Using Information Technology (IT) to Improve Medication Safety for Rural Elders (Oregon)

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Summary:

A major barrier to realizing the benefits of health information technology is "stovepiping" of clinical data in incompatible systems, creating what McDonald has called "islands of data." Availability of complete, accurate clinical data is especially critical for medication information relating to frail, chronically ill elders in Assisted Living (AL) and Skilled Nursing Facilities (SNFs), who are at greater risk for medication-related problems because of advanced age, frailty, high-risk medications, and multiple care providers. "Yet physician groups, hospitals, and other health care organizations operate as silos, often providing care without the benefit of complete information about the patient's condition, medical history, services provided in other settings, or medications prescribed by other clinicians" (IOM, 2003). To address this problem, we implemented and evaluated a Patient-Centered Medication Information System (PCMIS) to improve the health of frail, chronically ill elders in rural Oregon. The aims were to: 1) Provide secure access to accurate, complete, and current medication information for patients, clinicians, pharmacists, and nurses who prescribe, dispense, or administer medications; 2) Reconcile differences in medication information in separate, often discordant information systems of clinics, pharmacies, and residential care facilities; 3) Reduce medication errors and adverse effects by eliminating interactions, duplications, and inappropriate medications; 4) Provide a platform for evidence-based decision support and public health monitoring to improve the quality and efficiency of care; 5) Assess benefits and costs of the system through robust evaluation; and 6) Extend this information integration model statewide and beyond via the Oregon Rural Practice Based Research Network (ORPRN).This project was the work of a consortium of (a) rural providers and community organizations with a record of collaboration to implement technology; (b) organizational support of ORPRN; and (c) scientific expertise of University faculty in computer science, informatics, medicine, nursing, pharmacy, and epidemiology.

Using IT to Improve Medication Safety for Rural Elders - 2008

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    HS04-011: Transforming Health Care Quality through Information Technology (THQIT)
  • Grant Number: 
    UC1 HS 014928
  • Project Period: 
    09/04 – 09/08, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,496,748
  • PDF Version: 
    (PDF, 60.35 KB)


Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Synthesis and Dissemination

Summary: People with multiple chronic conditions typically receive care from many physicians, nurses, pharmacists, and other clinicians practicing in diverse settings such as primary care clinics, specialty clinics, hospitals, nursing homes, home health agencies, and various pharmacies. Each of these clinicians or organizations generally maintains a medication list, in many cases electronic, designed to support a specialized role such as prescribing, dispensing, administering, or monitoring medications. These medication systems also are designed to support related business practices of the organizations, such as inventory and quality control. However, the medication management work practices of these historically independent organizations are rarely integrated, and their medication information systems are not designed to interact or exchange information electronically. Traditionally, this medication information moves, as one clinician put it, “by foot, phone, or fax.” As a result, the medication lists that these organizations maintain do not match, and discrepancies between these lists are a threat to patient safety and the quality of care.

The clinical setting for the project was long-term care of elders with multiple chronic conditions in assisted living and skilled nursing facilities in a rural community on the Oregon coast. This project was essentially an attempt to build a mini-regional health information organization (RHIO) focused on medication management. The project involved developing a novel technology, RxSafe, which brings together the medication information contained in the diverse and isolated information systems of multiple independent organizations (clinics, hospital, pharmacies). This enables authorized clinician users to obtain a more complete picture of each patient’s medications and to use this information for clinical tasks.

Formative evaluation of the prototype application was conducted in fall 2005 using qualitative methods approximately 1 year after initial deployment. In general terms, the intended outcome was to provide a medication management tool that clinical users would adopt into work practices and that would be sustainable on the basis of the preferences of clinical users and commitment from the local organization. Though this Agency for Healthcare Research and Quality-funded technology implementation project concluded as of September 2008, the technology remains in local use, and refinement of the system continues. Further development of the technology is underway as part of a subsequent project, with plans to make selected functionality available as Web-based application services that can be used to support medication management technologies under development by others.

