Beyond the basics: Refills by electronic prescribing

Beyond the basics: Refills by electronic prescribing

i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 507–514 journal homepage: www.intl.elsevierhealth.com...

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journal homepage: www.intl.elsevierhealth.com/journals/ijmi

Beyond the basics: Refills by electronic prescribing Roberta E. Goldman a,b , Catherine Dubé c,d , Kate L. Lapane c,e,∗ a

Brown University Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, RI 02860, United States Department of Family Medicine, Warren Alpert Medical School of Brown University, Pawtucket, RI 02860, United States c Department of Community Health, Warren Alpert Medical School of Brown University, Providence, RI 02912, United States d Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI, United States e Department of Epidemiology and Community Health, Virginia Commonwealth University, Richmond, VA 23298, United States b

a r t i c l e

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Article history:

Introduction: E-prescribing is part of a new generation of electronic solutions for the med-

Received 24 February 2010

ical industry that may have great potential for improving work flow and communication

Received in revised form

between medical practices and pharmacies. In the US, it has been introduced with mini-

16 April 2010

mal monitoring of errors and general usability. This paper examines refill functionality in

Accepted 18 April 2010

e-prescribing software. Methods: A mixed method study including focus groups and surveys was conducted. Qualitative data were collected in on-site focus groups or individual interviews with clinicians and

Keywords:

medical office staff at 64 physician office practices. Focus group participants described their

Electronic prescribing

experiences with the refill functionality of e-prescribing software, provided suggestions for

Computerized physician order entry

improving it, and suggested improvements in office procedures and software functionality.

Alerts and reminders

Results: Overall, ∼50% reduction in time spent each day on refills was reported. Overall

Ambulatory care

reports of refill functionality were positive; but clinicians and staff identified numerous difficulties and glitches associated managing prescription refills. These glitches diminished over time. Benefits included time saved as well as patient convenience. Potential for refilling without thought because of the ease of use was noted. Clinicians and staff appreciated the ability to track whether patients are filling and refilling prescriptions. Discussion: E-prescribing software for managing medication refills has not yet reached its full potential. To reduce work flow barriers and medication errors, software companies need to develop error reporting systems and response teams to deal effectively with problems experienced by users. Examining usability issues on both the medical office and pharmacy ends is required to identify the behavioral and cultural changes that accompany technological innovation and ease the transition to full use of e-prescribing software. © 2010 Elsevier Ireland Ltd. All rights reserved.

1.

Introduction

Electronic prescribing is the direct computer-to-computer transmission of prescription information from physician offices to pharmacies. By the end of 2008, about 12% of office-

based practices were using some variant of this technology in the United States (http://www.surescripts.com; accessed on February 18, 2010). E-prescribing, still in its infancy and experiencing the requisite growing pains, will take on a greater role in patient management in general [1]. The overall potential for e-prescribing is enormous as it will provide physicians

∗ Corresponding author at: Virginia Commonwealth University, Box 98012, 830 East Main Road, Richmond, VA 23298, United States. Tel.: +1 804 628 2506; fax: +1 804 828 9773. E-mail address: [email protected] (K.L. Lapane). 1386-5056/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijmedinf.2010.04.003

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with a system to track patient refill histories, streamline the administration of patient records, check for drug conflicts and facilitate better communication between pharmacies and physician offices [2]. E-prescribing is expected to assist in reducing medication errors [3,4]. Nevertheless, there may be significant obstacles to the successful implementation of e-prescribing software in physician office practices. Users of e-prescribing software participate in a “live experiment” until the goal of error-free transmission is realized. While studies of the utility of drug alerts in eprescribing exist [5,6], research regarding functionality issues specific to refills is sparse. Thus, this paper specifically examines both the potential of e-prescribing for pharmacy refills and the barriers that currently exist that may impede the large-scale adoption of this new technology. We conducted a large one year study to evaluate healthcare providers’ opinions about the role of e-prescribing applications in improving patient safety and efficiency. This study summarizes qualitative and quantitative data collected via focus groups and surveys of 64 practices spread out across six states and using one of six different e-prescribing software systems. The current report focuses on statements or comments about using e-prescribing for processing refills.

2.

Methods

2.1.

