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Research ArticleOriginal Research

Impact of an Evidence-Based Computerized Decision Support System on Primary Care Prescription Costs

S. Troy McMullin, Thomas P. Lonergan, Charles S. Rynearson, Thomas D. Doerr, Paul A. Veregge and Edward S. Scanlan
The Annals of Family Medicine September 2004, 2 (5) 494-498; DOI: https://doi.org/10.1370/afm.233
S. Troy McMullin
PharmD
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Thomas P. Lonergan
PharmD, MBA
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Charles S. Rynearson
RPh, MS
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Thomas D. Doerr
MD
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Paul A. Veregge
MD, MS
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Edward S. Scanlan
MD
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  • Waiting for a National Health Information Infrastructure?
    Mark Frisse
    Published on: 21 November 2004
  • Integration into workflow
    Lee A. Green
    Published on: 23 October 2004
  • Important attributes of a successful decision support system
    S. Troy McMullin
    Published on: 07 October 2004
  • Interventions for Rising Prescription Expenditures
    Kenneth S. Fink
    Published on: 06 October 2004
  • Published on: (21 November 2004)
    Page navigation anchor for Waiting for a National Health Information Infrastructure?
    Waiting for a National Health Information Infrastructure?
    • Mark Frisse, Nashville, TN

    This article from pioneers in the field demonstrates an impact on costs correlated with "evidence-based decision support" linked to "an electronic prescribing model."

    The authors remind us of the value realized by evidence-based information. But how much more value could be realized if these systems could be easily integrated with a broader range of patient-specific data and be employed routinely in our practi...

    Show More

    This article from pioneers in the field demonstrates an impact on costs correlated with "evidence-based decision support" linked to "an electronic prescribing model."

    The authors remind us of the value realized by evidence-based information. But how much more value could be realized if these systems could be easily integrated with a broader range of patient-specific data and be employed routinely in our practices?

    The challenge, it seems, is not so much to prove that these technologies can provide marginal value as it is to extend the context of decision-making from pharmaceutical information to comprehensive, patient- specific information obtained in the course of care across many facilities. Laboratory results, allergy information obtained from other providers, diagnostic information, and other clinical items impact the value of e-prescribing. A National Health Information Infrastructure seems to be a promising idea.

    Hence two questions: How much impact will this infrastructure have on a practitioner's ability to employ and derive maximal patient care benefit from these technologies? And how soon do readers expect to see such an infrastructure in their communities?

    Competing interests:   Director, Tennessee Volunteer eHealth Initiative http://www.volunteer-eHealth.org

    Show Less
    Competing Interests: None declared.
  • Published on: (23 October 2004)
    Page navigation anchor for Integration into workflow
    Integration into workflow
    • Lee A. Green, Ann Arbor, MI

    This paper joins a long literature demonstrating the effectiveness of "smart" prescription systems, dating back to the late 1970's. As the authors note, there is also a literature of failure of prescription decision support systems, and as our group has worked in a related area we have become aware of a large number of unpublished failures as well.

    The key variable does indeed seem to be the degree to which the...

    Show More

    This paper joins a long literature demonstrating the effectiveness of "smart" prescription systems, dating back to the late 1970's. As the authors note, there is also a literature of failure of prescription decision support systems, and as our group has worked in a related area we have become aware of a large number of unpublished failures as well.

    The key variable does indeed seem to be the degree to which the decision support system fits into workflow. Fit is a complex concept however, and very underappreciated. Its power is such that physicians will not only not use, but will actively disable, decision support systems that fit poorly. For example, we have observed that the majority of physicians in the 42 VA centers we are working with have disabled the clinical reminders for hypertension built into their electronic medical record. Those reminders are clinically very appropriate, but from a human factors engineering standpoint are designed inappropriately.

    In this study the authors have insured use of the prescribing information because a diagnosis must be entered before a prescription can be written. Human factors engineers refer to that approach as a forcing function. In essence, it achieves fit by changing the workflow rather than the reminder, though of course it is materially aided by having the reminder not require a very large change in the workflow (the prescription system was apparently in use with or without the reminders). Given the low rate of adoption of free-choice reminders, forcing functions are a worthy avenue of further research.