Specific Aims

  • Create and maintain an organizational structure that would permit secure sharing of patient data across disparate institutions. (Achieved)
  • Design and implement a technical architecture that could enable clinicians to view medication list information from multiple sites at the same time. (Achieved)
  • Create a useful and usable prototype application integrated into clinical workflow that could take advantage of this shared medication list system. (Achieved)
  • Conduct a formative evaluation of the impact of this system on clinical users. (Achieved)

2008 Activities: The project achieved each of its aims during 2008, including:

  • Maintaining the organizational structure for the project through: 1) ongoing meetings with the local Chronic Care Committee, which served as a Community Advisory Board to the project; 2) regular contact between project staff and clinician users; and 3) responding to change in ownership of the main pharmacy collaborator to the project, requiring reestablishment of the agreements necessary to share patient medication information.
  • Continuing development of the technical architecture that connects participating medication information systems, including: 1) continuing work on parsing medication information in text output from some participating organizations; 2) revising the integration of hospital discharge medication information in concert with revised hospital discharge work process; and 3) expansion of the patient coverage to include a broader population of patients cared for by providers in participating clinics.
  • Expansion of the usability and usefulness of the prototype application through: 1) installation of the prototype, at the request of nursing staff and management, in additional nursing units such as day surgery; 2) modification of the report format to match changing requirements determined by changes in hospital medication reconciliation procedures; and 3) providing ongoing technical support to maintain system stability and respond to user concerns.
  • Formative evaluation was conducted in the form of interviews with nurses, physicians, management, and support personnel to identify perceived benefits, limitations, and impacts of the system. Analysis of these data was performed. Final reporting of these findings is underway at the end of the grant period.

Impact and Findings: The RxSafe project was essentially an attempt to build a mini-RHIO focused on medication management. As such, like so many projects that attempt to create a health information exchange, the RxSafe project had both successes and failures. The project team failed to successfully engage the entire group of organizations that would need to participate in order to achieve the vision of a shared medication management system. In addition, they also failed to achieve the complete technical integration of the medication information into existing information systems that had been part of their original vision. On the other hand they were successful at: 1) engaging active community involvement, 2) forming a core group of participating organizations that actively contributed both data and expertise to the project, 3) successfully implementing a prototype application which clinical users found useful and usable in common clinical tasks, and 4) conducting formative evaluation of the impact of the system. The RxSafe project demonstrated the feasibility and usefulness to clinicians of a shared medication management technology. The project also identified two formidable barriers to progress: 1) the absence of universally adhered to technical standards for exchange of health data (technical interoperability) and 2) the absence of a health care policy and regulatory environment that ensures true portability of each patient’s health information (organizational interoperability).

Selected Outputs

Bhupatiraju RT, Gorman P. "Doing the yellows" -- analysis of medication review processes by different clinicians in long term care. AMIA Annu Symp Proc; 2008 Nov 6:879.

Available at: Oregon Health and Science University. Welcome to RxSafe. http://www.ohsu.edu/RxSafe/index.html.

Grantee’s Most Recent Self-Reported Quarterly Status: The project concluded in September 2008, having met major milestones established in a revised project plan formulated midway through year 2 of the project.

Milestones: Progress is on track in some respects but not others.

Budget: On target.

Using Information Technology (IT) to Improve Medication Safety for Rural Elders - Final Report

Citation:
Gorman P, Ordelheide K. Using Information Technology (IT) to Improve Medication Safety for Rural Elders - Final Report. (Prepared by Samaritan North Lincoln Hospital under Grant No. UC1 HS014928). Rockville, MD: Agency for Healthcare Research and Quality, 2008. (PDF, 266.5 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
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This project does not have any related survey.

Making Medication Safe for Elderly People in Long-Term Care

High-tech champions often enthuse about the potential of electronic medical record systems, automated order entry programs, and other computer-based tools to reduce medication errors. But investigators for a project in Lincoln City, Ore., supported by a grant from the Agency for Healthcare Research and Quality (AHRQ), are finding that, when it comes improving medication safety at the community level, relationship-building -- not technology -- may hold the key.

Researchers from Samaritan North Lincoln Hospital, a facility of Samaritan Health Services, and Oregon Health & Science University (OHSU) are leading the AHRQ project, which focuses on ways to use information technology (IT) to improve medication safety for the chronically ill elderly.

