1. Variation in the implementation and use of e-prescribing in ambulatory settings Jesse C. Crosson, Douglas S. Bell, Nicole Isaacson, Debra Lancaster, Joshua L. Newman, Emily A. McDonald, Tony Schueth AcademyHealth Annual Research Meeting, June 5, 2007 Funded by the US Agency for Healthcare Research and Quality 1 U18 HS016391-01 PI: Bell

2. Background Better understanding of HIT implementation and usage patterns is needed to ensure the the realization of expected quality and safety improvements in typical practice settings.

3. Study Objectives To describe variations in the implementation and use of electronic prescribing in ambulatory settings and their potential clinical effects.

4. Methods: Design and Sampling Comparative case study of twelve ambulatory medical practice before and after e-prescribing implementation.

5. Methods: Data Collection Observation of physical environment, organizational culture, clinical and prescription workflow. In-depth interviews of physicians, office managers, and office staff involved in prescription workflow.

6. Methods: Analysis Used a template organizing style to identify common themes. Coding reports were used to generate data summaries and representative text segments were identified.

7. Results 5 practices (3 A, 2 B) installed and used. 3 (1 A, 2 B) installed but some prescribers stopped use. 2 (both B) installed but discontinued use. 2 (both A) failed to install.

8. Results: Successful Installation Positive Attitude: A physician expressed the hope that e-prescribing would eliminate prescription-related fax communications handled by nursing staff. Realistic Expectations: Another physician said the program would lead to “a little bit less paperwork … maybe fewer phone calls from the pharmacy (and) it may make it a little bit easier when a person comes in with multiple medicines to refill (but) … I’m not sure how much it’s going to speed visits up.”

9. Results: Partial Success Unrealistic expectations: One physician said: “anything you start new, it’s going to cause problems up front, but, I’m sure … within two weeks that will all be sorted out.” Concerns about clinical authority: Another physician stated that using a hand-held computer in the encounter to check dosages or to look up other clinical information is “not a good idea, it doesn’t instill confidence”

10. Results: Discontinued Use Lack of advance knowledge: The office manager asked the field researcher: “Is this something that the doctor will speak into when they would have something to do?” Unrealistic expectations: At follow up, one physician reported: “I realized that it wasn’t going to be a time improvement … (and) … I just can’t devote the time to become the expert I have to be to make it work flawlessly.”

11. Results: Failed to Install Lack of advance knowledge: One physician reported, “the only thing I know about (e- prescribing) is the presentation that was given to us.” High expectations: “the biggest thing that came across to me was … the reduction in medical errors and … (that the goal was) to try and speed up the process for the clinician.”

12. Conclusions Effective implementation and use will require:  Setting realistic expectations  Training and preparation  Methods to ensure appropriate use  Adoption incentives