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What’s New in the
Patient Safety World
October 2021
Tool to Prevent
Discontinued Medications from Being Dispensed
One of the biggest gaps in medication safety is failed
discontinuation of medications. A clinician decides to discontinue the
medication and either enters an order for that discontinuation or simply tells
the patient to stop taking the medication. But the community pharmacy or mail
order pharmacy is never notified of that discontinuation and continues to dispense
that medication. Our multiple prior columns on this problem are listed below.
Enter a tool called CancelRx. We
mentioned CancelRx in our March 2017 What's New in the Patient Safety World column “Yes!
Another Voice for Medication e-Discontinuation!”. Researchers at the University of Wisconsin recently demonstrated the
value of CancelRx in reducing outpatient medication
discrepancies by ensuring communication of medication discontinuation to
pharmacies (Watterson
2021).
CancelRx integrates with clinic EHR and pharmacy dispensing software and automates the manual
process that was previously delegated to clinic and pharmacy staff. It automatically
sends an electronic notification of a medication discontinuation from a clinic’s
EHR to a pharmacy’s dispensing software. After a clinic prescriber has discontinued
a medication and indicated that the pharmacy should be notified, the order is
processed by a third-party vendor, in this case SureScripts
(the same platform used to communicate electronic prescriptions). For the
cancellation message to be electronically transmitted via CancelRx,
the functionality must be “turned on” at SureScripts
for both the clinic sending the message and the pharmacy receiving the message.
The research team used an interrupted time series analysis
(ITSA) to evaluate the effect of CancelRx to decrease
medication discrepancies in the EHR and pharmacy management software. The
impact was quite striking. Approximately 34% of prescriptions were successfully
cancelled in the pre-CancelRx period. There was an
immediate and significant increase in the proportion of successful medication
discontinuations after CancelRx implementation, with
an average of 92.78% prescriptions successfully discontinued in the post
period. The impact was sustained in the year after the initial launch.
Of interest was a disparity between
primary care and specialty care clinics. The ITSA found that there were
significant differences between the proportion of successful medication
discontinuations pre-CancelRx implementation (difference 17.7%, P<0.001).
Specialty clinics had a greater proportion of medications that were
successfully cancelled in the preintervention period compared to primary care
clinics. During the year prior to CancelRx
implementation, the percentage of medications successfully cancelled from
primary care clinics was approximately 26%, whereas the percentage from
specialty clinics was approximately 44%. However, immediately after CancelRx implementation, the proportion of successful cancellations
across the 2 clinic types converged and became the same on average
(approximately 98% in both the primary care and specialty clinics, difference
1.6%).
Also, prior to CancelRx
implementation there was considerable variation in the time to medication
discontinuation. In comparison, after CancelRx
implementation, medication discontinuations were all completed on the same day!
CancelRx requires that both the clinic
and the pharmacy have the functionality turned on through the third-party
vendor.
Watterson et al. note that CMS added CancelRx to the 2017 Stage 3 Meaningful Use EHR
Certification Criteria, required to qualify for the Medicaid Promoting Interoperability
Program. Certification criteria requires that a user be able to not only
create, change, or refill but also cancel prescriptions within the EHR
technology according to NCPDP SCRIPT Standard (which includes CancelRx). But, for a variety of reasons, organizations
have been slow to adopt this functionality. The
authors note, however, that more and more entire health systems, private
clinics, and pharmacies are now upgrading their systems to receive and utilize CancelRx functionality.
The results of the Watterson study should serve as an
impetus for all health systems and clinics to begin using CancelRx.
Some of our other
columns on failed discontinuation of medications:
May 27, 2014 “A
Gap in ePrescribing: Stopping Medications”
March 2017 “Yes!
Another Voice for Medication e-Discontinuation!”
February 2018 “10
Years on the Wrong Medication”
August 28, 2018 “Thought
You Discontinued That Medication? Think Again”
December 18, 2018 “Great
Recommendations for e-Prescribing”
August 2019 “Including
Indications for Medications: We Are Failing”
August 6, 2019 “Repeat
Adverse Drug Events”
References:
Watterson TL, Stone JA, Brown R, et al. CancelRx:
a health IT tool to reduce medication discrepancies in the outpatient setting,
Journal of the American Medical Informatics Association 2021; 28(7): 1526-1533
https://academic.oup.com/jamia/article-abstract/28/7/1526/6211610?redirectedFrom=fulltext
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