Implementing Prescribing Portraits — Therapeutics Initiative

Authors

Dr. Jill Norris (biography and disclosures)

Disclosures: Received honoraria from Therapeutics Initiative for time spent as a facilitator and preparation and presentation of a webinar. My co-author on this article is a member of Therapeutics Initiative and so has influenced the content. My contribution reflected my personal clinical experience of using a tool offered by Therapeutics Initiative. Mitigating potential bias: Only published trial data is presented. Recommendations are consistent with current practice patterns. Treatments or recommendations in this article are unrelated to products/services/treatments involved in disclosure statements.

Dr. Jessica Otte (biography and disclosures)

Disclosures: Received payments from UBC Therapeutics Initiative (TI), Doctors of BC, Ministry of Health, Island Health Authority, Division of Family Practice (clinical payments, honoraria, and salary for work related to family medicine, palliative care, judicious use of resources). As a member of the TI, it is part of my role to promote our quality improvement efforts including Portrait and so remuneration from the TI has directly influenced the content. Received funding as a co-investigator on CIHR and UBC Strategic Innovation Fund grants unrelated to this article. Mitigating potential bias: Only published trial data is presented. Recommendations are consistent with current practice patterns. Not promoting any for-profit products; I follow a strict code of no conflicts of interest with industry.

What I did before

Primary care clinicians face an overwhelming volume of information to process and tasks to complete. There are new and sometimes conflicting guidelines and practice standards, forms to fill out, emails about meetings, and an inbox full of labs, documents to review, and messages to respond to. All the while, a gnawing feeling grows about whether or not we have the capacity to maintain a high standard of patient care grows. We often wonder if certain aspects of our practices are informed by the best available evidence, or if we are just practicing based on tradition or outdated processes and ideas. While we want to make sure we are prescribing well, we don’t have the time to read all the studies and interpret them and then figure out if we are doing a “good” job.

We try to keep up on CME with conferences and events hosted by the Divisions of Family Practice, read journal articles when we can, and quickly read cases to learn how to better manage the unfamiliar. There are many useful resources that summarize evidence and support how we discuss evidence with patients (e.g., shared decision aids in Pathways). However, none of these shows us how our own practices compare with evidence-based practices.

As a resident, I learned how to do a chart audit in the EMR. While I can easily use the EMR to flag patients who are overdue for a pap test or chronic disease planning, it is too complicated (and my medication lists are too inaccurate) to figure out how many of my patients might be on too high a dose of pain medication or who might benefit from a statin vs who might have been one unnecessarily. The Health Data Coalition (HDC) dashboard offers some great metrics to compare with my peers, and with this information, I can then find the evidence about what I should be doing so that I know if and how to make a change. In Alberta and other provinces, prescribers get feedback on the tests they order and the prescriptions they write along with practice guidelines as a part of educational modules, but what does BC offer?

What changed my practice

The UBC Therapeutics Initiative is known for its rigorous reviews of evidence and avoidance of financial conflicts of interest. I attended a Therapeutics Initiative Conference more than a decade ago, and to be frank, I left confused that a lot of what was presented was different from what I had learned before. I was uncertain about what to do next. Were there any medications I should be prescribing?! The evidence presented was compelling, but I wasn’t sure where to go from there. I feel I can trust what the TI has to say even if it is a bit different from what I’ve heard at a talk or read in a guideline. I appreciate the clear communication of the known harms and benefits of medications. I feel it offers a grounded perspective that is a useful counterbalance to other sources of information. As such, it supports my critical thinking about the care I provide as I want to ensure the medications I offer my patients are likely to help them and aren’t harming them.

However, the new information I learned (from whatever source) wasn’t always translating into practice change. Then I learned about prescribing Portraits from the TI. Initially, I received them in the mail, and now I’ve signed up to access them online. They are a tool for BC clinicians that combines up-to-date clinical evidence with personalized prescribing data. When the Portraits were launched, I was curious, and a bit scared to be honest. How am I doing?  Am I providing care consistent with the evidence?

Each Portrait is also accompanied by a Therapeutics Letter (a 2-page summary reference document) with more background information on the nuances of the available evidence. I sometimes need to adapt the recommendations for my specific patients but I like that the Portrait provides a straight-forward message that I can consider adopting for most of my patients right away.

Getting compensated for this quality improvement work is important, and means I am more likely to actually do it.  Whichever payment model we work under, as physicians it may be possible to get paid for doing this work. It’s considered indirect patient care, panel management, or clinical administration. It is quality improvement.

What I do now

Now that I get Portraits in my email inbox from time to time, I schedule time to look at them. If I don’t schedule it, it doesn’t happen. I log in, read them, and focus on the listed recommendations and whether my pattern of practice is close to where it should be according to the evidence, and if not, why not. Maybe it’s because I never really thought twice about what I learned back in medical school or read in a guideline, or I haven’t had time to attend any CME recently on a specific topic. The time I spend looking at the prescribing Portrait depends on the type of prescribing it addresses; for Portraits that address episodic, short-term prescriptions, a brief review of the evidence and my prescribing pattern leads to a mental note to prescribe differently when I next start a first-line medication.  For Portraits that suggest changing a dose or drug type for a longer-term prescription, I may choose to schedule more time to make a plan so that I can select from and implement the learnings.

