# Presentation: 383706

## Maximizing the Effectiveness of E-Prescribing Between Physicians and Community Pharmacies:Implementation

**Maximizing the Effectiveness of ****E-Prescribing Between Physicians and Community Pharmacies:****Implementation**

**AHRQ 2007 Conference **
**September 27, 2007**

- Principal Investigator:
*Kate Lapane, PhD*
- Project Manager:
*Ken Whittemore, MBA*
- Co-Investigators:
*Catherine Dubé, EdD*
*Mike Rupp, PhD*
*Terri Jackson, PhD*

## OVERVIEW

**Testing **of interoperability of the standards; certification processes and pilot testing

**Evaluation** of the implementation of the standards from multiple perspectives using mixed-method approach

**BREADTH: geography, e-prescribing technologies, practice settings, perspectives**
**  ****6 states, 6 vendors, ~275 docs in ~88 practices , 276 retail pharmacy stores, ~1100 patients**

**OBJECTIVES OF THE PROJECT**

## The Perspectives

## Evaluation Strategies:

**Mixed-method approach**
- Qualitative methods:
- Focus groups
- Performance analyses (on-site observation) – physician practice only
- Quantitative
- Survey
- Providers (physicians and other prescribers, pharmacists and pharmacy techs)
- Patients
- Documentation of interventions (pharmacy)

## Clinician perspectives

## Just because a practice has e-Rx capabilities....

- Not all clinicians within the practice e-rx
- Training issues
- Lack of understanding of benefits
- Not all clinicians use e-rx with all patients
- Not with all prescriptions
- Regulations (scheduled drugs)
- Not all functionalities of e-Rx

## Frequency of reviewing patient PBM med history

**Physician Software Vendor**

**Notes:**
Notes:  The extent to which physicians use medication history at baseline varied by software product used.  

## Non-clinician use of review of medication history

** ****Users of two vendors reported significant use of functionality among non-clinicians.**

**Review patient medication history?**

**Frequency of use of functionality?**

** ****If workflow structured to permit it, non-clinicians use functionality frequently.**

**Vendor**

**Vendor**

## Variation in frequency of updating medication list with patient

**Physician Software Vendor**

**Notes:**
Notes:  The extent to which physicians use medication history at baseline varied by software product used.  Vendor C 61% ALWAYS viewed med history, vs. only 15% of Vendor D. This is likely a function of ease of access – we will be trying to link characteristics of the software to these data to understand how technology can be integrated to help docs use it.
Vendor E had only one respondent.  So – be leary.

## Usefulness of patient’s medication history provided through your e-prescribing software in reconciling the active medication list? 

**Usefulness of patient’s medication history provided through your e-prescribing software in reconciling the active medication list?**

## Med history – missed opportunities?

- Data may not be displayed optimally
- Used mostly if there is a problem–
- drill back down to learn more
- Need to harness the power of med history and train clinicians to use data prospectively to prevent medication issues

## Patient perceptions regarding frequency of discussion with clinician

_**Adherence**_

_**Accuracy of Medication List**_

## ALERT FATIGUE.......

**Physician Software Vendor**

**DOSE CHECKS**

**DRUG-DRUG INTERACTIONS**

## Pharmacy perspective

## Pharmacy chain organizations

**Pharmacy chain organizations**

- Note: Respondents from 276 stores with minimum e-Rx activity (5 per day).

**RUPP, JACKSON. **

## Pharmacy perspective

**RUPP M, JACKSON T****. **

## Pharmacist perceptions

**RUPP M, JACKSON T****. **

## Variation in how e-RX processed

- Most chains drop e-Rx into the store fill queue
- Some print e-RX and then process (phasing out, short term transition issue)
- Most auto populate fields
- Images of e-RX available on some systems
- Some chains treat e-Rx with lower response urgency than:
- Customers waiting in line
- Clinicians on the phone
- Faxes on the printer
- Other chains grant e-RX the *highest *fill priority

## Medication history for pharmacists?

- Currently not available to pharmacists
- Some chain wide
- Some store only
- No sharing across pharmacies

## Patient Perspectives

## Does E-Rx offer potential?

## Geriatric patient perspective on e-Rx

**Notes of caution Q&A:**
_**When do you expect your Rx to be ready?**_

_**Paper RX helps me remember to pick up my RX?**_

**18% IMMEDIATELY!**

**57% - 74% agree! **

## Geriatric patient perspective

- Mismatch in perceptions
- Clinicians think that discussions are occurring more frequently than patients report
- Med history and formulary/benefits:
- Potential to increase the frequency of medication discussions
- Change in quality of discussions unknown
- Missed opportunities for improvement?
- Engaging the patient in the process

## Summary

- Less than optimal use of functionality
- How do we build it to make them come?
- 2nd generation issues
- Who should come?
- Engaging:
- Pharmacists – med history at point of dispensing?
- Physicians – using med history in practice
- Patients – tools for them?

## Bibliography

- Lapane KL, Quilliam, Dore. Roadblock on the Health IT Superhighway: E-prescribing and the Controlled Substances Act. J Opioid Management 2007; 3(4):xxx-xxx.
- Lapane KL, Dube C, Schneider K, Quilliam BJ. Patient Perceptions Regarding E-prescriptions: Is the Geriatric Patient Ready? J Am Geriatr Soc. 2007 Aug;55(8):1254-9.
- Dube C, Lapane KL, Rosen R. The business case for e-prescribing (in preparation)
- Goldman R, Dube C, Lapane KL. The status of electronic processing of refills (in preparation)
- Lapane KL, Waring ME, Schneider KL, Quilliam BJ, Dube C. A mixed-method Study Of The Value Of Drug Alerts At Point Of E-Prescribing In Primary Care  (in revision, JGIM)
- Dube C, Lapane KL. Medication history at the point of prescribing: changing clinical practice (in preparation)
- Lapane KL, Dube C, Schneider K, Quilliam BJ. (Mis)Perceptions of Patients and Providers Regarding Medication Issues, In revision, Am J Managed Care
- Lapane KL, Waring ME, Dube C, Schneider KL, Whittemore K. E-prescribing as an agent of patient safety: A mixed-method study. (under review AHRQ)
- Rupp M, Jackson T. Pharmacy personnel attitudes towards e-prescribing. (in preparation)
- Jackson T, Rupp M. Medication therapy interventions on e-prescriptions. (in preparation)
- Lapane KL, Waring ME. Medicare Part D implementation: Lessons learned (in preparation)