Mobile Technology’s Potential for Addressing ADEs

By Juliann Schaeffer

Despite the technology’s capabilities, it’s little used by nursing home physicians.

Nursing home physicians who use mobile devices affirmed that having drug reference information at the bedside is beneficial for reducing adverse drug events (ADEs) in older adults, according to a study by researchers at the University of Pittsburgh. However, only four in 10 nursing home physicians currently use such devices in their day-to-day drug prescribing duties.

“Although mobile devices equipped with drug reference software may help prevent ADEs in the nursing home by providing medication information at the point of care, little is known about their use and perceived benefits,” says Steven M. Handler, MD, PhD, of the department of biomedical informatics at the University of Pittsburgh School of Medicine, who led the study. “The goal of this study was to conduct a survey of a nationally representative sample of nursing home physicians to quantify the use and perceived benefits of mobile devices in preventing ADEs in the nursing home setting.”

Though long term care and other health care facilities grapple daily with issues related to ADEs, they received renewed attention with a recent Office of Inspector General (OIG) report finding that 22% of Medicare beneficiaries—roughly one in five—experienced an adverse event during their skilled nursing facility stay. An even more alarming statistic, according to the report, is that 59% of these adverse events were determined to be preventable.

“The No. 1 cause of harm was medication-induced delirium,” says Rod Baird, MS, a partner and the previous president of Extended Care Physicians, a 70-provider long term care medical group covering two states and 100-plus skilled nursing facility/nursing facility locations, and president of long term care physician electronic health record (EHR) software developer Geriatric Practice Management. “Overall, 37% of problems were medication related.”

Baird adds that the OIG study’s error rate was based on a single month, “so it is likely an individual patient has a much higher risk during their entire stay.”

Why is mobile technology use in the nursing home environment so low, and could mobile devices capable of ePrescribing help to reverse the troubling trend of preventable ADEs, particularly in long term care? The survey on nursing home physicians’ usage of mobile technology gives a glimpse into this issue, but according to Handler, more research must be conducted to better determine barriers to adoption of this technology and its precise impact on nursing home ADEs.

Study Particulars
Published online in the Journal of the American Medical Directors Association, the study surveyed 558 medical directors on their use and thoughts around mobile device use for patient care. Only 42% of respondents noted using the devices to help with drug prescribing, yet 88% of the physicians who integrated mobile devices into their workday said they believed the technology helped to prevent at least one potential ADE in the previous month.
Physicians noted consulting such devices for general medication information or specifics on drug-drug interactions.

A particularly surprising finding, according to Handler, was that respondents who spent less time overall working in nursing homes actually were more likely to use mobile technology. “Respondents spending 26% to 50% of their clinical time in the nursing home were 64% more likely to be mobile device users compared with those spending most of their time in the nursing home,” he says. “I would have thought that physicians who provide care in the nursing home more frequently would be more dependent on mobile devices since access to reliable drug information is more difficult in this setting.”

Handler believes the lower adoption rate of mobile devices likely stems from two factors. “First, the study was completed in 2010, and the availability of these devices was more limited,” he says. “Second, the majority of those who provided medical care in the nursing home were older physicians. Studies have shown that older physicians are, in general, less likely to purchase, use, and adopt mobile devices in their clinical practice.”

He says other potential barriers (though not formally evaluated in this study) likely related to cost of mobile devices, drug information software, and connectivity, though he says these barriers largely have been addressed over the past four years.

Mobile Devices for Preventing ADEs
Though mobile technology use in the nursing home setting is low, Handler and Baird say physicians’ use of such technology could go a long way toward preventing many ADEs.

“Having access to high-quality medication information at the time of prescribing could allow physicians to make the most appropriate medication selection, dose in accordance with renal function, dose in accordance with federal guidance in terms of maximum daily dose for geriatric patients, and avoid potential drug-drug interactions,” Handler says.

Several peer-reviewed academic studies have shown that ePrescribing helps reduce adverse medication events, Baird adds, noting that a physician could utilize mobile ePrescribing technologies anywhere there’s a cell tower or a Wi-Fi connection.

And not surprisingly, Handler and Baird agree that the nursing home setting is an environment in which integrating mobile technology into physicians’ workflow is especially important because of the high number of nursing home residents taking multiple medications. “I would suggest that using mobile devices to prevent potential adverse drug events in the nursing home setting is particularly important, as these residents take a disproportionate number of medications, which is a risk factor for the development of drug-drug interactions and adverse drug events,” Handler says.

“Many residents have cognitive impairment, and we need to rely more heavily on signs/symptoms/lab abnormalities as opposed to self-reported adverse events,” he adds. “Finally, older adults have diminished physiologic reserve—for example, kidney and liver function—making it more difficult to eliminate medications which can lead to toxicity.”

Though Handler notes that every nursing home resident is required to have a medication administration record that notes medication specifics, he says gaining access to this information—which often is in a paper format—is difficult, and consulting such information while rounding in the nursing home doesn’t fit easily into physicians’ typical workflow.

“There are elaborate manual processes in place to reduce errors, but paper is inadequate,” Baird says. “The labor burden to have the physician check each of these medications [on a patient’s medication administration record] against all possible interactions is overwhelming. The only possible solution is electronic order management.”

Also considering that most nursing homes don’t currently use electronic medical records (EMRs), Handler says this makes even more critical the integration of mobile devices with drug reference information into physicians’ workflow. “Without an EMR coupled with clinical decision support, rules cannot provide guidance with regard to drug-drug interactions, drug-disease interactions, potentially inappropriate medications, restricted medications/formularies, and therapeutic interchange,” he says.

Baird says smartphones work well for looking up a single medication or approving a single new prescription, but he notes that most smartphones don’t have enough real estate (adequate screen size) to effectively manage medications. He recommends that nursing home physicians use a tablet device, at minimum, as their mobile device of choice.

Regarding the specifics of why more nursing home physicians aren’t using mobile technologies and just how much they could improve ADEs, Handler says more research is necessary. Yet Baird suggests that many of these barriers—at least as they relate to physicians—are an illusion masquerading as an inevitability.

“Everyone tells long term care physicians that it is impossible to use technology in the long term and post–acute care setting, and physicians accept this as a fact,” Baird says, noting that he’s seen firsthand that integrating mobile and other technologies in the long term care environment is indeed possible. “Of my practice employees [roughly 70 long term care physicians/extenders], 100% use a cloud-based EHR, and most also use their smartphones to access drug databases for drug prescription support. They would use their EHR, but [most] long term care pharmacies currently do not support ePrescribing.”

Until nursing home physicians and long term care facilities and pharmacies are on board, the issue of ADEs won’t be adequately addressed, according to Baird. “One hundred percent of long term and post–acute care medications exist in an electronic record at the long term care pharmacy; they simply haven’t made it a priority to share this data with the patient’s attending physician,” he says. “People who are patients in long term and post–acute care will continue suffering avoidable morbidity/mortality until long term care physicians, facilities, and pharmacies participate in three-way ePrescribing.”

— Juliann Schaeffer is a freelance writer and editor based in Alburtis, Pennsylvania.