It’s a seemingly small change. Prescriptions written at University of Colorado Hospital now include the indications that the medications treat.

No big deal? Surprisingly, the hospital is the first in the country to turn on the “indications of use” feature in the Epic electronic health record (EHR). When a provider selects a medication in the EHR, Epic displays checkboxes with FDA-approved indications. If the provider wants to insert patient-friendly terminology or reasons for off-label use of a medication, he or she can type it into a free text box within the prescription.

The feature went live May 14; as of June 18, UCH providers had written some 105,000 prescriptions for more than 58,000 patients. All of them include the indicated use on the patient’s medicine bottle, after-visit summary, and medication list.
Amanda Nenaber (left) of the Heart Failure Program and Kate Perica of Pharmacy convinced UCH providers that including indications of use for medications in the Epic EHR was a “meaningful click.”
For now, the feature is live only at UCH, but the chief medical officers at UCHealth Northern Colorado and UCHealth Colorado Springs have approved turning it on at their hospitals in the upcoming months, said Kate Perica, PharmD, medication reconciliation coordinator at UCH. The ultimate goal, Perica added, is to make it live at ambulatory clinics throughout UCHealth as well.

Information, please

The additional prescription information is a plus for both patients and providers, said CT Lin, MD, chief medical informatics officer for UCHealth.

“As a patient it helps me to understand what a drug is for,” Lin said. “It plugs me into treating my own illness.” That knowledge could help to boost medication adherence in patients, particularly those with chronic conditions like hypertension, heart failure or diabetes.

Providers stand to benefit by having information in the medical record about unfamiliar medications, Lin added. “There are tons of new drugs pushing the envelope,” he said. “If I’m an ophthalmologist, I probably haven’t kept up with the most recent cardiology medications. Now I see their indications in the record.”

The feature also promises to improve patient safety, simply by making more information easily available, said Jean Kutner, MD, MSPH, chief medical officer for UCH.

“A large number of our patients take many medications for multiple indications,” she said. “If I see a patient is taking three medications for high blood pressure, we can talk about whether we need all three. And we have good data that shows that many patients who are readmitted to the hospital didn’t understand the importance of their medications. Showing the indications of use could help us to improve patient outcomes.”

Spreading the change

The discussion of turning on the indications of use feature began in September 2015. Around that time, Perica said, the hospital learned that the functionality to require an indication on prescriptions could be activated department by department; it didn’t have to be turned on system-wide.

Heart failure patients are admitted to many units throughout the hospital and followed in multiple outpatient clinics, so the program’s manager, Amanda Nenaber, DNP, APRN, spoke with Perica about putting indications of use on medications for all patients.

“The Joint Commission currently requires indication of use through a quality measure for heart failure patients only, but we wanted to take this one step further and build a sustainable process and one that would benefit every patient,” Nenaber said.

The idea encountered concerns from some providers who felt they already had enough clicks to get through in their medical record documentation, Lin said.

“Some said the current practice was good enough,” Lin said.

Providers also worried about putting indications for use on medication bottles for “stigmatized conditions,” such as depression and bipolar disorder, Perica said. She noted the ability for providers to free-text terminology eased that concern. “Treatment of mood,” for example, might be used instead of “major depressive disorder.”
With the ability to turn the feature on selectively, Perica and Nenaber launched a trial of it in two inpatient units and two outpatient clinics. Pre- and post-implementation surveys demonstrated that providers were initially skeptical of the function but overwhelmingly found it useful and minimally burdensome after they actually used it.

Building the backing

The silence after the implementation at University Internal Medicine – Lowry, one of the pilot sites, was deafening, Kutner said. “It was a total non-event because we all started with the ‘why’ and focused on what’s best for patients.”

Perica and Nenaber also did the groundwork to garner support for the idea. They received strong backing from Lin and Kutner, as well as Chief Quality Officer Jeff Glasheen, MD, Medical Staff President Ethan Cumbler, MD, and the Epic team. The two presented details to key groups, including the inpatient and outpatient medical directors. A member of the Patient and Family Centered Care group also recounted her own experience as a patient and caregiver with struggling to remember the reasons for the medications she and her father were prescribed.

Glasheen credited Perica and Nenaber for pushing persistently for positive change. “What they’ve demonstrated is that the best way to solve vexing, complex, highly chaotic problems is leadership,” he wrote in an email. “The story of their success is written in passion, hard work and expert change management skills.”

The effort ultimately paid off with Medical Board approval for turning on the function across all units and clinics at UCH. In this instance, at least, the work helped to change many providers’ perceptions of the word “clicks,” Nenaber said.

“These are meaningful clicks,” she said. “They remind providers of why we are here: to do the right thing for our patients and have a positive impact on our colleagues.”