Patient Safety Tip of the Week
May 27, 2014
A Gap in ePrescribing:
Stopping Medications
A recent case report in the Medical Journal of Australia (Tong
2014) brought to light a substantial gap in our current systems for
e-prescribing. The authors describe a case where an 82 y.o.
man on warfarin for atrial fibrillation develops bruising with a severely
prolonged INR after cessation of rifampicin, which he had been taking for
treatment of tuberculosis. The patient had previously been on warfarin 4 mg.
daily and that dose had been increased to 12 mg. daily in conjunction with
monitoring of INR levels while the patient was on the anti-TB regimen. The
warfarin therapy was managed by his PCP, while the antimicrobial therapy was
managed by a specialist. The rifampicin had been discontinued by the specialist
7 weeks before the hospital admission for the bruising. It was concluded that
there had been a significant drug-drug interaction between the warfarin and
rifampicin and that the cessation of rifampicin therapy had led to the
prolonged INR when the warfarin dose was not readjusted.
The case, of course, raises multiple issues. The most
obvious would be a problem in communication between the physicians managing the
various medications. This might be an endorsement for our frequent use of “coumadin clinics” where a nurse or pharmacist in
conjunction with a supervising physician regularly review all the patient’s
medications and adjust warfarin dosage based on expected interactions and INR
results.
But it also illustrates some of the issues we have with our
IT systems. Even though most regions are developing HIE’s or RHIO’s that
integrate health information from multiple sources, those resources are often
not routinely accessed by physicians and may not yet be intergrated
into the EMR’s and e-prescribing systems in physician offices.
But, importantly, this case illustrates another critical
issue: stopping a medication is much different than starting one. The clinical
decision support built into our EMR’s and e-prescribing systems generally is
pretty good at identifying potentially serious drug-drug interactions and
generating alerts at the time a medication is prescribed. That presumes the
alerts are turned on and the “severity” threshold for the particular alert is
enabled. (To avoid alert fatigue we usually recommend that only the more
serious alerts are enabled.)
But stopping a medication is much different. Most systems
are not programmed to generate any alerts at the time you discontinue a
medication. Hence, even if your system would have generated a drug-drug
interaction alert when you first prescribed a medication, it would not likely
generate an alert later when you discontinue that medication. Moreover,
starting a medication requires an active process – you either write a
prescription, enter one into a computer, or call the pharmacy. Whereas
discontinuing a medication is often more passive – you may just tell the
patient over the phone to stop it when the patient calls about a potential side
effect. You don’t call the pharmacy to stop it. And, if there was no associated
office visit, you might forget to update the patient’s medication list in your
EMR (or paper records) until the patient’s next office visit.
Another problem is that a patient may continue to get
medications that you thought you had stopped. A study done in a large
multispecialty group practice in Massachusetts (Allen 2012) showed
that among targeted medications that were electronically discontinued (on the
practice’s EMR) 1.5% were subsequently dispensed by a pharmacy at least once.
And this was just at the practice’s internal pharmacy. How often this happened
at community pharmacies was not known. Moreover, when they did manual chart
reviews of selected high-risk medications that had been discontinued they found
that 12% of cases were associated with potential harm.
The authors note that when a physician discontinues a
medication on an EMR he/she often (erroneously) assumes that such information
is being transmitted to the pharmacy. Such is seldom the case with today’s EMR
systems. Further, many pharmacies today have sophisticated systems that let you
know, as a patient, that you have a refill waiting for you at the pharmacy.
Patients may erroneously presume that their physician restarted that
medication.
These examples highlight the continuing struggles we have in
optimizing medication reconciliation. The need to do medication reconciliation
at every office (or hospital) visit is obvious.
While we need to rely on technology vendors and HIE/RHIO’s to come up with some better electronic and interoperability solutions, you also need to look at your own practice. How do you update your patients’ medication lists after you do that over-the-phone medication discontinuation? How do you let the pharmacy know you have stopped a medication? How do you find out if your patient is still being dispensed a discontinued medication? How do you find out that another physician has discontinued a medication on one of your patients? And how do you recognize that the medication you’ve discontinued may have had a drug-drug interaction with another medication (the dose of which you may now need to adjust)?
Lots of questions. No easy answers.
References:
Tong EY, Kowalski M, Yip GS, Dooley MJ. Impact of drug
interactions when medications are stopped: the often forgotten risks
Med J Aust 2014; 200 (6): 345-346
Allen AS, Sequist TD. Pharmacy
Dispensing of Electronically Discontinued Medications. Ann Intern Med 2012; 157(10): 700-705
http://annals.org/article.aspx?articleid=1391698
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