At OntarioMD, we talk frequently about how we add value to the health care system by helping physicians and stakeholder partners realize digital health’s tremendous potential to improve efficiency, reduce wait times, and improve population health management and patient outcomes. That’s a key focus of our 2017-2020 Strategic Plan, and is interwoven in everything we do.
But what does this mean in practice, exactly? It means that each offering under OntarioMD’s products and services umbrella – whether it’s something developed in-house like Health Report Manager, or a product like eConsult that our head office staff and field teams deploy on behalf of one of our partners – needs to meet these objectives. And it means that the primary care providers that look to OntarioMD as a trusted advisor are confident we’ve done the work needed to ensure the products and services we bring to their practice will help them with patient care and practice efficiency.
Our ongoing work on the EMR Quality Dashboard initiative is a prime example of the rigorous testing and analysis we apply to ensure our offerings aren’t simply digital health tools, but innovations that integrate and add value to the system. We launched a proof of concept in 2015 to demonstrate how user-friendly dashboard tools use real-time EMR data for improved clinical outcomes and practice efficiency. In phase 1 of the proof of concept, we worked with vendor partners TELUS Health and OSCAR EMR, physician advisory board members and other health care sector stakeholders, to develop a framework that would allow clinicians to view their patients’ data measured against a range of widely-accepted health indicators, and to take immediate action by identifying patients in need of follow up.
We’ve since expanded both the number of health indicators incorporated into the dashboard and the number of participating clinicians. Today, more than 400 clinicians from across the province are participating in the proof of concept. Their feedback and experiences will be reflected in a benefits evaluation after phase 2 ends in December. But we already know that by using the dashboard to view their patient population data across indicators for conditions including smoking status, cancer and diabetes, participating clinicians can see and quickly respond to preventive care trends among their population.
They can also easily see where the data in the EMR appears to not match their patient care experience. For example, if the Dashboard shows that smoking status isn’t recorded for most patients, but the clinician knows it is, they can then take action to make sure the information is stored in the right place. An EMR’s potential can only be tapped into if data is being entered effectively.
In recognition of the importance of change management and ongoing support in the adoption of new tools, this initiative has incorporated the expertise of OntarioMD’s EMR Practice Enhancement Program (EPEP) practice advisors. They are deploying the Dashboard to all participating clinicians and supporting them in getting the most out of the tool. The EPEP process involves first analyzing a practice’s workflow and EMR data and then working one-on-one with clinicians to improve their data quality so that the patient information in their EMR can be effectively used for better patient care. When paired with a digital health innovation like Dashboard, that’s a powerful combination that can lead to better patient care for all.
We’re currently working on a business plan for the eventual province-wide availability of the Dashboard that will ensure that clinicians on all EMRs have access to both the tool and, crucially, the data quality support offered by OntarioMD’s EPEP team.
Front-line health care providers, quality improvement organizations, digital health delivery leaders and government recognize that digital health delivery has become an indispensable support to keep up with increasing health system demands. It is no longer imaginable that health care could be delivered without digital information technology to manage the array of information processed and recorded for patients every minute in Ontario physician practices, hospitals, home care, long-term care homes, public health units and health care provider practices across the continuum of care. All have adopted digital health tools, in varying degrees, to manage and support patient care.
There is a lot of discussion about what digital health doesn’t do yet – the promise not yet fulfilled, and definitely the glass half empty analogy. What about the glass half full? It is truly important to understand what digital health is doing every day in the health care system.
I’m going to focus on digital health in primary care because that is the area in which we spend our time as an organization. OntarioMD has been at the forefront to rollout digital tools and services across the province to support and enable efficient and effective practice and underpinning the delivery of excellent care to patients. We are known for our success in getting electronic medical records (EMRs) into the hands of community-based family physicians and specialists. From a province with one of the lowest adoption rates when our work began, to now one of the highest. How valuable are EMRs to the health care system? They’re more valuable than people may realize. More than 15,000 physicians and more than 1,100 nurse practitioners are using them to care for about 11 million Ontarians.
EMRs in primary care enable clinicians to manage your personal health information in a secure manner. EMRs require login credentials to access information, and no charts will be misplaced or lost. Protecting personal health information is critical to all of us. EMRs are the secure virtual filing cabinet to protect your information and make it accessible only to those to whom you give consent. We take privacy and security obligations very seriously and we offer a comprehensive program to enable physicians to stay up-to-date on their obligations and how to protect your information in their EMR systems.
