Medical Subject Headings
Building a Standards-Based and Collaborative
E-Prescribing Tool—MyRxPad
Stuart J. Nelson, MD, FACMI, Kelly Zeng, MS, John Kilbourne, MD
U.S. National Library of Medicine
National Institutes of Health
Bethesda, Maryland, USA
{nelson, zeng, kilbourj}@nlm.nih.gov
Abstract-MyRxPad is a prototype application developed at the National Library of Medicine that helps prescribers lower some of the e-prescribing adoption barriers and encourages an early positive experience of e-prescribing. We envision a practitioner-patient collaborative approach towards e-prescribing: patients play an active role in their healthcare by maintaining up-to-date and accurate medication lists. Prescribers make well-informed and safe prescribing decisions based on personal medication records contributed by patients. In the paper, we discuss the development of MyRxPad, a vehicle for collaborations with patients using MyMedicationList. Integration with personal medication records in the context of e-prescribing is thus enabled. An early version of MyRxPad is available at http://rxp.nlm.nih.gov.
Keywords-RxNorm; e-prescribing; Continuity of Care Document (CCD); Personal Health Record (PHR).
I. INTRODUCTION
Electronic prescribing (e-prescribing) is defined as the use of computers to enter, modify, review, issue and/or transmit medication prescriptions [1]. Studies have demonstrated that e-prescribing can improve patient safety, enhance office practice efficiencies, and reduce medical costs [2]. Several bills have been enacted in the recent years to expedite the adoption of e-prescribing: including the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) [3] and the Health Information Technology for Economic and Clinical Health (HITECH) Act provisions of the Recovery Act of 2009 [4]. Both legislations authorize e-prescribing incentive programs.
With the impetus and legislative push for e-prescribing, prescribers, especially those in small practices (solo and small group), face substantial challenges to adopt e-prescribing. The initial and long-term cost and information technology requirements present some of these challenges [5]. Small practices have limited resources to purchase software and hardware, to hire health IT professionals for installation and system configuration and to support system maintenance.
Besides adoption difficulties, lack of access to relevant information, in particular the patient medication history presents another obstacle for e-prescribing. A physician's prescribing decisions depend on knowledge of the patient's medication list. Errors and drug interactions can occur when patients are treated without the prescribers' full knowledge of medications that have been previously ordered [6].
Informed by these challenges, we began our present study by investigating tools that facilitate e-prescribing adoption and patient medication history integration. Our investigation started by searching the available e-prescribing tools on the market. We identified the following major requirements for the tool.
- It should be free and maintained regularly.
- It should offer adequate protection of prescriber and patient information.
- It should be standards-based to facilitate information exchange.
- It should enable integration of patient medication data across disparate providers.
Additionally, to ensure adequate protection of patient information, we believe this tool should have standalone architecture: it should store information locally and not require a login to a remote computer.
We referred to the list of tools found in SureScripts Certified Solution Providers™ [7]. The only tool found there that is free is "Allscripts/National ePrescribing Patient Safety Initiative". It is web based and requires user logins and information storage on remote computers, raising potential concerns over privacy and security. Some standalone applications do offer free trials. Once the trial period expires, the tool is no longer free. In addition, they require registration prior to try out the software.
After a study of the e-prescribing systems on the market revealed no free standalone applications that met our requirements, we decided to create MyRxPad. This tool would lower some of these barriers experienced by prescribers wanting to start e-prescribing. This tool addresses another challenge of e-prescribing, the incompleteness of information on patient medication histories [8]. We propose a patient-centric approach: the patient maintains an updated and accurate personal medication list and shares the list with the prescribers.
The objective of this paper is to discuss the design and implementation choices made while developing MyRxPad. As a prototype, MyRxPad could envision how future e-prescribing systems might address specific problems-such as encouraging medication data integration by the patient, or improving patient understanding and communication with providers.
II. BACKGROUND
A few emerging standards are becoming more widely adopted in the e-prescribing setting, notable among them is the CDA/CCD as the standardized document model for clinical document exchange.
A. HL7 Clinical Document Architecture (CDA)
CDA is a document markup standard that specifies the structure and semantics of a clinical document (such as a discharge summary, progress note, procedure report) for the purpose of exchange. A CDA document can be transferred within a message, and can also be used independently of the transferring message [9]. CDA Release One became an American National Standards Institute (ANSI)-approved Health Level 7 (HL7) Standard in November 2000. CDA Release Two became an ANSI-approved HL7 Standard in May 2005. CDA documents are encoded in Extensible Markup Language (XML). A CDA document contains a header and a body. The header identifies and classifies the document and provides information on authentication, the encounter, the patient and the involved providers; the body contains the clinical report and can be structured or not. CDA defines an optional Medication section for a patient's current and prior medication information, as well as the patient's prescription history.
