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

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.

Impact of CancelRx on Discontinuation of Controlled Substance Prescriptions

“…CancelRx demonstrated a 92.4% successful rate in which a medication was discontinued in the prescriber’s EHR and successfully discontinued in the pharmacy’s dispensing software. 19 Similarly, a study by Chui et. al, showcased not only a 93% success rate for CancelRx communication medication discontinuations, but also a drastic reduction in the amount of time required for a medication to be discontinued in the pharmacy software after it was cancelled at the clinic.…”

“…CancelRx is a health IT functionality that utilizes the same electronic pathway as e-prescriptions. [12][13][14][15][16][17][18][19] A third party vendor (SureScripts) sends a communication directly from the clinic EHR to the pharmacy dispensing software, but instead of authorizing the fill of a medication, it details its cancellation. Depending on the community pharmacy integration, a CancelRx can even identify and halt the processing of a previously e-prescribed prescription, working behind the scenes to ensure a prescription is effectively cancelled.…”

Identifying Vulnerabilities in HealthIT: A Case Study of CancelRx Implementation in Clinic and Pharmacy Sociotechnical Systems

“…The process of conducting such an assessment may help the implementation team to recognize potential issues and develop mitigation strategies. 3 Some initial work surrounding the identification of failure modes through proactive risk assessment has been conducted as part of a pilot of CancelRx, 4 but further exploration is warranted regarding system-wide CancelRx implementation. Following the implementation of CancelRx at a large Midwestern academic health system and guided by methodology developed by Hundt et al, 3 our team sought to conduct a proactive risk assessment in order to identify vulnerabilities, consequences, and the actors involved in the implementation of CancelRx.…”

Impact of CancelRx on discontinuation of controlled substance prescriptions: an interrupted time series analysis

“…There are various ways in which these medication discontinuations can be communicated, including notes attached to e-prescriptions, clinic staff telephone calls, faxed messages, or novel health information technology (health IT) such as CancelRx. CancelRx is a health IT functionality that utilizes the same electronic pathway as e-prescriptions [ 16 – 23 ]. A third party vendor (SureScripts) sends a communication directly from the prescriber’s EHR to the pharmacy dispensing software, but instead of authorizing the fill of a medication, it details its discontinuation.…”