The Journal of the American Board of Family Medicine published in its March-April 2012 issue a mixed method study on care coordination.  The authors concluded:


The real value of this care coordination initiative was that coordination tasks were transferred from family physicians (FP) to nurse practitioners (NP).  This transfer and time-savings to FPs took place once trust was established among members of the team.  The authors point out that the contributions of various actors were not expected (e.g., pharmacist and NPs).

Interestingly, the EMR contributed little to care coordination.  The EMR had been in place for four years but the electronic "To Do" note did not offer a means of adjusting care plans (scanned into system) so current information was not available.  Taken together (roles of team members and impact of EMR), this suggests that future EMR/EHR designs should be more chart-based (i.e., coordination artifact) rather than role-based as currently done.

Source:

Legault, F., Humbert, J., Amos, S., Hogg, W., Ward, N., Dahrouge, S. & Ziebell, L. (2012) 'Difficulties Encountered in Collaborative Care: Logistics Trumps Desire', The Journal of the American Board of Family Medicine, Vol. 25, No. 2, pp. 168-176.

The blogsphere is abuzz about Surescripts February 1 press release announcing increased adherence with e-prescribing.  The study does not appear to be publicly available so my impressions from press release may not accurately reflect the study.  That said my initial impressions are that the term "costs" used loosely.  Cost to whom should be asked?  One should also ask if e-prescribing is the only way to improve adherence?

Surescripts relies upon the Roebuck et al (2011) study which estimated that adherence for four vascular conditions reduced medical spending by the ratios cited by Surescripts (3 to 10 times less).  We will need to see what kind of medications have increased first fill adherence in the Surescripts study.  These ratios are based on vascular diseases and Fischer et al (2010) reported adherence less than 30% for chronic diseases even though the overall adherence was 78% (similar to Surescripts study).

The Roebuck et al study also says "one should not necessarily expect to see immediate reductions in medical costs from improved medication adherence. This is a particularly salient point for insurers with short time horizons."  Can improvements in first fill adherence rates be generalized to continued adherence, especially if costs to patient becomes an issue?

The Roebuck et al (2011) study summarized its study: "Our findings indicate that programs to improve medication adherence are worth consideration by insurers, government payers, and patients, as long as intervention costs do not exceed the estimated health care cost savings."  What is the cost of e-prescribing?  Why has the elimination of patient co-payments for chronic medications, known to increase adherence, been lost in the discussion?  See Sipkoff (2004) which includes quoting Mark Fendrick that "We believe that some people should indeed get their drugs for free, and for a small class of people, should even be paid to take them".

It seems e-prescribing just shuffles the costs around to different categories that may or may not be included in a "cost" number.  Higher adherence means more medication costs to the patient to save payers the cost of hospitalization.  E-prescribing means medical practices and pharmacies pay for the cost of systems and transaction fees to increase adherence so that payers avoid the cost of hospitalizations.

Given that Surescripts press release is claiming the benefit ratio from chronic vascular diseases, one must ask if payers paying the co-pay of an at-risk population might be cheaper than the billions already spent on e-prescribing.  I hope someone does the math.

Sources:

Fischer, M, Stedman, M, Lii, J, Vogeli, C, Shrank, W, Brookhart, M & Weissman, J 2010, 'Primary Medication Non-Adherence: Analysis of 195,930 Electronic Prescriptions', Journal of General Internal Medicine, Vol. 25, no. 4, pp. 284-90.

Roebuck, MC, Liberman, JN, Gemmill-Toyama, M & Brennan, TA 2011, 'Medication Adherence Leads to Lower Health Care Use and Costs Despite Increased Drug Spending', Health Affairs, Vol. 30, no. 1, pp. 91-9.

Sipkoff, M 2004, Not So Much of a Reach: Let Sick Pay Less for Drugs, October, January 18, 2007, <http://www.managedcaremag.com/archives/0410/0410.benefitbased.html>.

Social media may seem a bit off-topic from my usual focus on HCIT failure and effectiveness, but we need to be prepared whether we understand the phenomena of social media or not.  I found this excerpt while preparing for my MBA-level Social Media Management Strategy course.

Here is an excerpt from 2012 Social Marketing & New Media Predictions compiled by Awareness.

“In the world of health care, the biggest social marketing development in 2012
is the convergence between the worlds of marketing and IT,” observes Pamela
Johnston of The Lahey Clinic. “These two distinct teams are learning from
and about each other in ways that will make us smarter, faster and more patient-centric
in the years to come. We need to combine our resources to reach patients
with relevant messages on the platforms they desire.”

I fear we are behind on the socio-organizational implications of social media technology on the way healthcare gets done.

