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A nationwide computerized patient medication history: evaluation of the Austrian pilot project e-Medikation

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To manage medication treatment and to assure medication safety, health care professionals need a complete overview of all drugs that have been prescribed or are taken by a patient. In 2009, Austria launched the pilot project "e-Medikation"
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  i   nter   nati   o   na   l    journa   lo   fme   di   c   a   l   info   r   mati   c   s   8   3   (   2   0   14)   655–669  j   ournal   h   omepage:www.ijmijournal.com A   nationwide   computerized   patient    medicationhistory:Evaluation   ofthe   Austrianpilot    project “e-Medikation” ElskeAmmenwerth a , ∗ ,   GeorgDuftschmid b ,   WalterGall b ,WernerO.Hackl a ,AlexanderHoerbst a ,StefanJanzek-Hawlat b ,Martina    Jeske c ,   MartinJung d ,KlemensWoertz d ,   WolfgangDorda b a InstituteofBiomedicalInformatics,UMIT–UniversityforHealthSciences,MedicalInformaticsandTechnology,HallinTirol,Austria b SectionforMedicalInformationManagementandImaging,CenterforMedicalStatistics,InformaticsandIntelligentSystems,MedicalUniversityofVienna,Austria c PharmacyDepartment,InnsbruckUniversityHospital,Austria d Instituteof    HealthInformatics,UMIT–UniversityforHealthSciences,MedicalInformaticsand   Technology,HallinTirol,Austria a   r   t   i   c   l   e   in   f   o  Articlehistory: Receivedin   revisedform3June2014Accepted4June2014 Keywords: PatientsafetyMedicationreconciliationPrescriptionsMedicalorderentrysystemsEvaluationstudiesElectronichealthrecordsPharmacyservices a   bs   tr   a   ct Purpose: Tomanagemedicationtreatmentandtoassuremedicationsafety,healthcarepro-fessionalsneeda   completeoverviewof    alldrugsthathavebeenprescribedoraretakenbya   patient.In2009,Austrialaunchedthepilotproject“e-Medikation”inthreepilotregions.E-Medikationgivesaccessto   apatient’snationwidemedicationlistandincludesmedicationsafety   checks.Theobjectiveof    thispaperistoreportontheevaluationresultsandlessonslearnt. Methods:   A   formativeevaluationstudyperformedbetweenJulyandDecember2011com-priseda   standardizedsurveyof    participatingphysicians,pharmacists,andpatients,as   wellas   an   analysisof    thee-Medikationlogfiles. Results: Duringtheevaluationperiod,18,310prescriptionsand13,797dispensingswere   doc-umented,and22,359medicationsafetycheckswereperformed.Overall,61   physicians,68pharmacists,and553patientsrespondedtoa   writtensurvey.Theresultsshowedhighaccep-tanceoftheideaofe-Medikationamongpharmacistsandpatientsandmixedacceptanceamong    physicians.Thesatisfactionwiththe   qualityofthesoftwareusedinthepilotprojectwaslow. Conclusions: Theoverallaimto   increasemedicationsafetyseemsachievablethroughe-Medikation,butseverallimitationsof    thepilotprojectneedto   besolvedbeforeanationalrollout.Basedontheevaluationresultsandafterredesignof    e-Medikation,Austriaisnowplanninganationwideintroductionof    e-Medikationstartingin2015.©   2014Publishedby   ElsevierIrelandLtd. ∗ Correspondingauthorat :   InstituteofBiomedicalInformatics,UMIT–   UniversityforHealthSciences,MedicalInformaticsandTechnology,EduardWallnöferZentrum1,   6060HallinTirol,Austria.Tel.:+4350   86483809;fax:+4350864867   3809.E-mailaddress:elske.ammenwerth@umit.at(E.Ammenwerth).http://dx.doi.org/10.1016/j.ijmedinf.2014.06.0041386-5056/©2014Publishedby   ElsevierIrelandLtd.  656   i   nter   na   ti   o   naljou   r   nalo   fme   di   c   ali   nf   o   r   mat   i   cs   83(2014)   655–669 1.   