Let’s say you were in the hospital emergency department last week and experiencing severe abdominal pain. If your physician used an EMR, they would be getting your discharge summary about your visit from the hospital directly to the EMR through OntarioMD’s Health Report Manager (HRM). They see your discharge summary in their EMR inbox, with a summary of your visit and it is increasingly likely that they may have called you for a follow-up appointment before you call the office.
Whether you are a patient with a single lab test or you require regular laboratory tests to be performed. Physicians are sent your results electronically by the laboratory, and they can also query OLIS (Ontario Laboratory Information System) to see your results. EMRs enable the physician to display results graphically, and this makes a lot easier to review trends in your results, supporting discussions about what might be working well or where attention needs to be focused.
Prescriptions generated and managed in EMRs provide extraordinary value. With an EMR, your physician can alert about drug indications or potential conflicts with current medications. Thousands of Ontarians experience adverse events due to drug interactions every year. EMRs have helped to reduce adverse drug events. It is one of the most valuable things digital health delivers for patients and the health care system.
If your physician wants to ask a specialist about something, he or she can make a request through an online portal and get an answer often in hours. This means you don’t have to wait for months and then take time away from family or work to go to a specialist for something that could have been dealt with by your family physician. OntarioMD is working with our partners in the Ontario eConsult Program to make it even easier for physicians to request an eConsult through their EMRs. This is just one of the ways we’re connecting the health care system to benefit patients.
Back to the glass half empty – can everyone in the health care system seamlessly exchange data electronically to care for patients? No, but we’re getting there. Ontario physicians understand that the way forward is digital. They see its value and potential by using their EMRs and connecting to OntarioMD products and services and those of our partners that augment the value of digital health to realize better patient outcomes and healthier Ontarians.
What about the physicians who use digital health and their needs? It’s great that they’re using digital health in increasing numbers to care for patients. We care about their workflows and ensuring that they get the training and ongoing support they need. We know that it is important to create capacity in a physician’s office to support their adoption and best use of digital health tools and services, all while they are getting on with their most important work – delivering excellent care to their patients.
Let’s keep working together to fill that glass and realize even more value for our health care system!
In this fourth entry in our video series on the EMR Quality Dashboard, OntarioMD CMO Dr. Darren Larsen discusses the importance of good data quality and how analytics can help patient care through population health management.
Contributed by Surya Qarin, OntarioMD Practice Management Assistant
Anyone that has known me long enough knows I have spent much of my life in and out of hospitals – and that’s not because the doctors are cute. As a matter of fact, Etobicoke General’s nurses and I are on a first name basis now, and they know exactly which vein works best when drawing blood, and which ones “hide.”
As a child, I was hospitalized every other week for severe asthma. It seemed to subside after I turned 12… at least I thought it did. I didn’t even think asthma was a real issue for adults. I’d always been told people outgrow it. But this is not the case: According to the Centers for Disease Control and Prevention, 9.7% of women aged 18 or older have asthma and are more likely to die of asthma than men. Adults are also four times more likely to die of asthma than children. Asthma Canada stats show that up to 250,000 Canadians are living with severe asthma.
Asthma returned to my life a few years ago, as a moderate condition. I had become more active, believing it would help with my other health issues (which it did). As long as I took my puffers before and after working out, I would not have any issues with breathing.
Then flu season hit, and I got sick a few times between December 2016 and February 2017. Those who know me understand my strong belief that I am super woman and do not like to complain about being sick or having “a little cold.” Unfortunately, this was not just a small cold: it had turned from a cold, to bronchitis, to full blown pneumonia by April 2017. Even then, I still refused to see a doctor. One day, on my drive home from work, I felt a sharp chest pain, and something didn’t seem right. I was not just having a little difficulty while breathing as I had been the last few months. I actually could not breathe.
Gasping for air, I pulled over, sent a quick text to my sister and drove to Humber River Hospital. There, I realized how difficult it would be for me to get my medical records: My family doctor was not affiliated with the hospital, nor was Etobicoke General. They were, however, able to pull my past drug history from my pharmacy and go based off that information. I was stabilized and discharged.
