# Presentation: 377689

## Pediatric e-Prescribing:

**Pediatric e-Prescribing:**

- Kevin B. Johnson, MD, MS
- Department of Biomedical Informatics
- Department of Pediatrics
- Vanderbilt University

**Is the PDA a Prescription for Safety?**

## How Common?

- From 5.7% (pediatric inpatient) -11% (critical care)
- Dosage mis-calculations the most common contributor to medication prescribing errors in pediatric patients

- JAMA. 2001 Apr 25;285(16):2114-20.
- Pediatric Critical Care Medicine. 5(2):124-132, March 2004.

## How Big Is the Issue?

- 40% of medication errors due to prescribing (Hariharan, S, 2001)
- 16% illegible prescriptions
- Children are twice as likely to incur a prescription error (IOM, 2001)
- 70% of pediatric care is outpatient-based

- (National Ambulatory Care Survey, 1998)

## How Big Is the Issue?

- Represents 230 million ambulatory cases seen
- (National Ambulatory Care Survey, 1998)

- 70% of pediatric cases are seen in ambulatory settings

## There’s A Little Dory In ALL Of Us

## Error Prevention Strategies

- Use printed (typed) characters
- Add indication
- Use metric weights
- Do NOT use abbreviations
- Use a leading zero (0.5)
- Do NOT use a trailing zero (5.0)

- American College of Physicians, June, 2002

## Error Prevention Strategies

- We should comply with safe prescribing recommendations
- Show mg/kg dosing strategy
- Show child’s weight
- Include child’s age
- Show indication for the prescription
- Sign and date all prescriptions

- Pediatrics 112(2):431

**Notes:**
Get REFERENCES HERE

## Paper-based Prescription Compliance 

- Number of prescriptions with missing information: 3,096 / 7951 (39%)

- Johnson, KB et al, 2004

## “For children < 4, it is important to include:”

- Weight

- 5.0

- 4.0

- 3.0

- 2.0

- 1.0

- 40

- 30

- 20

- 10

- 0

- Mean = 4.7

- Dosing Strategy

- 5.0

- 4.0

- 3.0

- 2.0

- 1.0

- 40

- 30

- 20

- 10

- 0

- Mean = 4.6

- Indication

- 5.0

- 4.0

- 3.0

- 2.0

- 1.0

- 30

- 20

- 10

- 0

- Mean = 4.1

- 5.0

- 4.0

- 3.0

- 2.0

- 1.0

- 7

- 6

- 5

- 4

- 3

- 2

- 1

- 0

- Mean = 4.3

- 5.00

- 4.00

- 3.00

- 2.00

- 1.00

- 12

- 10

- 8

- 6

- 4

- 2

- 0

- Mean = 4.83

- 5.00

- 4.00

- 3.00

- 2.00

- 1.00

- 10

- 8

- 6

- 4

- 2

- 0

- Mean = 4.67

- Faculty
- n = 12

- Residents
- N = 47

- *measured on Likert scale: 1 = strongly disagree –> 5 = strongly agree

## “For patients > 16 years, it is important to include:”

- Faculty
- n = 12

- Residents
- N = 47

- Indication

- Dosing Strategy

- Weight

- *measured on Likert scale: 1 = strongly disagree –> 5 = strongly agree

## Why Not Always Prescribe Safely? 

- Residents and faculty may not value all safe prescribing practices for all age groups.
- Education about safe prescribing practice will need to specifically address rationale for documenting weights, indications, and dosing guidelines.
- Faculty are not exempt from this education!

## Why Consider PDAs?

- 17-20% of providers use PDA in practice (Harris Poll, 2002)
- 64% of medical facilities (represented by membership in AMDIS) use PDAs at an enterprise level (HIMSS, 2002)
- Prescription reference material the most common resource on physicians’ PDAs

**Notes:**
Note that institutions with gross revenues under 10 million have approx 50% use of PDAs

## PDAs:  Current Uses

- Daily schedules
- Reference tool
- Charge capture
- ...
- E-prescribing

## Handheld Prescription Writing (HPW): Advantages

- Low startup infrastructure costs when using physician-owned devices
- Minimal training
- Integrated prescribing and decision support
- Easily integrated into workflow (geographically)
- May be integrated into workflow  functionally

