PDSA worksheet Michael Bode - UNC School of Medicine

PDSA worksheet

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Project Lead Michael Bode Title Intervention to improve e-
prescribing rates
Team August 16-September 19, Change
Date Range 2011 Cycle # 3

Key Words E-prescribing, meaningful use,
intervention

BACKGROUND: What led you to start this project? Is this cycle a continuation of another
cycle? Why is this topic relevant? Include any baseline data that has already been collected.
Include relevant information from literature.

This project was inspired by the data gathered for e-prescribing rates in the first
month of the 2011-2012 academic year, with the recognition that these rates are below the
goal of 40% that UNC has set. According to data presented by Dr. Christopher Hauck for the
beginning of the 2011-2012 academic year, third year Internal Medicine residents e-
prescribed 25.1% of all eligible prescriptions, while first year Internal Medicine Residents e-
prescribed 25.3% of all eligible prescriptions.

While the data has demonstrated a 24.5% increase in e-prescribing by third year
residents from their first month of residency to the first month of the 2011-2012 academic
year, this rate still falls below the goal of 40%. For attending physicians, this 40% e-
prescription rate is part of the Medicare “Meaningful Use” Plan.

“Meaningful Use” was instituted as part of the American Recovery and Reinvestment
Act of 2009. In order to qualify for incentive payments from the Centers for Medicare and
Medicaid Services, hospitals and providers must demonstrate three components of
“Meaningful Use.” First, the Electronic Health Record (EHR) must be used for a good
purpose, including e-prescription. Second, the EHR should be used to exchange information
to improve healthcare, and third, the EHR should be used to submit clinical quality
measures. Thus, e-prescription is critical to ensure millions of dollars of Medicare
reimbursement in the next several years. For resident physicians, the use of e-prescribing is
part of a hospital-wide initiative to exceed the mark of 40%.

In addition to meeting federal requirements, e-prescribing increases patient safety,
efficiency, and formulary compliance. Medication errors are responsible for approximately
7,000 deaths each year in the United States. E-scripts reduce medication errors when the
physician writes the prescriptions from the electronic record containing previous medication
doses, allergies, and drug interactions. Most electronic medical records (EMRs), including
WebCIS, can perform allergy and interaction checks. An estimated 30% of written
prescriptions require callbacks to the provider. E-scripts help reduce this number and can
increase clinic and hospital efficiency. Furthermore, prescription databases which provide
access to formularies can help increase compliance and provide patients with cheaper
medications. Affordable medications increase patient compliance, resulting in better patient
outcomes.

Starting in 2015, not complying to these meaningful use requirements will become a
penalty with approximately 15% of our Medicare reimbursement is at risk.

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This is the continuation of the second cycle of this project. Earlier in the second cycle,
Nicole Harlan and Julia Hughes identified barriers to e-prescribing among residents and
attendings, defined a baseline e-prescription rate for each physician and implemented an
intervention to increase e-prescription rates which was a one-on-one training session for
each resident.

PLAN:

Aim/Objective Statement for this cycle What do you hope to learn? What are you trying
to improve (aim), by how much (goal) and by when (timeframe)?
The first goal for the second part of the second cycle of this project is to facilitate the
training sessions by following progress, which residents have been trained so far and
helping the trainers to interpret schedules and finding locations. I also plan to speed up
training process.
The second goal was to get feedback from the residents to evaluate what impact the
training sessions have on the residents prescribing practice.
The third goal is to look at updated e-prescribing data to get an impression in which
direction e-prescribing rates are training. It would be too early to use this data to draw
conclusions about the impact of the intervention because not all the residents have been
trained, yet and the data always lags one month behind.
The fourth goal is to set a long term awareness component. The current intervention will
raise short term awareness but a year from now e-prescribing will still be important and
awareness has to be kept at a constant level in the future to keep e-prescribing rates high.
The fifth goal was to look at results from a previous survey that evaluated barriers to e-
prescribing.
As part of the next cycle, we will determine how rates have changed following the
intervention.

Predictions/Hypotheses (What do you think will happen?)
1. By receiving knowledge of their individual e-prescribing rates and participating in a
simple intervention, physicians will increase their use of e-prescriptions. When
physicians receive feedback about their e-prescription rates and have an attainable
goal set for them, they will improve their use of e-scripts.
2. Resident physicians will improve their rates of e-prescribing more than attending
physicians. Because resident physicians do not yet have fixed prescribing habits, we
may be able to change their habits more easily than attending physicians. This may
also be partly because attendings are already e-prescribing at a higher rate than
residents.
3. Long term awareness will be higher if there is some constant reminder about e-
prescribing.

Plan for change/test/intervention
- Facilitating training sessions:

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o Follow the progress
o Support trainers
- Speed up training processs:
o Contacting residents who have no clinic in September by email and set up

individual locations for training in the hospital for them.
- Feedback about training sessions:

o Contact residents that have been trained and ask them to answer an email
with four short questions about the training to evaluate the training process.

- Set up a long term awareness component:
o Set up a biweekly follow up email that is sent to attendings and residents
who have e-prescribed less than 40% in the past 2 weeks that reminds them
to e-prescribe.
o Create a list that is updated biweekly of e-prescription rates together with
Shaun McDonald that is used to create these emails

- Evaluate survey:
o Find barriers to e-prescribing

Measures (What will you measure in order to meet your aims? How will know that a
change is an improvement? Will you use outcome or process measures?)

