CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting

Understanding the Information Needs of Pharmacy Staff Using CancelRx: A Qualitative Study of the Use of Prescription E-cancellation

Background

Although electronic prescription cancellation such as via CancelRx can facilitate critical communication between prescribers and pharmacy staff about discontinued medications, there is little work that explores whether CancelRx meets the needs of pharmacy staff users.

Objective

This study leverages qualitative interviews with pharmacy staff to address the following question: When medication changes are made by a prescriber using CancelRx, what information is needed by pharmacy staff to make correct and effective decisions in their roles in medication management?

Methods

We conducted an inductive thematic analysis of interviews with 11 pharmacy staff members (pharmacists and pharmacy technicians) across three outpatient community pharmacy sites within an academic health care system.

Results

Three information needs themes were consistently identified by both pharmacists and pharmacy technicians: prescriber intent when initiating the CancelRx, clinical rationale for the medication change, and intended medication regimen. Notably, both pharmacists and pharmacy technicians often reported seeking multiple information needs not fully addressed by CancelRx in the electronic health record (EHR) to achieve the shared goals of correct dispensing of medications and supporting patient self-management.

Conclusions

Our qualitative analysis reveals that outpatient community pharmacy staff in an academic health care system often seek additional information from the (EHR) following medication changes communicated by CancelRx to meet their information needs. Ideally, the prescriber would provide sufficient information through CancelRx to automatically identify all discontinued prescriptions. These limitations highlight the need for design features that support routine communication of needed information at the time of a medication change, such as structured data elements.

CancelRx case study: implications for clinic and community pharmacy work systems

BACKGROUND

Medication prescribing and discontinuation processes are complex and involve the patient, numerous health care professionals, organizations, health information technology (IT). CancelRx is a health IT that automatically communicates medication discontinuations from the clinic electronic health record to the community pharmacy dispensing platform, theoretically improving communication. CancelRx was implemented across a Midwest academic health system in October 2017. The health system also operates 15 outpatient community pharmacies.

OBJECTIVE

The goal of this qualitative study was to describe how both the clinic and community pharmacy work systems change and interact over time regarding medication discontinuations, before and after CancelRx implantation.

APPROACH

Medical Assistants (n = 9), Community Pharmacists (n = 12), and Pharmacy Administrators (n = 3), employed by the health system were interviewed across 3-time periods between 2017 and 2018- 3-months prior to CancelRx implementation, 3-months after CancelRx implementation, and 9-months after CancelRx implementation. Interviews were audio recorded, transcribed, and conducted a hybrid analysis with deductive content analysis following the Systems Engineering Initiative for Patient Safety (SEIPS) framework and inductive analysis to capture additional codes and themes.

KEY RESULTS

CancelRx changed the medication discontinuation process at both clinics and community pharmacies. In the clinics, the workflows and medication discontinuation tasks changed over time while MA roles and clinic staff communication practices remained variable. In the pharmacy, CancelRx automated and streamlined how medication discontinuation messages were received and processed, but also increased workload for the pharmacists and introduced new errors.

CONCLUSIONS

This study utilizes a systems approach to assess disparate systems within a patient network. Future studies may consider health IT implications for systems that are not in the same health system as well as assessing the role of implementation decisions on health IT use and dissemination.

Pharmacy e-Prescription Dispensing Before and After CancelRx Implementation

Importance

An estimated 1.5% to nearly 5% of medications are dispensed after discontinuation in the electronic health record (EHR), with 34% meeting criteria for high risk of potential harm.

Objective

To evaluate the association of the implementation of e-prescription cancellation messaging (CancelRx) with medication dispensing after discontinuation of e-prescriptions in the EHR.

Design, Setting, and Participants

This case series with interrupted time series analysis included patients who had at least 1 medication e-prescribed in ambulatory care to a health system pharmacy and discontinued in the 2-year study period from 1 year prior to approximately 1 year after CancelRx implementation (January 15, 2018, to December 7, 2019). Prior to CancelRx implementation, changes to e-prescribed medications within the EHR were not electronically communicated to health system pharmacies, which used separate pharmacy management software. Statistical analysis was performed from November 2020 to June 2023 (primary analysis from March 2021 to May 2022).

Exposure

Implementation of CancelRx.

Main Outcomes and Measures

The primary outcome was the proportion of e-prescribed medications dispensed and sold to patients by pharmacies within 6 months after discontinuation in the EHR. A medication was defined as dispensed after discontinuation if the timestamp of dispensing was at least 1 minute and less than 6 months after the timestamp of discontinuation in the EHR. A secondary outcome was the proportion of discontinued medications that was reordered within 120 days.

