Utilizing the Electronic Medical Record to Reduce Inappropriate Medication Use Alan White, PhD – Abt Associates Valerie Weber, MD – Geisinger Health System

Abt Associates Footer Information goes here Background Falls are a common problem threatening the independence of older individuals. – Falls have serious health and economic consequences – One of every three adults over the age of 65 in the United States suffers one or more falls each year, as do almost 50 percent of elders more than 80 years old – 1.8 million fall-related ER visits among over 65 population (34.7 million persons) – cost $16.4 billion (Lewin 2000) Previous studies have shown that medications (number and use of psychotropic medications) is a risk factor for falls.

Abt Associates Footer Information goes here Study Questions Computerized reminder systems have improved the performance of cancer screening, and other preventive services. Can they work to influence polypharmacy, and perhaps decrease falls, in the elderly at risk population? – Would physicians read and respond to the messages they received as part of the intervention? – Would the intervention lead to changes in the use of medications, particularly psychotropic medications? – How would the intervention affect falls and medical costs?

Abt Associates Footer Information goes here Population Studied and Design Patients for study were identified based on age and medications – Patients of Geisinger Health System, which serves predominantly an aging and elderly rural population spread across 31 counties in central Pennsylvania. – Age over 70 – 4+ active medications; at least one psychotropic medication Patients were assigned to intervention or comparison group by clinic. – Stratified by location to ensure that physicians receiving intervention were not caring for comparison group patients. – 15 intervention sites (n=413); 3 comparison sites (n=207)

Abt Associates Footer Information goes here The intervention Pharmacist review of medications – Primary care physician was advised of the results of a review of the patients medications by a pharmacist, using a messaging function on the EMR. – The message informs the physician that the patient has been identified as being at risk of falls because of their age and medication history. – Made individualized suggestions regarding medications, often focused on the use of psychoactive medications – Sent through the EMR Message to physician included a link to best practice guidelines based on material from the American Geriatrics Society/American Academy of Orthopedic Surgery

Abt Associates Footer Information goes here The Message: As part of a research study on patient safety in the elderly being conducted by the Department of General Internal medicine, your patient (name) has been identified as being at risk for falls based on age and medication history. Falls are a major cause of morbidity in the elderly and account for 6% of all medical expenditures in this population. Decreasing polypharmacy in the elderly, and in particular certain medications such as benzodiazepines, has been shown to reduce the risk of falls in this population. (Patients name) has had a medication review conducted via EPICcare by a GHS pharmacist. The following medications should be reviewed/changed as you deem appropriate: (Specific recommendations inserted here) An evidence-based guideline for fall prevention in the elderly is found under the Pathways button on EPICcare for your review. This guideline contains simple, practical ways to reduce the risk of falls in your patients. Thank you, Elderly Falls Study Team

Abt Associates Footer Information goes here Data Sources Survey of participating physicians GHS Electronic Medical records (hospitalizations, physician encounters, prescription medications); no nursing home data Fall-related encounters identified based on diagnosis and procedure codes. Chart review was used to determine whether some encounters were fall-related. Patient telephone survey: Self-reported information on number of falls (collected quarterly by a GHS nurse)

Abt Associates Footer Information goes here Almost All Physicians Read the Messages They Received and Many Responded In Some Way 78% reported having read all of the message 47% reported having reviewed the fall guideline 26% reported having altered their patient management in some way, including: asked more about falls (62%) Increased awareness about falls (50%) More attention to polypharmacy in the elderly (100%) Changed medications (63%) Stopped medications (25%) High response may be due to personal nature of message from pharmacist-- not an automated reminder.

Abt Associates Footer Information goes here Intervention Had No Apparent Impact on Number of Medications Started

Abt Associates Footer Information goes here Number of Psychotropic Medications Decreased for Intervention Group (Months 1-6)

Abt Associates Footer Information goes here Number of Psychotropic Medications Started: No Significant Impact

Abt Associates Footer Information goes here Impact Was Significant for Subset of Patients with Two or More Psychotropic Meds at Baseline

Abt Associates Footer Information goes here

Results – Falls Two measures of falls– medical records (EpicCare) and patient survey – Fall rates over the 12-month study period: Medical Records: 20% intervention group, 23% for comparison group (insignificant difference) Self-Reported: 36% for intervention group, 40% for comparison group (significant difference only in quarter 2) Multivariate results: – Medical Records: Intervention associated with significantly fewer fall-related diagnoses (p <.01) – Self-Reported: Insignificant difference

Abt Associates Footer Information goes here Medical Costs No statistically significant difference seen in total health care costs between the intervention and control groups Lack of data on nursing home costs limits our ability to conduct cost-effectiveness analysis

Abt Associates Footer Information goes here Conclusions The current study supports the use of the EMR to drive best practice. We believe that using a pharmacy driven EMR protocol can reduce the use of psychotropic medications in the elderly and therefore falls. Pharmacist-physician partnerships hold great promise and are underutilized. The intervention is not costly and could be replicated in health care systems without an EMR. One factor limiting adoption may be that the savings in terms of avoided medical costs are not captured by the organization that pays for the intervention.