A few days later, my breathing difficulties returned. I went into Etobicoke General, and they were able to pull my history right away and admit me to hospital within the hour. Turns out my lungs had started shutting down due to the pneumonia and asthma, and as it was high-humidity and high-allergy season, being outside did not help me. During my stay in the hospital, my family doctor received hospital reports via Health Report Manager (HRM) and he was kept updated on my condition, as were my respirologist and cardiologist.
After a few weeks of recovery, I thought all was well. However, I caught a “cold” again in October, and this time things deteriorated fast! I ended up in hospital yet again. My respirologist was made aware of my condition in real time via the hospital’s EMR and was able to work with the other respirologist on duty and doctors working on my case to provide the best course of treatment given my history. My current spirometry test results were easily available for the clinicians, and the instant connectivity between those on my medical team helped improve my care and recovery process.
Once again, my family doctor’s ability to receive hospital reports to his EMR through HRM enabled him to follow-up accordingly, ensure I had the contacts I needed for my health, schedule regular testing, and most importantly, help ensure that I didn’t end up in the hospital again. I’m happy to say that I have not been hospitalized overnight since November of 2017.
As a member of the team at OntarioMD, I help clinicians across the province understand the value that EMRs and digital health tools such as HRM can bring to their practice and the quality of patient care they’re able to provide. But being a patient in the health care system has really demonstrated the importance of these tools to me first-hand. If you’re a clinician who has questions about optimizing your EMR use, or you want to connect to HRM or the wide range of other digital health tools in Ontario, contact OntarioMD at email@example.com.
Today’s Digital Health Shift vlog is the third in a video series of OntarioMD CMO, Dr. Darren Larsen, speaking about the EMR Quality Dashboard. In this segment, Dr. Larsen discusses how leadership and collaboration amongst health care organizations are driving change to benefit patient care.
Dr. Darren Larsen is Chief Medical Information Officer (CMIO) at OntarioMD. As CMIO, Darren provides clinical advice to many provincial and national steering committees and clinician advisory groups and has been instrumental in forging system-level partnerships in many sectors. Darren is a tireless champion of optimization of EMRs and health informatics in empowering Ontario’s physicians, with a focus on quality patient care and practice efficiency. He provides a clinician perspective and guides all aspects of OntarioMD’s work to evolve and advance EMRs and digital health for primary care and community specialist clinics. This includes clinical practice change, quality improvement, data quality and analytics, and EMR maturity measurement. He recently shared his insights with RDP Associates on the state of innovation in Canada’s digital health sector.
Canada’s biotech and health-tech industries are among the most dynamic and innovative sub-sectors of the tech industry. But despite its dynamism, scaling up and go-to-market remain pressing challenges. Why is that?
Indeed, Canadian minds are anteing up some amazing ideas in the digital health space. We have such a strong well to draw upon for creativity and innovation. There is an endless need for new products, services and thinking in health care, for patients, providers and the health system, yet despite the demand, it is incredibly hard to bring innovation to market. I frequently say that real change requires resolution not revolution, and it is hard to maintain excitement and enthusiasm when the system falls short of the needs of innovators beyond the ideation phase. The reasons for this are complex, but some key issues that we could collectively work on to try to improve the situation quickly bubble up.
a) There is very low tolerance for failure in health care. Some of this is predictable, based on clinicians’ training in evidence. Some fall at the health system level, where even small failures lead to blame rather than learning, and it often becomes a story on the front pages of a newspaper. Some of this is even cultural. As Canadians, we do not trust our own innovators until they have been proven in another market or immediately hit the news.
b) Our classic public-sector procurement rules are complicated and hard to navigate. This leads to a bias toward established companies which have greater capability to persist and respond.
c) There is a basic distrust of business in our socialized health care system. The private sector is viewed with suspicion, and the introduction of profit motives makes those of us who believe and have invested in socialized medicine, somewhat wary. We must find a middle ground.
d) Regulatory issues abound in health-tech, from Health Canada medical device status rules, to technical standards often being vague, to privacy legislation being used as an excuse to stop innovation even when it is designed to permit it.
e) The investment/venture capital landscape is different and less permissive in Canada than it is in the US. It is frankly easier to find investors and backers south of the border than it is within our own country.
f) The desire to take a chance on promoting and partnering with new companies is low in Canada. We are guilty of “death by a thousand pilot projects” and accept this as the norm. Most pilots are created to test a very narrow product or service window of safety rather than facilitate scale and spread of the same. Unlike in the start-up space, in healthcare, we lack the “fail fast and fail forward mentality”, which is essential to the innovative process.