Results

A total of 53 298 qualifying e-prescriptions that were discontinued were identified for 17 451 unique patients (mean [SD] age, 50.6 [18.2] years; 9332 women [53.5%]). After CancelRx implementation, 22 443 (85.9%) of the 26 127 discontinued e-prescriptions resulted in a CancelRx transaction. In interrupted time series analysis, the proportion of prescriptions dispensed after discontinuation decreased from a baseline of 8.0% (2162 of 27 171) to 1.4% (369 of 26 127; P < .001), without a significant week-to-week trend (β = 0.000158; P = .37).

Conclusions and Relevance

In this case series with interrupted time series analysis, findings suggest that CancelRx implementation was associated with an immediate and persistent reduction in the proportion of e-prescriptions sold after discontinuation in the EHR. Widespread implementation of CancelRx may significantly improve medication safety through the reduction of medication dispensing after discontinuation by prescribers.

CancelRx Case Study: Implications for Clinic and Community Pharmacy Work Systems

Background

The medication prescribing, and de-prescribing process is complex with numerous actors, organizations, and health information technology (IT). CancelRx is a health IT that automatically communicates medication discontinuations from the clinic electronic health record to the community pharmacy's dispensing platform, theoretically improving communication. CancelRx was implemented across a Midwest academic health system in October 2017.

Objective

The goal of this study was to describe how both the clinic and community pharmacy work systems change and interact over time regarding medication discontinuations.

Approach

Medical Assistants (n = 9), Community Pharmacists (n = 12), and Pharmacy Administrators (n =3), employed by the health system were interviewed across 3-time periods- 3-months prior to CancelRx implementation, 3-months after CancelRx implementation, and 9-months after CancelRx implementation. Interviews were audio recorded, transcribed, and analyzed via deductive content analysis.

Key Results

CancelRx changed the medication discontinuation process at both clinics and community pharmacies. In the clinics, the workflows and medication discontinuation tasks changed over time while MA roles and clinic staff communication practices remained variable. In the pharmacy, CancelRx automated and streamlined how medication discontinuation messages were received and processed, but also increased workload for the pharmacists and introduced new errors.

Conclusions

This study utilizes a systems approach to assess disparate systems within a patient network. Future studies may consider health IT implications for systems that are not in the same health system as well as assessing the role of implementation decisions on health IT use and dissemination.

Discontinuation of outpatient medications: implications for electronic messaging to pharmacies using CancelRx

Electronic communication of prescription discontinuation, or CancelRx, has the potential to improve medication safety. We aimed to describe the proportion of discontinued outpatient medications that would result in a CancelRx message to understand its impact on medication safety. We used a data report to identify all outpatient medications discontinued in the electronic health record (EHR) of an academic health system in 1 month (October 2018). Among all 63 485 medications discontinued, 23 118 (36.4%) were e-prescribed, 25 982 (40.9%) were patient-reported or reconciled, and the remainder prescribed nonelectronically. Discontinued high-risk medications were more likely to be e-prescribed (2768 of 5896, 47.0%). A discontinuation reason was specified in 37 353 (58.9%) of all discontinued medications. Approximately one-third to one-half of discontinued medications were e-prescribed within the same EHR and would result in a CancelRx message to the pharmacy. Extension of this functionality to medications reconciled in the EHR could significantly expand the impact of CancelRx on medication safety. In addition, complete and accurate discontinuation reasons are needed to optimize CancelRx implementation.

The Impact of Electronic Communication of Medication Discontinuation (CancelRx) on Medication Safety: A Pilot Study

OBJECTIVES

This study aimed to evaluate the impact of electronic communication of medication discontinuation from prescribers to pharmacies (CancelRx) on medication safety.

METHODS

We used electronic health record (EHR) data to identify medications that were e-prescribed from a pilot practice to a health system pharmacy and subsequently discontinued before or after CancelRx implementation (January 16-April 15, 2018 versus 2019). We matched these EHR data to pharmacy management software data to identify medications that were sold to patients in the 6 months after discontinuation. As a surrogate for unintended cancellation, we also identified medications refilled within 120 days of discontinuation. We conducted a medical record review to identify documentation of prescriber intent to discontinue these medications.

