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of our practices are informed by the best available evidence, or if we are just practicing based on tradition or outdated processes and ideas.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:
- 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.
- 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!
- Read the Therapeutics Letter on the topic and consider making a mental note to choose to prescribe differently where appropriate.
- Schedule time to search for relevant patient cases and consider adjusting care for those individuals (indirect patient care, panel management).
- 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
- 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.
- 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.
- 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.
- Coaching and Mentoring Program for rural physicians to connect with a peer mentor. Read more.
- 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.
- eCoach self-directed assessment tool can walk the learner through different topics and practice areas. Read more.
References
- 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)
- Therapeutics Initiative. Audit and feedback: Personal Prescribing Portrait. Therapeutics Initiative, UBC. August 27, 2020. Accessed August 18, 2023. (View)
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This was an amazing TCMP! I immediately used the link to sign up for TI Portraits and I look forward to using it to improve my standard of care for my patients!!! A huge thanks to Dr. Norris for writing this article.
How do Ontario docs register?
For Bill Watson: Portraits are limited to prescribers in BC only, so you would be unable to register. Portraits use prescribing data that is only available within our province and unfortunately Ontario doesn’t have as extensive a database. There are some feedback programs in Ontario, which you may already be familiar with, but if not you might start here: (https://www.hqontario.ca/quality-improvement/practice-reports/primary-care.
You can view the sample Portraits of course at https://www.ti.ubc.ca/portrait/portrait-topics/ but would not be able to receive feedback on your specific practice.
While the UBC Therapeutics Initiative is not involved with any feedback programs in Ontario, we are part of a research project called CANBuild-AMR that involves building a national framework for feedback on antibiotic prescribing.
TI is super intrusive. I received an unsolicited “Prescribing Portrait” from TI out of the blue. So much for registering, as they clearly have all my details already. I’m not sure who gave TI the authority to access my personal prescribing data, reassurances regarding confidentiality notwithstanding, but it certainly wasn’t me.
A good practice in medicine, as in life, is to obtain consent, particularly when it comes to professional matters.
For Russell:
Receiving feedback on prescribing can be uncomfortable, but it sounds like your concerns are not about the information regarding your practice but rather on the processes used to get that information to you. We take privacy and security extremely seriously and I hope that having more detail will be helpful:
• The information used to address and mail a Portrait is the publicly available information from the CPSBC and other professional colleges
• Before any Portrait was sent, we sent a letter explaining Portraits, our security and privacy measures, as well as information about how to opt out;
• With each Portrait, we send the same letter and opportunity to opt out; there is also a link on our website to opt out
• The content of the Portrait comes from Pharmanet, MSP, and hospital data, which we access with permission from our provincial government; as part of our agreement to access the data, we are never allowed to see individual physician or patient level data. We can access that in aggregate (eg. total number of patients who had a 595 billing code on their file in a year, and proportion of those who got nitrofurantoin or another antibiotic).
• When Portraits are generated, the data presented in your Portrait is yours and yours alone; no one at the TI or anywhere else is privy to your individual prescribing data. It is de-identified and a random code is generated. The Portrait is sealed in a privacy envelope with the number put on the outside. A printing company matches the coded privacy envelope with the mailing envelope.
Portraits were mailed to all eligible prescribers in British Columbia, but future Portraits will be distributed via the online-only process. The advantages of this are many, including lower environmental impact, less cost, and quicker turn-around time. Unless you opt in, you will not receive any further Portraits.
The impact of this quality-improvement initiative is based on evidence that prescribing feedback improves practice; the effect of Portrait is also being studied via randomized controlled trial which is approved by the University of British Columbia Clinical Ethics Review Board.
We are publicly funded and operate independently, doing this work on behalf of the residents of British Columbia in keeping with our mandate – to provide physicians, nurse practitioners, pharmacists, allied health professionals & the public with up-to-date, independent, evidence-based, practical information on healthcare interventions.
Please send an email to portrait@ti.ubc.ca if you have any further questions or I have failed to adequately address your concerns. It sounds like the Portrait was an unwelcome surprise and I am sorry for that; if there was an error that led to your not receiving an introductory letter and opt-out information for the program, please reach out and we can try to look into what may have happened as we want to be sure it doesn’t recur.
