Enhancing Health Management: Predicting Physician Utilization of Integrated Electronic Prescribing Laurel K Taylor McGill University 6 June 2007 Orlando,

Enhancing Health Enhancing Health Management: Management:

Predicting Physician Utilization ofPredicting Physician Utilization ofIntegrated Electronic PrescribingIntegrated Electronic Prescribing

Laurel K Taylor

McGill University

6 June 2007

Orlando, Florida

Messages

o Things can be better in health care

o Technology is a key facilitator for improvement

o Technology uptake extremely variable

o Utilization of technology can be predicted / modified

Electronic Decision Support Electronic Decision Support SystemsSystems

The PotentialThe Potential

o Provide complete information on current drugs for Provide complete information on current drugs for physicians and pharmacists physicians and pharmacists

o Reduce prescribing and transcription errorsReduce prescribing and transcription errors

o Improve match between need and therapyImprove match between need and therapy

o Enhance complianceEnhance compliance

o Improve disease management and patient outcomesImprove disease management and patient outcomes

o Increase clinical and cost effectiveness of treatmentIncrease clinical and cost effectiveness of treatment

Number of prescribing physiciansPro

port

ion

of

pati

en

ts w

ith

at

least

on

e in

ap

pro

pri

ate

pre

scri

pti

on

0

20

40

60

80

100

120

1 2 3-4 5-8 9+

1 physicians

27%

9+physicians

3%

5-8 physicians

16%

3-4physicians

30%

2 physicians

24%

49% of patients visit 3 or more physicians

Source: Tamblyn, CMAJ, 1993

Inappropriate Prescriptions Inappropriate Prescriptions -The Canadian Context--The Canadian Context-

25

26

27

28

29

30

31

32

Inap

prop

riate

Rx

per

1,00

0 Pa

tient

Vis

its

One Pharmacy Many Pharmacies

Only 1 Pharmacy

59%

Multiple Pharmaci

es41%

Many patients visit multiple pharmacies

Source: Tamblyn, CMAJ, 1993

Inappropriate Prescriptions Inappropriate Prescriptions -The Canadian Context--The Canadian Context-

Electronic Decision Support Electronic Decision Support SystemsSystems

The ChallengesThe Challengeso Inconsistent features across applicationsInconsistent features across applications

o Lack of integration with existing IT Lack of integration with existing IT systemssystems

o Poor integration with provider work flowPoor integration with provider work flow

o Lack of systematic and rigorous Lack of systematic and rigorous evaluation methodologyevaluation methodology

Electronic Decision Support Electronic Decision Support SystemsSystems

The ChallengesThe Challenges

Extreme variability in physician utilization

Unrealized benefits

Primary Care And IT Primary Care And IT -The Canadian Context--The Canadian Context-

o 23% - electronic medical records23% - electronic medical records

o 15% - access to hospital records 15% - access to hospital records

o 11% - e-prescribing capabilities 11% - e-prescribing capabilities

o 8% - electronic test ordering8% - electronic test ordering

International Health Policy Survey of Primary Care Physicians in Seven Countries,

The Commonwealth Fund, 2006

Research Objectives

To define and analyze predictors of physician utilization of electronic prescribing through an integrated drug and disease management system.

Research Setting MOXXI Project

(Medical Office of the XXI Century)

o 61 general practitioners61 general practitioners

o 26 practice sites26 practice sites

o Located in an urban Canadian centreLocated in an urban Canadian centre

o Developed physician and practice characteristics Developed physician and practice characteristics based on 18 months of data prior to based on 18 months of data prior to implementationimplementation

o Survey dataSurvey datao Medical services claims databaseMedical services claims databaseo Medication services claims databaseMedication services claims database

o Collected 6 months of electronic prescribing Collected 6 months of electronic prescribing utilization data subsequent to implementation of utilization data subsequent to implementation of an electronic integrated drug and disease an electronic integrated drug and disease management system.management system.

o Electronic audit trailsElectronic audit trails

Printed PrescriptionRe-prescribing function

List of RX prescribed by OthersRefill Compliance Indicator

Drug Interactions

Info on ER visits & Hospitalization

Drug Monograph

Drug Cost Information

Very Benefici

al

Not Beneficial

1 2 3 4 5

MOXXIMOXXIPerceived Benefits of the SystemPerceived Benefits of the System

Current Medications List

Stop/Change Function

Physician Questionnaire Rating 4 Months Post Implementation (October 2005 – Physician Questionnaire Rating 4 Months Post Implementation (October 2005 – February 2006)February 2006)

