Abstract
Data play key role play in prescribing and drug therapy: data on patient health and co-morbidity status, on prescribed medication, on over-the-counter (OTC) drugs and other self-medication etc. In Germany, data are not yet flowing with the patients (or the prescriptions) on their way from GP practice into pharmacy, from hospital discharge to the GP or into the nursing home or across any sectoral boundaries characterising complex care trajectories. The ongoing national e-prescription programme is set to launch operation in 2024 but has been plagued by implementation issues. From 2017, a consortium comprising statutory health insurances, associations of statutory health insurance physicians, GP practices, hospitals, pharmacies, software providers, academic partners and citizens began implementing a cross-sectoral process to improve drug prescription for polypharmacy patients (>= 5 drugs / agents). This is being done through three projects funded by the Innovation Fund of the German healthcare system. The projects were implemented in three regions: the Saarland, Westphalia-Lippe and Berlin/Brandenburg. Interventions were and are available to people insured with the participating health insurances and being recruited into the project by their GP or hospital in accordance with each study’s inclusion criteria.
AdAM (2017-2021) focussed on medication reviews in the GP practice to detect unwanted polypharmacy, inadequate prescribing and potential drug interactions. TOP (2020-2024) focusses on pharmaceutical reviews at hospital admission and passing a revised medication plan on to primary care (and potentially social care) at discharge. eRIKA (2022-2026) focusses again on medication reviews in the GP practice, but now with a more active role of the pharmacy, as well as making use of the new national e-prescription mechanism and digital medication plan. Processes in all projects are supported by one software using claims data of the statutory health insurances (which include prescription data, but also diagnoses) to build a view of a patient’s medication that is as up-to-date and complete as is possible with available real-world data. Clinicians and pharmacists can enter additional active agents that they are aware of, e.g. being informed by the patient or by registering OTC sales.
AdAM was able to show a trend towards reduction in all-cause mortality and hospital admissions for the intervention group (AdAM study group, forthcoming). GPs reported a higher sensitisation to polypharmacy risks and patients expressed an overall positive attitude. The lack of a national standard for coding medication therapy of varying complexity currently prevents a deep integration of project software and practice information systems, which was reported as a major drawback. Following the mainstreaming procedures of the Innovation Fund, AdAM received a recommendation that project results and practical experiences should be taken up by the federal health ministry and national IT infrastructure provider gematik. Projects TOP and eRIKA are still ongoing. Initial results of the eRIKA Living Lab co-design approach will be reported at ICIC24.
Experiences from all three projects throw a light on the challenges of implementing digital prescribing approaches in Germany and underpin the necessity to tailor processes to the limited timespans available at the point of care in particular.