Optimizing Medication Use

Background

The MOXXI project is a computerized system to manage medications and electronically write prescriptions. The goal of the research project is to study the impact of these new technologies on quality of care delivered and on patient outcomes.

Optimal management of prescription medications is an increasingly complex challenge. In order to ensure the best and safe treatment of their patients, physicians and pharmacists must keep their knowledge about medications and their use up-to-date. Today there are:

  • More than 33,000 drug interactions,
  • More than 6,500 prescription drugs that are counter-indicated in the presence of certain illnesses,
  • More than 3,500 prescription drugs that can cause allergic reactions.

 

Project Goals

To determine whether the MOXXI system can prevent undesirable drug-induced effects by testing:

  • An electronic prescription module, including therapeutic intent, in order to reduce errors in the prescription, transcription, and delivery of medications.
  • A therapeutic advisor, to rapidly detect drug interactions and ineffective treatments.
  • A module for the follow-up of drug treatment adherence.

What we found:

01

Article Summary: 

The Development and Evaluation of an Integrated Electronic Prescribing and Drug Management System for Primary Care.

Problems with prescribed drugs may cause serious illness. These problems account for almost one in four admissions to hospital. This happens when the same drug is prescribed more than once, when too much or too little of a drug is prescribed, when drugs that should not be taken together are prescribed or when the patient has an allergy but the doctor does not know this.
We felt that computers could be used to give doctors the help they needed to reduce these kinds of mistakes. We developed a computer system for family doctors called MOXXI. It allows doctors to look at drug and health data for each patient and print prescriptions. We got data about the patients' health and drugs from the province's health and drug insurance programs. For 20 months, 28 family doctors used MOXXI with 13,515 patients. We asked the doctors what they liked best about the system.

What doctors liked the most was being able to print prescriptions, seeing the list of drugs a patient was taking and being able to quickly renew prescriptions. The doctors were faster at using MOXXI after three months but they still found it faster to write new prescriptions by hand. The doctors did find it faster to renew prescriptions with the system. Doctors were more likely to look at the drug list for patients who were
taking more drugs, made more visits to the emergency room and saw other doctors. These are also the kind of patients who are more likely to have problems with prescribed drugs.

The doctors in our study thought a system like MOXXI would help with patient care and they were more likely to use it for patients getting complex care from many sources.

Original Article: 

Tamblyn R, Huang A, Kawasumi Y, et al. The Development and Evaluation of an Integrated Electronic Prescribing and Drug Management System for Primary Care. Journal of the American Medical Informatics Association. 2006;13:148-159.
Download and read the original article.

02

Article Summary: 

A Randomized Trial of the Effectiveness of On-demand versus Computer-triggered Drug Decision Support in Primary Care.

Medication-related illness very often results in the hospitalization of patients. Is now the sixth cause of death. This medication related problems are sometimes avoidable. There is a system that could let doctors know about those events when they are writing a prescription. This eventually could prevent some problems, but most of these systems use so many warnings that doctors do not pay attention to every warning.

For example, somebody is taking a medication. The doctor gives him/her another medication because he/she has pain. It could be that these two medications do not mix very well and the patient could have a very bad reaction. This could not have happened if the doctor had been given a warning about the two medications not mixing well.
In this study the authors wanted to try a new method. This was a computer system that could warn doctors about possible problems with the medication they were about to prescribe. To do this they set two groups. The first group of doctors would receive the alerts all the time. The second group of doctors could check the alerts whenever they wanted.
 
The authors found a difference between the two groups. Doctors who received the alerts all the time did not pay attention to them 9 out of 10 times. Doctors who were able to check the alert whenever they wanted to paid attention to them much more often. The fact that doctors could receive an alert when they felt it was needed may be more helpful. But for both groups there were prescribing problems still existed. The alert systems still need more work. 

Original Article: 

Tamblyn R, Huang A, Taylor L, et al. A Randomized Trial of the Effectiveness of On-demand versus Computer-triggered Drug Decision Support in Primary Care. Journal of the American Medical Informatics Association. 2008; 15:4

03

Article Summary: 

Increasing the Detection and Response to Adherence Problems with Cardiovascular Medication in Primary Care through Computerized Drug Management Systems: A Randomized Control Trial.