    There is one other key variable in the success of online decision support systems, whether built into prescribing modules or electronic medical records. That is the stage of training of the users. Results are consistently better for residents still in the formative stages of their training, than for experienced clinicians whose decision patterns are well established. I did not find where the current paper discussed whether or to what extent residents provided the care under study. Perhaps the authors can comment on that.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (7 October 2004)
    Page navigation anchor for Important attributes of a successful decision support system
    Important attributes of a successful decision support system
    • S. Troy McMullin, Bend, Oregon USA

    We appreciate Dr. Fink’s comments and agree with him that successful implementation of a computerized decision support system (CDSS) hinges on the ability of the system to fit seamlessly into physicians’ workflow. We also agree that CDSS should add meaningful value to the patient care experience. In an independent survey conducted by a sponsoring health plan, 100% of surveyed physicians agreed that our system added valu...

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    We appreciate Dr. Fink’s comments and agree with him that successful implementation of a computerized decision support system (CDSS) hinges on the ability of the system to fit seamlessly into physicians’ workflow. We also agree that CDSS should add meaningful value to the patient care experience. In an independent survey conducted by a sponsoring health plan, 100% of surveyed physicians agreed that our system added value to their practice, and most (83%) agreed with the highest emphasis (i.e., felt strongly). Furthermore, the system was so readily accepted at the Affinity Health System study sites, that all 200 of their physicians are now using the CDSS.

    One of the features that makes this CDSS so unique is that the information is continuously updated. Every evidence-based review in the system is a living document that is updated by our editorial staff each time an important new study is published. On average, these topics are updated every 2 to 4 months and a complete Medline search is performed a minimum of twice per year to ensure completeness. In addition, the evidence-based “Messages of the Day” are almost exclusively targeted toward recently published literature. In fact, 99% of the daily messages in 2004 have involved studies or treatment guidelines that were published this year. Most of these messages run within a few days or weeks of publication, depending on their importance. Because of the timeliness and quality of their content, our messages and evidence-based reviews are also accredited for continuing medical education by the Washington University School of Medicine in St. Louis, Missouri.

    Dr. Fink’s mention of the recent Vioxx (rofecoxib) withdrawal represents yet another excellent example of why CDSS must remain current, as well as another important advantage of electronic health records. Within hours of the first FDA recall alerts, WELLINX had provided every medical office with the contact information for each patient who had an active prescription for Vioxx, as well as information on how patients could receive reimbursement for unused portions of their prescription. Not surprisingly, one of our daily messages in the prior month had summarized five recent reports suggesting that Vioxx was associated with a significantly increased risk of cardiovascular events.

    We also agree with Dr. Fink that more comprehensive evaluations are needed to fully assess the cost-effectiveness of CDSS. For that reason, we believe it is important to note that the six-month savings reported in our study were estimated based only on the data for new prescriptions and their refills. These prescriptions represented less than one-fourth of all pharmacy claims during the study period. A 12-month follow-up analysis that assessed differences in the average cost per prescription for all pharmacy claims data (> 75,000 prescriptions in each group) suggested that the group using the CDSS produced an average savings of $843 per physician per month during the first year of use. When changes in the cost per member per month (PMPM) were analyzed, the average savings over the 12-month period were estimated to be $914 per physician per month. In both of these analyses, the average savings in the second half of the year were approximately twice as large as those observed in the first six months. Interestingly, similar results have now been observed in a second controlled trial of our system. Because each of these studies found that savings increase substantially over time, we expect that savings will be higher in subsequent years.

    It is also important to note that these estimates represent the savings achieved at a single health plan. Approximately 35% of the patients treated by physicians in our study were covered by Network Health Plan, which supplied the pharmacy claims data. If similar savings were realized in other patients, the total prescription savings in the first year of use would be approximately $2500 per physician per month.

    Finally, the savings reported from our trial are limited to prescription costs, and do not include other potential benefits that could be achieved through the use of CDSS (e.g., prevention of medical errors, avoidance of drug-drug interactions, improvements in quality of care, or enhanced physician office efficiencies related to the automated refill process and reduced pharmacy call backs). It is possible that the savings in drug expenditures only represent a small portion of the overall benefits to patients and the health system. Unfortunately, we only had access to pharmacy claims data and could not assess these other important outcome measures. Nevertheless, it is interesting that the annual savings from medications alone appear to be more than ten times higher than what is needed to cover the cost of this system.

