jlassiter's blog

Under DEA regulations that took effect June 1, e-prescribing of controlled substances is now permitted in the United States. All the dust has not yet settled, however; APhA joined with other pharmacy associations to suggest ways that the process could be improved. In addition, software developers may need at least a year  to make the updates to computer systems that will allow prescribers to transmit scheduled medication orders, intermediaries to process the prescriptions, and pharmacies to receive them.

DEA has been moving for years toward allowing e-prescribing of controlled substances. The latest push began in June 2008 when the agency announced its intention to create an alternative to manual prescriptions. After the February 2009 economic stimulus act created incentives for increased use of health information technology by physicians, pressure increased for DEA to offer a structure for e-prescribing.

As pointed out in the article, pharmacists may not have to opportunity review a electronically submitted controlled substance prescription for 6-12 months, until this new process has sufficient time to be implemented. However, this is a long overdue - and welcome - policy change.

For additional information from the DEA, navigate your browser to the following site: http://www.deadiversion.usdoj.gov/ecomm/e_rx/index.html

The National Institutes of Health (NIH)/National Library of Medicine (NLM) released a BETA version of a tool to help patients and healthcare providers identify medications via its physical properties (e.g., shape, color, imprint) and provide with FDA content consisting of links to medication information and labeling.

Although this tool is not really ready for full-time, clinical use - as evidenced by the disclaimer and the broken URLs - this has the potential to be a very helpful tool, free of subscription fees.

Lastly, I see projects like these as further evidence that the demand for informatics-trained clinicians will far exceed the supply in the marketplace.

Although this is a PhRMA sponsored (sanofi-aventis) iPhone application, it appears to be very helpful and useful for on-the-go tracking of nutritional information. It seems designed specifically for diabetic patients, however, its uses appear to extend to any disease state where managing nutrition is important (e.g., hypertension, hyperlipidemia, metabolic syndrome, etc.).

I would consider this app in the realm of telemedicine - or at least mobile health - and the only suggestion I have for improvement, at first glance, is the ability to export or somehow otherwise share this information with healthcare providers.

Follow-up visits conducted via a secure Web site may result in similar clinical outcomes as in-person visits among patients with acne, according to a report in the April issue of Archives of Dermatology, one of the JAMA/Archives journals.

'Ensuring timely access to high-quality care is currently a challenge for the stressed U.S. health care system. Many specialities, including internal medicine, psychiatry and dermatology, are struggling to accommodate a growing demand for appointments owing to a critical shortage of health care providers,' the authors write as background information in the article. Dermatology, in particular, faces challenges such as an increase in skin cancer and a work force that is not equally distributed geographically. 'One potential solution to these issues may be the adoption of innovative, technology-enabled models of care delivery.'

'In this trial, delivering follow-up care to subjects with mild to moderate acne via office and online visits produced equivalent clinical outcomes by several different metrics,' the authors conclude. 'These findings suggest that dermatologists obtain sufficient information from digital images and survey responses to make appropriate management decisions in the treatment of acne. In addition, this model of care delivery was popular with both physicians and patients, likely owing to the convenience and/or time savings associated with e-visits.'

Although this article discusses follow-up care for a fairly benign condition - mild to moderate acne - it highlights the growing need for, and benefits of, telemedicine.

Health information technology: A new world for pharmacy

AUTHORS: Lisa Webster, BPharm, MS, and Rachelle F. Spiro, BPharm, FASCP

Activity Preview

This article provides a primer on Health Information Technology (HIT) for pharmacists, including the current state of HIT, future expectations, and strategies to ensure success.

Learning Objectives After participating in this activity, the pharmacist will be able: List at least five ways in which health information technology (HIT) is predicted to improve patient care. Provide at least five ways in which patient care might be at risk as a result of the adoption of HIT. Discuss six actions that pharmacists can take to help prevent patient harm related to the implementation and use of converging technologies. List four reasons for physician resistance to HIT implementation. Name six organizations involved in the development of HIT standards. State seven ways in which HIT is expected to benefit U.S. patients.

[note: free subscription required to access CPE activities]

Objective: To examine whether physicians' use of information technology (IT) was associated with better knowledge of drug costs.