Heart disease is the number one cause of death. The severity of heart disease has decreased a lot mostly due to medication. The benefit of those treatments is limited because a big portion of people do not take the medication as they are supposed to. These patients have twice the chance to end up in a hospital. Unwanted reactions and not having enough money may be why the patients do not to take the medications. If the doctor does not know this, they may give the patient a new medication for the wrong reasons. For example a patient is not getting better. The doctor decides to add another medication. Now the patient is taking two medications and is still unwell. The real problem is that the patient was not taking the first medication from the beginning and did not tell the doctor.

There may be a tool that could help doctors to deal with this problem. Doctors were divided in to two groups. In the first group doctors could have the computer give them complete information about the medication the patient was taking. A computer would send a warning to the doctor when the patient was not taking the medication for their heart disease. In the second group the doctor would have only basic information and what the patient told them. No warnings would be sent.
It was found that having all the information and receiving the alerts may have an advantage. Those doctors may more often detect if their patients do not take their medication. But how to deal with that may not be that easy. Things that only the patient knows may be influencing their decisions.

Original Article: 

Tamblyn R, Reidel K, Huang A, et al. Increasing the Detection and Response to Adherence Problems with Cardiovascular Medication in Primary Care through Computerized Drug Management Systems: A Randomized Control Trial. Medical Decision Making, 2009.

04

Article Summary: 

The Impact of Electronic Prescribing on the Professionalization of Community Pharmacists: A Qualitative Study of Pharmacists' Perception.

The role of the pharmacist has changed a lot. Many years ago he/she used to play a part from the preparation until the sale of the medication. Now pharmacists are also concerned with helping patients stay healthy. The use of computer based electronic prescribing system may help. Doctors will use a computer instead of paper to write the prescriptions. The pharmacist will receive the prescription electronically and will serve the patient. This prescription will also tell the pharmacist why the prescription is been written. This may have a big benefit.
An example is a patient with more than one disease who has more than one doctor. One doctor prescribes him/her electronically a few medications. Not only the pharmacist but also the others doctors will receive the prescription. All the team will have access to clinical and treatment information. They could work together in order to improve the patients health.
What pharmacists think about this type of electronic prescribing is not well known. A study was conducted to find out. A few pharmacists using the new technology were asked about their experiences with it. In general pharmacists had a good opinion about electronic prescribing. They think it may be a way to work as a team with physicians. It could give them the chance to work more closely with the patient. This new technology may boost their efforts to provide better services.

Original Article: 

Motulsky A, Winslade N, Tamblyn R, et al. The Impact of Electronic Prescribing on the Professionalization of Community Pharmacists: A Qualitative Study of Pharmacists' Perception  J Pharm Pharmaceut Sci. October 2008; 11 (1) 131-146.

05

Article Summary: 

Inappropriate Prescribing Practices: The Challenge and Opportunity for Patient Safety.

Prescription errors can lead to serious health problems. Recently, we developed an electronic prescribing system called MOXXI. It helps doctors to decide which drugs to prescribe. The MOXXI system is meant to alert doctors of possible dosing errors, allergic reactions or age risks. It also relays information to doctors about drugs that should not be taken at the same time or with a certain disease.
For nine months, we asked 28 doctors to evaluate the electronic drug alert system. Of 22 419 prescriptions, 29% generated alerts. 14% of these alerts led to changes in prescriptions. In some groups (e.g. dosing errors), about one quarter of prescriptions were changed.
 
Although this system can improve the prescribing process, some questions still need to be addressed. We need to know if these changes help keep patients out of the hospital and in better health. This will be the next major challenge when studying the MOXXI system.

Original Article: 

Taylor L, Kawasumi Y, Bartlett G, et al. Inappropriate Prescribing Practices: The Challenge and Opportunity for Patient Safety. Healthcare Quarterly. October 2005;8: 81-85.

06

Article Summary: 

Evaluation of the use of an integrated drug information system by primary care physicians for vulnerable population.