A great systems topic to explore how these silos can be put together and submit your findings to the Clinical Informatics area of the systems-oriented Health Systems.

The Crosson et al (2012) study just published in The Journal of the American Board of Family Medicine reinforces what has been known for some time.  E-prescribers continue having trust issues with electronic formulary checks and electronic medication histories.  Why would an e-prescriber spend the time checking an unreliable e-formulary if the pharmacy must do so anyway for adjudication?  How do you trust the completeness of a medication history (from claims database) when many filled prescriptions may not appear (e.g., paying cash for $4 generic at Target rather than $25 for same generic via insurance coverage).  The authors point out pharmacy sales data might be a better alternative.  Even if the information were available, there are issues with secondary use of pharmacy sales data that need to be addressed.

The premise of e-prescribing is that increasing the ease of information access enables collaboration in this inter-organizational network.  Information integrity has been a known problem in inter-organizational environments as the importance of controlling integrity via the infrastructure has not been appreciated (Wilkin and Chenhall, 2010).  There are no easy solutions but a meaningful dialogue must begin.  The prescribers do want this information (Lapane et al, 2011).


CROSSON J C, SCHUETH A J, ISAACSON N and BELL D S  (2012)  Early adopters of electronic prescribing struggle to make meaningful use of formulary checks and medication history documentation. The Journal of the American Board of Family Medicine  25(1), 24-32.

LAPANE K L, WARING M E, DUBÉ C E and SCHNEIDER K L  (2011)  E-prescribing and patient safety: Results from a mixed method study. The American Journal of Pharmacy Benefits  3(2), e24-e34.

WILKIN C L and CHENHALL R H  (2010)  A review of IT governance: A taxonomy to inform accounting information systems. Journal of Information Systems  24(2), 107-146.

Mini-Track Cochairs: Nelson King and Sweta Sneha

Healthcare information technology (HIT) is shaping the future of healthcare whether by mandate or the desire of healthcare organizations to improve the quality of patient care.  The push is towards integrated HIT which arguably mirrors the push over the past 20 years to move from silos of automation to enterprise systems.  This mini-track seeks papers that take a systems view towards clinical informatics.

Clinical informatics brings together clinical workflow and business strategies of a healthcare organization through timely and accurate exchanges of information.  Healthcare organizations and the information they exchange are becoming increasingly complex necessitating fresh methodological and theoretical approaches on the part of researchers.  Submissions with a systems orientation and clearly articulated context of use that showcase inter-disciplinary thought are trademarks of papers published in this area.  The boundaries of the system should be defined and the interplay within and external to the system should be described. 

By systems, we mean a broader view than a singular focus on the efficacy of a feature or function within a specific HIT.  An integrated system might be multi-function HIT like an EMR/EHR or a set of technologies that result in measurable outcomes.  Such outcomes should reflect the interplay between functionality, workflow, information and strategy.  Alternatively, the implications of infrastructure on HIT functionality and system use could be explored (e.g., e-infrastructures). The system might also be the interplay between social and technical aspects of an HIT. 

Submissions that can be readily extended to a quality journal article will be considered for fast-tracking by the editors of Health Systems Journal (HSJ) coordinated by Nelson King (Clinical Systems Area Editor).  Any invitation would be subject to the willingness of reviewers to continue through the HSJ submission process and an assessment that a solid extension of the work is feasible.

A complete description of the Systems-oriented Clinical Informatics Mini-Track is available on the AMCIS 2012 website.

E-prescribing is all about achieving efficiency to the practice and pharmacy to compensate for the cost of acquiring and implementing the technology.  The just released Grossman et al (2011) study suggests there is some work to be done (excerpts follow):

New Prescriptions
"Pharmacies typically resolved transmission problems by calling physicians for verbal orders"

Refills
"Eight of these pharmacies lacked the functionality, and the rest chose not to use the feature, mainly to avoid Surescripts transaction fees"

"As one physician explained, ‘Sometimes the patient will call, the pharmacy will fax, and [send something via] Surescripts, all for the same patient, the same prescription, on the same day. That is cumbersome.’

'If they [don’t] respond, that’s where we run into problems. We fax the next day because we can’t send a duplicate request electronically.'

Mail order connectivity
"some practices first tried electronic routing for new prescriptions or renewal responses, followed by faxing or printing the prescription if unsuccessful."

These workarounds to intended system usage are just for the logistics of sending prescription information.

These so-called digital e-scripts still require manual intervention: "Three prescription fields commonly required manual manipulation: medication name, quantity, and patient instructions".  Dosing and quantity seem to be problematic according to the study.  The e-prescriber must know all the variations of drug packaging at a particular pharmacy in order to reduce the risk of digitally transmitted information containing an error that must be corrected at the pharmacy.  This issue represents the role changes that occur with the introduction of technology.  There are others in (a hope to see published) article I have under review.