E-prescribing systems

SureScripts, LLC, the nation’s largest e-prescribing network, identified states with the highest electronic prescribing activity on their network in the fall of 2005. From these, we included six states in this study to provide geographic diversity: Florida, Massachusetts, New Jersey, Nevada, Rhode Island, and Tennessee. Within these states, we worked with SureScripts, LLC to identify physician software vendors with substantial activity: OnCallData, InstantDX, LLC, Gaithersburg, MD in Rhode Island, PocketScript, Zix Corporation, Dallas, TX; Rcopia in Massachusetts and New Jersey, DrFirst, Inc., Rockville, MD in Massachusetts, Care360, Medplus, Inc., Mason, OH in New Jersey and Florida, eMPOWERx, GoldStandard Multimedia, Inc., Tampa, FL in Florida, and Touchworks, AllScripts, LLC, Chicago, IL in Nevada and Tennessee. SureScripts, LLC provided the volume of refill transactions by month throughout the study period (January through October 2006).

2.2.

Subjects

Focus group participants were part of a larger study of eprescribing standards funded by the Agency for Healthcare Research and Quality. The physician software companies above assisted in recruitment of ambulatory care practices with a patient-mix of at least 25% Medicare eligible patients. The data for the current study represent information derived from focus groups conducted in 64 practices with experience using electronic prescribing. These practices participated in focus groups, observation, and other data collection administered at their sites. All data were collected before any changes to the electronic prescribing software were made to accommodate the electronic prescribing

standards. Physicians participating in the study received a $500 incentive for participating in two surveys, conducting a survey of their patients, participating with partners and office staff in the focus group, testing the software changes, and allowing on-site observation lasting 1/2 day. The Brown University Institutional Review Board approved the study protocol.

2.3.

Clinician surveys

In advance of or during the site visit, clinicians (n = 157) completed surveys available via the web or paper. Most preferred the web-based option. A multidisciplinary advisory team including practicing clinicians, pharmacists, and researchers designed the survey to elicit and assess clinician perceptions of the impact of e-prescribing on efficiency, workflow, and quality as well as their views on patient communication regarding medication issues. The survey included the following questions related to refills: “How many minutes in a typical work day do you (or did you) respond to and process refill/renewal requests, before and after you started using e-prescribing software (total minutes per day)?” Participants were also asked “In a typical week, how often do you use e-prescribing software to enter information for refills/renewals?” and to what extent participants would view alerting the physician when the patient has NOT picked up a prescription as useful (Very, somewhat, or not at all useful). We also asked what the clinician would do “if the e-prescribing software alerted you to when patients did not pick up prescriptions that would have serious medical consequences if not taken”. Responses included: call the patient, address it at the next visit, nothing, or other. Lastly, we asked participants “How concerned are you about liability if you know a patient did not pick up a prescription?” (Very, somewhat or not at all concerned). We cross-tabulated clinician responses to these questions by physician software system. Vendor-specific results are presented without identifying the name of the vendor.

2.4.

Development of the focus group guide

The multidisciplinary research team consisting of pharmacists, physicians, software vendors, and researchers developed a semi-structured facilitator guide. The guide outlined the major subject areas to explore during the focus group discussion. These included: (1) overall impressions of e-prescribing usability, implementation barriers, and impact on patient safety; (2) refill functionality ways it makes job easier, mechanisms to improve safety and efficiency, information desired; (3) access to medication history; and (4) access to formulary and benefit information. The guide included probes for each topic. The research team piloted the protocol by conducting several pilot focus groups with users of an e-prescribing software solution not included in the study and who were faculty at Brown University. An investigator (CD) received feedback from the pilot participants regarding the questions with the goal of refining the guide before launching the full study. The focus of this paper is on the comments made in response to the section on refill functionality.

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Table 1 – Focus group discussion topics. Experiences with electronic prescribing and e-prescribing software. How did your practice change when e-prescribing software was implemented? What do patients think of electronic prescribing? Thoughts about medication history; thoughts about adherence? Thoughts about formulary and benefits features? Suggestions for improvement and other ideas

2.5.