For those who prefer to see the evidence summary and BC averages but not your own data, you can periodically check https://www.ti.ubc.ca/portrait/portrait-topics/
Any chance something like this may become available to dentists in the future?
@Eha: Yes! Coming very soon. Feel free to email me Jessica.otte@ubc.ca to learn a bit more.
How come pharmacists are unable to access the program? They have some prescribing authority as well.
@Amrit: Thanks for your interest! Pharmacists have only recently been able to prescribe for minor ailments; right now we don’t have enough data to be able to share meaningful feedback with Pharmacists but this is something we are working toward in future!
I am very careful with the newest innovation, treatments, medication, approach, etc. and usually wait before making my choice for more evidence-based info beyond the initial hysterical excitement of sensational medias.
I have always practiced with up-to-date info, and tested newly legitimately adopted therapies before applying them all over. At times, I build my own database from trusted authors and institutions who use the best research methodologies. The BC database is another resource among others I wish I could access.
However, we physicians are not always well trained to criticise or trust scientific publications, to select which one is trustworthy or not. Even the FDA falls into pharmaceutical companies’ publication traps and precipitates approval for meds with zero efficacy (Alzheimer for instance). We need to know who builds the reference bank of data, how regularly is it updated, on which criteria, etc before we should give it full trust.
Unfortunately, Board of Physicians sometimes do not update their bank of data and fail their members based on outdated science during their investigations.
In the description, the tool leads the author to believe that there is “room to improve on deprescribing for patients over 70 on a statin for primary prevention”.
I think this is a misleading statement. I am not familiar with any RCT that indicates safety of deprescribing statin in patients over the age of 70 who were previously started on primary prevention. The only RCT that looks at this focused primarily on outcomes at 60 days in patients with a life expectancy of < 1 year (JAMA 2021;4(12). Multiple studies, though observational, indicate that in fact, deprescribing over the age of 75 is associated with increased risk of MACE outcomes, even in primary prevention (J Am Geriatr Soc. 2023;71:2685–2689). The only ongoing RCT that I am aware of that looks specifically at this is yet unpublished (SITE trial). This issue is also addressed in the Best Science Medicine Podcast by James McCormack who ran a recent podcast on statins in the elderly (episode #551) in which the presenters also agree interpreting the evidence of starting a statin in someone over the age of 75 is very different than systematically deprescribing one.
I agree that polypharmacy should be addressed as patients age, but I think Thomas et al say it best in that “the decision to deprescribe must be tailored to the patient’s individual setting, functional status, comorbidities and personal values.”
Response to Harjinder Parwana:
Thank you for submitting your comments and questions. As a member of the UBC Therapeutics Initiative who was involved in developing the Portrait and Therapeutics Letter on statins (https://www.ti.ubc.ca/2021/06/13/130-evidence-for-statins-in-people-over-70/), I wanted to address some of your concerns. You noted that you felt misled by the statement that there is “room to improve on deprescribing for patients over 70 on a statin for primary prevention.”
After explaining how the Portrait can be used in practice, Dr Norris wrote “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.”
Using Portrait in this way, to identify patients who could consider starting and stopping, led to shared decision-making with the patient. This seems to be in alignment with your suggestion that “the decision to deprescribe must be tailored to the patient’s individual setting, functional status, comorbidities, and personal values.” We agree and continue to assert that Portrait is a valuable tool to reflect on prescribing and as a resource when engaging patients in discussions about their medications. The “room to improve on deprescribing” might involve a commitment to discuss the likelihood of benefit and harm with patients and offer deprescribing as one of several options (especially for interventions where the evidence is uncertain, mixed, or the risk-benefit likelihood might be unfavourable).
It is true that the impact of deprescribing statins in elderly patients for primary prevention is unknown and that ongoing randomized trials will likely provide some clarity. It would be important for prescribers to note this uncertainty in discussions about the possibility of deprescribing statins as part of shared, informed [delete comma] decision-making.