Electronic Prescribing (erx)

Transcription

1 Electronic Prescribing (erx) Good News (and Sad News) Stories From Around the World II Andalusia Rational Drug Utilization Conference Sevilla, Andalucia October 26, Feb-08 D. Protti - University of Victoria and City University London 1

2 A bit about my history 14-Feb-08 D. Protti - University of Victoria and City University London 2

3 Outline 1. Setting the scene 2. Good news stories (in primary care) from recent international studies 3. Sad news stories from North America 4. How does Andalucia compare? 5. Concluding comments 14-Feb Feb-08 D. Protti - University of Victoria and City University London 3

5 IOM Reports on 1. Preventing Medication Errors 2. Crossing the Quality Chasm 14-Feb-08 D. Protti - University of Victoria and City University London 5

6 IOM Report Findings 44,000 98,000 unnecessary deaths in the US. Even using the lower estimate, more people die from clinical mistakes each year than from highway accidents, breast cancer, or AIDS 7,000 Americans are die each year from medication errors alone approximately 16% more than the number attributable to work-related injuries Medical errors cost the U.S. approximately $38 billion per year, with about $17 billion of those costs associated with preventable errors 14-Feb-08 D. Protti - University of Victoria and City University London 6

7 At least 1.5 million preventable ADEs occur each year in the United States Hospitals: ~400,000 Ambulatory Care: ~530,000 Long-term care: ~800,000 Likely underestimates! In 2004, the US Pharmacopeia MEDMARX system identified the sources of medication reconciliation errors. 66% occurred during the patient's transition or transfer to another level of care, 22% during the patient's admission to the facility, and 12% at the time of discharge. 14-Feb-08 D. Protti - University of Victoria and City University London 7

8 How Hazardous Is Health Care? 100,000 DANGEROUS REGULATED ULTRA-SAFE (>1/1000) (<1/100K) Health Care Driving Total lives lost per year 10,000 1, Mountain Climbing Bungee Jumping Chartered Flights Chemical Manufacturing Scheduled Airlines European Railroads Nuclear Power ,000 10, ,000 1,000,000 10,000,000 Number of encounters for each fatality Lucian L. Leape, MD, Harvard School of Public Health, Psychiatric Society Risk Management Conference

9 Risk of Death as an Airline Passenger and as a Patient Admitted to an Acute Care in Hospital in Canada Airline industry Air Canada South West Airlines Canadian acute care hospitals 1 death in 2 million passengers deaths in 2 million passengers deaths in 9.5million flights 2 7,400 19,000 deaths in 2 million patient admissions 3 1. Leape LL et al Reducing Adverse Drug Events, IHI, According to AirSafe.com 3. By extrapolation from Baker GR, Norton PG et al The Canadian Adverse Events Study, JMAC 25 May 2004; Feb-08 D. Protti - University of Victoria and City University London 9

10 Rx Patient safety Between 1.5%-4.0% prescriptions are in error with serious patient risk Adverse drug events occur in 5%- 18% of ambulatory patients Quality of care - Compliance 20% of scripts are never filled Patient satisfaction is declining Cost of errors: $2 billion / year Impact on productivity* Physician practice: 3 hours per day Pharmacy: 4 hours per day (up to 1 call per Rx) Inefficient delivery Rx Illegible handwriting Phone tag and fax tag Patient waiting in the pharmacy 14-Feb-08 D. Protti - University of Victoria and City University London 10 Rx

11 American physicians write 4.5 billion prescriptions each year.... On Paper! The Challenge of Prescription Hand-offs Illegible Handwriting Unclear Abbreviations and Doses Verbal Communication Among Physicians, Patients and Pharmacists 14-Feb-08 D. Protti - University of Victoria and City University London 11

12 1. Ability to create a prescription electronically 2. Ability to receive automated decision support during script creation Drug interactions, drug-allergy, etc. Medication lists and information Eligibility determination Formulary coverage from insurer including co-pay information Prior authorization 3. Ability to send script electronically to a pharmacy using standard transmission messaging Electronic Prescribing is not faxing or printing paper prescriptions 4. Ability for a pharmacy to process electronic script in their system 5. Ability to receive/authorize pharmacy initiated-renewals electronically 6. Ability to determine fill status as a measure of compliance (medication history) 7. Potential for information sharing with other health care partners Medication History Eligibility/formulary information Patients Slide used by permission from SureScripts

