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Enabling Medication Management Through Health Information Technology
Evidence Reports/Technology Assessments, No. 201
Authors
Investigators: K Ann McKibbon, PhD, Cynthia Lokker, PhD, Steve M Handler, MD, PhD, Lisa R Dolovich, PharmD, MSc, Anne M Holbrook, PharmD, MD, Daria O’Reilly, PhD, Robyn Tamblyn, PhD, Brian J Hemens, BScPhm, MSc, Runki Basu, BSc (Hons), MA, Sue Troyan, BA, RT, Pavel S Roshanov, BSc, Norman P Archer, PhD, and Parminder Raina, PhD.Affiliations
Structured Abstract
Objective:
The objective of the report was to review the evidence on the impact of health information technology (IT) on all phases of the medication management process (prescribing and ordering, order communication, dispensing, administration and monitoring as well as education and reconciliation), to identify the gaps in the literature and to make recommendations for future research.
Data sources:
We searched peer-reviewed electronic databases, grey literature, and performed hand-searches. Databases searched included MEDLINE,® EMBASE,® CINAHL® (Cumulated Index to Nursing and Allied Health Literature), Cochrane Database of Systematic Reviews, International Pharmaceutical Abstracts,© Compendex,© INSPEC© (which includes IEEE®), Library and Information Science Abstracts,® E-Prints in Library and Information Science,® PsycINFO,® Sociological Abstracts,© and Business Source® Complete. Grey literature searching involved Internet searching, reviewing relevant Web sites, and searching electronic databases of grey literatures. AHRQ also provided all references in their e-Prescribing, bar coding, and CPOE knowledge libraries.
Methods:
Paired reviewers looked at citations to identify studies on a range of health IT used to assist in the medication management process (MMIT) during multiple levels of screening (titles and abstracts, full text and final review for assignment of questions and data abstrction). Randomized controlled trials and cohort, case-control, and case series studies were independently assessed for quality. All data were abstracted by one reviewer and examined by one of two different reviewers with content and methods expertise.
Results:
40,582 articles were retrieved. After duplicates were removed, 32,785 articles were screened at the title and abstract phase. 4,578 full text articles were assessed and 789 articles were included in the final report. Of these, 361 met only content criteria and were listed without further abstraction. The final report included data from 428 articles across the seven key questions. Study quality varied according to phase of medication management. Substantially more studies, and studies with stronger comparative methods, evaluated prescribing and monitoring. Clinical decision support systems (CDSS) and computerized provider order entry (CPOE) systems were studied more than any other application of MMIT. Physicians were more often the subject of evaluation than other participants. Other health care professionals, patients, and families are important but not studied as thoroughly as physicians. These nonphysicians groups often value different aspects of MMIT, have diverse needs, and use systems differently. Hospitals and ambulatory clinics were well-represented in the literature with less emphasis placed on long-term care facilities, communities, homes, and nonhospital pharmacies. Most studies evaluated changes in process and outcomes of use, usability, and knowledge, skills, and attitudes. Most showed moderate to substantial improvement with implementation of MMIT. Economics studies and those with clinical outcomes were less frequently studied. Those articles that did address economics and clinical outcomes often showed equivocal findings on the effectiveness and cost-effectiveness of MMIT systems. Qualitative studies provided evidence of strong perceptions, both positive and negative, of the effects of MMIT and unintended consequences. We found little data on the effects of forms of medications, conformity, standards, and open source status. Much descriptive literature discusses implementation issues but little strong evidence exists. Interest is strong in MMIT and more groups and institutions will implement systems in the next decades, especially with the Federal Government’s push toward more health IT to support better and more cost-effective health care.
Conclusions:
MMIT is well-studied, although on closer examination of the literature the evidence is not uniform across phases of medication management, groups of people involved, or types of MMIT. MMIT holds the promise of improved processes; clinical and economics studies and the understanding of sustainability issues are lacking.
Contents
- Acknowledgments
- Executive Summary
- Introduction
- Methods
- Results
- Results of the Literature Search
- KQ1 Within and across the phases of medication management continuum, what evidence exists that health IT applications are effective?
- KQ2 What knowledge or evidence deficits exist regarding needed information to support estimates of cost, benefit, impact, and net value with regard to enabling health IT applications in terms of prescribing, order transmission, dispensing, administering, and monitoring, as well as reconciliation, education, and adherence? Discuss gaps in research, including specific areas that should be addressed and suggest possible public and private organizational types to perform the research and/or analysis
- KQ3 What critical information regarding the impact of health IT applications implemented to support the phases of medication management is needed to give clinicians (physicians, nurses, psychologists, dentists), pharmacists, health care administrators, patients, and their families a clear understanding of the value proposition particular to them?
- KQ4 What evidence exists regarding the impact of the characteristics of medication management health IT applications, such as open source, proprietary, conformity with Federal and other interoperability standards, and being Certification Commission for Healthcare Information Technology (CCHIT) certified, impact, likelihood for purchase, implementation, and use of such IT applications
- KQ5 What factors influence sustainability (use and periodic updates) of health IT applications that support a phase of medication management continuum (prescribing, dispensing, administering, and patients’ taking of medications)?
- 5a To what extent does the evidence demonstrate that health care settings (inpatient, ambulatory, long-term care, etc.) influence implementation, use, and effectiveness of such health IT applications?
- 5b What is the impact (challenges, merits, costs, and benefits) of having electronic access to patients’ computerized medication records, formulary information, billing information, laboratory records in the quality and safety of care provided by health IT applications that support at least one phase of the continuum of medication management (prescribing, dispensing, administering, and patients taking of medications)?
- KQ6 Two-Way Prescriber and Pharmacy Electronic Data Interchange (e-Prescribing)
(a) What evidences exists demonstrating the barriers and drivers of implementation of complete EDI that can support the prescription, transmittal and receipt, and perfection process of e-Prescriptions
(b) How do barriers, facilitators, and economic incentives vary across pharmacists, physicians and other relevant stakeholders with respect to adoption and use of complete EDI (e-Prescribing/ordering with e-transmission)? - KQ7 What evidence exists regarding the extent of integration of electronic clinical decision support (CDS) in a health IT system for prescribing and dispensing of medications?
To what extent does the use of CDSS in a health IT system for prescribing and dispensing of medications impact the various outcomes of interest including health care process, intermediate and clinical?
- Discussion
- Future Research
- Conclusions
- References
- Acronyms and Abbreviations
- Appendixes
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10060-I, Prepared by: McMaster Evidence-based Practice Center, Hamilton, ON Canada
Suggested citation:
McKibbon KA, Lokker C, Handler SM, Dolovich LR, Holbrook AM, O’Reilly D, Tamblyn R, Hemens BJ, Basu R, Troyan S, Roshanov PS, Archer NP, Raina P. Enabling Medication Management Through Health Information Technology. Evidence Report/Technology Assessment No. 201. (Prepared by the McMaster University Evidence-based Practice Center under Contract HHSA 290-2007-10060-I). AHRQ Publication No. 11-E008-EF. Rockville MD: Agency for Healthcare Research and Quality. April 2011.
This report is based on research conducted by the McMaster Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10060-I). The findings and conclusions in this document are those of the author(s) who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decision-makers; patients and clinicians, health system leaders, and policymakers, make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in this report.
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