Figure 1 illustrates such a Medication section. It contains a narrative block (j) wrapped by the <text> element that renders human readable contents and several coded CDA entries (k) for automatic processing purposes. The example document indicates that the patient is currently taking "Celebrex 200 MG Oral Capsule", identified by RXCUI:213469 in RxNorm (l). This medication was started on Feb. 4, 2009 (m). Dose is "1 capsule" (n) and frequency is "once a day" (o). The generic counterpart of this drug is "Celecoxib 200 MG Oral Capsule" (p). This medication was prescribed February 4, 2009 by Dr. John Jose (q). Number of refills is 3 (9) and quantity dispensed is 90 (r).
B. Continuity of Care Document (CCD)
CCD is a CDA Release 2 implementation that maps the Continuity of Care Record (CCR) elements into a CDA representation, harmonizing CCR and CDA into a common framework. While CDA was established as a HL7 standard, CCR was developed as an ASTM International standard. CCR is a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more encounters. CDA and CCR have many similarities, yet differ from each other. From the perspective of CDA, the CCR is a standardized data set that can be used to constrain CDA specifically for summary documents. One such constraint is that CCD should contain exactly one and shall not contain more than one Medication section. The resulting CCD specification is a collaborative effort between ASTM and HL7 [10].
C. RxNorm
RxNorm is a controlled vocabulary of normalized names for clinical drugs [11]. It serves as a standardized nomenclature for prescribable medications. RxNorm organizes drug names from various drug information sources to its standardized concepts, which are assigned a unique identifier (RXCUI) [12]. Distinct, named relationships link concepts within RxNorm. For example, a clinical drug (e.g., "Celecoxib 200 MG Oral Capsule") is linked to its ingredient (Celecoxib), ingredient-strength (Celecoxib 200 MG), dose form (Oral Capsule), and ingredient-dose form concepts (Celecoxib Oral Capsule) through explicit named relationships. RxNorm also includes branded counterparts, linked to their branded components (e.g., "Celebrex 200 MG Oral Capsule").
Figure 1. An example of Medication section (with prescription history) in the CDA body
III. DESIGN AND IMPLEMENTATION
The design and implementation of MyRxPad is driven by the requirements introduced earlier. From an architecture perspective, patient information should be adequately protected. From the data model perspective, medication and prescription information need to be understand by other systems, requiring standards-based information exchange. To enable patient medication data integration across disparate providers, we explore an approach in which the patient maintained medication list serves as the reliable source for complete and accurate patient medication information. And finally, from the usability perspective, the tool should be easy to install and maintain; it should fit into prescriber's current workflow.
A. Architecture: patient privacy and data security
Security and privacy remains a primary concern for potential users of an e-prescribing system. Most e-prescribing products available on the market are web-based, which means that a third party is involved (the provider of the service), and that both patients and prescribers have little or no control over where their information is stored. Additionally, in a web based setting, information is transmitted from the system to the user and vice versa, making information potentially vulnerable during the transmission process. Authentication of the user is a major concern; one which has not been adequately solved.
Our choice is to give prescribers complete control over where patient and prescription information is stored. By default via MyRxPad, prescribers save prescriptions as files in CCD format on prescribers' local computers, which are usually protected by usernames and passwords. For added security, prescribers can choose to encrypt patient files. They could also import files into databases, thus enabling additional data integrity and security features provided by database management systems such as data recovery and back-ups.
In order to accommodate the ability to store information locally, MyRxPad is developed as a standalone Java application that runs locally on prescribers' computers. The tool is available via a URL link, through which the tool is automatically downloaded to prescribers' computers, but the data are stored locally.
B. Data model: standards-base information exchange
MyRxPad uses RxNorm as the terminology for clinical drug names and codes, and the CCD standard as the document model in which prescriptions and patient medication information are stored. Using standards both at the document level and the terminology level enables users to exchange information generated by MyRxPad with other EHR systems. In particular, as the Certification Commission for Health Information Technology (CCHIT) accelerates the adoption of CCD [13], adding CCD import/export as a requirement, we expect most CCHIT certified EHR systems be able to import patient medication and prescription data generated by MyRxPad. Accordingly, MyRxPad would be able to import data generated by these EHR systems as well.
C. Medication data integration across disparate providers: incorporation of patient maintained medication record
A physician's prescription decisions depend on knowledge of the patient's medication list. Aggregating medication histories from multiple sources is often difficult for the following four reasons.
First, information from disparate sources is often incomplete. Medication history is available from a number of sources, but no single source provides a comprehensive listing [14].
Second, medication reconciliation remains difficult [15]. Creating an accurate list of all medications for a patient from disparate sources usually involves mapping different codes and names into standard names and codes. The mapping process can be labor intensive and error prone.