Many government grants are generic, but some are industry-specific such as those for clean-tech and agri-tech. Do we need specific grants that target biotech and health-tech sectors to ease some of the challenges they’re facing?
This might well be an option to try. The use of grant money could be tied to co-design or creative procurement that does not predict the final end-point for a product, but rather allows it to evolve organically until it reaches a desired state or value. Design thinking methodology could, and likely should be placed into the grant awarding process. Technology engineers, designers, and providers must align to ensure that they have created a product or service that is actually needed. Then, a shift to value-based funding and support might ensure ongoing success. Currently, many innovation grants do not consider scale and spread of an idea or product. There are incubators that provide in-kind expertise rather than cash. And there are investors who want to see successful companies move forward. The sweet spot is combining these in partnerships.
How would you describe the relationship between the government and Canada’s tech sector including its startup community? Where do health-tech and health care fit into their dynamics?
I possess a cautious optimism in this space. There is certainly an increase in the promotion of start-ups and a growing community of innovators who network and learn from each other. Also, we are seeing some fantastic government-supported or -partnered innovation hubs like MaRS, McMaster Innovation Park, the BMZ and DMZ at Ryerson University, and Velocity at the University of Waterloo, which are great as examples in Ontario alone (and more nationally: Ontario even has a Chief Health Innovation Strategist in the Ministry of Health and Long-Term Care, William Charnetski. These are great starts, but these are early days and this is still nascent work. It will take a long time to change a culture.
Are there sub-sectors of Canadian healthcare that conduct a significant amount of R&D?
I see a lot of progress in Canada now with the creation of health care “living labs“. These are unique spaces where partnerships are used to test products in working environments like hospital units (Mackenzie Health, Southlake Hospital) or human-centred design spaces (UHN Centre for Global eHealth Innovation, JLabs by Johnson and Johnson, Bridgepoint Active Healthcare) or digital health evaluation spaces (MEDIC at Mohawk College, WIHV at Women`s College Hospital). These serve as platforms for integrated thinking about solving clinical problems using integrated technology, not as siloed projects that are procured individually. I believe these may be our future.
What is your definition of a ‘value-based healthcare system’ and what are its key defining parameters?
Value takes many forms and changes according to who is looking for it and what their goal is. Certainly, from the government’s perspective, the value can be calculated in the ratio of quality (or outcomes) over cost. This is very important when setting budgets and ensuring that they are getting what they pay for. This is often the default value proposition in a publicly-funded health system, and it is indeed important.
Value, as measured by a patient, is a whole other proposition. They may value being listened to, having a concern demystified, or simply being told they will be fine.
The clinician perspective exists in the intersection of the health system and patient lived experience. We face the multifaceted challenges of unprecedented demographic change, medical system evolution, and continual demands to innovate every day. But on the positive side, this can challenge physicians in creating solutions.
Ultimately, the value can be only generated in trusted relationships. All three players in healthcare (funder, provider, patient) must work on mutual trust to achieve common goals. This is more than value; it is being valuable.
Do you think the newly revamped tax laws in the U.S could be incentivizing Canadian health-tech companies to move south?
Certainly, permissive tax rules may have an influence, but I believe that tech companies venture south before developing a strong presence in Canada for some far more basic reasons. The US market is much larger. An entrepreneurial spirit is deeply ingrained in American culture. There is greater degree of tolerance for failure. There is much more capital to draw upon from investors who are willing to take a chance on health-tech, knowing that they will win some and they will lose some. Still, there are challenges in the US too. It is a dog-eat-dog world in health care south of our border. Sometimes the stories of speed in success or failure are a distraction from a business purpose that enables longevity. Real change requires resolution rather than revolution.
This interview was conducted by Reza Akhlaghi, a digital content and social media strategist at RDP Associates.
On January 24, OntarioMD had the honour of welcoming Norway’s Ambassador to Canada, Her Excellency, Mrs. Anne Kari Hansen Ovind, and the Minister of Health and Care Services, Mr. Bent Høie and his delegation, to our office. The purpose of the visit was to discuss common themes in digital health faced by Norway and Ontario, and how lessons learned in both jurisdictions can impact how we enable system priorities, leadership, and innovation looking forward.
