Safer prescription of drugs: impact of the PREFASEG system to aid clinical decision-making in primary care in Catalonia

Background In 2008, the Institut Català de la Salut (ICS, Catalan Health Institute) implemented a prescription decision support system in its electronic clinical workstation (ECW), which automatically generates online alerts for general practitioners when a possible medication-related problem (MRP) is detected. This tool is known as PREFASEG, and at the time of beginning a new treatment, it automatically assesses the suitability of the treatment for the individual patient. This analysis is based on ongoing treatments, demographic characteristics, existing pathologies, and patient biochemical variables. As a result of the assessment, therapeutic recommendations are provided. The objective of this study is to present the PREFASEG tool, analyse the main alerts that it generates, and determine the degree of alert acceptance. Methods A cross-sectional descriptive study was carried out to analyse the generation of MRP-related alerts detected by PREFASEG during 2016, 2017, and 2018 in primary care (PC) in Catalonia. The number of MRP alerts generated, the drugs involved, and the acceptance/rejection of the alerts were analysed. An alert was considered "accepted" when the medication that generated the alert was not prescribed, thereby following the recommendation given by the tool. The MRP alerts studied were therapeutic duplications, safety alerts issued by the Spanish Medicines Agency, and drugs not recommended for use in geriatrics. The prescriptions issued by 6411 ICS PC physicians who use the ECW and provide their services to 5.8 million Catalans through 288 PC teams were analysed. Results During the 3 years examined, 67.2 million new prescriptions were analysed, for which PREFASEG generated 4,379,866 alerts (1 for every 15 new treatments). A total of 1,222,159 alerts (28%) were accepted. Pharmacological interactions and therapeutic duplications were the most detected alerts, representing 40 and 30% of the total alerts, respectively. The main pharmacological groups involved in the safety alerts were nonsteroidal anti-inflammatory drugs and renin-angiotensin system inhibitors. Conclusions During the period analysed, 28% of the prescriptions wherein a toxicity-related PREFASEG alert was generated led to treatment modification, thereby helping to prevent the generation of potential safety MRPs. However, the tool should be further improved to increase alert acceptance and thereby improve patient safety.

Audit on prolactin monitoring for patients on oral risperidone, intramuscular risperidone, and intramuscular paliperidone

AimsThe aim of this audit was to investigate whether sufficient Prolactin monitoring was completed in a patient sample in the Torfaen area of Aneurin Bevan University Health Board. This audit targetted patients an oral or intra-muscular formulation of Risperidone in the year 2018 with the hypothesis that Prolactin monitoring is done less frequently than recommended.BackgroundRisperidone is the anti-psychotic drug most frequently associated with hyperprolactinemia which is often asymptomatic but can present with symptoms of oligomenorrhea, amenorrhea, galactorrhea, decreased libido, infertility, and decreased bone mass in women. Men with hyperprolactinemia may present with erectile dysfunction, decreased libido, infertility, gynecomastia, decreased bone mass, and rarely galactorrhea. The BNF advises monitoring of Prolactin at baseline, after 6 months, and then annually.MethodRetrospective review of 150 patients’ clinical letters to identify if they are on the above medications, using the local digital records system EPEX. Emails were also sent to community psychiatric nurses asking them if they could highlight any patients they were caseholding on the above medication. Depot clinic lists were also examined. Patients identified as being on the above medication had their blood tests reviewed on the online system Clinical Workstation (CWS) to determine whether they had their Prolactin level tested. A single spot sample of all patients on Talygarn ward in January 2019 was also included.Result1. 28 Risperidone2. 23 of 28 never had any Prolactin measurements3. 2 of 28 patients had the appropriate level of monitoring done for the year of 2018a. One patient complained of Galacotorrheab. Another patient had baseline done while on the ward and isn't due for any further monitoring at the time of writing.ConclusionThe above results identify that Prolactin monitoring is not being routinely completed for patients on the studied medication at an acceptable compliance level. Limitations around utitlity of prolactin monitoring may be the contributing factors; eg. Prolactin levels or medication dose may not be positively associated with adverse effects.. Further efforts were made to highlight the importance of baseline prolactin monitoring, as well as including a baseline Prolactin as an admission blood test for patients presenting with psychotic symptoms or on an anti-psychotic. A complete audit of metabolic monitoring and Prolactin levels for all patients on anti-psychotics would be an appropriate next step.