Third, correct identification of a patient remains a hard problem. The same person may be given different identifiers by different sources. Identification strategies that match on patient demographic data such as name, date of birth and/or Social Security Number are yet to be proven completely effective and accurate [16].
Fourth, retrieval of medication histories from disparate sources might not be sufficiently fast. The latency, sometimes unpredictable, makes retrieval and incorporation of medical histories difficult to include in a clinician's workflow.
An alternative approach, as we have explored, is to find patient medication history from a single source: the personal medication record maintained by the patient. We have provided MyMedicationList (MML) [17], a tool that helps patients with their personal medication lists and makes the records available to health professionals when needed. In particular, a patient uses MML to maintain and update his medication list and shares his medication list (brought in on a USB drive or emailed beforehand) with prescribers. Using MyRxPad, prescribers write new or refill prescriptions, and make necessary changes on the patient medication list (for example, to discontinue a medication, or change the dose of a medication). Accordingly, the patient obtains an updated medication list that might include refilled medications with new stop dates, up-to-date prescription history and other medication adjustments. The patient can then use MML to add the new prescriptions to his "current medications" without manually entering the medication names. Integration of patient medication histories with e-prescribing in the context of MyMedicationList and MyRxPad is illustrated in Figure 2. As the patient carries along the medication list to various prescribers, the evolving and updated list serves as the integrated medication data across disparate providers.
Figure 2. Integration of patient medication histories with e-prescribing: MyMedicationList and MyRxPad
D. Usability: installation/maintenance and workflow
MyRxPad is free open-source desktop application that runs locally on users' computers. It is implemented in Java, allowing cross-platform use. The tool is available via a URL link, through which the tool is automatically downloaded to users' computers. With available computer resources, internet connections and Java, which is freely available and usually installed by default on most platforms, prescribers can start using the tool on the practice's computers. As prescribers continue to use the tool via the same URL link, the application is automatically updated with the latest version. No extra upgrade effort is needed. To save prescriptions in a central location within the practice, practices with multiple computers should map a network drive where all prescriptions generated by MyRxPad will be stored.
The graphic user interface of MyRxPad resembles the look and feel of a traditional paper prescription pad. Prescriber's profile, including name, address, phone number and NPI (National Provider Identifier), is present on each screen, similar to letterheads on paper prescription pads. Patient information (name, date of birth, etc) is present on all screens as well.
Data entry in MyRxPad is facilitated by an auto-completion mechanism, allowing the user to select a generic or branded name. The corresponding drug and code in RxNorm is automatically retrieved. Related information, including Sig. (directions for patient), is entered with widgets such as drop-down lists or formatted fields. Additional useful knowledge, such as prescribing information and lists of adverse reactions, are available through a link to DailyMed [18], an NLM website that provides information about marketed drugs, including the FDA approved labels, as well as links to other information sources.
When a prescription is confirmed (the prescriber reviews the content on the confirmation page and clicks on "OK"), the prescription is saved in standard CCD format in the prescriber's file system as well as in the patient medication record. The prescriber can then print out the saved prescription and give it to the patient.
IV. RESULTS
The early working version of MyRxPad includes the following basic functionalities: creating a new prescription, refilling a prescription that is already on the patient medication list (via checkboxes alongside "current medications"), looking up medications via RxNorm and prescribing information via DailyMed, saving the prescription in the CCD format (in the practice's file system as well as in the patient medication record), and printing the prescription. A typical screen shot (medication list view) is presented in Figure 3. An early version of MyRxPad is available at http://rxp.nlm.nih.gov.
V. DISCUSSION
Early feedbacks of MyRxPad seem positive. Throughout a number of webcasts and conference demonstrations of MyRxPad, the audiences generally welcome the standards-based and collaborative model in an e-prescribing setting. The audiences particularly like the fact that patient medication lists and prescription files are stored in standard CCD format. Most often, the audiences want to see the actually XML content of the CCD files.
A. Early e-prescribing adoption
As a small footprint application that runs locally on prescribers' computers, MyRxPad fosters early adoption of e-prescribing as a low risk trial. Prescribers do not have to sign up for services that release private data such as their credentials and patient information to third party service providers. No further investment in software and hardware is required prior to trying out the tool and no ongoing support is necessary. The tool provides a reasonable set of features that facilitates medication lookup, patient safety check and prescription record keeping. The resemblance of a paper prescription pad and the replica of traditional workflow help prescribers use the tool with comfort and confidence.
Given the bewildering number of vendors in the United States, choosing the right e-prescribing system is an overwhelming task. Through MyRxPad, prescribers acquire hands-on experiences with the e-prescribing process. They develop a better familiarity with e-prescribing standards, workflow and technologies. In addition to providing a viable option for e-prescribing, MyRxPad can provide real-world experience that will inform decision-making about other e-prescribing systems under consideration.