 

Study Design/Methods: A 2007 statewide survey of 247 primary care physicians in Hawaii regarding IT use and self-reported knowledge of formularies, copayments, and retail prices.

 

Results: Approximately 8 in 10 physicians regularly used IT in clinical care: 60% Internet, 54% e-prescribing, 43% electronic health records (EHRs), and 37% personal digital assistants (PDAs). However, fewer than 1 in 5 often knew drug costs when prescribing, and more than 90% said lack of knowledge of formularies and copayments remained a barrier to considering drug costs for patients. In multivariate analyses adjusting for sex, practice size, years in practice, number of formularies, and use of clinical resources (eg, pharmacists), use of the Internet—but not e-prescribing, EHRs, or PDAs—was associated with physicians reporting slightly better knowledge of copayments (adjusted predicted percentage of 23% vs 11%; P = .04). No type of IT was associated with better knowledge of formularies or retail prices.

 

Conclusions: Despite high rates of IT use, there was only a modest association between physicians’ use of IT and better knowledge of drug costs. Future investments in health IT should consider how IT design can be improved to make it easier for physicians to access cost information at the point of care.

While we work to refine the Google Health product, we also continue to pursue integration agreements with providers to make it even easier for people to access their own medical information. We've learned over these past two years that getting a current and past medication history assembled and ready in case of emergencies is one of the strongest value propositions for using an online Personal Health Record (PHR). So today at HIMSS, we're announcing an integration with Surescripts, the leading electronic prescribing network in the United States, to help accelerate the availability of prescription drug history to our users. The Surescripts network connects doctors who prescribe medication to all of the nation’s major pharmacy chains, leading health insurance plans and pharmacy benefits managers (PBMs), as well as more than 10,000 independent pharmacies nationwide. Surescripts provides access to prescription benefit and history information on behalf of health insurance plans representing 65 percent of patients in the U.S.

I am glad to see this announcement as we need more integration and development of PHRs.

PracticeRx by Doctor’s Digest delivers real time breaking news about medication safety (including instant alerts and hazard alerts of National Importance) to your iPhone/iPod Touch, PLUS the latest practice management and medication safety tips and instant error reporting tools from Doctor's Digest and the Institute for Safe Medication Practices (ISMP).

Doctor’s Digest and ISMP Essential Practice Tips, with links to FREE ISMP medication safety material, and in-depth information on the same or other practice-management topics at www.doctorsdigest.net. Tips will be uploaded twice weekly and are based on cutting-edge information from over 1,600 thought leaders and experts from the Doctor's Digest practice management medical journal and the latest medication safety expertise from ISMP, available in text, audio and video format.

MERP - Medication Errors Reporting Program – - A direct link to a HIPAA-compliant error reporting form from ISMP with three options right from this App: NOW…report errors via one-touch direct dial directly to ISMP, leave a voice-recording, or complete a HIPAA-compliant form.

ISMP – MedSafety Alerts -- Audio Alert accompaniment of urgent drug alerts in real time.

...More

Very cool [free] new application for iPhone - and, eventually, for the iPad - that has built int medication safety information and reporting from ISMP.

Recent passage of the American Reinvestment and Recovery Act (ARRA) increases pressure on health care practitioners and organizations to implement currently available electronic health records (EHRs). Research and experience gained to date show that such implementation efforts are difficult, costly, time-consuming, and fraught with many unintended consequences.¹ Evaluation of these systems after implementation suggests that they do not routinely meet safety standards of other safety-critical industries.² The aggressive timeline proposed in the ARRA bill means that a large number of practitioners and health care organizations will soon be attempting a monumental feat without the time or ability to customize these systems to their local workflows.³

Pfizer announced today results of a survey the company recently sponsored that shows physicians are more likely to report side effects through an electronic health records (EHR) system, as compared to traditional paper methods. Nearly 60 percent of physicians who responded to the survey also agreed that adverse event reporting through an EHR system would improve patient care.

“Patient safety continues to be a top priority at Pfizer,” said Freda Lewis-Hall, MD, Pfizer’s chief medical officer. “This survey furthers our understanding about how we can best use electronic health records systems to collect critical information about the safe and appropriate use of our products so that we can improve patient safety.”