Plan for data collection
Who (will collect): Julia Hughes, Nicole Harlan, Michael Bode, and ISD trainers
What (measures): E-prescription rates for Blocks 2-4 of 2010-2011 , surveys about e-
prescription use and barriers to use, data on who is participating in the interventions
(attendance)
When (time period): Blocks 2-4: 8/8/2011-10/17/2011, or until most residents have
completed training sessions
Where (location): Ambulatory Care Clinic Continuity Clinic resident workroom/precepting
room; Attending offices
How (method): Data on attendance/participation will be collected by the ISD trainers.
Survey data will be collected electronically via the UNC survey function. As the intervention
begins to take place, data on e-prescribing rates will be collected via EHR and compiled by
Sean McDonald.

__________________________________________________________________
___________
DO: Carry out the change/test. Collect data.
Note when completed, observations, problems encountered, and special circumstances.
Include names and details.

1. Facilitated training sessions by following the progress of the interventions in close
communication with the ISD trainers. The trainers were supported by interpreting

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schedules for them, helping them to contact specific residents and finding specific
locations.
2. The training process was sped up by contacting residents who had no clinic in
September by email and set up individual locations for training in the hospital for
them or set up teaching sessions by phone for those who were too busy to attend a
training session.
3. Collected feedback about training sessions by creating a short questionnaire that
was sent out via email with four short questions about the training.
4. Set up a long term awareness component in form of a biweekly follow up email that
will be sent to attendings and residents who have e-prescribed less than 40% in the
past 2 weeks that reminds them to e-prescribe. To be able to set up this email, a list
was created first together with Shaun McDonald that is updated biweekly and
contains the e-prescriptions rates of the past two weeks and fiscal-year-to-date for
each provider in the internal medicine department. The data for the emails is pulled
from this list.
5. Evaluated the survey to find barriers to e-prescribing. Results below.

______________________________________________________________________________
STUDY: Summarize and Analyze data (quantitative and qualitative). Include charts, graphs.

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Follow
 up
 on
 training
 sessions
 (8
 out
 of
 35
 answers
 received
 so
 far)
Question
 1:
 Was
 the
 training
 helpful
 to
 reduce
 barriers
 to
 e-­‐prescribing?

  Yes:
 37.5%
 
 
 No:
 62.5%
Question
 2:
 Do
 you
 think
 you
 are
 e-­‐prescribing
 more
 now?

  Yes:
 37.5%
 
 
 No:
 62.5%
Question
 3:
 What
 did
 you
 like?

  Opportunity
 to
 ask
 questions.
 It
 was
 short.
Question
 4:
 What
 did
 you
 not
 like?

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Bi-weekly email:

UNC
 Health
 Care
 

To:
  [email protected]
 
From:
  Tolson,
 Sandra
 
Date:
  9/16/2011
 
Re:
  <40%
 ePrescriptions
 

Prescriber:
  CARLTON
 
 
 
 
 
 
 R
 MOORE
 

EPrescriptions
 
  0%
 

Comments:
  Please
 remember
 to
 ePrescribe
 directly
 to
 the
 patient’s
 pharmacy
 whenever
 possible.
 
 
 

  When
 necessary,
 print
 the
 Confirmation
 immediately
 following
 transmission.
 
If
 ePrescription
 is
 not
 an
 option
 (controlled
 substance,
 pharmacy
 not
 included
 in
 the
 SureScripts
 listing)
 
Resources:
  ePrint
 the
 prescription
 from
 WebCIS,
 apply
 your
 signature,
 and
 give
 to
 the
 patient.
 
 
 

Call
 the
 ISD
 Help
 Desk
 65647
 for
 technical
 problems
 
Send
 an
 email
 to
 [email protected]
 to
 request
 customized
 WebCIS
 tutoring.
 

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Overall e-prescription rates for department of internal medicine
July 2011: 39.1 %

FYTD (September 1, 2011) : 45.9 %

______________________________________________________________________________
ACT: Document/summarize what was learned. Did you meet your aims and goals? Did you
answer the questions you wanted to address? List major conclusions from this cycle.

1. The survey showed that major barriers to e-prescribing are getting the patients to
agree, finding the correct pharmacy in the program and mail order pharmacies.

2. The data to evaluate the training sessions is insufficient at this point as more
answers to the survey are needed. The survey, however, shows that many residents

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already use e-prescribing but that nevertheless for some of them the training
sessions were still useful and appreciated.
3. The current e-prescribing data for the department of internal medicine shows that e-
prescription rates went up from 39.1% in July to 45.9% at the beginning of
September. However, this is not necessarily the sole effect of the training sessions
for residents but might also be the result of increased awareness in the department
for other reasons or it might be due to the fact that now medication refill orders that
are sent from the pharmacies to some attendings electronically are now included in
the data.
4. Training sessions were scheduled in a manner so that over 90% of the residents will
be trained by the end of September.
5. A bi-weekly email was set up to remind every physician who falls below 40% e-
prescription rate. It will likely be used by other departments in the future as well.

Define next steps. Are you confident that you should expand size/scope of test or
implement? What changes are needed for the next cycle?

1. Continue to arrange Resident e-prescribing sessions via Sandra Tolson
([email protected] )and e-mail residents and ISD trainers (Craig Brown and
Crystal Johnson) regarding the specific date and time they are scheduled for. These
times are typically 12:45 pm-1:10 pm on Mondays and Wednesdays. Location is in
the ACC continuity clinic workroom. The list of residents who have no training
scheduled yet is called “To be scheduled”.

2. Continue to monitor attendance/participation rates by attending and residents and
survey results via Sandra Tolson.

3. Determine if there are any early problems with the bi-weekly reminder e-mail and
determine who will appear as the sender in this email.

4. Contact Sean McDonald for updated e-prescribing rates as the intervention is
completed.

5. Determine whether rates of e-prescribing for clinic attending and residents have
improved following the intervention.

6. Decrease barriers by improving the e-prescription software so that pharmacies can
be found easier (i.e. with the help of a map, better name recognition, mail order
pharmacy recognition)

7. Determine whether any additional interventions are needed.

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