An informative study that speaks volumes to practices and pharmacies putting up with all these system design problems because overall e-prescribing is better.  Just imagine if some thought had been made in advance to system design so these unintended consequences would not be a problem.

Center for Studying Health Systems Change provides access to this article by Transmitting and processing electronic prescriptions. (pdf)  For the interview protocols appendix click here. (pdf)

Article Citation:
Grossman, J.M., Cross, D.A., Boukus, E.R. & Cohen, G.R. (2011) 'Transmitting and Processing Electronic Prescriptions: Experiences of Physician Practices and Pharmacies', Journal of the American Medical Informatics Association.

Patient handoffs in hospitals involve more than information transfer.  There is also a handoff of responsibility and control along with resilience that is embodied in the handoff routine according to a new article:

Hilligoss, B. & Cohen, M.D. (2011) 'Hospital Handoffs as Multifunctional Situated Routines: Implications for Researchers and Administrators', In: J.D. Blair & M.D. Fottler (eds.), Biennial Review of Health Care Management, (pp. 91-132), Emerald Group, Vol. 11.

The authors note that standardization (e.g., EMR/EHR) is the most common approach to improve handoffs but "introduce new sources of error (e-iatrogenesis) and eliminate established error-catching capabilities."  It is a very careful literature review that characterizes the handoff on two dimensions: multi-functionality and situatedness.  A thought provoking piece that probably can be applied to other handoff routines like e-prescribing, hospital discharge, and ambulatory care coordination.

A study by Dr. Bhargava (2011) at UC Davis was the focus of several articles at the end of 2010: 

EHRs have varying effects on productivity: UC Davis study and EMR not boosting productivity? It could be a mismatch between system and specialty.  The study concluded that specialty made a difference which makes sense that the inherent processes in an EMR can’t be completely generic but reflect some model of work.

His office just sent me the SSRN link to their EMR and Physician Productivity study.

When there is a fit, productivity does seem to increase after six months (Cheriff et al. 2010).   In addition to EHR fit, one should also look at the related literature.  Reardon and Davidson (2007) point to the learning capacity especially in small physician practices.  Productivity is important because patients have more confidence in their physician the more time is spent (Wood et al. 2009).

Bhargava, HK & Mishra, A 2011, Electronic Medical Records and Physician Productivity: Evidence from Panel Data Analysis, <http://ssrn.com/abstract=1952287>.

Cheriff, AD, Kapur, AG, Qiu, M & Cole, CL 2010, 'Physician Productivity and the Ambulatory Ehr in a Large Academic Multi-Specialty Physician Group', International Journal of Medical Informatics, Vol. 79, no. 7, pp. 492-500.

Reardon, JL & Davidson, E 2007, 'An Organizational Learning Perspective on the Assimilation of Electronic Medical Records among Small Physician Practices', European Journal of Information Systems, Vol. 16, no. 6, pp. 681–94.

Wood, GC, Spahr, R, Gerdes, J, Daar, ZS, Hutchison, R & Stewart, WF 2009, 'Patient Satisfaction and Physician Productivity: Complementary or Mutually Exclusive?' American Journal of Medical Quality, Vol. 24, no. 6, pp. 498-504.

The JAMIA paper that concluded e-prescribing had no impact on error rates (see post: e-Rx: Same Error Rates?) has evoked a response statement from Surescripts and the authors.  Those of us citing this study are to note that the term e-prescribing as used in the study "does not accurately reflect the way the terms are used today and should be avoided".  The e-scripts (from 2008) analyzed in the JAMIA paper were sent by fax or printed out.  Note that Surescripts is consistent with the definition but in the 2007 National Progress Report they put it in the fine print (footnote 1).  The pioneers of e-prescribing/EMR systems had to efax because there wasn't connectivity (sometimes the EMR - sometimes the pharmacy) - but the escript certainly was computer generated.

While greatly improved now, e-prescribing in the study era forced most pharmacies to dual screen the e-script with the entry form since the pharmacy systems had not incorporated the functionality or pharmacies had not upgraded.  So I see the results as being historically valid.

FierceHealthIT blog follows up the joint statement with the post Surescripts' reaction to e-prescribing study doesn't erase the need for improvement.  One suggestion of the study was a "forcing function" to make fields required on e-scripts.  If my experience yesterday was any indication, one must consider this function carefully.  I was getting a medical history taken and many of my medications (or dosage) did not show up on the list.  Therefore the clinician chose to omit the drug from the medication history because there was no means of inputting something not on the list.

The Surescripts statement also ignores the fact that e-iatrogenesis errors from computerized inputs can't be ignored.