The Norwegian delegation was very interested in learning about OntarioMD’s success in implementing electronic medical records (EMRs) in community-based family physician and specialist practices and how successes with EMR integrated products and services align with Ontario’s Patient’s First Digital Health strategy and priorities. While there will always be more to do, these products and services are already leading to a more connected digital health system in Ontario given the strong and connected foundation that they now represent.
We talked about the critical success factors and methodologies used to deploy products and services to physician practices. OntarioMD’s engaged EMR vendor community and our EMR Certification Program are key enablers for digital health and have created a very valuable mechanism to translate health system priorities using EMR Specifications, into EMR functionality that drives EMR use by physicians. Other partnerships have also led to the success of our work. There are many organizations that want to deploy their products to physicians but reaching the diversity and range of physician practices across the province is a challenge. There is increasing recognition that to be more effective as a system we must make it easier for physicians to adopt technology, being very attentive to minimizing the administrative burden for physicians and minimizing disruption at the practice level which means a responsibility to create alignment with our partners. We also need to provide the opportunity for innovative vendors with great solutions in health care to have a delivery channel that makes sense for all.
For the adoption and sustained use of digital health products and services, robust change management support is a core ingredient. This support is available to physician practices anywhere in Ontario and provided by Practice Advisors with in-depth knowledge of EMRs and other digital health products and services; a network of over 50 Peer Leaders (physicians, nurse practitioners and clinic managers) mentor and educate physicians and their staff on how to make improvements to their EMR use; and the EMR Practice Enhancement Program that provides intensive coaching for physician practices to standardize data, improve the quality and integrity of data, improve preventive care, improve internal workflow processes to enhance the patient experience and much more. We agreed that digital health is often NOT about the availability of technology, but about creating capacity and support for the clinicians who are end users.
The delegation and OntarioMD had a lot of shared themes to discuss – from population health priorities, the impact of privacy and security, access to data, quality improvement, and patient engagement and how innovation and new technology will continue to present great opportunities and challenges alike. Norway has tackled many of these themes and has also developed methodologies and best practices that have been effective in its digital health eco-system. With increased globalization, we increasingly recognize that forums, such as the one we were privileged to participate in, will continue to advance our paradigms and challenge our thinking about the future of digital health.
This blog post was contributed by Summer Intern, IT Deployment and Integration Graeme Larsen.
“Digital Health” is a complicated idea. To the uninitiated, the phrase could mean all manner of things, from robots performing surgery, to artificial intelligence solving diagnostic problems, to information networks connecting doctors to their patients hundreds of kilometers away. Nevertheless, regardless of how the words are interpreted, I am sure everyone agrees that “Digital Health” is important.
Flung head-first into this crazy new world – wow – did I ever feel out of my depth!
Four months ago, I began my journey as an intern at OntarioMD, a provincial leader in Digital Health, where I quickly learned that it’s not at all about robots.
The most important aspects of digital health concern information management. For instance, OntarioMD has developed a service called Health Report Manager (HRM), which connects Ontario’s primary care providers to surrounding hospitals to facilitate the sending and receiving of patient information. It is responsible for many things I used to take for granted. Think about the impact of electronic sending and receiving of an x-ray report immediately after it is issued – it is colossal. Doctors are now able to receive patient information in real time, and are immediately notified when a patient is discharged from hospital. They can then follow up right away, thus improving quality of care when the patient needs it the most. Digital upgrades like this have substantially improved patient outcomes in Ontario, and have contributed to a greater standard of care across the province.
As an intern, I was lucky to be directly involved with HRM as a part of the OntarioMD Deployment Team. This was a big opportunity for someone my age. I was responsible for the early stages of the on boarding process, connecting medical clinics to the HRM system. I can hardly begin to think of how many patients may be positively affected by my work.
I also had the opportunity to be involved in the development of the company’s new Client Relationship Management system. I was invited to take part in discussions and to offer possible improvements and strategies to be used in the process. It was a privilege. Only a few months ago, I was a naïve 18-year-old with not a clue that this complex, corporate world existed. That has all changed.
The trust that OntarioMD placed in me early on left a positive, lasting impression in my mind. This company trusts and hires the right people. Sarah Hutchison and her team of executives have worked tirelessly to push change and innovation in the healthcare sector, and working with them has inspired me to want to do the same. From the executives, all the way down to the other interns, everyone is extremely welcoming, encouraging, and they are all working towards the same goal: to improve Ontario’s healthcare system.
