1. 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

2. 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

3. The Perspectives

4. 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)

5. Clinician perspectives

6. 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

7. Frequency of reviewing patient PBM med history Physician Software Vendor

8. 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

9. Variation in frequency of updating medication list with patient Physician Software Vendor

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

11. 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

12. Patient perceptions regarding frequency of discussion with clinician AdherenceAccuracy of Medication List

13. ALERT FATIGUE……. Physician Software Vendor DOSE CHECKS DRUG-DRUG INTERACTIONS

14. Pharmacy perspective

15. Pharmacy chain organizations Note: Respondents from 276 stores with minimum e-Rx activity (5 per day). RUPP, JACKSON.

16. Pharmacy perspective RUPP M, JACKSON T.

17. Pharmacist perceptions RUPP M, JACKSON T.

18. 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

19. Medication history for pharmacists? Currently not available to pharmacists –Some chain wide –Some store only No sharing across pharmacies

20. Patient Perspectives

21. Does E-Rx offer potential?

22. 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!

23. 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

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

25. 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)