Leveraging and Improving Refill Protocols at Your Health System

Abstract

Objectives: Medication refill processing is a repetitive and predictable time-intensive task for ambulatory primary and specialty care. Refill protocols are a clinical decision support (CDS) tool that allow clinicians to quickly and safely determine appropriateness of a refill request. Our health system opted to improve the quality and breadth of EHR vendor-supplied protocols to consistently leverage best practices and emerging evidence and to create novel protocols that further support clinicians. Methods: We established a refill protocol governance group to guide new protocol build, and to review existing protocols regularly to keep current with emerging guidelines. Data-driven prioritization was used to create new protocols for the most frequently refilled medications, as well as for less-prescribed but higher-risk medications. Ad-hoc specialist inclusion as subject matter experts provided greater detail, accuracy and broader consensus in protocol criteria. Results: Approximately 11 million refills are processed each year by our health system’s providers. The proportion of refill requests supported by a protocol increased over a two-year period from 49% to 82%, representing a net increase of 3.63 million refills in the second measurement year as compared to the start of the first measurement year. All published refill protocols were reviewed by the governance group over the measurement years for compliance with clinical guidelines. In addition to the structure of the refill protocols’ clinical decision support, the process was supported by filters that enable practices to quickly approve refills that pass protocol, providing more time for clinicians to review refills that fail protocol or for which no protocol exists. Conclusions: A refill protocol is a valuable CDS tool that can improve efficiency, effectiveness and user satisfaction when processing refill requests. A refill protocol governance structure is an effective way to review, edit, and build refill protocols within a health system.

Governance of Electronic Health Record Modification at U.S. Academic Medical Centers

“…Describing these and other governance strategies is the first step toward discovering optimal approaches and stewarding scarce resources for EHR maintenance while permitting health innovation. EHR customization through clinical decision support, ordersets, and other tools is thought to improve EHR usability and effectiveness [20][21][22][23] but may exacerbate the most common problem reported by CMIOs: the mismatch between high demand for EHR modification requests and low supply of clinical informaticists or EHR analyst time. 19 From the demand side, we find that requests for customization often involve bottlenecks during request intake, where requestors have high levels of specific domain expertise but limited informatics knowledge/experience.…”

“…For example, Tokazewski et al describe an innovation to improve medication refill protocols, in which the end user may see a significant improvement in their experience, but not realize the governance effort required to create and monitor such systems. 23 Furthermore, a lack of metrics around the effects of governance in terms of patient or provider outcomes makes it difficult for health systems to justify allocating additional resources to overcome these bottlenecks. One system empowers end users submitting EHR modification requests to be champions throughout the governance process and requires these champions to define and evaluate metrics for success for each such request.…”