As an intern, I was not grabbing coffee. I was contributing to important projects, systems, and conversations in a significant way. I am extremely grateful to OntarioMD for trusting me as one of their own. My time here is guaranteed to benefit my future career – and I know that I leave with lasting friendships, and a wealth of knowledge that could not have come from anywhere else.
In short, I identified 414 of my patients on a PPI, 314 (76%) of which were on rabeprazole or pantoprazole, the two cheapest options. I calculated the potential monetary savings by switching every patient in my practice who is on a more expensive PPI (esomeprazole, lansoprazole, omeprazole, dexlansoprazole) to generic rabeprazole; projected tally would be $22,340 over the course of a year. Not an insignificant sum.
It’s one thing to project a cost savings. But would it actually work?
I embarked on a very simple intervention in January 2017. Using my EMR (Telus PS Suite), I created a reminder that would place the note “Consider switch to cheaper PPI” on the chart of every patient on esomeprazole, lansoprazole, omeprazole, dexlansoprazole, or pantoprazole.
That reminder would appear on their chart, and would prompt a discussion at their next appointment about a potential trial of rabeprazole.
(I am intentionally omitting the issue of de-prescribing from this analysis, as de-pescribing PPIs has been another important undertaking in my practice, yet this analysis was strictly looking at looking at cost-saving from cheaper PPIs. The above reminder did prompt many instances of de-prescribing, but these were not as easily quantifiable retrospectively. In addition, I bristle at the idea of openly quantifying and applauding the cost savings from de-prescribing, as it would rightfully raise the question in patients’ eyes whether we are de-prescribing out of concern for their health, or simply to save money. This analysis looks at cost-savings from switching from one PPI to another, the goal of which is to produce no clinical negative change).
Of the patients who were engaged in a discussion, many were found not to be appropriate for a rabeprazole trial, either because of intolerance or lack of efficacy from previous trials of rabeprazole. Other patients were not open to a trial because of lack of interest in “rocking the boat” or because of an upcoming trip and concern about impacting travel insurance.
28 patients (some private pay, some publicly-funded) who required ongoing PPI therapy (due to ongoing indication or due to previous failure with PPI wean) agreed to a rotation to rabeprazole as a trial. 7 patients described a clinical worsening of symptoms (most within the first two weeks), and requested to be put back onto their initial PPI (5 patients on lansoprazole, 1 on pantoprazole, and 1 on omeprazole). 21 patients saw no clinical change, and those 21 have been found to be stable at the 3-month mark post-rotation (11 on lansoprazole, 4 on omeprazole, 4 on esomeprazole, and 2 on pantoprazole).
The cost savings were as follows (using rabeprazole 20mg tablet, $0.24/pill):
Esomeprazole – $1.86 per pill ($1.62 savings/d, $591.30/yr per patient)
Omeprazole – $0.41 per pill ($0.14 savings/d, $51.10/yr per patient)
Lansoprazole – $0.50 per pill ($0.26 savings/d, $94.90/yr per patient)
Pantoprazole – $0.30 per pill ($0.06 savings/d, $21.90/yr per patient)
Total yearly savings from these 21 patients now stable on rabeprazole: $3657.30
A few things to take away from this:
This was a ridiculously simple intervention, and took me virtually no time to create the reminder or to have those discussions with patients.
This should be a wake-up call to the Ministry of Health on the importance of working with physicians on finding efficiencies in our system. Physicians know where these efficiencies are, so allow innovation and creativity, reward it appropriately, and we’ll find the money.
It is critical that the first script for the rabeprazole be of short duration (I prescribed two weeks), otherwise 3 months of wasted pills for the 25% failure rate would have erased some of the cost savings.
Most practices will likely see greater savings than I achieved in my practice, as I have been consciously working to prescribe exclusively rabeprazole for some time now. Even if you assume my prescribing rate to be on par with the Ontario average (2200 patients), extrapolating this out to Ontario’s population of 13.6 million, this simple intervention would amount to a provincial total of $22.6 million.
Note that most of the savings were found in switching patients from esomeprazole. Please don’t use it unless you are absolutely handcuffed. It is insanely expensive compared to others in the class.
All of us have these opportunities in our practices for small interventions that we may actually find some element of satisfaction in evaluating, especially with the power of a well-functioning EMR behind us.