    Competing interests:   Dr. McMullin is employed by WELLINX, a company that markets an electronic prescribing system with integrated evidence-based decision support

    Show Less
    Competing Interests: None declared.
  • Published on: (6 October 2004)
    Page navigation anchor for Interventions for Rising Prescription Expenditures
    Interventions for Rising Prescription Expenditures
    • Kenneth S. Fink, Rockville, MD

    At a time of rapidly growing healthcare expenditures, new medications becoming available with heavy marketing, and often the absence of comparative effectiveness studies, providing healthcare providers with evidence-based information to support their decision-making becomes increasingly important. McMullin et al. conducted a well done study investigating the effect of a computerized decision support system (CDSS) on pres...

    Show More

    At a time of rapidly growing healthcare expenditures, new medications becoming available with heavy marketing, and often the absence of comparative effectiveness studies, providing healthcare providers with evidence-based information to support their decision-making becomes increasingly important. McMullin et al. conducted a well done study investigating the effect of a computerized decision support system (CDSS) on prescribing patterns.(1)

    They found that giving physicians prescribing options with supporting evidence for a given diagnosis at the point of care resulted in a shift in prescribing to less expensive medications. However, without following up on other healthcare utilization such as return visits or even hospitalizations, the cost-effectiveness of the shift in prescribing is unknown. In addition, patient satisfaction was not reported.

    But it’s an important point that newer and more expensive does not necessarily mean better. Often the newer and more expensive medication is marginally more effective than or equally effective to an older, cheaper one, such as treatment for insulin diabetes with short acting insulin analogues and regular human insulin.(2) Perhaps the newer medication is more effective, but the added benefit is appreciated only by a select sub- population as is the case with cyclo-oxygenase-2 antagonists.(3) However, these medications are often used for indications beyond those with the greatest value and can potentially result in a balance where harms outweigh benefits as was recently identified with rofecoxib (Vioxx).(4) Newer more expensive medication may have unknown harms.

    A CDSS is only as good as the information entered and its ease of use. The authors did not mention how often the information is reviewed and updated or the physicians’ satisfaction with using the system. The participating physicians were selected because they expressed interest in the project. Implementing a new health information technology system has challenges, as was experienced by Cedars-Sinai when it withdrew its computerized order entry after physicians’ complaints.(5)

    McMullin et al. take an important step by evaluating the efficacy of their CDSS for decreasing prescription expenditures; however, further work is needed on the effectiveness of such systems which includes system development, implementation, updating, and impact on health outcomes, in addition to cost.

    1. McMullin ST, Lonergan TP, Rynearson CS et al. Impact of an evidence-based computerized decision support system on primary care prescription costs. Ann Fam Med 2004;2:494-498.

    2. Siebenhofer A, Plank J, Berghold A, et al. Short acting insulin analogues versus regular human insulin in patients with diabetes mellitus. Cochrane Database Syst Rev 2004(2):CD003287.

    3. Spiegel BM, Targownik L, Dulai GS, Gralnek IM. The cost- effectiveness of cyclooxygenase-2 selective inhibitors in the management of chronic arthritis. Ann Intern Med 2003;138(10):795-806.

    4. Arthritis drug Vioxx being pulled. <http://www.cnn.com/2004/HEALTH/09/30/vioxx.withdrawn.reut/> (accessed October 5, 2004).

    5. Doctors pull plug on paperless system. <http://www.ama- assn.org/amednews/2003/02/17/bil20217.htm> (accessed October 5, 2004).

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
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Impact of an Evidence-Based Computerized Decision Support System on Primary Care Prescription Costs
S. Troy McMullin, Thomas P. Lonergan, Charles S. Rynearson, Thomas D. Doerr, Paul A. Veregge, Edward S. Scanlan
The Annals of Family Medicine Sep 2004, 2 (5) 494-498; DOI: 10.1370/afm.233

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Impact of an Evidence-Based Computerized Decision Support System on Primary Care Prescription Costs
S. Troy McMullin, Thomas P. Lonergan, Charles S. Rynearson, Thomas D. Doerr, Paul A. Veregge, Edward S. Scanlan
The Annals of Family Medicine Sep 2004, 2 (5) 494-498; DOI: 10.1370/afm.233
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