14-Feb-08 D. Protti - University of Victoria and City University London
1
Electronic Prescribing (eRX)
Good News (and Sad News) Stories From
Around the World
II Andalusia Rational Drug Utilization Conference
Sevilla, Andalucia
October 26, 2007
14-Feb-08 D. Protti - University of Victoria and City University London
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14--FebFeb--0808 D. Protti D. Protti --University of Victoria and City University LondonUniversity of Victoria and City University London 33
Outline
Outline
1.
1.
Setting the scene
Setting the scene
2.
2.
Good news stories (in primary care) from
Good news stories (in primary care) from
recent international studies
recent international studies
3.
3.
Sad news stories from North America
Sad news stories from North America
4.
4.
How does Andalucia compare?
How does Andalucia compare?
5.
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14--FebFeb--0808 D. Protti D. Protti --University of Victoria and City University LondonUniversity of Victoria and City University London 44
Outline
Outline
1.
1.
Setting the scene
Setting the scene
2.
2.
Good news stories (in primary care) from
Good news stories (in primary care) from
recent international studies
recent international studies
3.
3.
Sad news stories from North America
Sad news stories from North America
4.
4.
How does Andalucia compare?
How does Andalucia compare?
5.
14-Feb-08 D. Protti - University of Victoria and City University London
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IOM Reports on
1. Preventing Medication Errors
14-Feb-08 D. Protti - University of Victoria and City University London
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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
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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.
How Hazardous Is Health Care?
Number of encounters for each fatality
Total lives lost per year
1
10
100
1,000
10,000
100,000
1,000,000
10,000,000
DANGEROUS
DANGEROUS
REGULATED
REGULATED
ULTRA
ULTRA
-
-
SAFE
SAFE
(>1/1000)
(<1/100K)
1
100,000
10,000
1,000
10
100
Health
Care
Mountain
Climbing
Bungee
Jumping
Driving
Chemical
Manufacturing
Chartered
Flights
Scheduled
Airlines
European
Railroads
Nuclear
Power
14-Feb-08 D. Protti - University of Victoria and City University London
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Risk of Death as an Airline Passenger and as a Patient
Admitted to an Acute Care in Hospital in Canada
0.0 deaths in 9.5million
flights
2South West Airlines
7,400 – 19,000 deaths in 2
million patient admissions
3Canadian acute care hospitals
0.67 deaths in 2 million
passengers
2Air Canada
1 death in 2 million
passengers
1Airline industry
1.
Leape LL et al Reducing Adverse Drug Events, IHI, 1998.
2.
According to AirSafe.com
3.
By extrapolation from Baker GR, Norton PG et al The Canadian Adverse Events Study,
JMAC 25 May 2004; 1684.
14-Feb-08 D. Protti - University of Victoria and City University London
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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
z
Illegible
handwriting
zPhone tag and
fax tag
zPatient waiting
in the
pharmacy
Rx
Rx
Rx
14-Feb-08 D. Protti - University of Victoria and City University London
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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
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
14-Feb-08 D. Protti - University of Victoria and City University London
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823 million visits to
physician offices in 2000
1
4 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
1) Pastor PN et. al. Chartbook on trends in the health of Americans. Health, United States, 2002. National Center for Health Statistics. 2002. 2) The chain pharmacy industry profile. National Association of Chain Drug Stores. 2001.
3) Agency for Healthcare Research and Quality. MEPS Highlights #11: distribution of health care expenses, 1999.
3.5 Billion Total Filled Prescription
Transactions in 2003
1.4 B 0.4 B 0.5 B 1.5 BRefills
New Scripts
Renewals
Unfilled
14-Feb-08 D. Protti - University of Victoria and City University London
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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
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14--FebFeb--0808 D. Protti D. Protti --University of Victoria and City University LondonUniversity of Victoria and City University London 1919
Outline
Outline
1.
1.
Setting the scene
Setting the scene
2.
2.
Good news stories (in primary care) from
Good news stories (in primary care) from
recent international studies
recent international studies
3.
3.