According to a recent study, poison control centres in the US receive a call about medication errors every 13 seconds, and that rate has doubled in the past 12 years (1). Doctors, nurses and nurse-practitioners prescribe medications (and more recently focus on de-prescribing many drugs) on a daily basis, largely without a second thought. These medicines change the lives of our patients every day – often for the better, but unfortunately sometimes for the worse. Given the power of drugs and the authority we wield every time we sign our name to a prescription, it’s important that we do everything we can to focus on safety and effectiveness.
Most prescribers become familiar enough with a handful of different medicines to confidently prescribe them without risk. But sometimes we introduce a distinct cognitive bias by extending our comfort level with one set of drugs to others, including rare, unfamiliar and dangerous ones. It is impossible for any human being to remember all the details of side effects and interactions for the thousands of medications we are thought to be experts on when we prescribe. Add in the notion that individual genetics dictate the way or bodies consume and dispose of medications, and it’s easy to see how this overconfidence and generalization can have dramatic consequences for patients.
Fortunately, there are systems and processes in place that lower our risk of error dramatically. Computerized provider order entry applications like e-prescribing involve electronic entry and transmission of medical orders, and have been found to reduce medication error rates by over 50%.(2)The EMRs used by most community-based physicians in Canada have built-in interaction checkers that compare not only drug-to-drug interactions, but also drug-to-disease-state interactions. And they will alert us when a potential problem arises – assuming we are using the most current version of our EMR and drug database, and have not turned off alert capabilities due to information overload.
While we certainly don’t want our prescription modules to alert us incessantly, we do need to understand the likelihood of severe interactions every time we prescribe. Reminder alerts can also be set up in the EMR for therapeutic monitoring, which is frequently forgotten when prescribing titrated drugs like lithium or anti-seizure meds. It may also be worthwhile to incorporate alerts regarding Beers List drugs that should never be prescribed to elderly patients.
Of course, these types of alerts are only as reliable as the accuracy of the patient information and medication lists in our EMR. So, it’s important for every provider to take the time needed to update medication lists at every patient visit, whether or not it’s considered our direct responsibility to do so.
Tools like EMR, CPOE and automated alerts represent the tipping point in our ability to avoid medication errors using digital health. But there’s more on the horizon. Integration of province-wide databases such as the Digital Health Drug Repository, Digital Health Immunization Repository and Narcotics Monitoring System through the ConnectingOntario and Clinical Connect viewers will be a huge leap forward, giving us the ability to review medications prescribed and dispensed from all practitioners involved in a patient’s care. Integrating this information into EMR prescribing modules will have an even greater impact.
The ability to quickly view and analyze data across our entire patient roster will soon be possible for all using the OntarioMD EMR dashboard.. Work being done on the EMR dashboard – in partnership with Health Quality Ontario, the Ontario College of Family Physicians, the Association of Family Health Teams of Ontario, Association of Ontario Health Centres and the College of Physicians and Surgeons of Ontario – will make it easier to track drugs of interest among our own patients, and will provide a practice-wide population health perspective. This becomes imperative when considering high risk prescribing scenarios like narcotics doses above 50 morphine mg equivalents per day, in immunocompromised patients, and for those on multiple medications with more than one complex chronic disease.
Important digital tools, combined with appropriate policy, education and advice on how to cautiously prescribe and monitor risky drugs, have the potential to help us stave off adverse reactions, overdoses and even deaths. But we must also focus on ensuring that we understand new prescribing guidelines, screen for misuse, employ narcotics contracts and periodically review long-term medication use with patients as diligently as we analyze new drug starts.
With the privilege of prescribing comes great responsibility. Thinking about prescribing safely at the point of care and asking ourselves if we’ve taken advantage of every tool available to make this work easier will give us the best chance we have in doing the right thing for our patients, our practices and ourselves.
Nichole L. Hodges, Henry A. Spiller, Marcel J. Casavant, Thiphalak Chounthirath, Gary A. Smith. Non-health care facility medication errors resulting in serious medical outcomes. Clinical Toxicology, 2017; 1 DOI: 10.1080/15563650.2017.1337908
Nuckols TK, Smith-Spangler C, Morton SC, et al. The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Systematic Reviews. 2014;3:56. DOI: 10.1186/2046-4053-3-56.