Beyond ePrescribingFactors Influencing Patient Safety in Medical Group Practices - September 26th, 2007AHRQ 2007: Improving Healthcare, Improving LiveLarry Garber, M.D. – Medical Director for Informatics

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Overview

• Sources of Adverse Drug Events (ADE’s) in the ambulatory setting

• Reducing anticoagulant-related ADE’s• Future plans and barriers to reducing

ADE’s

SourceSource Total ADEsTotal ADEs Preventable Preventable (%)(%)

ER notesER notes 187187 37%37%

Hospital D/C’sHospital D/C’s 166166 35%35%

Computer Computer signalssignals

439439 34%34%

Electronic notesElectronic notes 565565 20%20%

Provider reportsProvider reports 168168 15%15%

Incident reportsIncident reports 55 60%60%

Sources of ADE Information

Field, TS et al. JAMIA 2004;52:1349-1354.

ADE Rates in the Ambulatory Setting

• ADEs:50 per 1000 person-years

• Preventable ADEs:14 per 1000 person-years (28%)

• Extrapolated to total Medicare 65+:1,446,949 ADEs per year438,046 preventable ADEs/year

• This is likely to be an underestimate

Gurwitz JH et al JAMA 2003;289:1107-1116

Financial Cost of ADE’s

0.00

500.00

1000.00

1500.00

2000.00

2500.00

12-11 10-9 8-7 6-5 4-3 2-1 1-2 3-4 5-6 7-8 9-10 11-12

Pre-Period Post-PeriodDay of the ADE

Weeks Before and After Date of ADE

Field TS, et al Medical Care 2005;43:1171-6

Financial Cost of ADE’s

• Increase in costs after an ADE: $1310Increase after a preventable ADE: $1983

• Extrapolated to 1000 adults age 65+Costs per year to treat preventable ADEs:$27,365

ADE Severity in the Ambulatory Setting

Fatal 0.6%

Life-threatening

11.1%

Serious 28.3%

LessSerious

60%

Severity & Preventability

Preventable52%

Of fatal & life-threatening events

Preventable20%

Of less serious events

Source of Errors

Other19%

Ordering39%

Monitoring42%

So where do you start?

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Fallon Approach to Preventing ADE’s

• First target the Fatal & Life-Threatening preventable ADE’s Warfarin

• Then do a system-wide solution for the others

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Preventing Warfarin ADE’s

• Ordering/Prescribing ePrescribing with drug interaction

checking Simplified referrals to Anticoagulation

Clinic

• Monitoring Converted Anticoagulation Clinic to Epic’s

EHR Simplified tracking of lab no-shows

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Full dosing information is entered and available to be seen by all physicians and staff

Date of next INR is entered to trigger tickler system

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INR Reminder automatically appears in the Anticoagulation Clinic In-basket on the patient’s due date, and doesn’t disappear until the due date is changed

INR Reminder automatically appears in the Anticoagulation Clinic In-basket on the patient’s due date, and doesn’t disappear until the due date is changed

Preventing Other ADE’s

• Use probabilistic risk assessment to: characterize systemic and behavioral

elements that increase of ADE’s during ordering/monitoring

identify potentially high-yield and likely-to-be-successful interventions

• Estimate likelihood that interventions at any given step would be successful in reducing errors at that step

• Select interventions for implementation19

Field TS et al AHRQ Grant # 1P20HS017109-01

Barriers to preventing ADE’s

• Most organizations don’t have EHR’s• ePrescribing doesn’t solve the

monitoring problem• Many EHR’s don’t currently have the

functionality to provide alerts for missing events without being in the context of a patient encounter

• MD compliance• Time and money required to build

interventions20

Summary:

• ADEs are common and often preventable

• Types of errors suggest focus on prescribing and monitoring Provision of information to physicians and

assistants at right time, right place…Use of automated tickler systems

• Costs are high and savings from preventing ADEs could partially offset costs of interventions

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Questions?

Larry Garber, M.D.Lawrence.Garber@FallonClinic.org

Special thanks to Terry Field, PhD and Jerry Gurwitz, M.D. for their assistance on this presentation and never-ending work to

study and prevent ADE’s