For the UTI Portrait, for example, I thought I was doing well with using nitrofurantoin as the first line antibiotic for an uncomplicated UTI, but was surprised (and a bit chagrined) to see I wasn’t doing as well as my peers. With a brief deeper dive, I realized this was for two reasons: I was avoiding nitrofurantoin in patients with CKD (it was news to me that nitrofurantoin has been approved for short-term use for GFRs >30) and the definition of complicated UTI that I was using was broader than the evidence dictated. I am now choosing nitrofurantoin in my patients with GFRs above 30, as well as in my older patients.

For the Portrait on statins in patients over age 70, I read through the information and was reassured to see I was treating most of my patients with proven occlusive vascular disease with a statin. But I still had room for improvement and room to improve on deprescribing for patients over 70 on a statin for primary prevention. I decided to schedule and do a quick QI project on this. Using the Portrait and my EMR, I identified patients who might benefit from starting a statin and those who weren’t likely to benefit from being on a statin. I made a note in their chart to discuss this at their next visit. Working with the EMR wasn’t very exciting and it did take time, but not as much as I thought. And in the end, my care of individual patients changed for the better.

Receiving a prescribing Portrait and finding a way to be compensated for the work, triggered a change in my practice. And because there are only 2 or 3 Portraits per year, it feels manageable to make incremental changes to align with the best evidence. By engaging with Portrait, I can claim 5 CME credits per Portrait through Linking Learning to Practice on the CFPC member site.

Here are some suggestions for ways you might consider using Portraits:

1. Start with self-compassion and by acknowledging that the volume and rate of change of medical information can be overwhelming, and for generalists, the breadth of medical topics is expansive.
2. Check how you are doing relative to your peers and if there is room for improvement consider scheduling time to read the full Therapeutics Letter, if you are doing relatively well, pat yourself on the back and keep at it!
3. Read the Therapeutics Letter on the topic and consider making a mental note to choose to prescribe differently where appropriate.
4. Schedule time to search for relevant patient cases and consider adjusting care for those individuals (indirect patient care, panel management).
5. Meet with your local practice support program (PSP) provider and do a QI project to actively implement changes.

Overall, using Portrait allows me to work on quality improvement in a simple, professionally satisfying, and self-reflective way. It supports my work toward evidence-based prescribing, and better-informed discussions with patients and peers, and helps me navigate through the daily torrent of new medical information.

Resources

1. Prescribing Portraits, TI UBC: offered at no cost to BC general practice physicians and nurse practitioners. Visit the website for more information, to see sample Portraits, and to register. Read more.
   • To register you will need to submit your name, College License number, and MSP billing number to ensure that the person getting the Portrait is in fact the person whose data is represented – and all those who register will have their email and identity verified before activating the account. The UBC Therapeutics Initiative and Portrait team follow the Ministry of Health’s privacy protocols to ensure that only you (the clinician), and no other person or organization (including the TI), will ever be able to view the data in your prescribing Portraits. After registration, you can log in and see any previous Portraits. New Portraits are uploaded about twice a year, and you’ll receive a notification email every time there’s a new one to view.
2. Health Data Coalition: The HDC is a physician-led data-sharing network that encourages self-reflection and practice improvement in patient care. The mission of the HDC is to provide trusted and meaningful access to health information to support new knowledge, improvement of patient outcomes, and the sustainability of health care. HDC also supports the aim of optimizing the provider experience by supporting learning and practice improvement within a community of trusted colleagues. A not-for-profit organization funded by the Family Practice Services Committee. Read more.
3. Practice Support Program: Support included via psp@doctorsofbc.ca to direct the learner’s request to the appropriate PSP team member to support the learner’s needs. Read more.
4. Coaching and Mentoring Program for rural physicians to connect with a peer mentor. Read more.
5. Personal Learning Plans (PLP) Program for physicians new to rural practice (less than 5 years) and International Medical Graduate (IMG) physicians to access educational resources. Read more.
6. eCoach self-directed assessment tool can walk the learner through different topics and practice areas. Read more.

References

1. Dormuth CR, Carney G, Taylor S, Bassett K, Maclure M. A randomized trial assessing the impact of a personal printed feedback portrait on statin prescribing in primary care. J Contin Educ Health Prof. 2012;32(3):153-162. doi:10.1002/chp.21140 (View with CPSBC or UBC)
2. Therapeutics Initiative. Audit and feedback: Personal Prescribing Portrait. Therapeutics Initiative, UBC. August 27, 2020. Accessed August 18, 2023. (View)

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Implementing Prescribing Portraits — Therapeutics Initiative

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