Quality Project Ambulatory E-Prescribing

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Improving Ambulatory Office Workflow, Efficiency and Reducing Prescribing Error Through the Use of E-Prescribing CPOE.

Problem Statement

Background

“The current system of prescribing and dispensing medications in the United States has widespread problems with safety and efficiency”.(3) Yet drug therapy is an integral component of many ambulatory treatment regimens recommended for chronic and acute medical conditions. Americans made 906.5 million outpatient visits in 2000(1) and half of the US population takes one prescription daily, with one in six taking three or more a day.(2) This includes 3.27 billion prescriptions and more than 10% of the national health spending.(2) In the Crossing the Quality Chasm article, The Institute of Medicine challenged us to create a new system that is safe, effective, patient-centered, timely, efficient and equitable. Our current ambulatory prescribing and dispensing systems do not meet those criteria. There appears to be one glaring weak link; inadequate implementation of ambulatory computerized patient ordering entry (ACPOE) systems for medications. i.e. electronic prescribing (eRx).

To the patient the prescriptive process seems quite simple. They are given a written prescription, take it to the pharmacy (or mail it in), pay the allotted amount due, receive and consume the medications. In all reality there is a complex and convoluted system that manages the drug industry’s transactions including the retail or mail order pharmacy, pharmacy benefit manager, payer, manufacture, wholesaler as well as technology venders for transaction networks, clinical information databases and software. This is further complicated by a serpentine economic trail of rebates and incentives. From the point a person turns in their prescription to when they pick it up, the processes are all electronic and have proven effective managing 3.27 billion prescriptions a year! Yet this process currently starts with a paper prescription process greater than 85% of the time.(1) This is the “weak link” where the majority of ambulatory medication errors occur. Converting the prescribing process from paper to an electronic process is often referred to as the “final mile” for ambulatory electronic medication management.(2).

Because of the immense potential seen for ePrescibing to reduce errors and cost, Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 was passed requiring the ePrescribing process adhere to specific standards.(3,4) Subsequently President Bush has called for linking reimbursement rendered for medical services covered by government sponsored plans to ePrescribing. A 2007 report issued by the Health and Human Services suggested that “electronic prescribing is still in its infancy” however the findings are encouraging. Although there is still work to be done implementing the remaining standards, the report encourages “interested stakeholders to fully adopt and implement electronic prescribing in order to reap its many potential benefits”.(3)

Errors in the medication process include prescribing, transcribing, dispensing, consuming and monitoring. Estimates suggest there are 8.8 million ambulatory adverse drug events (ADE) a year, of which 2.1 million are preventable and 130,000 are life threatening.(3) Preventable prescribing and transcribing errors include illegible written prescriptions, incorrect dosing, drug/allergy, drug/drug and drug/condition errors. Estimates vary on just how many of these ADE would be averted depending significantly on the software functionalities and human factors.(1)

Unfortunately making a business case for implementation of health information technology in an independent primary care office has been difficult. The vast majority of the savings from ePrescribe go to the purchasers and payers of health services, not the physician.(1,3). Physicians will, however, migrate to eRx when they perceive the benefit to their practice outweigh the costs. The primary physician office benefits and costs are in the financial, productivity, service and hassle areas. It is anticipated that as eRx systems are able to meet these needs, adoption will increase.

Aim

Our mission is to improve the office workflow efficiency and safety within the ambulatory prescription process of a primary care office within six months.

Goals

  • Reduce total telephone calls by 25%
  • Reduce drug/allergy prescribing errors to zero
  • Increase patient satisfaction to medication refill times by 50%
  • Develop and implement a staff satisfaction survey tool These address the efficiency, safety, and patient-centered goals of the IOM quality improvement initiative.

Processes and Prioritization

Process affected

  • Office workflow and efficiency
  • Measure
  • Phone calls
  • Process affected
  • Prescriptive safety
  • Measure Cancelled prescriptions
  • Process affected Patient satisfaction
  • Measure Patient satisfaction to medication refill times

Intervention Plan

Get baseline measure of phone calls, plot flow diagram of current workflow process and idealized workflow for patient refills

Do Reengineer office workflow so that prescription refills initate at the pharmacy

Study Measure phone calls after reengineering and plot phone calls before and after reengineering on p chart.

Act Institute reengineered workflow and initiate e-prescribing

PDSA 2 Reiterate above, but in addition, measure cancelled rx thru e-prescriptive process

PDSA 3 Reiterate, and institute patient satisfaction tool

References

The following websites were accessed for information and references ==

www.ahrg.gov

www.ihi.gov

www.mpro.org/doquit

www.ncbi.nlm.nih.gov (pubmed)


References

  1. Johnston,DS,Pan,E,Walker,J,Bates,DW, Middleton,B, Patient Safety in the Physician’s Office. Assessing the Value of Ambulatory CPOE, I-Health Reports April,2004.
  2. Sarasohn-Kahn, J., Holt, M, The Prescription Infrastructure. Are We Ready for ePrescribing? I-Health Reports, January,2006.
  3. Findings From The Evaluation of E-Prescribing Pilot Sites; AHQR Publication No. 07-0047-EF, April, 2007 4. Johnson,KB,Fitzhenry,F, Case Report:Activity Diagrams for Integrating e_Prescribing Tools into Clinical Workflow, JAMIA 13(4) 2006. 391-96.
  4. Papshev,D,Peterson,AM, Electronic Prescribing in Ambulatory Practice:Promises,Pitfalls, and Potential Solutions, AmJManagCare 7(7)2001. 725-36.
  5. Bell,DS,Friedman,MA, E-Prescribing and the Medicare Modernization Act of 2003, Health Affairs 24(5) 2005. 1159-69.
  6. Wang,CJ,Marken,RS,Meili,RC,Straus,JB,Landman,AB,Bell,DS, Functional Characteristics of Commercial Ambulatory Prescribing Systems. A Field Study, JAMIA 12(3) 2005. 346-56.
  7. Tamblyn,R, et al, The Development and Evaluation of an Integrated Electronic Prescribing and Drug Management System for Primary Care, JAMIA 13(1): 148-59.
  8. Gandhi,TK, Weingart,SN,Seger,AC, et al, Outpatient Prescribing Errors and the Impact of Computerized Prescribing, J Gen Int Med 20() 2005. 837-41.
  9. West,DR,Westfall,JM et al, Using Reported Primary Care Errors to Develop and Implement Patient Safety Interventions :A Report from the ASIPS Collaborative, Advances in Patient Safety Vol 3.
  10. Feifer,RA,Nevins,LM,McGuigan,KA,Paul,L, Lee,J, Mail-Order Prescriptions Requiring Clarification Contact with the Prescriber:Prevalence, Reasons, and Implications, JMCP 9(4) 2003 :346-52.