In order to accurately collect the intervention data, software was designed and integrated into the pharmacy dispensing systems. This software communicated with a remote repository, which allowed easy collation of all pharmacy data for analysis.
2.4.1
PROMISe user interface
The two dispensing software vendors that were involved in the PROMISe project were FRED® (FRED Health, Melbourne, Australia) and Aquarius® (Simple Retail, Sydney, Australia). The FRED® dispense system had over 50% of the market share in Australian pharmacies150, allowing a large number of pharmacies to take part in the trial. Aquarius® was established in over 500 pharmacies151 (approximately 10% of the market) and had substantial penetration in the NSW, Victorian and Tasmanian markets. The PROMISe software was integrated into the dispensing systems to ensure that the PROMISe interface had the same “look and feel” as the dispensing system that the participating pharmacists were accustomed to.
The user interface was activated by clicking on the PROMISe icon or by pressing ‘Alt + i’ on the keyboard. Additionally, FRED® users could also access the interface by selecting ‘New Intervention Note’ from the ‘Activities’ menu. Activation of the interface could be made at any stage of dispensing a prescription and fields would appear pre-populated where possible. The user interface can be seen in Figure 2-2.
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Figure 2-2: PROMISe intervention documentation interface (FRED®) The DOCUMENT classifications and extra notes sections were available in the tabbed sections of the screen as shown in Figure 2-2. The intervention classification tabs were listed in order from left to right to reflect workflow in both dispensing systems – category, recommendations, significance, and extra information. The category tab detailed the DOCUMENT DRP category, the recommendation tab listed the options for the
pharmacist’s recommendations to the patient, and the significance tab contained the four possible significance categories for the intervention. The pharmacist was required to select the most appropriate sub-category from each of these tabs. The notes or extra information section provided a free text box for the pharmacist to write a short description of the intervention.
The time taken to perform the intervention and the pharmacist initials were both mandatory fields. As requested by the focus groups, a pharmacist was able to save the intervention as a draft and complete it at a later time to help to improve the workflow surrounding the documentation process.
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By clicking the ‘Display Help Panel’ checkbox, information about the selected sub-
categories could be seen at the bottom of the intervention screen. Information displayed here included details of when and when not to use, and examples of use of each
classification selection within the DOCUMENT system, as can be seen in Figure 2-3.
Figure 2-3: Help function within the PROMISe interface
Once an intervention was documented against a patient, the PROMISe logo appeared in the patient’s dispensing history indicating that the patient had been subject to an intervention, which allowed a pharmacist to access the information regarding the intervention in the future. The information about each completed intervention was transmitted to a secure repository.
2.4.2
Feedback mechanisms
Feedback from pharmacists in the initial focus groups indicated that encouragements and reminders may prompt more interventions than would otherwise have occurred.
Therefore, several electronic feedback mechanisms, including web-based reports, a statistic display, non-specific reminders and specific prompts, were built into the PROMISe software.
All participants were able to access the web-based reports through the PROMISe website that displayed individual pharmacy and pharmacist intervention details. The reports also provided the intervention rates for each state and a breakdown of intervention types, recommendations, and drug groups, which were aimed to motivate the participants.
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A real time statistic display was incorporated into the intervention screen to provide accessible motivational feedback to all pharmacists, an example of which can be seen in Figure 2-4. The PROMISe repository was polled several times daily to update the current overall trial intervention rate. The display showed the entire trial intervention rate as shown by All in the FRED® figure and Global in the Aquarius® figure. The individual pharmacy intervention rate was entitled Site in the FRED® figure and Local in the
Aquarius® figure. These screenshots were taken prior to the trial going live, therefore the percentages are inaccurate.
Figure 2-4: Statistics display for FRED® (left) and Aquarius® (right) Feedback and support was also provided through pharmacy visits. The visits ranged in duration from fifteen to ninety minutes depending on the needs of the pharmacists. During the visits, the pharmacists were shown how to access the online reports and they were also given the opportunity to ask any questions and relay any problems back to the project team. The other aim of the visits was to obtain additional pharmacy data.
Pharmacies also received reminder phonecalls at various times throughout the trial.
2.4.2.1
Reminder
For selected pharmacies only, a non-specific reminder was timed to appear at 11am and 3pm. It aimed to remind pharmacists to document their interventions or to complete their draft interventions (Figure 2-5).
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The timing of the reminder targeted periods of the day where the pharmacist may have enough time to document the interventions (morning tea and afternoon tea time). These times were similar to the peaks in number of interventions documented by Rupp et al., whose article reported that the most interventions were documented during 10-11am and 4-5pm.57
2.4.2.2
Prompt
The use of a prompt for one specific intervention (the prophylactic use of aspirin in patients with diabetes) was trialled in the PROMISe II project to test the function of influencing a specific type of intervention.81 The presence of the prompt resulted in an increased frequency of the targeted intervention, as well as an increase in the overall intervention rate.136
In PROMISe III, prescriptions of high-dose proton pump inhibitors (PPIs), specifically pantoprazole (Somac®) and esomeprazole (Nexium®), were targeted with a specific intervention prompt. This particular intervention was chosen on the basis of high publicity from a National Prescribing Service (NPS) media release in May 2009.152 The prompt, shown in Figure 2-6, was activated in selected pharmacies when pantoprazole 40mg or esomeprazole 40mg were chosen for dispensing. It encouraged pharmacists to discuss with eligible patients the possibility of reducing their medication dosage on consultation with their GP. The pharmacists had the choice to continue dispensing, print the patient information leaflet or print the pharmacist/GP information leaflet. These leaflets can be found in Appendices 5 and 6.
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Figure 2-6: Specific prompt built into the PROMISe software