RESULTS

CancelRx implementation prevented prescriptions from being sold after discontinuation in the EHR (42 of 392 [10.7%] versus 0 of 387 [0.0%], P < 0.0001), but only 15 of 42 (35.7%) had documented intent to discontinue the medication (15 of 392, or 3.8% overall). There was a nonsignificant increase in the proportion of discontinued medications reordered within 120 days (10.0% versus 12.7%, P = 0.23). Medical record review of reordered prescriptions after CancelRx implementation found that 10 of 49 (10 of 387, or 2.6% overall) might have been unintentionally canceled.

CONCLUSIONS

Implementation of CancelRx eliminated the sale of e-prescribed medications after discontinuation in the EHR but might result in the unintentional cancellation of some prescriptions. Strategies to increase situational awareness of providers and pharmacy staff, including increased visibility of CancelRx, clear distinctions between active and expired prescriptions, and transmission of the reason for discontinuation, might reduce the risk of unintentional cancellations.

Impact of CancelRx on discontinuation of controlled substance prescriptions: an interrupted time series analysis

Background

Prescription opioid misuse is a serious national crisis; in 2018 the top drugs involved in prescription overdose deaths included pain medications (opioids), benzodiazepines, and stimulants. Health information technology (health IT) provides a means to address this crisis through technologies that streamline the prescribing and discontinuation process. CancelRx is a health IT function that communicates when medications, such as controlled substances, are discontinued at the clinic and therefore should not be filled at the pharmacy. Prior to CancelRx, the communication of discontinued medications was a manual process, requiring the patient or a clinic staff member to personally contact the pharmacy to inform them of the change. The objective of this study was to assess how controlled substance medication discontinuations were communicated over time, before and after the implementation of CancelRx.

Methods

Secondary data from a midwestern academic health system electronic health record and pharmacy platform were collected 12-months prior to CancelRx implementation and for 12-months post implementation. The study utilized an interrupted time series analysis (ITSA) to capture the percentage of controlled substance medications that were discontinued in the clinic’s electronic health record and discontinued in the pharmacy’s dispensing software. The ITSA plotted the percentage of successful discontinuation messages over time, particularly after the health system’s implementation of CancelRx, a novel technology.

Results

After CancelRx implementation there was an immediate (change = 77.7 percentage point) and significant (p < 0.001) increase in the number of controlled substance medications that were successfully discontinued at the pharmacy after being discontinued in the clinic. This change was sustained in the year following CancelRx (slope = 0.03 pp, 95% CI − 0.050 to 0.110) and did not revert to pre-CancelRx levels. The health IT functionality was able to effectively complete discontinuation tasks and potentially reduce workload for clinic staff.

Conclusions

Overall, this study demonstrates the role that technology can play in promoting communication between clinics and pharmacies, especially when medications such as controlled substances are discontinued.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01779-9.

CancelRx implementation: Observed changes to medication discontinuation workflows over time

Introduction

When patients are seen in an ambulatory outpatient clinic, such as their primary care provider's office, the prescriber often stops or discontinues medications. Although medication discontinuations are documented in the clinic's health record, this information may not be communicated to the pharmacy. Within the last decade, CancelRx has attempted to address this issue by sending a message from the clinic to the pharmacy when a medication has been discontinued or changed.

Objectives

This project studied pharmacy medication discontinuation workflows and pharmacists' perspectives at 3 UW Health outpatient pharmacies before and after implementation of CancelRx.

Methods

CancelRx was implemented at UW Health in October 2017. Pharmacists from 3 outpatient pharmacies were observed at 3 distinct time points. The research team conducted 9 observations 3-months before CancelRx implementation (July 2017). Additionally, 9 observations were completed at 3-months after CancelRx implementation (January 2018) and at 9-months after CancelRx implementation (July 2018). Collective case study and comparative workflow modeling were used in this study. Observation field notes were deductively coded and aggregated to determine task frequency, occurrence, and patterns using an interpretivist theoretical approach.

Results

During the study, 106 medication discontinuation instances (referred to as cases) were observed; 28 cases 3-months prior to CancelRx, 59 cases 3-months after CancelRx, and 16 cases 9-months after CancelRx. Medication discontinuation tasks aligned with the predetermined workflow: receiving and investigating the discontinuation messages, matching the message to the medication in the patient's profile and discontinuing it, documenting and communicating the message to others as necessary. After implementing CancelRx, the workflow changed as most pharmacists eliminated the investigating and documenting tasks.

Conclusions

This study provided insight into the medication discontinuation workflow in community pharmacies, especially after implementing CancelRx. Organizations are recommended to proactively consider the implications for novel health information technology before implementation to anticipate workflow and pharmacy practice changes and improve acceptance and effectiveness.