their daily workflow and used frequently. On the other hand, several users do not yet have complete knowledge of the functionality of the application (e.g., what the colors on the screen represent).

Survey results showed that physicians have generally positive attitudes regarding e-prescribing and the impact of e-prescribing on the efficiency and safety of prescribing. Physicians using e-prescribing systems that are integrated into comprehensive electronic health records use more e-prescribing functionalities on a more regular basis than physicians who use stand-alone e-prescribing systems. However, the cost of stand-alone e-prescribing systems is considerably lower, which is attractive for many physicians and practices.

Strategic Goal: Develop and disseminate health 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: Synthesis and Dissemination

Project Details - Ended

Summary:

Under current systems of care delivery, sub-optimal prescribing practices in outpatient settings can result in preventable and costly errors. Electronic-prescribing (e-prescribing), a technology that allows prescribers to write prescriptions electronically has been shown to create safer, more efficient prescribing practices. In order for the positive effects of e-prescribing to occur, e-prescribing systems must have utility for prescribers and must be integrated into the workflow of routine medical practice. For e-prescribing to improve quality and safety, it must have valid and usable decision-support capabilities that are available at the point of care.

The primary aim of this study was to evaluate the implementation of an e-prescribing system in ambulatory settings. ZixCorp’s PocketScript system was one of the most widely used outpatient e-prescribing systems during the period of this study. It included functions that addressed multiple clinical safety and efficiency issues, including safety alerts, formulary decision support, and drug history.

This study evaluated how this e-prescribing system affected the processes of prescribing for physicians in order to assess characteristics of successful and productive adoption. It also evaluated how physicians used the functionality of the e-prescribing system and how the functionalities used affected the medications used by patients. The specific aims of the study were to:

  • Measure physician use of two safety-related e-prescribing functions: safety alerts and dispensed drug history.
  • Measure the effect of e-prescribing on processes of prescribing for physicians to assess characteristics of successful and productive adoption.
  • Extend and expand ongoing research to assess whether the adoption of e-prescribing is associated with improved clinical outcomes for patients.

Focus groups, direct observation, and semi-structured interviews were conducted with physicians, practice managers, nurses, and other medical staff. Following several iterations of focus group data, hypotheses regarding clinician perception of e-prescribing were revised as more data were collected and interpretations were formulated. A large-sample survey was mailed to physicians using e-prescribing systems. Survey results evaluated the relationship between measures of e-prescribing system use and the types of e-prescribing systems used, as well as physician and patient characteristics. E-prescribing records were evaluated to identify patterns of how physicians used the features of the system and how these correlated with medications used by patients.

Qualitative analyses identified seven hypotheses regarding clinician perception of e-prescribing, ranging from positive to neutral to negative, that affect how physicians adopt new technologies. Survey results found that physicians using e-prescribing systems that were part of an integrated electronic health record were more likely to use advanced e-prescribing features than were physicians using stand-alone e-prescribing systems. Quantitative analyses showed that over time physicians used e-prescribing systems more frequently and used more of the features. Overall results indicate that, as more physicians use health information systems, attention to integration and design will be important to ensure robust uptake and appropriate use by clinicians.

Impact of Office-Based E-Prescribing on Prescribing Processes and Outcomes - Final Report

Citation:
Fischer M. Impact of Office-Based E-Prescribing on Prescribing Processes and Outcomes - Final Report. (Prepared by Brigham and Women's Hospital under Grant No. R18 HS017151). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 77.22 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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