About CERTs
Annual Report Year 4
CERTs Progress
Advancing Knowledge | Informing Providers and Patients | Improving the System | Referenced Projects
Improving the System
The CERTs' most broad-reaching efforts are those aimed at improving aspects of the health care system related to therapeutics. We conduct research that evaluates the policies that govern health care delivery. We also evaluate computer technology to improve the efficiency of health care, make therapies safer, and give health care providers better access to current treatment information.
EFFECTS OF CHANGING DELIVERY OF MENTAL HEALTH CARE11
People with mental illnesses such as schizophrenia need long-term treatment to prevent psychotic episodes and hospitalization. Many patients with mental illnesses receive care through state Medicaid programs. To save money, some states are turning over care of these patients to specialty behavioral health organizations. This often means that patients have to see new health care providers, a disruption that can cause them to stop their treatment. Once patients stop treatment, they may not start again, which puts them at risk for serious decline.
We studied the effects of changes in Tennessee's mental health services from a Medicaid program to a specialty behavioral health organization, TennCare Partners. After the change, patients were more likely to miss therapy for more than 60 days. Patients who had been hospitalized for psychosis were among those most likely to miss therapy. These results suggest that organizational changes may put patients at risk and that such risks should be minimized by keeping patient care constant or by incorporating special safeguards.
TESTING WHETHER PRESCRIPTION REVIEW PROGRAMS REDUCE ERRORS12
All state Medicaid programs are required to conduct a retrospective drug utilization review, which is intended to decrease errors in drug prescriptions. In the review, a computer sorts through a patient's prescribed medicines and reports certain errors, such as harmful interactions or incorrect dosage. A drug use review board reviews the computer reports and recommends appropriate educational programs to improve drug therapy. The Medicaid program conducts the educational programs specified by the drug use review board, which can include contacting the prescriber to suggest changes in prescribing practices.
We studied the effectiveness of retrospective drug reviews in six Medicaid programs. Based on an examination and evaluation of six drug utilization programs, the study's authors concluded that such programs do not reduce the frequency of medication-use problems or of medication-related admissions. Given the lack of evidence for effectiveness and suggestions from previous research of possible harm, policymakers may wish to evaluate the use of such programs.
USING TECHNOLOGY TO REDUCE MEDICAL ERRORS AND INCREASE EFFICIENCY
Computerized provider order entry programs allow physicians to enter prescriptions into a computer rather than write them out by hand. Programs are designed to reduce medical errors by providing health care providers with relevant information about their patients, such as a patient's allergies, and general reference information about treatment guidelines, warnings, and drug interactions. There are anecdotes and some research findings that these systems improve prescribing by reducing the number of errors. However, much of this research has involved only small numbers of patients in an institutional setting.
Some providers believe that the programs are difficult to use and take more time than writing a prescription. Others find that the alert messages for drug allergies and interactions are annoying and inaccurate.
Computerized provider order entry programs have been slow to catch on in private practice. But they are common in government medical centers, such as Veterans Affairs and Department of Defense medical centers. We are currently studying the programs at 10 Veterans Affairs medical centers to learn how well they work and how they could be improved. This study has three parts: (1) evaluating the order entry process at each medical center; (2) asking doctors how satisfied they are with the process; and (3) studying whether the process decreased harmful drug interactions and improved patients' health outcomes.
Pharmacies have been on the forefront in using technology to improve drug safety and save time. Unfortunately, current systems are not perfect. Patients still sometimes receive combinations of medicines that have harmful interactions despite computerized warnings to the pharmacist. No one knows for certain why pharmacists do not always act on these alerts. It could be because of overwork, a training issue, or the sheer volume or type of alerts.
We are also studying ways to improve pharmacy systems and prevent harmful drug interactions to patients. We are surveying community pharmacies to learn more about where systems work well and where they do not. This should help pharmacies and software developers design better ways to identify harmful drug interactions.
FDA's new requirement for bar coding of prescription drugs is another area that has the potential to reduce medical errors.
USING SURVEILLANCE SYSTEMS TO IMPROVE SAFETY
When we access information about medical therapies, the information available should be as accurate and complete as possible. Several CERTs projects focus on gathering information about the safety of therapeutics so that health care providers can be confident in the treatments they prescribe.
One study aims to learn more about the safety of prescription drug use by pregnant women. We will record drug use before and during pregnancy for 150,000 women in eight different health systems and geographic regions. Our goal is to assess how often unborn babies are exposed to drugs that may cause them harm. This is the first such study in the United States.
We worked with the United States Pharmacopeia to develop recommendations for safe prescribing for children. Together we studied more than 5,600 medication errors reported by more than 500 hospitals to the United States Pharmacopeia's anonymous Web-based reporting system, MEDMARXSM. We considered the error reports and the best published evidence on the causes of and solutions to pediatric medication errors. Based on this information, we made five sets of recommendations about all phases of medication use. These topics ranged from packaging and storing, to prescribing and administering medications to pediatric patients. In April 2003, the United States Pharmacopeia published the recommendations on its Web site: www.usp.org/patientSafety/tools/pedRecommnds2003-01-22.html. The recommendations can be used by all health care providers who treat children.