Effects of an e-Prescribing interface redesign on rates of generic drug prescribing: exploiting default options.

OBJECTIVE: Increasing the use of generic medications could help control medical costs. However, educational interventions have limited impact on prescriber behavior, and e-prescribing alerts are associated with high override rates and alert fatigue. Our objective was to evaluate the effect of a less intrusive intervention, a redesign of an e-prescribing interface that provides default options intended to "nudge" prescribers towards prescribing generic drugs. METHODS: This retrospective cohort study in an academic ambulatory multispecialty practice assessed the effects of customizing an e-prescribing interface to substitute generic equivalents for brand-name medications during order entry and allow a one-click override to order the brand-name medication. RESULTS: Among drugs with generic equivalents, the proportion of generic drugs prescribed more than doubled after the interface redesign, rising abruptly from 39.7% to 95.9% (a 56.2% increase; 95% confidence interval, 56.0-56.4%; P < .001). Before the redesign, generic drug prescribing rates varied by therapeutic class, with rates as low as 8.6% for genitourinary products and 15.7% for neuromuscular drugs. After the redesign, generic drug prescribing rates for all but four therapeutic classes were above 90%: endocrine drugs, neuromuscular drugs, nutritional products, and miscellaneous products. DISCUSSION: Changing the default option in an e-prescribing interface in an ambulatory care setting was followed by large and sustained increases in the proportion of generic drugs prescribed at the practice. CONCLUSIONS: Default options in health information technology exert a powerful effect on user behavior, an effect that can be leveraged to optimize decision making.

Patient activation and use of an electronic patient portal.

PRIMARY OBJECTIVE: Electronic patient portals give patients access to personal medical data, potentially creating opportunities to improve knowledge, self-efficacy, and engagement in healthcare. The combination of knowledge, self-efficacy, and engagement has been termed activation. Our objective was to assess the relationship between patient activation and outpatient use of a patient portal. RESEARCH DESIGN: Survey. METHODS AND PROCEDURES: A telephone survey was conducted with 180 patients who had been given access to a portal, 113 of whom used it and 67 of whom did not. The validated patient activation measure (PAM) was administered along with questions about demographics and behaviors. RESULTS: Portal users were no different from nonusers in patient activation. Portal users did have higher education level and more frequent Internet use, and were more likely to have precisely 2 prescription medications than to have more or fewer. CONCLUSION: Patients who chose to use an electronic patient portal were not more highly activated than nonusers, although they were more educated and more likely to be Internet users.

A long-term follow-up evaluation of electronic health record prescribing safety.

OBJECTIVE: To be eligible for incentives through the Electronic Health Record (EHR) Incentive Program, many providers using older or locally developed EHRs will be transitioning to new, commercial EHRs. We previously evaluated prescribing errors made by providers in the first year following transition from a locally developed EHR with minimal prescribing clinical decision support (CDS) to a commercial EHR with robust CDS. Following system refinements, we conducted this study to assess the rates and types of errors 2 years after transition and determine the evolution of errors. MATERIALS AND METHODS: We conducted a mixed methods cross-sectional case study of 16 physicians at an academic-affiliated ambulatory clinic from April to June 2010. We utilized standardized prescription and chart review to identify errors. Fourteen providers also participated in interviews. RESULTS: We analyzed 1905 prescriptions. The overall prescribing error rate was 3.8 per 100 prescriptions (95% CI 2.8 to 5.1). Error rates were significantly lower 2 years after transition (p<0.001 compared to pre-implementation, 12 weeks and 1 year after transition). Rates of near misses remained unchanged. Providers positively appreciated most system refinements, particularly reduced alert firing. DISCUSSION: Our study suggests that over time and with system refinements, use of a commercial EHR with advanced CDS can lead to low prescribing error rates, although more serious errors may require targeted interventions to eliminate them. Reducing alert firing frequency appears particularly important. Our results provide support for federal efforts promoting meaningful use of EHRs. CONCLUSIONS: Ongoing error monitoring can allow CDS to be optimally tailored and help achieve maximal safety benefits. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov, Identifier: NCT00603070.

Promoting generic medication prescribing by order interface redesign: small change, large impact.

Prescription drugs are a significant component of the ever increasing health care costs. We describe the effects on generic medication prescribing behavior achieved through redesign of the order entry interface of our institutions ambulatory electronic health record. The redesign involved custom programming that automatically substituted brand medications with their generic equivalents and only allowed continuation with the brand medication if the clinician made an extra mouse click selecting "dispense as written". We conducted a before-after retrospective study around the time of the redesign and witnessed a net 36.9% percentage increase in the number of generic medications prescribed.

Physician experiences transitioning between an older versus newer electronic health record for electronic prescribing.

PURPOSE: Federal incentives to adopt interoperable, certified electronic health records (EHRs) with electronic prescribing (e-prescribing) are motivating providers using older EHRs to transition to newer EHRs. The objective of this study was to describe, from the perspective of experienced EHR users, the transition from an older, locally developed EHR with minimal clinical decision support (CDS) for e-prescribing to a newer, commercial EHR with more robust CDS for e-prescribing. METHODS: This qualitative, case study consisted of observations and semi-structured interviews of adult internal medicine faculty members (n=19) at an academic-affiliated ambulatory care clinic from January through November 2009. All providers transitioned from the older, locally developed EHR to the newer, commercial EHR in April 2008. We analyzed field notes of observations and transcripts of semi-structured interviews using qualitative methods guided by a grounded theory approach. RESULTS: We identified key themes describing physician experiences. Despite intensive effort by the information systems team to ease the transition, even these experienced e-prescribers found transitioning extremely difficult. The commercial EHR was not perceived as improving medication safety, despite having more robust CDS. Additionally, physicians felt the commercial EHR was too complex, reducing their efficiency. CONCLUSIONS: This is among the first studies examining physician experiences transitioning between an older, locally developed EHR to a newer, commercial EHR with more robust CDS for e-prescribing. Understanding physician experiences with this type of transition and their general preferences for prescribing applications may lead to less disruptive system implementations and better designed EHRs that are more readily accepted by providers. In this way, productivity and safety benefits may be maximized while mitigating potential threats associated with transitions. TRIAL REGISTRATION: ClinicalTrials.gov, Identifier: NCT00603070.