## Potential HPW Challenges

- Robustness
- Integration into EMR
- Integration into workflow (including pharmacy!)
- Security
- Wireless capabilities
- Battery life
- Cost of properly configured HPW device\
- State regulations  may impede use (EDI, scanned signatures)

## The True Cost Of Enterprise PDAs

- Hot spares (20% failure rate in high-use environments
- Wireless (wi-fi)
- Extra battery power
- Spare batteries
- Chargers
- $1200 or more per device

## PDA for Prescribing

- Settings:  primary care pediatric clinic and pediatric emergency department
- Timeframe:  3/04– 11/04
- 2 months using PDA, 2 months using paper alternating randomly from April through November
- Residents asked to complete survey in October

## Survey Details

- Modified Questionnaire for User Interface Satisfaction (QUIS Chin, J. P., Diehl, V. A, Norman, K. (Sept. 1987))
- Questions added/modified specifically to address PDA workflow issues, use of stylus, specific domain functionality

## Survey Process

- Distributed through mail, in clinic, in emergency department  (77)
- Response rate 51/77 = 66%

## HPW  Use

- When given a choice of PDA versus desktops,
- 17/51 used PDA routinely
- 34/51 did not use PDA

## Overall Reaction to HPW

## Overall Reaction to HPW

- Wonderful (38%)
- Easy (36%)
- Satisfying (23%)
- Stimulating (23%)
- Flexible (14%)
- Fast (27%)

- Selecting patients is easy (50%)
- Logon is short (54%)
- Faxing is easy (53%)
- Faxing is safe (58%)
- Good terminology (58%)

- percent = percent with score between 6-9 on 0-9 point scale

## Screen Design and Layout

## HPW Screen Layout

- Easy to read (72%)
- Stylus easy (88%)
- Message position (72%)
- Messages clear (83%)
- Organization on screen clear (72%)

- Sequence of steps clear (72%)
- Computer keeps me informed of state (44%)
- Error messages helpful (22%)

- N = 28/77;  percent = percent with score between 6-9 on 0-9 point scale

## Learning the PDA

## Learning the PDA

- Easy (66%)
- Exploring features is easy (60%)
- Remembering commands (64%)
- Straightforward process (60%)

- Speed is fast enough (47%)
- Good reliability (27%)
- Correcting mistakes is easy (20%)
- Experience makes process easier(36%)

- percent = percent with score between 6-9 on 0-9 point scale

## PDA Issues

## Other Issues

## Conclusions

- HPW not well accepted in the setting of widely available desktop workstations
- HPW user interface presents barriers to adoption of eRx
- Desktop workstation-based eRx may be more readily adopted, and offers more benefits for a similar cost

## Implications

- In environments where  desktop workstations are easily installed, these devices may be easier to adopt than existing PDA technology.

## Thank you!

- AHRQ  HS11868
- Coda Davison
- Lynette Forrest
- Mary Landrum
- PedsSTEP team!

## The PedSTEP Project

## Our Major Aims

- Assess the medication error rate and types of errors in ambulatory pediatric settings
- Identify the facilitators and barriers to implementing and successfully adopting handheld prescription writing (HPW) tools and e-Rx in general
- Evaluate the effect of e-Rx on the medication error rate and types of errors in ambulatory pediatric settings

## Step 1: Baseline Data Collection

## Prescription Compliance Summary

**Total number of prescriptions written:****	****7,951**
**Participants writing prescriptions:**
**Attendings – 6**
**First Years – 18**
**Second Years – 13**
**Third Years - 12**
**Fellows, 1****st**** year – 2**
**Fellows, 2****nd**** year – 1**
**Fellows, undeclared years – 2**
**No position defined - 1**

## Hypothesis

- Resident behavior (not completing required prescription information) is due to misinformation about causes of error and uses of prescription data

## Design

- Setting: Primary care clinic in an urban academic medical center
- Subjects:  Pediatrics residents (74) and preceptors (14)
- Methods:  self-administered anonymous survey
- Data analysis: primarily descriptive; Kendall’s Tau B and one-way ANOVA to assess effect of co-variates  (gender, year of training, exposure to medication errors)

## Results

- Surveys returned: 48/74 (65%)
- PGY1 = 		18/25 (72%)
- PGY2 = 		14/25 (56%)
- PGY3 = 		14/24 (58%)
- Preceptors = 	12/14 (86%)
- Gender:  Female : 42 (72%)