B. Collaborations between prescribers and patients
With patients' contributions and prescribers' collaborations, patient maintained medication records can be used as the single reliable source for well-informed and safe medication prescribing decisions. As prescribers open the patient medication record, write new or refill prescriptions based on the patient current medication list, check for duplicates and adverse interactions can be performed to ensure patient safety. As the prescription is recorded in the patient medication record, the patient can add the prescription directly to his current medication list. This collaborative approach addresses the related issues of medication reconciliation and incomplete medication information. We believe that the involvement of the patient in maintenance of the list will insure better accuracy than simple recall during a visit.
C. Decision support
With the availability of patient medication data via MyRxPad, prescribers are able to make well-informed decisions based on patient medication history. In addition, when a new prescription is created, MyRxPad checks for overdose at the ingredient level and alerts the prescriber if any of the patient current medications already contains the ingredient of the newly prescribed medication. Other decision support includes linking to DailyMed for current prescribing information. Furthermore, prescribers should also be able to aggregate information and query about patient data. Patient medication and prescription information can be imported into a database management system and can provide answers to queries such as "find all patients on Vioxx". Additional decision support can be achieved by linking MyRxPad (via standard RxNorm codes) to other resources (for example, drug-drug interaction) and by interfacing MyRxPad with other personal health record systems to obtain related patient specific information such as lab results.
D. A module for e-prescribing systems
In addition to being a standalone application, MyRxPad has the potential for becoming a plug-in module for retrieving RxNorm names and codes. In fact, e-prescribing systems could integrate MyRxPad as part of their application or delegate the entry of medications to MyRxPad. Because MyRxPad is based on standards, the prescription information it records can be easily exchanged with other systems. We intend to follow the CCHIT process to certify MyRxPad as an open-source e-prescribing module.
VI. FUTURE WORK
MyRxPad has not yet been fully evaluated. We plan to invite prescribers for evaluation through the NLM outreach program, as well as invite users who visit the website to try it out.
To make the system more fully functional, we plan to implement electronic transmission of prescriptions using the NCPDP SCRIPT standard. Inclusion of formulary and benefits information would be an additional feature. Extending the application to a platform of a hand held device is much more likely to insure acceptance and use by many prescribers.
REFERENCES
[1] eHealth Initiative. Electronic Prescribing: Toward Maximum Value and Rapid Adoption. Washington, DC April 14, 2004.
[2] Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. Oct 21 Jama 1998;280:(15):1311-1316.
[3] http://www.govtrack.us/congress/bill.xpd?bill=h110-6331
[4] http://www.hhs.gov/recovery/reports/plans/onc_hit.pdf
[5] Halamka J, Aranow M, Ascenzo C, et al. EPrescribing collaboration in Massachusetts: early experiences from regional prescribing projects. J Am Med Inform Assoc. 2006 May-Jun;13(3):239-44.
[6] Gleason, KM, Groszek JM, Sullivan C. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health-Syst Pharm. 2004;61:1689-95.
[7] http://www.surescripts.net/certification-status.html
[8] Kilbridge P, Classen D. The informatics opportunities at the intersection of patient safety and clinical informatics. J Am Med Inform Assoc. 2008;15:397-407.
[9] Dolin RH, Alschuler L, Boyer S, Beebe C, Behlen FM, Biron PV, Shabo Shvo A. HL7 Clinical Document Architecture, release 2. J Am Med Inform Assoc 2006;13(1):30-39.
[10] Health Level Seven. HL7 implementation guide: CDA release 2 – Continuity of Care Document (CCD). Ann Arbor, MI: Health Level Seven, Inc., 2007.
[11] http://www.nlm.nih.gov/research/umls/rxnorm/index.html
[12] Liu S, Ma W, Moore R, Ganesan V, Nelson SJ. RxNorm: Prescription for electronic drug information exchange. IT Pro 2005;7(5):17-23.
[13] http://www.health.state.mn.us/e-health/wgs0708/cchit/cchitaddendumccdambip.pdf
[14] http://www.cms.hhs.gov/eprescribing/downloads/e-rxreporttocongress.pdf
[15] Hamann C, Poon E, Smith S, et al. Designing an electronic medication reconciliation system. AMIA Annu Symp Proc. 2005;976.
[16] Grannis SJ, Overhage JM, McDonald CJ. Analysis of Identifier Performance Using a Deterministic Linkage Algorithm. AMIA Annu Symp Proc. 2002:305-9.
[17] Zeng K, Bodenreider O, Nelson SJ. Design and implementation of a personal medication record--MyMedicationList. AMIA Annu Symp Proc 2008:844-848.
[18] http://dailymed.nlm.nih.gov/
Figure 3. MyRxPad screenshot (medication list view)