MOXXI MOXXI -Patient Characteristics--Patient Characteristics-

ParticipatingParticipating Not ParticipatingNot Participating

SexSex n (%)n (%) n (%)n (%)MaleMale 7471 (40.2)7471 (40.2) 29166 (40.2)29166 (40.2)

FemaleFemale 11133 (59.8)11133 (59.8) 40873 (56.4)40873 (56.4)

Age (years)Age (years)

<30<30 1334 (7.2)1334 (7.2) 23226 (32.0)23226 (32.0)

30-4530-45 2728 (14.7)2728 (14.7) 16439 (22.7)16439 (22.7)

46-6046-60 6045 (32.5)6045 (32.5) 17140 (23.6)17140 (23.6)

>60>60 8497 (45.6)8497 (45.6) 13233 (18.3)13233 (18.3)

n (SD)n (SD) n (SD)n (SD)Average # VisitsAverage # Visits 4.4 (3.7)4.4 (3.7) 2.5 (2.6)2.5 (2.6)

n (%)n (%)

Year of GraduationYear of Graduation >1980>1980 31 (51)31 (51)

1960-19791960-1979 30 (49)30 (49)

SexSex MaleMale 33 (54)33 (54)

Prior Computer ExperiencePrior Computer Experience <5 hours/week<5 hours/week 36 (58)36 (58)

5-155-15 22 (35)22 (35)

>15>15 3 (5)3 (5)

Physician TypologyPhysician Typology PragmatistPragmatist 39 (64)39 (64)

ReceptiveReceptive 9 (15)9 (15)

SeekerSeeker 10 (16)10 (16)

TraditionalistTraditionalist 3 (5)3 (5)

MOXXIMOXXI -Physician Characteristics--Physician Characteristics-

MeanMean SDSD RangeRange

Number of Unique Number of Unique PatientsPatients

1840 877 19-3880

Number of Patient Number of Patient VisitsVisits

4193 1703 23-9085

Continuity of Care Continuity of Care IndexIndex

0.57 0.09 0.22-0.72

Average Medication UseAverage Medication Use 2.84 0.83 1.27-4.74

MOXXIMOXXI-Practice Characteristics--Practice Characteristics-

Study Period:

1 Oct, 2005 – 3 July, 2006

Include all patients consented before index date.

Select patients that had an outpatient visit during the study period.

Denominator: Select patients consenting to MOXXI before 1 Oct 2005.

Numerator: Select all patients included in the denominator.

Select visit if e-Rx written (prescription, not dins) from MOXXI .

