Improving HIT Prescribing Safety by Incorporating Indications Into Computerized Prescriber Order Entry

Project Overview

The Agency for Healthcare Research and Quality (AHRQ) has funded the Brigham and Women’s Hospital (BWH) Center for Patient Safety Research and the Massachusetts College of Pharmacy (MCPHSU) to lead a multi-year project to improve HIT prescribing safety by redesigning computerized prescriber order entry (CPOE) to incorporate a medication indication into the prescription order. This project is funded under AHRQ Grant R01 HS023694.

Introduction

The time has come to complete the 5-rights of safe medication use (right drug, dose, patient, route, time) with an element missing from each medication prescription, one that impacts and complements each of the other "rights," and stands on its own as a "6th right." It is a crucial piece of information needed for every prescription—the right indication. Health IT provides the vehicle for fulfilling this requirement and is crippled in myriad ways without it.

As will be demonstrated in this project, there are multiple synergistic perspectives and requirements pointing to the need to move toward indications-based prescribing. With the majority of prescriptions now being written electronically, this need and opportunity is particularly timely and compelling.

Critical Areas of Impact

There are six broad overlapping critical areas where the proposed interventions will have an important impact on HIT safety:

  • Improved safety through error prevention, reduction, mitigation: Medication choices narrowed to those indicated for a specific problem and patient are much less error-prone, and any mismatches will be more easily recognized by staff and patients.
  • Facilitating patient education: Providing efficient and effective patient guidance to indicate a reason for their medications supports care team roles in counseling and aiding adherence.
  • Promoting prescribing of drugs of choice: Indications-based prescribing model supports busy clinicians’ need for efficient support to inform increasingly complex pharmacotherapy choices that can overwhelm human memory limits.
  • Enhancing team communication: Indications are key to ensuring an informed dialogue between prescribers, pharmacists, and patients about what is being treated, why, and what the desired outcomes are, which supports the ability to ask and answer informed questions.
  • Aiding medication reconciliation: Medication reconciliation would be improved through clarifying additions, deletions, and reconciling duplicates if medication lists were organized by indications rather than randomly or alphabetically.
  • Supporting quality, outcomes and effectiveness research: Indications would allow clearer treatment comparisons, and quality assessments require indications to assess appropriateness, exceptions, and off-label uses for each prescription.

Project Aims

The project has three specific aims; each is designed to take one year.

  • Aim 1 - Convene six high-level stakeholder expert panels, to achieve consensus and buy-in on the rationale, multi-user needs, operational and interoperability requirements, interface design elements, limitations and barriers, and policy implications of incorporating medication indication into CPOE, with publication of a Sounding Board and white paper.
  • Aim 2 - Design and build a working prototype of an indications-enabled CPOE system using a rigorous user-centered design process and incorporating the recommendations from Aim 1.
  • Aim 3 - Test the prototype by comparing it to two widely deployed CPOE systems using pre-defined use-case clinical scenarios in the following categories: ordering speed, error rate, user experience/satisfaction of the prescribers, as well as enhanced usefulness and safety of the prescriptions generated for pharmacists and patients.

Our team will address a series of critical synergistic medication safety concerns by using HIT, safety lessons, and experts to advance this safety-enhancing prescribing paradigm.

Year 1: Convening Stakeholder Expert Panels

Year 2: Design and Build a Working Prototype (under way)

A webinar was held on June 7, 2016 to provide an update on this project's status.

Update Panel: User Centered Design and First Iteration Prototype

Chairs: G. Schiff, P. Neri

  1. Briefly review the concept and goals of indications-based prescribing and summary of the "specs" that emerged from our Year 1 six stakeholder panel calls.
  2. Present progress in further refining stakeholder user CPOE system requirements including results from these user-centered design activities:
    1. Contextual inquiry sessions with prescribers to observe prescribing activities and workflow
    2. Participatory design sessions to observe how prescribers would approach different the design of CPOE, indications, and prescribing related problems
    3. Coding and qualitative analysis to develop newest iteration of user requirements
  3. Share early prototype design models of an indications-based prescribing system and solicit input from the webinar audience to improve our design.

Building on learning and recommendations from Aim 1, we will deploy a user-centered design approach to plan, design and develop an indications-based CPOE prototype and toolkit. We will use standardized methods including contextual inquiry, participatory design, and usability testing to gather user requirements and design feedback. The user centered design process is outlined below.

Contextual Inquiry Sessions

These sessions will involve structured observation and interviews with prescribers to walk through their current prescription ordering process. During the contextual inquiry sessions the interviewer and participant will work together to understand the medication ordering process, learn about the prescriber’s cognitive processes, and assess ways Indications based CPOE would fit into their workflow.

Two Participatory Design Sessions

Groups of users and other stakeholders will participate in drafting paper and pencil versions, and offer alternate design options, of an indications-based CPOE interface via mapping the workflow process. Then we will discuss and prioritize the user requirements including various features, functions, interaction behaviors, and data elements that are important to design.

Develop Low-Fidelity Interactive Prototype

We will design a prototype of an indications-based CPOE based on the user requirements and input gathered to date.  We will present this prototype for feedback from the larger stakeholder group during Spring 2016. This prototype will be used for the first round of usability testing.

Three Rounds of Iterative Usability Testing and Prototype Revisions

To identify usability problem areas within the interface, users will be asked to think aloud as they walk through various tasks in the system. Revisions to the prototype will be made based on the analysis of the qualitative data received during those sessions.

Physician and Patient Evaluations

To evaluate the quality and usability of the prescriptions generated from the indications-based CPOE prototype, we will gather feedback from pharmacists and patients. We will ask questions related to the usefulness, meaning and content of items on the medication list and prescription information sent to the pharmacy.

Revise Design and Begin Development on Higher-Fidelity Prototype

The final high-fidelity indications-based prototype will be built based on the open source SMART (Substitutable Medical Applications, reusable technologies) platform. The prototype will be fully functional as a standalone module (as well as capable of being integrated into other SMART-enabled applications) and will be designed to be capable of performing the indications-enabled ordering for the test scenarios used to test the prototype.

Year 3: Test the Prototype

We hypothesize that the high-fidelity prototype we build will, in a series of realistic head-to-head comparisons with two current EMR CPOE systems, demonstrate superior performance on a number of key metrics. This evaluation will be both quantitative and qualitative, using existing validated tools from our team’s prior IT evaluation and research studies.

Project Contacts

Project PI – Gordon Schiff, MD (gschiff@partners.org)
Project Director – Lynn Volk, MHS (lavolk@partners.org)

Page last reviewed March 2017
Page originally created March 2017
Internet Citation: Improving HIT Prescribing Safety by Incorporating Indications Into Computerized Prescriber Order Entry. Content last reviewed March 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/chain/research-tools/featured-certs/improving-hit-prescribing-safety.html