Easing hospitalist electronic health record burden through clinical workstation single sign-on

Background: Computer workstation single sign-on (SSO) was implemented in 19 hospitals to reduce manual keyboard login and expedite access to the electronic health record (EHR) and clinical applications.Objective: To quantify hospitalists time liberated from EHR keyboard to focus on patient care, and estimate financial value of this time for hospitalists.Methods: Login duration prior to and after SSO implementation were compared in eight hospitals. Using national estimates of hospitalist hourly wage, dollar values of time liberated from keyboard were calculated, stratified by different levels of total EHR use.Results: Following SSO implementation, first of shift login decreased 5.3 seconds (15.3%), and reconnect duration decreased 20.4 seconds (69.9%). The volume of hospitalist EHR use among all physician end users comprises 70%-90% of all electronic documentation and clinical orders issued, yielding an annual range of 10,302 hours (or 858.5 12-hour shifts) to 13,245 hours (or 1,103.8 12-hour shifts) in hospitalist time liberated from keyboard for patient care, with recurrent annual value of $1,164,126 to $1,496,685.Conclusions: Hospitalists gained meaningful amounts of time for patient care from SSO implementation. This time accrued to substantial financial value. SSO eases the EHR burden of hospitalists, and facilities using hospitalists extensively should consider SSO implementation.

Adjacent Joint Arthrodesis Risk After First Metatarsophalangeal Joint Arthrodesis: A 10 Year FollowUp Study

Category: Midfoot/Forefoot Introduction/Purpose: Arthrodesis remains the gold standard for end stage symptomatic first metatarsophalangeal (MTP) joint osteoarthritis. Based on several ankle arthrodesis studies, it is well known that adjacent joints are put under more stress leading to secondary osteoarthritis. However, the direct association between first MTPJ arthrodesis and the progression of adjacent joint arthrosis remains unclear. The purpose of this study was to determine the progression of interphalangeal (IPJ) and 1st tarsometarsal joint (1st TMT) degeneration following first MTP joint arthrodesis. Methods: All patients treated with first MTP joint arthrodesis from 2003 to 2008 were identified from our regional centre. Data was obtained from our institution’s electronic clinical workstation which included demographic information, radiographs and clinical letters. A telephone survey with a predetermined written script was carried out in patients as we were not able to obtain ethics to perform repeat radiographs. Results: A total of 166 first MTPJ arthrodesis were included with at least 10 year follow-up. We excluded patients who have moved out of region. There was a 3:1 female to male ratio, with an average age at time of operation being 63 (27- 83). 25% of the patients reported adjacent joint pain (15% at IPJ, 10% at 1st TMTJ) at final follow up. 3 (1.8%) patients required arthrodesis of adjacent joints (1 at IPJ, 2 at 1st TMTJ). Conclusion: This study improves the understanding of biomechanical impact on the foot following 1st MTPJ fusion and is helpful in the consenting process.

Information technology and diffusion in the New Zealand public health sector

Purpose The purpose of this paper is to identify the influential agents that led to the successful acceptance and diffusion of the Concerto clinical workstation at the Northern District Health Board. Design/methodology/approach The paper draws on Rogers’ diffusion of innovation theory to interpret and analyse the factors that enabled acceptance and successful implementation of the innovative Concerto clinical workstation. Findings The authors conclude that human factors (clinicians) and non-human factors (the software package) simultaneously influenced the ready acceptance of the innovation. The reason for the positive acceptance and full diffusion of Concerto as compared to iHealth is the increased functionality it offers and its ability to provide clinicians with comprehensive patient records over a period of time, which assists in making informed decisions regarding the treatment, discharge, hospitalisation and recommendations for the future well-being of patients. Research limitations/implications The study focused on only one district health board (DHB); therefore, the outcomes may not be representative of all DHBs. Practical implications The study has practical implications for clinicians, DHB members and public health regulators. The outcomes illuminate the “agents” that positively influenced the diffusion of Concerto. The regulators and the DHBs can use this as a benchmark to determine how to lead the successful diffusion of information technology (IT) innovation in the public health sector. Social implications The impact on society is evident in the paper, as the use of an innovation, such as Concerto, saves time taken by clinicians to make more informed decisions regarding their patient care. Originality/value This study contributes to new knowledge by investigating the diffusion process of IT innovation with an intention of establishing the factors that enabled this process.