Select patients visiting physician in outpatient setting

MOXXIMOXXIUtilization Indicator – e-Rx/visitsUtilization Indicator – e-Rx/visits

# e-Rx

# visits

MOXXIMOXXIResults: Full Model RResults: Full Model R22=.4997=.4997

Physician Characteristics E-Rx Rate

p-value

SexSex MaleMale

FemaleFemale33.233.2

27.527.5.2528.2528

refref

Grad YearGrad Year 19651965

19811981

19991999

36.336.3

30.830.8

24.824.8

.2787.2787

TypologyTypology

SeekerSeeker

ReceptiveReceptive

PragmatistPragmatist

TraditionalistTraditionalist

24.024.0

37.737.7

32.532.5

4.54.5

.0732.0732

.0042.0042

.0058.0058

RefRef

Prior Computer Prior Computer ExperienceExperience

< 5 hrs/week< 5 hrs/week

5-15 hrs/week5-15 hrs/week

> 15 hrs/week> 15 hrs/week

27.027.0

35.835.8

48.848.8

.0040.0040

MOXXIMOXXIResults: Full Model RResults: Full Model R22=.4997=.4997

Physician/Practice Characteristics E-Rx Rate

p-value

Continuity of CareContinuity of Care Lowest QuartileLowest Quartile

Second QuartileSecond Quartile

Third QuartileThird Quartile

Highest QuartileHighest Quartile

33.734.328.825.6

ref.7063.4717.5843

Average Medication Average Medication UseUse

(2.9 drugs)(2.9 drugs) 30.630.6 .0358.0358

Patient VolumePatient Volume

Lowest QuartileLowest Quartile

Second QuartileSecond Quartile

Third QuartileThird Quartile

Highest QuartileHighest Quartile

34.534.5

29.329.3

36.136.1

22.422.4

refref

.6209.6209

.7881.7881

.3103.3103

MOXXIMOXXI Results: Final Model RResults: Final Model R22=.4633=.4633

Physician/Practice Characteristics Estimates

p-value

TypologyTypology SeekerSeeker

ReceptiveReceptive

PragmatistPragmatist

TraditionalisTraditionalistt

.1971.1971

.3310.3310

.2989.2989

RefRef

.0404.0404

.0010.0010

.0010.0010

RefRef

Prior Computer Prior Computer ExperienceExperience

.0096.0096 .0018.0018

Medication UseMedication Use .0758.0758 .0027.0027

Practice VolumePractice Volume Third Third QuartileQuartile

.0740.0740 .0974.0974

MOXXIMOXXI - Implications for Practice- - Implications for Practice-

o Implementation may require staged approach

o Modular approach to physicians with little or no computer experience

o Early intervention where necessary

o Deeper understanding of credible evidence for practice decisions

o Integration into current workflow important

MOXXI MOXXI - Implications for Policy- - Implications for Policy-

o IT availability insufficient to sustain utilization

o Need to identify strategies to enhance adoption and utilization

o May require availability of customized training programs

o Rigorous evaluation of clinical applications

for features, workflow integration assessment

AcknowledgementsAcknowledgements

Support for this research was provided by:Support for this research was provided by:

o The Commonwealth Fund.”The views presented here are those of the authors and should not be

attributed to The Commonwealth Fund or its directors, officers, or staff.”

o Canadian Institutes of Health Research NET Canadian Institutes of Health Research NET GrantGrant

o Canadian Health Services Research Canadian Health Services Research FoundationFoundation

*Total Patient Consents = 9052

*Total e-Rx Written = 7990

Medical Office Of The XXI Century Medical Office Of The XXI Century (MOXXI) (MOXXI)

-Backup Slides--Backup Slides-

PrinterPrinter

ChartChart PatientPatient

Server

PharmacPharmacyy

eRxeRx

eRxeRx

Doctor’s OfficeDoctor’s Office

Régie de l’assurance maladie

Real-time Real-time adjudicatioadjudicatio

nn

MOXXI System Overview MOXXI System Overview

Technology Adoption Model Technology Adoption Model

2 ½%2 ½%InnovatorsInnovators

13 ½%13 ½%Early adaptorsEarly adaptors

34%Early

majority

34%Late

majority16%

Laggards

Time of adoption innovationsTime of adoption innovations

Developed by Davis in 1989 for predicting user Developed by Davis in 1989 for predicting user acceptance of computersacceptance of computers

Behavior Intention

Perceived Usefulness

Perceived Ease of Use

Computer Usage

Understanding Predictors of UtilizationUnderstanding Predictors of UtilizationThe TAM (Technology Acceptance) Model The TAM (Technology Acceptance) Model

SeekerSeeker ReceptiveReceptive TraditionalistTraditionalist

Evidence

PragmatistPragmatist

Experience

Nonconformity

Practicality

Green, Gorenflo and Wyszewianski, 2002Green, Gorenflo and Wyszewianski, 2002

Understanding Predictors of Understanding Predictors of UtilizationUtilization

The Physician Typology Model The Physician Typology Model

*Total Patient Consents = 9052

*Total e-Rx Written = 7990

Study Period:

1 Oct, 2005 – 3 July, 2006

Include all patients consented before index date.

Select patient if ≥ 1 dispensed DIN during study period

Denominator: Select patients consenting MOXXI patients before 1 Oct 2005.

Numerator: Select the DINs from denominator and match to an eRx during the study period

Select patients with RAMQ coverage (75% not gaps) during study period

Medical Office Of The XXI Century Medical Office Of The XXI Century (MOXXI) (MOXXI)

Utilization Indicator – e-Rx/RxUtilization Indicator – e-Rx/Rx

# e-Rx DINs

# visitsSelect DINs prescribed during study period