Conduct of the sessions

Data was collected between April and August 2006 during on-site visits including focus groups or individual interviews with 276 clinicians and staff. Two trained research assistants facilitated each of the focus groups which were held before the medical practice opened in the morning, at lunch, or after hours. A meal was provided to participants, and consent forms and demographic surveys were collected. A sign listing the main topics for discussion was placed on the table for participants to view (Table 1). An open-ended approach was used to elicit information about the benefits and drawbacks of e-prescribing, including specific questions relating to medication refills. Focus group participants were asked to describe their experiences with e-prescribing software as well as provide their suggestions for improving e-prescribing. Probes explored what aspects of e-prescribing participants found valuable or difficult, and elicited suggestions for improvements in office procedures and software functionality. Focus groups lasted approximately one hour, were digitally recorded, and professionally transcribed. Research assistants then reviewed each transcript for potential errors and corrected them as needed.

2.6.

Data analysis

An extensive hierarchical coding structure and codebook were initially developed to handle the large volume of qualitative data. This initial structure was developed based on the focus group protocol and review of initial transcripts, and revised

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and/or expanded during active coding using NVivo qualitative data management software. A codebook was created to define all categorical “nodes” and their relationships. Coders were rigorously trained in node definitions, overall coding structure, and coding protocols. Consistency in coding across team members was maintained in a number of ways. Research assistants attended intensive training sessions led by one of the investigators (CD) where they learned about the coding process and node definitions. They then coded transcripts as a group. Next, 19% of the transcripts were coded independently by more than one research assistant for comparative analysis of coding results. Regular coding meetings were held throughout the coding phase of the project, coded transcripts were spot-checked, and node reports were reviewed by this same investigator who provided feedback to the research assistants.

3.

Results

3.1.

Participant characteristics

Sixty-four focus group sessions were held in spring of 2006 over a period of several months. A total of 276 persons participated in the focus groups (median number of participants = 4). Sixty-four percent were clinicians and the remainder included the office staff involved in the e-prescribing process. Forty-five percent of the practices were internal medicine, 39% were family medicine. Twenty-four percent were solo practices. Forty percent were single specialty practices. Twenty-three percent of current users of e-prescribing and 33% of initiators had a dedicated pharmacy line receiving between 3–175 calls and 35–375 faxes per week. Thirty percent of practice currently using e-prescribing had a phone number for refills while 44% of those just initiating e-prescribing had a phone number for refills. Overall, 47% of respondents indicated that it would be very useful to have the pharmacy automatically alert the prescriber if a prescription was not filled with 3/4 indicating that they would call their patients if they did not pick up prescriptions that would have serious medical consequences if not taken. Forty-four percent indicated that they were very con-

Fig. 1 – Number of refill requests by month, overall and by vendor.

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Fig. 2 – Time savings with refills using e-Rx overall, by clinician/non-clinician, and e-Rx software.

cerned about liability if they knew a patient did not pick up a prescription.

3.3. Positive aspects of refills using e-prescribing software

3.2.

A summary of the findings is shown in Table 2. Overall, clinicians were extremely pleased with the benefits. However, participants reported fewer positive consequences of using e-pharmacy software than negative. They felt strongly that being able to identify adherent patients who regularly fill their prescriptions is beneficial to patient care. They perceive that patient satisfaction has improved with better communication and the ability to pick up medications on time.

Survey results

Overall 54% reported using the refill function all of the time, 17% reported using it some of the time, 22% reported using it sometimes and only 8% reported never using the refill function. Fig. 1 shows the volume of refill transactions observed during the study period by month, and by month and vendor. Panel A shows the increasing trend in the number of refill transactions observed, with most of these coming Vendor B. Fig. 2 shows the time participants reported spending on processing refill requests overall (Panel A), by e-prescribing software (Panel B), and by clinician status (Panels C and D). Overall participants reported spending about 55 min a day processing refills before switching to e-prescribing and 27 min per day after. For practices initiating e-prescribing, estimates of daily processing time for refills were similar to the “before” estimates provided by current e-prescribers. This pattern was observed regardless of e-prescribing software or whether the user was a clinician or not. Overall, participants reported that e-prescribing software with the capability of alerting the physician when the patient has not picked up a prescription would be very useful. Seventy-seven percent reported that they would call the patient if the e-prescribing software alerted them that their patient did not pick up prescriptions that would have serious medical consequences if not taken. Forty-four percent were very concerned and 46% were somewhat concerned about liability if they know a patient did not pick up a prescription.