13 From handwritten prescriptions to.. 14-Feb-08 D. Protti - University of Victoria and City University London 13

14 14-Feb-08 D. Protti - University of Victoria and City University London 14

17 823 million visits to physician offices in out of 5 patients who visit a physician leave with at least one prescription 2 65% of the US population (91% of Medicare) use a prescription medication each year 3 Renewals Unfilled 0.4 B 0.5 B 1.5 B 1.4 B New Scripts Refills 3.5 Billion Total Filled Prescription Transactions in ) Pastor PN et. al. Chartbook on trends in the health of Americans. Health, United States, National Center for Health Statistics ) The chain pharmacy industry profile. National Association of Chain Drug Stores ) Agency for Healthcare Research and Quality. MEPS Highlights #11: distribution of health care expenses, 1999.

18 Limitations of this talk In the interests of time Focus will be almost exclusively on primary care versus secondary (acute hospital inpatient) care Little on CPOE, decision support, bar medication administration, medication administration records e-rx is more common in 1 0 care than 2 0 care Documented benefits are coming from both sectors 14-Feb-08 D. Protti - University of Victoria and City University London 18

20 A Comparison of Information Technology in General Practice in Ten Countries International Study Conducted by Denis Protti Feb-08 D. Protti - University of Victoria and City University London 20

21 Background to the study Commissioned by Canada Health Infoway Goal: to identify the governmental, collegial, technological, and other factors contributing to the high levels of office automation in GP practices In all 10 countries, primary care physicians had computers (EMR) in their office that were used for clinical purposes 14-Feb-08 D. Protti - University of Victoria and City University London 21

22 Data collected in Australia Austria Denmark England Germany Netherlands New Zealand Norway Scotland Sweden 14-Feb-08 D. Protti - University of Victoria and City University London 22

23 Data was collected from Personal interviews with GPs, ministerial and vendor representatives Scientific literature OECD, government, and professional association reports and web sites Data quality ranges from very robust and trustworthy to estimates based on small sample sizes 14-Feb-08 D. Protti - University of Victoria and City University London 23

24 % GPs with electronic prescribing of medications (with varying degrees of decision support re: alerts, etc.) Australia Most Norway Most Austria Most Scotland Most Denmark Most Sweden Most England Most Germany Many New Zealand Most Netherlands Many Most = >75% Many = >50% Some = >25% Few = <25% 14-Feb-08 D. Protti - University of Victoria and City University London 24

25 Percent Primary Care Doctors Use of Electronic Patient Medical Records, AUS CAN GER NET NZ UK US Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

26 Practice Use of Electronic Technology (from Schoen et al Commonwealth Fund study) Percent reporting routine use of: AUS CAN GER NET NZ UK US Electronic ordering of tests Electronic prescribing of medication Electronic access to patients test results Electronic access to patients hospital records Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

27 % GPs transmitting medication prescriptions Denmark Sweden England Australia Austria Most Many Some Few Few Germany Netherlands Scotland New Zealand Norway Few Few Few None None Most = >75% Many = >50% Some = >25% Few = <25% 14-Feb-08 D. Protti - University of Victoria and City University London 27

28 Benefits of automation in GP practices (ranked scale of 1-8) Simplified Repeat Prescription #1 in Scotland and Sweden #2 in all other countries, except Norway (#3) and NZ (#4) Saving time #1 in Australia, England, Germany, Netherlands and New Zealand #7 in Austria 14-Feb-08 D. Protti - University of Victoria and City University London 28

29 Minutes per day Prescribers Office staff (2006 Study: Brown University) Slide used by permission from SureScripts

30 Benefits of automation in GP practices (ranked scale of 1-8) Quicker receipt of results range:1-5 Easier to find records range:1-5 Legibility of records and form range: 3-7 More timely communication with other clinicians range: 1-8 Availability of clinical data on Intranet or Internet range: 3-8 Data for clinical research range: Feb-08 D. Protti - University of Victoria and City University London 30

31 A crude ranking of the 10 countries Most = 4, Many = 3, Some = 2, Few = 1 Based on only 5 variables % GPs: 1. with electronic prescribing of medications 2. recording progress notes 3. transmitting medication prescriptions 4. receiving laboratory results 5. receiving discharge summaries 14-Feb-08 D. Protti - University of Victoria and City University London 31

32 A crude ranking of the 10 countries (Most = 4, Many = 3, Some = 2, Few = 1) Denmark (20) Scotland (15) New Zealand (14) Sweden (14) England (13) The Netherlands (12) Australia (11) Austria (10) Norway (10) Germany (7) * - unweighted data particularly in terms of confidence factor 14-Feb-08 D. Protti - University of Victoria and City University London 32