Of the 300 physicians surveyed, two-thirds utilized some form of an EHR system and one-third used a paper-based system. Half of all respondents and 60 percent of fully-functional EHR users reported that they would be much more likely to submit information about adverse events using an EHR system. Of those still using paper-based systems, 80 percent cited cost as a deterrent to investing in an EHR system.

Ipsos conducted the survey online among primary care physicians in the United States who were categorized as basic electronic health record users, fully functional electronic health record users or paper health record users. The research was conducted during September and October 2009.

Epocrates®, Inc., today announced its top-ranked clinical reference application for the iPhone® and iPod® touch devices will be customized for the new iPad™ computer tablet. The iPad is already receiving a warm reception from the healthcare industry with nearly 20 percent of clinicians expressing plans to purchase in an Epocrates survey conducted days after the Apple announcement.

"By optimizing our software for the iPad, we are capitalizing on the larger screen real estate and interactivity provided by this sophisticated device. We are committed to providing the most productive experience at the point of care, keeping physicians informed and focused on the patient rather than searching for answers," said Rose Crane, chief executive officer of Epocrates. "We are continuing to explore the advanced capabilities of the iPad and ways it can help Epocrates address the evolving healthcare technology needs."

In addition to announcing its engineers are using Apple's SDK to optimize Epocrates' offerings for the iPad, Epocrates surveyed more than 350 clinicians to gauge their interest in the new tablet. Findings include:

• Nine percent of survey respondents plan to buy the iPad when it was immediately available,
• Another 13 percent plan to buy it within the year,
• Thirty-eight percent of respondents expressed interest in the iPad with the request of more information to solidify their purchase decision.

I suspect that we'll see a lot of uptake by providers, however, I wonder if our health-systems' IT infrastructures are ready for the demand?

Nintendo Co. and Apple Inc. are helping drugmakers find new ways to get their products to customers as health-policy changes and new technologies force them to move beyond traditional marketing methods, audit firm Ernst & Young said in a report today.

Bayer AG, Germany’s biggest pharmaceutical company, has hooked its Didget glucometer to Nintendo’s video-gaming devices to encourage children with diabetes to monitor their blood sugar regularly. Johnson & Johnson is working with Apple to create an iPhone application that allows patients to upload and share their glucometer data.

Once again, another great opportunity for informatics pharmacists - and other clinicians - to help meet the needs of industry while making sure these types of projects are beneficial to unmet patient needs.

But for doctors treating patients with chronic diseases, text messaging can be an invaluable tool, according to Johns Hopkins Children’s Center pediatrician Delphine Robotham. “For better or worse, this technology is here,” she said, “and sending a text to a patient’s cell phone about an upcoming appointment or a test, or simply to remind them to take their meds, is a great example of how we can harness new communication technology for a greater good.”

Research has shown that up to half of patients may fail to take their daily medication properly, with forgetting being a top reason for nonadherence so, at least in some cases, a text reminder may be all that a patient needs, added Robotham, who has encouraged the use of appropriate texting among pediatricians at Johns Hopkins.

Several recent studies have looked at use of SMS (short message service, or text messaging) in a medical context, Robotham notes. For example, one study involving children with diabetes showed improved blood glucose testing rates among those using it. These children were also more likely to share their blood glucose test readings with their doctor’s office. In another study, patients on immunosuppressive drugs after a liver transplant had improved medication adherence. The liver study detected measurable clinical benefits from text messaging: Acute liver rejection episodes dropped dramatically as a result of better medication adherence. Chronic conditions that require daily medication, such as HIV, asthma and TB, or daily testing, such as diabetes, are great candidates for “SMS therapy,” Robotham said.

HITSP Chair Dr. John Halamka: “The iPad comes closer to my requirements than other devices on the market. However, the ideal clinical device would include a camera for clinical photography and video teleconferencing. Entering data via the touch screen with gloved hands may be challenging on a capacitance touch screen. Holding the iPad with one hand means hunt and peck typing with the remaining hand. The device is a bit large for a white coat pocket, may be hard to disinfect, and may not be tolerant of dropping onto a hospital floor. I look forward to trying one to validate these assumptions. My general impression is that it is not perfect for healthcare, but it is closer than other devices I’ve tried.” More (John D. Halamka, MD, MS is CIO of the Beth Israel Deaconess Medical Center, CIO and Dean for Technology at Harvard Medical School, Chairman of the New England Health Electronic Data Interchange Network (NEHEN), CEO of MA-SHARE, Chair of the US Healthcare Information Technology Standards Panel (HITSP), and a practicing emergency physician.)