Physician staff 1: “The office flow is better. It’s a little easier to get our refills and not have—this was a crisis for about five years before it happened, and people were very dissatisfied. It was a hard part of our practice just trying to get medication refills. The phone was busy. We’d lose stuff. You know, it was just a mess.” E-prescribing has impacted positively on tracking whether patients are taking their medications by checking the dates the prescriptions are filled. Participants felt that this kind of tracking is especially important for maintenance medication. They noted that the tracking system can be consulted and then compared to patient reporting, which is often not accurate. They also appreciated that they can check to see if patients are using narcotic prescriptions too quickly. Physician 1: “You can tell how much they took and make sure that they’re taking it properly. If they’re running out real quickly–if they’ve got a hundred pills and they’re done in a week–so it’s nice. It shows you–you just got this refill

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Table 2 – Summary points from the focus groups. Refill advantages

Refill concerns

Being able to identify adherent patients who regularly fill their prescriptions is beneficial to patient care. Patient satisfaction has improved with better communication and the ability to pick up medications on time. Physicians can check to see if patients are using narcotic prescriptions too quickly.

Certain elements of refill technology are clumsy, with the need to re-enter all patient data for each prescription.

Ability to refill prescriptions from wherever they are eliminating delays due to weekends and vacations. Saves time to process refills.

The appearance of refill lists “look too perfect,” and the inclination is to approve them all without critical review.

Does not have the ability to delete or edit data for each prescription. Difficulty in filling prescriptions independent of patient charts when the e-prescribing software is not linked to an EMR.

Potential for less scrutiny resulting in medication mix-ups and wrong medications prescribed.

on that date, so there’s no way you could be out of it this soon. You should have plenty left and stuff. So we check people for doctor shopping.”

data for each prescription is time consuming. They also complained of not having the ability to delete or edit data for each prescription.

An additional benefit of using e-prescription software for refills is that physicians can access the system from wherever they are, enabling them to fill prescriptions immediately and not wait until after the weekend or when they return from vacation.

Physician 4: “The problem is we can’t get it out of that escript unless we do it again. So we’re doing the same script two, three, four times. We can’t just click it and send it either, which should be the way it’s supposed to be. You should be able to click on it and send it back to the pharmacy. You click on it. You have to type in the patient’s name again.”

Physician 2: “Also, multiple prescriptions can be refilled very quickly. If you have to hand write–you know, our patients are an elderly population, and they’re on many medicines. And if you need to send something somewhere, and they need even six of them, it takes a few–just not even thirty seconds to just go through and refill everything. Whereas the other way you’d have to handwrite each and every one of those out.”

3.4. Complaints about using e-prescribing software for refills Participants in the focus groups raised a variety of problems that they have encountered when using e-prescribing software for refills. Some of the problems stem from cumbersome elements of the software for processes internal to the medical office, and others involved effective and accurate communication with pharmacies. Participants commented on their frustration with day-today glitches that occur with their software, and that technical representatives from e-prescribing software companies are often slow or non-responsive in addressing and correcting software glitches. Physician 3: “Why don’t we get our (software vendor) rep out here again then? And we had talked to him about that, and all he said to me was no other office is having this problem; nobody else is complaining about this. Then why don’t we have him come out again, and we’ll talk to him again? And I mean he sat there and saw me do it today, and it was just ridiculous. It’s four steps per patient to get them out of that–that little section there.” Participants felt that certain elements of their software technology are clumsy, and the need to re-enter all patient

Participants also noted having difficulty in filling prescriptions independent of patient charts when the e-prescribing software is not linked to an EMR. Some also stated that the refill lists must be carefully scrutinized; the way they appear on the screen “they look too perfect,” and the inclination is to approve them all without critical review. This results in medication mix-ups and at times the wrong medication is prescribed. Physician 5: “And then when those come over [medication requests], and it will say you have three refills waiting. And then you go to click on them, and there’s weird directions. Like we had an inhaler once that was number sixty-one with five refills. So you have to really scrutinize–.” The group continued to discuss a prescription for Allegra that included instructions to take it one-half hour before dental work. The group noted that it must be something in the transmission. Physician 6: “–the transmission. I’m sure it’s not being in transmission, but somehow when it comes from their computer it’s changed.” Physician 7: “It’s getting combined with something else that was in there.” Physician 6: “Yeah, but I mean you really have to scrutinize those.” And another group discussed: Physician 8: “I must say that once they fixed this problem through the course of the day I’m just–you know, I’ll be writing out–doing a prescription for a patient, and I’ll see that–I’ll hit the queue, and while I’m chatting with them I’ll

