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The Value of Health Information Technology in Improving Pharmacotherapy

SR Simon, JH Gurwitz, KA Chan, SB Soumerai, AK Wagner, SE Andrade, AC Feldstein, ... Raebel, MA, Lyons EE, Simon SR, et al. Lab Monitoring of High Risk ...

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The Value of Health Information Technology in Improving Pharmacotherapy

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    Slide 1:The Value of Health Information Technology in Improving Pharmacotherapy

    Steven R. Simon, MD, MPH Harvard Medical School and Harvard Pilgrim Health Care

    Slide 2:Objectives

    Problems with drug therapy in the elderly Overuse Underuse Misuse HIT-based interventions Expanding HIT: Role of QIOs Non-HIT based interventions

    Slide 3:Potentially Inappropriate Medication Use Among Elderly Persons in US HMOs, 2000-2001

    SR Simon, JH Gurwitz, KA Chan, SB Soumerai, AK Wagner, SE Andrade, AC Feldstein, JE Lafata, R Platt

    Slide 4:Sample Description

    Sample Age 65+ Eligible* *Eligibility Criteria: Age 65 years or older on January 1, 2000; continuously enrolled 1/1/00 6/30/01; continuous drug benefit during study period Total Eligible: 157,517

    Slide 6:Overall, 28.8% received 1 or more potentially inappropriate agent

    Slide 7:Underuse of Medications in the Elderly

    asthma cardiovascular disease depression dyslipidemia hypertension osteoporosis prevention pain management stroke prevention

    Slide 8:Underuse of Statins

    Evidence-based guidelines (NCEP): aggressive statin use to lower cholesterol Slow adoption of statins in early 1990s Among patients with AMI in 37 Minnesota hospitals in 1995, 37% received LLDs (Majumdar et al, JGIM 1999) Among elderly Medicare patients with CHD in 1997: 4.1% of patients with Medicare only on statins 27.4% of patients with employee-sponsored insurance on statins. (Federman et al, JAMA 2001)

    Statin Use among Patients with CHD or MI

    Slide 11:Examples of Misuse

    Drug-drug interactions Drug-allergy interactions Drug-disease interactions (e.g., renal dosing) Inadequate laboratory monitoring Prescribing, transcribing, dispensing errors Wrong drug Wrong dose Wrong route

    Slide 12:Lab Monitoring of High Risk Drugs at Initiation of Therapy

    Objective: Describe baseline lab monitoring among new users of HRDLMs N=2,000,000 (200,000 x 10 HMOs) 36 drugs/classes requiring monitoring ACE-inhibitors (Creatinine, K+) Amiodarone (liver, thyroid function) Lab monitoring error: No test 180 d before or 14 d after initiation. Raebel, MA, Lyons EE, Simon SR, et al.

    Slide 13:Lab Monitoring of High Risk Drugs at Initiation of Therapy

    Overall error rate: 38.6% 107,791 / 279,418 dispensings 39.2% starting ACEi did not have creatinine and K+ 57.2% starting amiodarone did not have liver and thyroid function tests Raebel, MA, Lyons EE, Simon SR, et al.

    Slide 14:Interventions: HIT-based

    Bates, D. W. et al. N Engl J Med 2003;348:2526-2534 Warning Displayed for a Drug Allergy BMJ. 2002;325:4917.

    Slide 20:Expanding HIT: Role of QIOs

    Slide 21:Increasing EHR Adoption in Massachusetts

    Goal: To improve the safety of patient care delivered by every outpatient provider in Massachusetts Approach: Develop partnership among key stakeholders Implementation: Staged over 5 years

    Slide 22:Components of Initial Proposal

    Build consensus among key stakeholders Identify vendors of computer hardware and EMR software interested in collaborating with Massachusetts Low number, ideally 2-4

    Slide 23:Components of Initial Proposal

    Identify purchasers or business groups willing to pay a premium to providers who are willing to make or have already made the transition to electronic records Identify incentive package that will make it attractive for providers to adopt

    Slide 24:Role of QIOs

    Establish consensus on quality measures Collect automated (EHR) quality data from practices Channel data to incentive-paying mechanism Use data to implement QI programs Broadly At level of individual practice (or provider?) Role in recruitment, implementation, evaluation, other?

    Slide 25:Non-HIT-based Interventions to Change Prescribing Behavior

    Mailed information Audit and Feedback Opinion Leaders Academic Detailing

    Slide 26:A Cluster-Randomized Controlled Trial of Individual versus Group Academic Detailing to Improve the Use of Antihypertensive Medications in Primary Care

    Supported by a cooperative agreement from the Agency for Healthcare Research and Quality SR Simon, SR Majumdar, KP Kleinman, S Salem-Schatz; C Warner; L Prosser; I Miroshnik, SB Soumerai

    HCHP (1995) 47 practice groups 9 practice groups randomized Individual Academic Detailing (N=3) Group Academic Detailing (N=3) Mailed Practice Guidelines (N=3) 114 Clinicians and 1066 HTN patients 120 Clinicians and 1007 HTN patients 133 Clinicians and 1619 HTN patients

    Slide 28:Academic Detailing Interventions

    Single educational outreach visit Trained physician-educator (detailer) Objective Address and overcome barriers to prescribing diuretics and beta blockers Credible messenger Unbiased information Individual or small group (N=6-8) visits

    Slide 29:Absolute increases in unadjusted rates of use of diuretics or -blockers among patients with incident hypertension

    Year 1 Year 2 Baseline Rates (58%) (59%) (58%) (58%) (59%) (58%)

    Slide 30:Take-Home Messages: Improving Drug Therapy in the Elderly

    Serious and widespread problems Overuse, underuse, misuse HIT-based interventions promising Need for expansion of HIT, especially EHRs Continued need for non-HIT-based interventions E.g., academic detailing

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