33 Primary Care Practices with Advanced Information Capacity Percent reporting 7 or more out of 14 functions* NZ UK AUS NET GER US CAN *Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions, access test results, access hospital records; computer for reminders, Rx alerts, prompt tests results; easy to list diagnosis, medications, patients due for care. Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

34 Comparing the Commonwealth Fund and CF rankings (7 functions) the Protti Rankings Protti rankings (5 functions) 1. New Zealand (87) 2. United Kingdom (83) 3. Australia (72) 4. Netherlands (59) 5. Germany (32) 1. New Zealand (14) 2. England (13) 3. Netherlands (12) 4. Australia (11) 5. Germany (7) 14-Feb-08 D. Protti - University of Victoria and City University London 34

36 Canada - medication safety has become an area of increasing awareness However, 72% of primary care doctors in Canada reported that it was somewhat or very difficult to generate lists of all of the medications taken by individual patients, if at all, including those prescribed by other doctors. International Health Policy Survey of Primary Care Doctors Commonwealth Fund: Feb-08 D. Protti - University of Victoria and City University London 36

37 Canadian situation Approximately 9,250 23,750 patients die annually due to preventable adverse events (harm experienced by patients given a drug but not necessarily caused by the drug) Adverse drug events (ADEs) refer to episodes of harm caused by a drug. Many such events are related to medication errors or inappropriate drug use. Baker, G.R., P.G. Norton, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada Canadian Medical Association Journal. 170: Feb-08 D. Protti - University of Victoria and City University London 37

38 Canadian situation (cont d) Only 11% of primary care doctors in Canada use electronic prescribing - the lowest of all of the surveyed countries. This compares to over 80% in both the Netherlands and Australia, which both reported a high percentage of doctors using electronic prescribing (85% and 81%, respectively). 14-Feb-08 D. Protti - University of Victoria and City University London 38

39 United States situation 3.2 Billion Prescriptions Written Annually Only 20% of prescriptions are electronically prescribed with 80% still handwritten Most electronic prescriptions are still sent by FAX National savings from universal adoption of electronic prescribing systems could be as high as $27 billion Sources: ehealth Initiative, 2004 and: Center for Information Technology Leadership, The Value of Computerized Provider Order Entry in Ambulatory Settings, 2003.

40 33% of health care IT professionals said that CPOE has had the greatest impact on boosting patient care 50% respondents said that the biggest challenge that IT presents to patient care is that health care providers are unwilling to enter data electronically Healthcare Information and Management Systems Society, October 11, Feb-08 D. Protti - University of Victoria and City University London 40

41 Pen Print 6% Fax 37% EDI + Decision Support 61% Source: CITL Slide used by permission from SureScripts

42 American exception The Veterans Administration (Total Daily Statistics) Documents (Progress Notes, Discharge Summaries, Reports) 779,000, ,000 each workday Orders 1.54 Billion ,000 each workday Images 425,000, ,000 each workday Vital Sign Measurements 957,000, ,000 each workday Medications Administered with the Bar Code system 754,000, ,000 each workday Statistics as of December 2005

43 10 Year Cumulative % Change in Costs - VA, Medicare, CPI VHA Cost per Patient Total Medical Care Obligations per Total Unique Patients (inc non Veterans) Average Medicare Payment per ( rchers/pubs/datacompen dium) Medical Consumer Price Index-- Bureau of Labor Statistics 50% 40% 30% 20% 10% 0% -10% -20% VHA Cost Per Patient % 0.8% -6.2% -8.6% -6.5% -7.3% -9.1% -4.6% 0.8% Avg. Medicare Payment/Enrollee 6.4% 14.9% 14.9% 12.8% 14.9% 25.5% 31.9% 40.4% 44.7% Medical CPI - 3.3% 5.9% 9.8% 13.5% 18.4% 23.7% 29.5% 34.7% 39.4% VHA Cost Per Patient Avg. Medicare Payment/Enrollee Medical CPI

45 % GPs with electronic prescribing of medications (with varying degrees of decision support re: alerts, etc.) Andalucia Most Australia Most Denmark Most England Most New Zealand Most Norway Most Most = >75% Many = >50% Scotland Most Sweden Most Austria Many Germany Many Netherlands Many Canada Few United States Few Some = >25% Few = <25% 14-Feb-08 D. Protti - University of Victoria and City University London 45