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just knock off a few more prescriptions, and by the end of the day–there used to be a giant stack of things to do and it is kind of taken care of.” Physician 9: “But that’s where this risk of not carefully reviewing the prescription and seeing it in context of the chart is a problem.” Physician 8: “But if there’s a black and white typed document that includes nonsense it is harder to recognize it, and it’s more easily overlooked or assumed to be correct, and I find that is one of my concerns about this [software]. It requires that I have to really focus on this list often times of prescriptions that are ready for me to electronically sign because they look very neat. They look very professional, and they sometimes are complete nonsense. And I have to stop myself from saying in a mind numbing sense, yup, yup, yup, yup, yup, yup and sign them all.” Participants reported that some patients tell them that pharmacies are not receiving refill orders. Physician staff 2: “The patient calls and checks with the pharmacy, and it isn’t done yet even though we’ve done it. Maybe it hasn’t been queued yet or something. I understand that, but there’s got to be a way to get it out of there without going through that whole thing again two or three times per patient. Now I can guarantee when I go up there and check it again today there may be two or three in there that I’ve already done.” Currently many of the practices are using parallel systems—the old methods along with the new technology. They still rely on paper patient charts while they use the eprescribing software. In addition, some medical offices are still getting faxes from pharmacies despite using e-prescribing software. Participants claim that this situation causes numerous logistical problems. Physician staff 3: “They fax it along with sending it through e-script. The pharmacy is faxing us a hard copy, and the patient will call. So we’re getting three things on the same prescription.”

4.

Discussion

We report on the benefits of refill functionality in e-prescribing software in a large, multi-state, multi-vendor study. Among a diverse group of clinicians and non-clinician staff with varied experience with e-prescribing, we report that overall the functionality saves time in processing refills, offers more patient convenience, and allows clinicians the flexibility to process refills from outside the office, and provides a mechanism for clinicians to check on adherence and overuse of prescriptions with abuse potential. Participants had numerous complaints about the refill functionality. Clearly, the interoperability of the functionality is not 100% fool-proof as participants noted mix-ups in drug instructions and repeat processing of refills from various pharmacies (via fax, call, and e-prescriptions). Most concerning was the potential for less scrutiny of the refills by clinicians owing to the “too

perfect” appearance of the refill requests. The ease of refill processing provides the setup for approval without critical review. Further, although some practices welcomed the ability to track patients’ adherence to drug regimens, the question of liability was not addressed. If a patient is non-adherent and the physician misses this fact thus resulting in a bad health outcome, would the physician be to blame? To what degree are physicians required to monitor such information? To what level are they obligated to intervene? Prior to e-prescribing physicians would only review medications at office visits and they relied exclusively on patient report. External validation of adherence raises new and important ethical and legal issues for physicians. Our study showed decreased time performing refill requests which were consistent across vendor and clinician status. However, our data are not consistent with two recent studies questioning the efficiency gains of e-prescribing. One study that suggested that e-prescriptions took on average 20 s longer than hand written prescriptions [7], while the other suggested no improvements [8]. Our data relating to time was based on self-report whereas the previous studies were based on time and motion studies not specifically related to processing refills. The time saved is related to pulling of charts and answering phones, aspects of work flow that was not a particular focus of the previous research. When implementing the technology, realistic expectations of the software should be communicated and staff appropriately trained to assure successful implementation [9]. Currently there are over 200 vendors for e-prescribing software and electronic medical records packages that include an e-prescribing option (http://www.surescripts.com; accessed on February 20, 2010). The heterogeneity of software standards and different data management systems may impact operability [10]. Discerning quality of software and related support is difficult for purchasers as it is a new industry with no real dominant manufacturer’s presence. In our study, issues related to refill interoperability were not specific to one vendor. It is unclear if interoperability issues have been completely resolved to date. Regardless of the issues reported on during our study time period, the refill functionality was still widely used. There are presently a number of government, nonprofit and private organizations that have published standards directed at interconnectivity between the different electronic component packages available to hospitals and medical practices. These standards have been created in addition to those promulgated under the Medicare Modernization Act [1]. Participants in our focus group study raised similar integration problems and these are likely to amplify as vendors increase and institutions add to previous EMR/EHR software packages that were previously purchased without e-prescribing software. As different software applications are added to practice electronic portfolios, it is inevitable that data access and connectivity issues will occur in the grey areas between applications. And it may be difficult to find support for technical problems from the multiple companies involved in any linkage domain. With the adoption of health information technology, including e-prescribing software, there is the risk that medical