Sad news stories from North America
Sad news stories from North America
4.
4.
How does Andalucia compare?
How does Andalucia compare?
5.
14-Feb-08
D. Protti - University of Victoria and City University London
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A Comparison of Information
Technology in General Practice in
Ten Countries
International Study Conducted by
Denis Protti
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D. Protti - University of Victoria and City University London
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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
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Data collected in 2005 - 06
• Australia
• Austria
• Denmark
• England
• Germany
• Netherlands
• New Zealand
• Norway
• Scotland
• Sweden
14-Feb-08
D. Protti - University of Victoria and City University London
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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
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% GPs with electronic prescribing of medications
(with varying degrees of decision support re: alerts, etc.)
• Australia
Most
• Austria
Most
• Denmark
Most
• England
Most
• New Zealand
Most
Most = >75%
Many = >50%
• Norway
Most
• Scotland
Most
• Sweden
Most
• Germany
Many
• Netherlands
Many
Some = >25%
Few = <25%
Primary Care Doctors Use of Electronic Patient
Medical Records, 2006
79
23
42
98
92
89
28
0
25
50
75
100
AUS
CAN
GER
NET
NZ
UK
US
Percent
Practice Use of Electronic Technology
(from Schoen et al Commonwealth Fund study)
48
84
90
78
34
27
76
Electronic access to
patients’ test results
40
19
44
11
7
15
12
Electronic access to
patients’ hospital
records
55
20
UK
59
27
GER
78
62
NZ
20
85
11
81
Electronic prescribing
of medication
22
5
8
65
Electronic ordering of
tests
US
NET
CAN
AUS
Percent reporting
routine use of:
14-Feb-08
D. Protti - University of Victoria and City University London
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% GPs transmitting medication prescriptions
• Denmark
Most
• Sweden
Many
• England
Some
• Australia
Few
• Austria
Few
Most = >75%
Many = >50%
• Germany
Few
• Netherlands
Few
• Scotland
Few
• New Zealand
None
• Norway
None
Some = >25%
14-Feb-08
D. Protti - University of Victoria and City University London
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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
Prescribers
Office staff
Minutes
per day
14-Feb-08
D. Protti - University of Victoria and City University London
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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
14-Feb-08
D. Protti - University of Victoria and City University London
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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
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D. Protti - University of Victoria and City University London
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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)
Primary Care Practices with Advanced
Information Capacity
*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.
Percent reporting 7 or more out of 14 functions
*
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
87
83
72
59
32
19
8
0
25
50
75
100
14-Feb-08
D. Protti - University of Victoria and City University London
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Comparing the Commonwealth Fund and
the Protti Rankings
CF rankings
(7 functions)
1. New Zealand (87)
2. United Kingdom (83)
3. Australia (72)
4. Netherlands (59)
5. Germany (32)
Protti rankings
(5 functions)
1. New Zealand (14)
2. England (13)
3. Netherlands (12)
4. Australia (11)
5. Germany (7)
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14--FebFeb--0808 D. Protti D. Protti --University of Victoria and City University LondonUniversity of Victoria and City University London 3535
Outline
Outline
1.
1.
Setting the scene
Setting the scene
2.
2.
Good news stories (in primary care) from
Good news stories (in primary care) from
recent international studies
recent international studies
3.
3.
Sad news stories from North America
Sad news stories from North America
4.
4.
How does Andalucia compare?
How does Andalucia compare?
5.
14-Feb-08 D. Protti - University of Victoria and City University London
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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: 2006
14-Feb-08 D. Protti - University of Victoria and City University London
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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. 170:1678-86. 2004
14-Feb-08 D. Protti - University of Victoria and City University London
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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).
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
Sources: eHealth Initiative, 2004 and: Center for Information Technology Leadership, “The Value of
Computerized Provider Order Entry in Ambulatory Settings,” 2003.
