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Changing default options in EHR increases generic prescribing rates

An intervention that changed default prescribing to dispense generic medications led to significantly increased overall generic prescribing rates, according to findings published in JAMA Internal Medicine.

The 23.1%-point increase could lead to increases in medication adherence and improved clinical outcomes, Mitesh S. Patel, MD, MBA, MS, an assistant professor of medicine and health care management at the Perelman School of Medicine and The Wharton School at the University of Pennsylvania, and colleagues wrote.

"The growing adoption of the electronic health record (EHR) brings new opportunities to improve physician decision making toward higher-value care," they wrote. "Default options, or the conditions that are set into place unless an alternative is actively chosen, have been shown to influence decisions in many contexts. However, the effectiveness of different ways of implementing defaults has not been systematically examined in health care, and many people may assume that changing defaults is a one-size-fits-all intervention that will always have the same effect."

According to Patel and colleagues, the University of Pennsylvania Health System changed its EHR defaults in November 2014. The change, which was implemented among all specialties, included the addition of a checkbox on the prescription screen which was labeled 'dispense as written.' The default state of the checkbox was unmarked, so physicians had to mark the checkbox to ensure that patients received a brand-name drug instead of a generic equivalent.

The researchers analyzed prescription data from outpatient clinics in the University of Pennsylvania Health System between January 2014 and June 2015. They included new prescriptions for oral medications commonly prescribed for 10 common conditions: seizure, pain, hypothyroid, acid reflux, anxiety and/or insomnia, bacterial infection, hypertension and/or congestive heart failure, hyperlipidemia, depression and diabetes, but excluded medications that did not have a generic equivalent.

Results showed that the overall prescribing rate of generic medications increased from 75.3% to 98.4% (P < .001).

The researchers noted a lesser increase for levothyroxine when compared with medications with similar baseline rates (adjusted difference-in-difference = –15.6% points; 95% CI, –16.4 to –14.8; P < .001), which may indicate recognition of a difference in formulation between the generic and brand-name.

"This provides a real-world illustration of what has been a hypothesis in the health care context: that the effectiveness of defaults in changing behavior is appropriately mitigated in the setting of strongly held preferences," Patel and colleagues concluded. "Our results are limited to one health system and, in some settings, our intervention may be less effective than it appears because brand-name prescriptions are often converted to generics at pharmacies before dispensing. Nonetheless, our findings indicate that the manner that default options are designed and implemented has an important influence on their effectiveness for changing physician behavior." – by Chelsea Frajerman Pardes

Disclosures: Patel reports no relevant financial disclosures. Please see the full study for a complete list of all other authors' relevant financial disclosures.