Appl Clin Inform 2019; 10(02): 336-347
DOI: 10.1055/s-0039-1688698
Research Article
Georg Thieme Verlag KG Stuttgart · New York

Understanding CancelRx: Results of End-to-End Functional Testing, Proactive Risk Assessment, and Pilot Implementation

Samantha I. Pitts
1  Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
,
Noah Barasch
2  Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
,
Andrew T. Maslen
3  Information Technology, Johns Hopkins Health System, Baltimore, Maryland, United States
,
Bridgette A. Thomas
4  Pharmacy Services, Johns Hopkins Home Care Group, Baltimore, Maryland, United States
,
Leonard P. Dorissaint
3  Information Technology, Johns Hopkins Health System, Baltimore, Maryland, United States
,
Krista G. Decker
5  Department of Quality Management, Johns Hopkins Home Care Group, Baltimore, Maryland, United States
,
Sadaf Kazi
2  Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
,
Yushi Yang
6  Armstrong Institute for Patient Safety and Quality, Johns Hopkins Health System, Baltimore, Maryland, United States
,
Allen R. Chen
7  Departments of Oncology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
› Author Affiliations
Funding Dr. Pitts was funded by a grant from the National Council for Prescription Drug Programs (NCPDP) Foundation.
Further Information

Publication History

21 November 2018

29 March 2019

Publication Date:
22 May 2019 (online)

Abstract

Background CancelRx allows prescribers to send electronic cancellation messages to pharmacies when medications are discontinued. Little is known about its functionality and impact on clinical workflows.

Objectives To understand CancelRx functionality, its potential impact on workflows and medication safety risks, and to develop mitigating strategies for risks introduced by implementation.

Methods We conducted direct observations and semi-structured interviews to develop CancelRx use cases and assessed CancelRx in an end-to-end test environment, proactive risk assessment, and pilot implementation from April 16 to July 15, 2018.

Results E-cancellations were sent upon discontinuation of e-prescriptions written within the electronic health record (EHR), but not other medications (e.g., printed prescriptions) and could be initiated by nonprescribers. In our proactive risk assessment, CancelRx implementation eliminated five of seven failure modes in outpatient prescribing to Johns Hopkins pharmacies, but introduced new risks, including (1) failure to act if an e-cancellation was not sent or was unsuccessful; (2) failure to cancel all prescriptions for a medication; (3) errors in manual matching; and (4) erroneous medication cancellations. We identified potential mitigation strategies for these risks. During pilot implementation, 92.4% (428/463) of e-cancellations had confirmed approval by the receiving pharmacy, while 4.5% (21/463) were denied, and 3.0% (14/463) had no e-cancellation response. Among e-cancellations received by the pilot pharmacy, 1.7% (7/408) required manual matching by pharmacy staff. Based on performance in testing, 73.4% (340/463) of completed e-cancellations would be expected to generate an in-basket message, including 21 (6.2%) denials and 319/340 (93.8%) approvals with a note from the pharmacy.

Conclusion CancelRx is an important functionality with the potential to decrease adverse events due to medication errors. However, changes in implementation in our EHR and pharmacy software and enhancements in the CancelRx standard are needed to maximize safety and usability. Further studies are needed to evaluate the impact of e-cancellation on medication safety.

Protection of Human and Animal Subjects

This study did not involve the use of clinical data requiring human subjects review.