Tamblyn R et al. 2003 "The medical office of the 21st century (MOXXI): effectiveness of computerized decision-making support in reducing inappropriate prescribing in primary care."
Reference
Tamblyn R, Huang A, Perreault R, et al. The medical office of the 21st century (MOXXI): effectiveness of computerized decision-making support in reducing inappropriate prescribing in primary care. Can Med Assoc J 2003;169(6):549-556.
Abstract
"Background: Adverse drug-related events are common in the elderly, and inappropriate prescribing is a preventable risk factor. Our objective was to determine whether inappropriate prescribing could be reduced when primary care physicians had computer-based access to information on all prescriptions dispensed and automated alerts for potential prescribing problems. Methods: We randomly assigned 107 primary care physicians with at least 100 patients aged 66 years and older (total 12,560) to a group receiving computerized decision-making support (CDS) or a control group. Physicians in the CDS group had access to information on current and past prescriptions through a dedicated computer link to the provincial seniors' drug-insurance program. When any of 159 clinically relevant prescribing problems were identified by the CDS software, the physician received an alert that identified the nature of the problem, possible consequences, and alternative therapy. The rate of initiation and discontinuation of potentially inappropriate prescriptions was assessed over a 13-month period. Results: In the 2 months before the study, 31.8% of the patients in the CDS group and 33.3% of those in the control group had at least 1 potentially inappropriate prescription. During the study the number of new potentially inappropriate prescriptions per 1000 visits was significantly lower (18%) in the CDS group than in the control group (relative rate [RR] 0.82, 95% confidence interval [CI] 0.69-0.98), but differences between the groups in the rate of discontinuation of potentially inappropriate prescriptions were significant only for therapeutic duplication by the study physician and another physician (RR 1.66, 95% CI 0.99-2.79) and drug interactions caused by prescriptions written by the study physician (RR 2.15, 95% CI 0.98-4.70). Interpretation: Computer-based access to complete drug profiles and alerts about potential prescribing problems reduces the rate of initiation of potentially inappropriate prescriptions, but has a more selective effect on the discontinuation of such prescriptions."
Objective
"To assess whether inappropriate prescribing would be reduced when primary care physicians had access to information on all prescriptions dispensed to their elderly patients."
Type Clinic
Primary care
Size
Small, medium and large
Geography
Urban
Type of Health IT
Decision support system
Electronic medical records (EMR)
Type of Health IT Functions
"Physicians in the CDS group obtained information on each patient by downloading updates of dispensed prescriptions from the [Regie de l'assurance maladie du Quebec] RAMQ drug-insurance program. These data were integrated into the patient's health record and categorized as having been prescribed by the study physician or by another physician. Alerts were instituted to identify 159 clinically relevant prescribing problems in the elderly, a list established previously by expert consensus: 26 problems were related to drug-disease contraindications, 23 to drug interactions, 17 to drug-age contraindications, 3 to duration of therapy and 90 to therapeutic duplication. The alerts appeared when the electronic chart was opened, when prescription-record updates were downloaded from the RAMQ, and when current health problems and prescriptions were recorded by the physician in the chart. Each alert message identified the nature of the problem and possible consequences and suggested alternative therapy in accordance with the expert consensus."
Context or other IT in place
"Each physician was given a computer, a printer, health record software and dial-up access to the Internet. The health record software documented health problems and medications prescribed."
Workflow-Related Findings
"During the study, the rate of initiation of an inappropriate prescription was significantly lower (18%) in the CDS group than in the control group. This trend was evident for drug-disease contraindications, drug-age contraindications, excessive duration of therapy and therapeutic duplication and was significant for drug-age contraindications and excessive duration of therapy."
"A physician's previous computer experience influenced the effectiveness of CDS. Among experienced computer users the rate of initiation of inappropriate prescriptions was 30% lower in the CDS group than in the control group (RR 0.70, 95% CI 0.55-0.89). Among the computer beginners the rate of initiation of inappropriate prescriptions was virtually identical in the 2 groups (RR 1.03, 95% CI 0.82-1.29)."
"CDS had no significant impact on the discontinuation of pre-existing inappropriate prescriptions. Although more patients in the CDS group than in the control group had all inappropriate prescriptions discontinued (47.5% v. 44.5%; or 35.5 v. 32.1 per 1000 visits; RR 1.14; 95% CI 0.98-1.33), the 14% difference was not statistically significant. The only substantially higher discontinuation rate for a specific prescribing problem was for drug interactions: 68.6 v. 51.5 per 1000 visits in the CDS and control groups respectively."
"Most of the therapeutic duplications and drug interactions occurred because prescriptions were written by both the study physician and another physician or another physician alone ... [With one exception], discontinuation rates in the CDS group were systematically higher for problems created by the combination of prescriptions from study physicians and other physicians than for the other types of prescription problems."
"[The pattern of] selectively greater impact of CDS on the initiation of inappropriate prescriptions than on the discontinuation of existing ones... was [also] observed in a drug review trial, in which physicians were reluctant to stop drug therapy, even when they agreed with the consulting pharmacist's recommendation, because of concerns for patient resistance or discomfort in discontinuing therapy prescribed by another physician. Physicians in the CDS group expressed similar concerns, particularly in relation to drugs prescribed by other physicians. [W]e found that the perception of responsibility for patients' treatment varied among the physicians...This lack of clarity in responsibility likely had an impact on the action taken when physicians identified problematic prescriptions." There is a lack of communication of who is responsible for making changes.
"22% of the physicians experienced frequent hardware or software failure in the early months of the study; the proportion declined to 4% by month 6. Physicians in the CDS group downloaded prescription information in 81% of the study weeks; however, those who had more computer problems downloaded information less often (r = -0.31)."
Study Design
Randomized controlled trial (RCT)
Study Participants
Eligible physicians were "general practitioners 30 years of age or older who had practices in Montreal, spent at least 70% of the week in private fee-for-service practice and had a minimum of 100 elderly patients." Of the eligible 440, 127 agreed to participate and the first 107 were chose to take part in the study.