Mountain View-based El Camino Hospital Vice Chief of Clinical Operations, Cheryl Reinking: “You could use this [iPad] in the operating room, when you need to document things quickly, or in the lab,” Reinking told the SF Chronicle. “Physicians could use the device at the bedside to make notes, or use it as a reference for medications. It could be an amazing tool.” More

Everyone talks about the capacity of cloud computing to transform government and reduce costs (one study estimates that federal agencies could eventually save 85% of their IT budgets by moving to the cloud). But the vast majority of the federal government's IT spending today is spent on traditional desktop or client-server computing. And until that changes, the federal government won't have the ability to tap the true potential of cloud computing.

That's why the inclusion of cloud computing in the Obama Administration's new FY 2011 budget is a big deal. Check out page 42 of the budget overview which identifies the problem:

A "PHR" is a Personal Health Record.  PHRs can collect and store official records, labs, tests, and claims data directly deposited by providers.  They can also store other health-related data such as heart rate, glucose levels, medications, allergies, exercise habits, lifestyle, sexual history, personal notes and other data you create.

The term 'PHR' implies you control this type of electronic health record - because its 'personal,' it's yours.  But that is simply not true of all PHRs.

How much control do you really have?

Think twice about who you allow to see, use, or control your most sensitive, personal health records, from DNA to prescriptions. Patient Privacy Rights (PPR) did our best to decode PHR privacy policies and spell out what control you have over your information.  PPR makes no recommendations on specific PHRs.  The Report Card is our opinion based on the information available on these companies' websites.

Interesting review from the Patient Privacy Rights (nonprofit) organization [1].

Spoiler: the current PHR offerings reviewed don't fare too well.

[1] "Patient Privacy Rights (PPR) works to empower individuals and prevent widespread discrimination based on health information using a grassroots, community organizing approach. We educate consumers, champion smart policies and expose and hold industry and the government accountable."

The Department of Health and Human Services (HHS) expects to award in March $60 million to universities and research centers to support the adoption and meaningful use of health information technology (IT). The Strategic Health IT Advanced Research Projects (SHARP) program is designed to address existing barriers in the following four areas:

• Security and risk mitigation policies and the technologies deemed necessary to build and preserve the public trust as health IT systems become ubiquitous.

• Patient-centered cognitive support to harness the power of health IT in a patient-focused manner and align the technology with the day-to-day practice of medicine to support clinicians as they care for patients.

• New and improved architectures necessary to achieve electronic exchange and use of health information in a secure, private, and accurate manner.

• Strategies to enhance the use of health IT in improving the overall quality of healthcare, population health, and clinical research while protecting patient privacy.

10. Usability - products are hard to use and not well engineered for clinician workflow.

9. Politics/naysayers - every organization has a powerful clinician or administrator who is convinced that EHRs will cause harm, disruption, and budget disasters.

8. Fear of lost productivity - clinicians are concerned they will lose 25% of their productivity for 3 months after implementation. Administrators are worried that the clinicians are right.

7. Computer Illiteracy/training - many clinicians are not comfortable with technology. They are often reluctant to attend training sessions.

6. Interoperability - applications do not seamlessly exchange data for coordination of care, performance reporting, and public health.

5. Privacy - there is significant local variation in privacy policy and consent management strategies/

4. Infrastructure/IT reliability - many IT departments cannot provide reliable computing and storage support, leading to EHR downtime.

3. Vendor product selection/suitability - it's hard to know what product to choose, particularly for specialists who have unique workflow needs

2. Cost - the stimulus money does not flow until meaningful use is achieved. Who will pay in the meantime?

1. People - its's hard to get sponsorship from senior leaders, find clinician champions, and hire the trained workers to get the EHR rollout done. (this was the #1 concern by far)

Great post from Dr. Halamka; a nice succinct "cheat sheet" for the [predictable] implementation barriers.