# Presentation: 537886

## Beyond ePrescribing

***Factors Influencing Patient Safety in Medical Group Practices  - ***September 26th, 2007
- AHRQ 2007: Improving Healthcare, Improving Live
- Larry Garber, M.D. – Medical Director for Informatics

## Slide 2

**Notes:**
There are many aspects to patient safety which are well described.
I’m just going to focus on our work with ADE’s in the ambulatory setting

## Overview

**Overview**

- Sources of Adverse Drug Events (ADE’s) in the ambulatory setting
- Reducing anticoagulant-related ADE’s
- Future plans and barriers to reducing ADE’s

## Sources of ADE Information

| Source | Total ADEs | Preventable (%) |
| --- | --- | --- |
| ER notes | 187 | 37% |
| Hospital D/C’s | 166 | 35% |
| Computer signals | 439 | 34% |
| Electronic notes | 565 | 20% |
| Provider reports | 168 | 15% |
| Incident reports | 5 | 60% |

**Sources of ADE Information**

***Field, TS et al. JAMIA 2004;52:1349-1354.***

**Notes:**
Study led by Jerry Gurwitz, David Bates, and Terry Field, funded by National Institute on Aging and AHRQ
~28,000 patients age 65 and older over the course of 1 year.
Systematically looked at each of these sources.
Computer signals were things like:
Digoxin Level >2
ICD9- code for “Poisoning by Cardiovascular Drug”
Potassium <2.9 or INR >5
Rx for Vitamin K
Note that MD’s don’t record or report their mistakes...

## ADE Rates in the Ambulatory Setting

- ADEs:50 per 1000 person-years
- Preventable ADEs:	14 per 1000 person-years (28%)
- Extrapolated to total Medicare 65+:1,446,949 ADEs per year**438,046 preventable ADEs/year**
- This is likely to be an underestimate

***Gurwitz JH et al JAMA 2003;289:1107-1116***

## Financial Cost of ADE’s

***Field TS, et al Medical Care 2005;43:1171-6***

**Notes:**
Diamonds are the ADE cases
Squares are the controls.

## Financial Cost of ADE’s

- Increase in costs after an ADE: $1310Increase after a preventable ADE: $1983
- Extrapolated to 1000 adults age 65+Costs per year to treat preventable ADEs:**$27,365**

**Notes:**
We could apply ~$750,000 each year to pay for the intervention

## ADE Severity in the Ambulatory Setting

**Notes:**
Less Serious = Non Urticarial Rash or fall without fracture
Serious = Urticaria or fall with fracture
Life threatening = hemorrhage with hypotension or ARF requiring hospitalization

##  Severity & Preventability

**Preventable**
**52%**

- Of fatal & life-threatening
- events

**Preventable**
**20%**

- Of less serious events

## Source of Errors

**Notes:**
Stages:
Ordering/prescribing
Dispensing
Patient Adherence
Monitoring – inadequate lab testing or delayed response to signs and symptoms

## So where do you start?

**Notes:**
Since we know the major problems are with prescribing and monitoring, it makes sense to identify which classes of drugs have the biggest bang for the buck

**Notes:**
Half of the 65+ patients on Cardiovascular drugs which accounts for its high volume of ADE’s
Antibiotics also are very common, but far fewer ADE’s.
In contrast, Anticoagulants are 1/7th as common, yet have a relatively high rate of ADE’s.

**Notes:**
Another way to see this is with the absolute rate of Preventable ADE’s.

**Notes:**
Or you can look at essentially the “Risk” of therapy.  
In other words, the chances of an ADE when you prescribe an Anticoagulant is 3 times higher than your risk when prescribing a Cardiovascular medication

## Fallon Approach to Preventing ADE’s

- First target the Fatal & Life-Threatening preventable ADE’s
- Warfarin
- Then do a system-wide solution for the others

**Notes:**
We took a different approach.  It turns out that the most serious ADE’s 

## Preventing Warfarin ADE’s

- Ordering/Prescribing
- ePrescribing with drug interaction checking
- Simplified referrals to Anticoagulation Clinic
- Monitoring
- Converted Anticoagulation Clinic to Epic’s EHR
- Simplified tracking of lab no-shows

## Full dosing information is entered and available to be seen by all physicians and staff

**Full dosing information is entered and available to be seen by all physicians and staff**

**Date of next INR is entered to trigger tickler system**

## INR Reminder automatically appears in the Anticoagulation Clinic In-basket on the patient’s due date, and doesn’t disappear until the due date is changed

**INR Reminder automatically appears in the Anticoagulation Clinic In-basket on the patient’s due date, and doesn’t disappear until the due date is changed**

**Notes:**
Here is the key.  These don’t go away until a lab is completed and another appointment is schedule

## Preventing Other ADE’s

- Use probabilistic risk assessment to:
- characterize systemic and behavioral elements that increase of ADE’s during ordering/monitoring
- identify potentially high-yield and likely-to-be-successful interventions
- Estimate likelihood that interventions at any given step would be successful in reducing errors at that step
- Select interventions for implementation

***Field TS et al AHRQ Grant # ****1P20HS017109-01*

## Barriers to preventing ADE’s

- Most organizations don’t have EHR’s
- ePrescribing doesn’t solve the monitoring problem
- Many EHR’s don’t currently have the functionality to provide alerts for missing events without being in the context of a patient encounter
- MD compliance
- Time and money required to build interventions

**Notes:**
Epic has Asynchronous Alerts starting in Spring ‘07

## Summary: 

- ADEs are common and often preventable
- Types of errors suggest focus on prescribing and monitoring
- Provision of information to physicians and assistants at right time, right place...
- Use of automated tickler systems
- Costs are high and savings from preventing ADEs could partially offset costs of interventions

## Questions?

**Questions?**

- Larry Garber, M.D.
- _[Lawrence.Garber@FallonClinic.org](mailto:Lawrence.Garber@FallonClinic.org)_

- Special thanks to Terry Field, PhD and Jerry Gurwitz, M.D. for their assistance on this presentation and never-ending work to study and prevent ADE’s