The complex and ambitious project involves sharing proprietary information among numerous players -- some more accustomed to competing than collaborating -- working together to implement a master medication list for patients in assisted living and skilled nursing facilities. Among the 20 or so entities involved in the AHRQ-funded project are the pharmacies at the corporate giants Safeway, Rexall, and RiteAid, as well as numerous hospitals, long-term care facilities, and physician's offices.

Medication safety is a critical issue for older adults. Yet administering medications properly to patients in long-term care facilities is fraught with challenges. "The moments of transferring a patient from a hospital to a nursing home involve many risks. The patient's medication list goes through so many hands, and fax machines get a real work-out, as information is updated and passed among nurses, doctors, and pharmacists," says Karl Ordelheide, M.D., the AHRQ project's co-principal investigator and a physician at Lincoln City Medical Center.

To complicate matters further, computers at pharmacies, long-term care facilities, hospitals, and physicians' offices don't "talk" to one another. This means that if a pharmacist or nurse spends an hour updating a patient's medication information, all of that labor may have to be repeated, because there is no guarantee that the other parties involved have access to the new data.

National studies show that adverse drug events are common in skilled nursing facilities, with approximately 350,000 adverse events annually. Over 50 percent of those are preventable. To best avoid medication errors, researchers involved in the AHRQ-funded project are testing a real-time IT program that will help deliver medication data to project participants.  Next year, after the program is ready for broader application, the program will be pilot tested with 150 patients to measure its effectiveness.

"Our new system will allow access to the medication lists from all involved parties--the doctors' offices, long term care facilities, and pharmacies. The goal is to get everyone on the same page prescribing, dispensing, administering, and monitoring patient medication information," says Paul Gorman, M.D., co-principal investigator and associate professor at OHSU.

But before the project reaches that point, the researchers must clear several hurdles. First, although national standards have been proposed, they are not ready for prime time, says Gorman. That makes it difficult to devise a program that might fall short of federal guidelines, once they are in place. The second hurdle involves the regulatory complexities of the federal Health Information Privacy and Protection Act (HIPAA).  "We must get 20 different organizations to agree on how to interpret HIPAA regulations to protect patient privacy. And as clear as these regulations try to be, each group will interpret them differently," Gorman says.

The third major hurdle involves breaking down competitive barriers among the project's participants. While senior care, hospitals, and rehab facilities are accustomed to sharing pharmaceutical data with one another, commercial pharmacies are not. "They are bitter rivals," Ordelheide notes. "The most treasured item to some of these companies is their database, and it's tough to get people to open up their computers. A large part of our challenge is to create a new set of relationships among these parties, to get them to trust one another."

Just getting them to agree to a time and sit down at a table together is tough, so Ordelheide communicates the old-fashioned way: by canvassing pharmacies in person. "I stop by the pharmacies once a week and chat with the pharmacists to keep them interested in the project. I call the out-of-town pharmacies once a week," he says. "It's about being persistent." That persistence is paying off, as half of the organizations that initially expressed interest during the planning process have signed business agreements to participate. And when one of the ultra-competitive pharmacies signs on, the rest will follow, Ordelheide predicts. "They'll all want to play. It's all part of their competition -- they want to keep up with each other."

Ultimately, the project will implement real-time, electronic prescribing among the major players in Lincoln City, which will serve as a model for replication by other communities. The data likely will be housed at a neutral location, such as the AHRQ-funded Oregon Rural Practice-based Research Network. The long-range goal is for the electronic prescribing system to serve as an information source to survey pharmaceutical use, conduct epidemiological studies, and to act as a disease registry.

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The AHRQ grant was awarded to Samaritan North Lincoln Hospital, a facility of Samaritan Health Services. Other organizations involved in the project include Oregon Rural Practice based Research Network, Lincoln City Medical Center, Bayshore Family Medicine, Hillside House Assisted Living Facility, Lincoln City Rehabilitation, Lincolnshire Retirement & Assisted Living. OHSU Department of Medical Informatics and Clinical Epidemiology, Oregon Graduate School of Science and Engineering of OHSU, Center for Evidence Based Policy.

Four pharmacies located in Lincoln City, Safeway, Bimart, RiteAid, and Rexall, and two pharmacy services providing medication for assisted living and skilled nursing facilities, Senior Pharmacy and Preferred Pharmacy, are also participating.

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This project does not have any related emerging lesson.