Using Information Technology (IT) to Improve Medication Safety for Rural Elders

High-tech champions often enthuse about the potential of electronic medical record systems, automated order entry programs, and other computer-based tools to reduce medication errors. But investigators for a project in Lincoln City, Ore., supported by a grant from the Agency for Healthcare Research and Quality (AHRQ), are finding that, when it comes improving medication safety at the community level, relationship-building -- not technology -- may hold the key.

Researchers from Samaritan North Lincoln Hospital, a facility of Samaritan Health Services, and Oregon Health & Science University (OHSU) are leading the AHRQ project, which focuses on ways to use information technology (IT) to improve medication safety for the chronically ill elderly.

The complex and ambitious project involves sharing proprietary information among numerous players -- some more accustomed to competing than collaborating -- working together to implement a master medication list for patients in assisted living and skilled nursing facilities. Among the 20 or so entities involved in the AHRQ-funded project are the pharmacies at the corporate giants Safeway, Rexall, and RiteAid, as well as numerous hospitals, long-term care facilities, and physician's offices.

Medication safety is a critical issue for older adults. Yet administering medications properly to patients in long-term care facilities is fraught with challenges. "The moments of transferring a patient from a hospital to a nursing home involve many risks. The patient's medication list goes through so many hands, and fax machines get a real work-out, as information is updated and passed among nurses, doctors, and pharmacists," says Karl Ordelheide, M.D., the AHRQ project's co-principal investigator and a physician at Lincoln City Medical Center.

To complicate matters further, computers at pharmacies, long-term care facilities, hospitals, and physicians' offices don't "talk" to one another. This means that if a pharmacist or nurse spends an hour updating a patient's medication information, all of that labor may have to be repeated, because there is no guarantee that the other parties involved have access to the new data.

National studies show that adverse drug events are common in skilled nursing facilities, with approximately 350,000 adverse events annually. Over 50 percent of those are preventable. To best avoid medication errors, researchers involved in the AHRQ-funded project are testing a real-time IT program that will help deliver medication data to project participants.  Next year, after the program is ready for broader application, the program will be pilot tested with 150 patients to measure its effectiveness.

"Our new system will allow access to the medication lists from all involved parties--the doctors' offices, long term care facilities, and pharmacies. The goal is to get everyone on the same page prescribing, dispensing, administering, and monitoring patient medication information," says Paul Gorman, M.D., co-principal investigator and associate professor at OHSU.

But before the project reaches that point, the researchers must clear several hurdles. First, although national standards have been proposed, they are not ready for prime time, says Gorman. That makes it difficult to devise a program that might fall short of federal guidelines, once they are in place. The second hurdle involves the regulatory complexities of the federal Health Information Privacy and Protection Act (HIPAA).  "We must get 20 different organizations to agree on how to interpret HIPAA regulations to protect patient privacy. And as clear as these regulations try to be, each group will interpret them differently," Gorman says.

The third major hurdle involves breaking down competitive barriers among the project's participants. While senior care, hospitals, and rehab facilities are accustomed to sharing pharmaceutical data with one another, commercial pharmacies are not. "They are bitter rivals," Ordelheide notes. "The most treasured item to some of these companies is their database, and it's tough to get people to open up their computers. A large part of our challenge is to create a new set of relationships among these parties, to get them to trust one another."

Just getting them to agree to a time and sit down at a table together is tough, so Ordelheide communicates the old-fashioned way: by canvassing pharmacies in person. "I stop by the pharmacies once a week and chat with the pharmacists to keep them interested in the project. I call the out-of-town pharmacies once a week," he says. "It's about being persistent." That persistence is paying off, as half of the organizations that initially expressed interest during the planning process have signed business agreements to participate. And when one of the ultra-competitive pharmacies signs on, the rest will follow, Ordelheide predicts. "They'll all want to play. It's all part of their competition -- they want to keep up with each other."

Ultimately, the project will implement real-time, electronic prescribing among the major players in Lincoln City, which will serve as a model for replication by other communities. The data likely will be housed at a neutral location, such as the AHRQ-funded Oregon Rural Practice-based Research Network. The long-range goal is for the electronic prescribing system to serve as an information source to survey pharmaceutical use, conduct epidemiological studies, and to act as a disease registry.

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The AHRQ grant was awarded to Samaritan North Lincoln Hospital, a facility of Samaritan Health Services. Other organizations involved in the project include Oregon Rural Practice based Research Network, Lincoln City Medical Center, Bayshore Family Medicine, Hillside House Assisted Living Facility, Lincoln City Rehabilitation, Lincolnshire Retirement & Assisted Living. OHSU Department of Medical Informatics and Clinical Epidemiology, Oregon Graduate School of Science and Engineering of OHSU, Center for Evidence Based Policy.

Four pharmacies located in Lincoln City, Safeway, Bimart, RiteAid, and Rexall, and two pharmacy services providing medication for assisted living and skilled nursing facilities, Senior Pharmacy and Preferred Pharmacy, are also participating.

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