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errors might increase [11]. Verifying the quality of integrated data errors, so that instead of propagating data errors, correction processes can take place, should be mandatory during implementation [12]. Our study suggests that issues related to data integration appear to remain, albeit infrequently. Further, new errors related to e-prescribing software such as drop down errors may occur [13]. Participants of our study noted that in particular with the refill functionality, errors may occur owing to less than careful scrutiny of the refill request because of the presentation of the requests. The changes in workflow related to refills have increased efficiency, but may prevent careful review because the practice of refilling drugs becomes overly routinized. These findings must be considered with several limitations in mind. By design, we did not use a random sample. We intentionally selected a sample to provide geographic diversity, to represent a variety of e-prescribing vendors, practice settings, and experience with e-prescribing. As such, we have likely introduced a bias that over-represents clinicians who are highly experienced with e-prescribing. The practices included in the study represent early adopters of e-prescribing in ambulatory care. We do not know how the experience of these clinicians compares to others. The participants of our study are representative of the most experienced e-prescribing users in primary care settings. Nevertheless, for qualitative analysis, purposefully selecting an informative sample is a valid approach that increases the quality and information of the data. We can already see numerous positive results of using e-prescribing software in medical practices. In particular, eprescribing can help decrease the incidence of medical errors for geriatric patients in terms of medication dosages, monitoring of medications, improved patient adherence and drug to drug interactions [14]. And our participants are enthusiastic in their anticipation of increased benefits for work flow and patient care when advanced features such as improved editing functions are added. The uptake of e-prescribing is likely to accelerate with meaningful use legislation and economic stimulus initiatives of late. We believe that some of the frustrations shared by our participants will disappear once the technology is being used widely and routinely by pharmacies. It is essential that development continue at a brisk pace, and efforts be dedicated to resolving the software integration and connectivity issues. What is at risk under the current experimental circumstances of e-prescribing software use is that with continued negative outcomes experienced by users, there could be a loss of public and professional confidence in a resource that should be expected to take a central place in health care practice in the coming years.

Author contributions All authors qualify for authorship by substantial contributions to the research and production of the manuscript. Dr. Goldman completed the analysis and interpretation of the data, drafted the article, and gave final approval of the final version of the submitted manuscript. Dr. Dube provided substantial input in the conception and design of the study and acquisition of the data, revised the draft critically, and gave final approval to the

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Summary points What is known about the topic: • E-prescribing has the potential to increase the efficiency of workflow in ambulatory settings. • The impact of this technology in ambulatory care settings is not well understood. • E-prescribing functionality that includes processing of refill requests automatically may improve the value of e-prescribing by reducing calls to the office for refills and calls between the pharmacy and physician’s offices for processing refills. What this study added: • Physicians greatly value the refill functionality of eprescribing software solutions. • Refill functionality saves overall time spent on processing refill requests. • Offices have changed workflow related to processing of refills, often directing patients to directly call the pharmacy for refill requests. This reduces the burden of calls to the physician office. • Refill functionality is not 100% perfect, with many glitches being reported by clinicians. • The potential for blindly accepting refills without careful review was noted.

submitted version of the manuscript. Dr. Lapane was the chief architect of the study design, critically revised the manuscript, and gave final approval of the manuscript.

Acknowledgments We gratefully acknowledge the assistance of Ken Whittemore, RPh, MBA, and Ajit Dhavle, PharmD, MBA, of SureScripts. This study was funded by the Agency for Healthcare Research and Quality, Department of Health and Human Services (Grant # 1 U18 HS016394-01 entitled Maximizing the effectiveness of eprescribing between physicians and community pharmacies). The funder had no role in the study design, collection, analysis and interpretation of data, writing of the manuscript and decision to submit for publication.

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