Professor Chui undertakes first study of implementation of
e-prescribing tool

By Katie Ginder-Vogel

When John Doe, a 58-year-old man, visited his doctor for a routine follow-up for congestive heart failure, the doctor discovered that one of the Doe’s medications, amiodarone, could be causing pulmonary fibrosis, a dangerous condition. The provider discontinued amiodarone in the clinic database and verbally communicated the discontinuation with the patient. Unfortunately, when the patient returned for a three-month follow-up visit, the doctor learned that the patient was still taking amiodarone because the patient hadn’t communicated the discontinuation with the pharmacy, so the pharmacy continued to dispense the amiodarone.

There are more of these stories. In fact, 34 percent of discontinued drugs that are later dispensed meet the high-risk criteria for a potential adverse drug event, according to a 2012 study in Annals of Internal Medicine.

Now, this problem is being addressed through technology, in order to automate medication discontinuations and help limit human error.

CancelRx to enhance patient safety

The technology is called CancelRx, an e-prescribing tool that automatically sends an electronic message to the pharmacy when a doctor discontinues a drug for a patient, so the pharmacy knows to discontinue that particular prescription, and the system can be updated. Built and standardized by the National Council for Prescription Drug Programs (NCPDP), the governing body of electronic medical information standards that guides the standards for electronic health records communication and use, CancelRx is the only tool of this type.

“CancelRx automates a process that’s automatable,” says Michelle Chui, associate professor and vice chair of the Social & Administrative Sciences Division at the UW–Madison School of Pharmacy.  

Chui, whose research investigates ways to improve medication safety for older adults in outpatient settings, received an 18-month grant from the Gordon and Betty Moore Foundation in November 2017 to work on a project called CancelRx: A Health IT Tool to Decrease Medication Discrepancies in the Outpatient Setting.

“Older adults take the most medications and are at the highest risk for adverse events that would land them in the emergency room or a nursing home,” says Chui. “The drugs they take are complicated and precarious, so I focus on whatever we can do to reduce their risks.”

“Unfortunately, communication breakdowns between patients and health care providers are a frequent source of medication errors.” –Steve Rough

Understanding the effectiveness

On October 27, 2017, UW Health implemented CancelRX, and its implementation is the focus of Chui’s research.

“Unfortunately, communication breakdowns between patients and health care providers are a frequent source of medication errors. At UW Health, we are supportive of all strategies, including technological approaches such as CancelRx, which may help to mitigate such breakdowns,” says Steve Rough, senior director of pharmacy at UW Hospital and Clinics.

Chui’s project will look at data from the 12 months preceding UW Health’s implementation of CancelRx and the 12 months following implementation to examine the percentage of medical discrepancies in both periods and determine how effective CancelRx is at eliminating over-prescription of prescription medication.

“Pre-CancelRx, we could see drug discontinuations at the physician level, but not at the pharmacy level,” says Chui. “Once CancelRx goes in, at least some of discontinuations should appear in the pharmacy system, so we’re looking at the proportion of discontinuations pre- and post- CancelRx.”

Chui’s project, as well as a second project funded by the National Association of Chain Drug Stores Foundation around the same time as Chui’s, is the first to analyze CancelRx. Chui’s research team will pull data from Epic and pharmacies and will also visit clinics and pharmacies to look at the workflow implications of the change.

“We know that anytime you implement an intervention, there are always unintended consequences,” says Chui. “Things change the system, for good or bad, that are unanticipated. We want to evaluate the impact on workflow, to help other organizations anticipate what they’ll be dealing with in their implementation of CancelRx.”

UW Health’s implementation of CancelRx should immediately reduce the workload of medical assistants (MA), because until now, discontinued prescriptions were emailed to clinics’ MAs so they could call the pharmacy to discontinue the drug.

“The medical assistant would have to call, the pharmacy would have to answer and know what to do, and the pharmacy would have to discontinue the drug,” says Chui. “It was a personnel-driven process in an environment where there are higher priorities. When we reviewed it, we found over 100 unread messages in inboxes, so we know it wasn’t working.”

CancelRx bypasses MAs and goes straight to the pharmacy, using the engineering principle of automating processes that don’t require human decision-making.

Implications for pharmacists

Chui expects pharmacies to modify their processes for what happens when the CancelRx message gets to the pharmacy over time.

“Part of the reason why we’re evaluating over 12 months post-go-live is that we think pharmacies will modify their workflow as things go,” Chui says. “We want to record their Continuous Quality Improvement (CQI) process, so that when they encounter a problem, we can observe how they address it. This is not a one-shot deal. Pharmacists will modify their work as they encounter problems.”

Chui and her team began their assessments, which include observations and interviews, in January 2018.

“I hope that this project will provide evidence that CancelRx will prevent medication errors in the future and can be implemented successfully without significant workload implications,” says Chui. “If I can produce this evidence, I think that health systems and pharmacies around the country will think about implementing it in their own organizations, thus improving medication safety for all patients.”

Chui isn’t afraid to think big, and she hopes health systems around the U.S. will implement CancelRx. She aims to be at the forefront of research on CancelRx, all in the interest of serving patients.

“I would like to study the implementation of CancelRx in other health systems and larger retail chain pharmacies, so that we can develop a toolkit for organizations that seek to implement this in the future,” says Chui.

Learn more about the Chui Research Group.