Transitioning between electronic health records: effects on ambulatory prescribing safety.

BACKGROUND: Healthcare providers previously using older electronic health records (EHRs) with electronic prescribing (e-prescribing) are transitioning to newer systems to be eligible for federal meaningful use incentives. Little is known about the safety effects of transitioning between systems. OBJECTIVE: To assess the effect of transitioning between EHR systems on rates and types of prescribing errors, as well as provider perceptions about the effect on prescribing safety. DESIGN, PARTICIPANTS: Prospective, case study of 17 physicians at an academic-affiliated ambulatory clinic from February 2008 through August 2009. All physicians transitioned from an older EHR with minimal clinical decision support (CDS) for e-prescribing to a newer EHR with more robust CDS. MAIN MEASUREMENTS: Prescribing errors were identified by standardized prescription and chart review. A novel survey instrument was administered to evaluate provider perceptions about prescribing safety. KEY RESULTS: We analyzed 1298 prescriptions at baseline, 1331 prescriptions 12 weeks post-implementation, and 1303 prescriptions one year post-implementation. Overall prescribing error rates were highest at baseline (35.7 per 100 prescriptions, 95% confidence interval (CI) 23.2-54.8) and lowest one year post-implementation (12.2 per 100 prescriptions, 95% CI 8.6-17.4) (p < 0.001). Improvement in prescribing safety was mainly a result of reducing inappropriate abbreviation errors. However, rates for non-abbreviation prescribing errors were significantly higher at 12 weeks post-implementation than at baseline (17.7 per 100 prescriptions, 95% CI 9.5-33.0 versus 8.5 per 100 prescriptions, 95% CI 4.6-15.9) (p <0.001) and no different at baseline than one year (10.2 per 100 prescriptions, 95% CI 6.2-18.6) (p = 0.337). Survey results complemented quantitative findings. CONCLUSIONS: Results from this case study suggest that transitioning between systems, even to those with more robust CDS, may pose important safety threats. Recognizing the challenges associated with transitions and refining CDS within systems may help maximize safety benefits.

Physician productivity and the ambulatory EHR in a large academic multi-specialty physician group.

PURPOSE: The impact of the ambulatory electronic health record (EHR) on physician productivity is poorly understood. Fear of productivity loss remains a major concern for practitioners and health care delivery organizations and inhibits system adoption. This study describes the changes in physician productivity after the implementation of a commercially available ambulatory EHR system in a large academic multi-specialty physician group. METHODS: Weill Cornell faculty members implemented on the EpicCare (Epic Systems) EHR between 2001 and 2007 were identified as potential study participants. Monthly visit volume, charges, and work relative value units (wRVUs) were compared pre and post each provider's EHR implementation go-live date. Practitioners who lacked at least 6 months of pre- and post-implementation visit volume and charge data were excluded. Practitioners who did not meet pre-determined system proficiency metrics were additionally identified and became the basis of a non-adopter comparison group. RESULTS: 203 physicians met criteria for the analysis. The eligible providers were divided into an adopter and non-adopter cohort based on system proficiency benchmarks. Those practitioners who adopted the EHR had a statistically significant increase in average monthly patient visit volume of 9 visits per provider per month. The non-adopter cohort's visit volume was statistically unchanged. Both the EHR adopters and non-adopters had statistically significant increases (22% and 16% respectively) in average monthly charges in the post-implementation period. Average monthly wRVUs were statistically unchanged in the non-adopter cohort, but showed a positive and statistically significant increase of 12 wRVUs per provider per month for the adopter group. The EHR adoption group showed an incremental increase in productivity once practitioners achieved 6 or more months experience with the EHR, consistent with a "ramp-up" period. A multivariable regression model did not reveal any association between the post-EHR implementation change in wRVUs and several potential confounding variables, including baseline provider average monthly visit volume and wRVUs, date of system adoption, and specialty categorization. CONCLUSION: Provider productivity, as measured by patient visit volume, charges, and wRVUs modestly increased for a cohort of multi-specialty providers that adopted a commercially available ambulatory EHR. The productivity gain appeared to become even more pronounced after several months of system experience. This objective data may help persuade apprehensive practitioners that EHR adoption need not harm productivity. The baseline differences in productivity metrics for the adopters and non-adopters in our study suggest that there are fundamental differences in these groups. Further characterizing these differences may help predict EHR adoption success and guide future implementation strategies.

Terminological reaction.

When the terminology services at our institution encountered the installation of a new multi-site laboratory information system (LIS), we pursued obtaining a regular dictionary feed to keep the central terminology up-to-date. What we didn't predict was the value added to the LIS implementation effort by a cooperative vocabulary strategy. In this report, we describe how preexisting terminology services were leveraged to facilitate the integration of 2 previously independent laboratories into a new cross-campus LIS.