National savings from universal adoption of
electronic prescribing systems
14-Feb-08 D. Protti - University of Victoria and City University London
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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, 2007
Pen
ª
6%
Fax
ª
37%
EDI
+
Decision
Support
ª
61%
American exception – The Veterans Administration
(Total…Daily Statistics)
•
Documents
(Progress Notes, Discharge Summaries, Reports)
–
779,000,000
…….. +
577,000
each workday
•
Orders
–
1.54 Billion………... +906,000 each workday
•
Images
–
425,000,000
……… +60
8,000
each workday
•
Vital Sign Measurements
–
957,000,000
……… +
665,000
each workday
•
Medications Administered with the Bar Code system
–
754,000,000……..…… +597,000 each workday
-20% -10% 0% 10% 20% 30% 40% 50%
VHA Cost Per Patient Avg. Medicare Payment/Enrollee Medical CPI
VHA Cost Per Patient - -0.3% 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% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
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 (www.cms.hhs.gov/resea rchers/pubs/datacompen dium) • Medical Consumer Price Index-- Bureau of Labor Statistics
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14--FebFeb--0808 D. Protti D. Protti --University of Victoria and City University LondonUniversity of Victoria and City University London 4444
Outline
Outline
1.
1.
Setting the scene
Setting the scene
2.
2.
Good news stories (in primary care) from
Good news stories (in primary care) from
recent international studies
recent international studies
3.
3.
Sad news stories from North America
Sad news stories from North America
4.
4.
How does Andalucia compare?
How does Andalucia compare?
5.
14-Feb-08
D. Protti - University of Victoria and City University London
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%
14-Feb-08
D. Protti - University of Victoria and City University London
46
% GPs transmitting medication prescriptions
•
Andalucia
Most
• Denmark
Most
• Sweden
Many
• England
Some
• Australia
Few
• Austria
Few
Most = >75%
Many = >50%
• Germany
Few
• Netherlands
Few
• Scotland
Few
•
United States
Few
• New Zealand
None
• Norway
None
•
Canada
None
Some = >25%
14-Feb-08
D. Protti - University of Victoria and City University London
47
A
crude
ranking of 13 “jurisdictions”
in terms of e-prescribing
(Most = 4, Many = 3, Some = 2, Few = 1)
•
Andalucia (8)
•
Denmark (8)
–
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)
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14--FebFeb--0808 D. Protti D. Protti --University of Victoria and City University LondonUniversity of Victoria and City University London 4848
Outline
Outline
1.
1.
Setting the scene
Setting the scene
2.
2.
Good news stories (in primary care) from
Good news stories (in primary care) from
recent international studies
recent international studies
3.
3.
Sad news stories from North America
Sad news stories from North America
4.
4.
How does Andalucia compare?
How does Andalucia compare?
5.
14-Feb-08 D. Protti - University of Victoria and City University London
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
.
14-Feb-08 D. Protti - University of Victoria and City University London
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
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
14-Feb-08 D. Protti - University of Victoria and City University London
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“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, 2002
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54
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, 2002.
Benefits
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14--FebFeb--0808 D. Protti D. Protti --University of Victoria and City University LondonUniversity of Victoria and City University London 5555
Finite
Finite
Gracias
Gracias
[email protected]
[email protected]
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14--FebFeb--0808 D. Protti D. Protti --University of Victoria and City University LondonUniversity of Victoria and City University London 5656
Additional Materials
14-Feb-08
D. Protti - University of Victoria and City
University London
57
In the past…
But now…
Very few pharmacies were directly connected to
physician practices
Over 95% of US pharmacies are connected into
a single network and growing
Electronic communications meant faxes
Computer applications can communicate directly
with each other
Only half the problem was being addressed…
writing new scripts
Renewals can be automated in addition to new
scripts
Software didn’t support the workflows in the
practice
Software integrates with existing practice
systems and smoothes office workflow
There were few real benefits for most practices
Most practices will save physician and staff time
as well as improve patient safety
There wasn’t a future path to additional benefits
Collaborate with pharmacies and payors on
patient compliance and other future functions
Automation was being driven by a few Health
Plans and small software vendors
State and nation-wide initiatives involving all
major stakeholders
14-Feb-08 D. Protti - University of Victoria and City University London