46 % GPs transmitting medication prescriptions Andalucia Most Denmark Most Sweden Many England Some Australia Few Austria Few Germany Few Netherlands Few Scotland Few United States Few New Zealand None Norway None Canada None Most = >75% Many = >50% Some = >25% Few = <25% 14-Feb-08 D. Protti - University of Victoria and City University London 46

47 A crude ranking of 13 jurisdictions Andalucia (8) Denmark (8) in terms of e-prescribing (Most = 4, Many = 3, Some = 2, Few = 1) Sweden (7) England (6) Australia (5) Scotland (5) Austria (4) Germany (4) New Zealand (4) Norway (4) The Netherlands (4)» United States (2)» Canada (1) * - unweighted data particularly in terms of confidence factor 14-Feb-08 D. Protti - University of Victoria and City University London 47

49 The evidence that IT can enhance patient safety and reduce costs is mounting Boston s Brigham and Women s Hospital, demonstrated that CPOE reduced error rates by 55% -- from 10.7 to 4.9 per 1000 patient days. LDS Hospital in Salt Lake City demonstrated a 70% reduction in ADEs after implementation of a CPOE system. A study published in the Journal of Managed Care Pharmacy in May 2005 reported the average cost per prescription was reduced by $2.57 and the per member per month drug cost was reduced by $1.07 in those physician practices equipped with full e-prescribing. Etc. 14-Feb-08 D. Protti - University of Victoria and City University London 49

50 The IT Value Iceberg Computers are just the catalyst Value comes from: People who know what to do with the information People who can effect change and innovation 14-Feb-08 D. Protti - University of Victoria and City University London 50

51 Change management. Lessons learned Balance between deployment of those modules that ease involvement and those that the Organization demands. Usability and adaptability vs. Regulation from the upper levels of the organization (political level). Involve professionals in the inception of the system in order to create useful tools for the clinical practice. Feedback of the information introduced in the system. Provide support to the management level information systems. Staff involvement. Political support. Explain crisis. Peer to peer training. Support to professionals: Field Contact centre Internal and external communication

53 Against a background of an explosively growing body of knowledge in the health sciences, current models of clinical decision making by autonomous practitioners, relying upon their memory and personal experience, will be inadequate for effective twenty-first-century health care delivery. Masys D Effects Of Current And Future Information Technologies On The Health Care Workforce HEALTH A F FA I R S, P. 33, Vo l. 2 1, No. 5, Feb-08 D. Protti - University of Victoria and City University London 53

54 Benefits 1. Patient Safety The decision support feature of the in-patient EMR identified 164,250 drug-drug, drug-allergy, drug-food, and drug-duplication alerts, resulting in 82,125 beneficial changes in treatment. Heib B, Handler T, Purchase E. How to Gain Value From Physician Order Entry. Strategic Analysis Report. Gartner; September 23, Feb-08 D. Protti - University of Victoria and City University London 54

55 Finite Gracias 14-Feb Feb-08 D. Protti - University of Victoria and City University London 55

56 Additional Materials 14-Feb Feb-08 D. Protti - University of Victoria and City University London 56

57 In the past Very few pharmacies were directly connected to physician practices Electronic communications meant faxes Only half the problem was being addressed writing new scripts Software didn t support the workflows in the practice There were few real benefits for most practices There wasn t a future path to additional benefits But now Over 95% of US pharmacies are connected into a single network and growing Computer applications can communicate directly with each other Renewals can be automated in addition to new scripts Software integrates with existing practice systems and smoothes office workflow Most practices will save physician and staff time as well as improve patient safety Collaborate with pharmacies and payors on patient compliance and other future functions Automation was being driven by a few Health State and nation-wide initiatives involving all D. Protti - University of Victoria and City Plans and small 14-Feb-08 software vendors University London major stakeholders 57

58 Cost of buying, installing and supporting a system Lack of reimbursement for costs and resources Increased time to use the system = reduced productivity (initially) Time required to review warnings, alerts and recommendations Still not considered a routine standard of practice 14-Feb-08 D. Protti - University of Victoria and City University London 58

59 Barriers State regulations are not a barrier Electronic signatures are not a barrier The biggest barrier or hindrance to electronic prescribing is educating the prescribers to the benefits of electronic prescribing and pharmacy readiness Think electronic prescribing is just New Rxs Are not aware of the significant ROI for automating refill authorizations 14-Feb-08 D. Protti - University of Victoria and City University London 59