More and more, many people are taking more than one medication at a time. Few doctors know all of drugs their patient is taking. Not having the right information can lead to mistakes. This can cause serious health problems for the patient. This can be a bigger problem in patients who are poorer. They are more likely to have serious health problems and be taking more than one drug at a time. It can be harder for them to get the care they need. Many do not have a doctor they see regularly, and this can lead to inconsistent care. As a result, they end up in the emergency room more often.
Computers could be used to help doctors give these patients better care. We developed a system for family doctors called MOXXI. It lets doctors look at drug and health information for each patient and print prescriptions. We got information on the patients' health and drugs from the province's health and drug insurance programs. Over 9 months, 28 family doctors used MOXXI with 4096 patients. We looked to see if they used the drug list more when the patient had a lower household income.
We found that patients with lower household income had more complex health problems and drug treatment. They also had less consistent care. Family doctors used the drug list more with these types of patients. This could be a helpful tool in helping give better care to these patients.

Original Article: 

Kawasumi Y, Tamblyn R, Platt R, et al. Evaluation of the use of an integrated drug information system by primary care physicians for vulnerable population. International Journal of Medical Informatics. 2008;77:98-106.

07

Article Summary: 

Reasons for Physician Non-Adherence to Electronic Drug Alerts.

We often link prescription drugs with relief - a safe treatment for an illness or disorder. But, the safety of such drugs depends on a reliable prescription system. The prescription system that is used by doctors today is prone to error. Prescription errors can lead to serious health problems and even death. In fact, these problems are the sixth leading cause of death in North America. The MOXXI project aims to help decrease these problems by giving an electronic prescribing system to family doctors. These systems can alert doctors of the harmful effects a prescribed drug may have on their patients. We explored the reasons for why some doctors ignore these drug alerts.
A personal digital assistant (PDA) plays a key role in the drug alert system. It flags drug problems like dosing errors, patient allergies or problems due to age factors. It can also tell the doctor whether the patient is taking another drug that may badly react with the prescription. For three months, 30 family doctors used the PDA for 6260 prescriptions. During the study period, 1869 alerts were generated. Of these alerts, 45% led to changed decisions and 55% were ignored. We asked why some doctors ignored these drug alerts.
The most common reasons for ignoring alerts were that the drug problem was already known or that it was not clinically relevant to the patient situation. Most reasons were linked to the doctor having more knowledge of the patient's medical situation than the PDA. This feedback will help further improve this drug alert system.

Original Article: 

Taylor L & Tamblyn R. Reasons for Physician Non-Adherence to Electronic Drug Alerts. MEDINFO. 2004; 1101-1105.

08

Article Summary: 

Non-participation Bias in Health Services Research Using Data from an Integrated Electronic Prescribing Project: The Role of Informed Consent.

The current method of prescribing by writing is prone to error. These errors may cause health problems. Recently, the electronic prescribing system called MOXXI was developed and is now being tested. Most studies have reported improved patient safety. But, such benefits may be misleading. When patients who participate in the study have different characteristics (age, sex, income etc.) than those who refuse, a bias may occur. The results of the study may then be misleading.
How does this bias distort the study finding? Consider an example: a physician sees two patients. The first is a 75 year old male who is very sick. The second is a 35 year old female who is very healthy but has a bacterial infection. The first patient participates in the study, but the other does not. When the system is used it might look like it is failing to promote patient safety, due to the poor health of the first patient. However, this is not necessarily the case. Our goal in this study was to see if this bias was occurring in an electronic prescribing project and why.
Characteristics of those patients who participated and those who did not were very different. Older patients with health problems, higher income and more visits to the doctor were more likely to participate. It was also found that the doctors also play a role in trying to get the patients to participate. Doctors with less knowledge in technology and who see more patients were less likely to get patients to participate. Doctors who tend to see patients who are not their "regulars" were also less likely to get patients to participate. All of these factors can lead to bias in the results making the system look better or worse than it really is.

Original Article: 

Bartlett G, Tamblyn R, Kawasumi Y, et al. Non-participation Bias in Health Services Research Using Data from an Integrated Electronic Prescribing Project: The Role of Informed Consent. Acta Bioethica. 2005;11(2): 145-159.