Background   and   objectives Acomprehensivemedicationoverviewis   essentialforhealthcareprofessionalstomanagemedicationtreatmentandtoassuremedicationsafetywhenprescribingorchangingdrugs.Traditionally,toobtainthecompletemedicationhistoryatthefirstencounter,thephysicianasksthepatientaboutthecurrentmedication.Anynewordersarebalancedwiththisinformation.Thismedicationreconciliationprocessisdesignedtopreventmedicationerrorsatpatienttransitionpoints[1]andisseenasan   importantpreconditionformedicationsafety[2–7].Medicationreconciliationincludes creatingthemostcompleteandaccuratelistpossible(theso-calledbestpossiblemedicationhistory)ofallmedicationsthepatientis   currentlytaking.Itis   essentialtocomparethislistagainstanynewmedicationordersthatareissuedinthecourseofadmission,transfer,and/ordischarge;toidentifyanydiscrepanciesandbringthemtotheattentionofthe   prescrib-inghealthprofessional;and,ifappropriate,tomakechangestotheorderswhileensuringthatchangesaredocumented.Updatingthelistasnewordersarewritten,communicat-ingthelisttothenextcareproviderwheneverthe   patientistransferredordischarged,andprovidingthelisttothepatientatthetimeofdischargecontributestopatientsafety[8].Severalstudiesreporteddecreasesinmedicationerrorratesaftersuccessfullyimplementingmedicationreconcilia-tionprogrammes[9–11].However,medicationinformationobtaineddirectlyfromapatientduringa   firstpatient–physicianencounterhasbeenfoundtobeerror-prone[12–15],   especiallyinthecaseofelderlypatientsandpatientsaffectedbypolypharmacy[16,17].   Toimprovethissituation,applicationshavebeendevelopedtosupportpatientsin   managingtheirownmedicationlistonline,andtomakethemavailabletotheirhealthcareproviders[18].However,thesepatient-managedmedicationlistsalsobeartheriskofbeingincomplete.“AssuringMedicationAccuracyatTransitionsinCare”and“CommunicationDuringPatientHand-Overs”aretwoofthenineWHO   patientsafetysolutions[8].Clearly,theaccuracyofthemedicationhistorymaybe   improvedwhenhealthcareprovidersuseanelectronicmedicalrecord(EMR)[16]thatpro-videsaccesstoinformationonrecentprescriptions.However,thesemedicationlistsmaybefragmentedbetweendifferentEMRsystems.Germanyhasdevelopeda   machine-readable,paper-basedmedicationplantoallowtheexchangeofa   med-icationhistorybetweeninstitutionalEMRs[19]–however,communicationofthisinformationbetweeninstitutionsisnotguaranteed,asthepaperworkmustbehandedoverbythepatient.Also,medicationplansderivedfromEMRsoftenshowlargediscrepanciestotherealmedicationtakenbythepatients[20,21],   forexampleincaseswherethe   patientreceivesprescriptionsfromdifferenthealthcareproviders,wherethepatienttakesover-the-counterdrugs(OTC),orwhereaprescribedmedicationisnolongertaken[22].Besidesusingprescriptioninformation,the   medicationhistorycanalsobebasedondispensinginformationavailablefrompharmacies.Thisinformationis,however,alsotypicallyfragmentedbetweennumerouspharmacysystems.Duetotechnicalandorganizationalchallengesofdataintegration,medicationlistssolelybuiltoninformationfrompharmacysystemsarecommonlyincomplete[23,24].Insomecountries suchastheScandinaviancountriesandtheNetherlands[25–28],e-Prescriptionisbeingintroduced.Here,anelectronicprescriptionthatiscommunicatedautomaticallyfromthehealthcareproviderto   a   pharmacyreplacesthepaper-basedprescription.Bothprescriptionanddispensinginformationareusuallymadeavailablethrougha   nationale-Prescriptiondatabasethateithercontainsthe   prescriptioninformationitselforan   indextothisinformation.Thisinformationcanbeusedtocomplementthe   medicationhistory[17,23].   Turkeyalsohasa   nationalmedicationlistthatisusedatthemoment,albeitonlyforaninventorycheckinthepharmacies[29].   Inothercountries,suchasDenmarkandIreland,reimbursementdatabasescontainallinformationondispensedandreim-bursedmedication[30,31].   However,theautomaticintegrationofOTCdrugspurchaseddirectlyata   pharmacyremainsinallcasesproblematic,asnoprescriptionforthemisavailable[23].Inaddition,theexistenceofaprescriptionordispensingdoesnotalwaysmeanthatthemedicationistrulytaken.Finally,eventhosecountrieswithanationalprescriptiondatabasenoticediscrepanciesbetweenthe   medicationcurrentlytaken,asstatedbythepatient,themedicationlistsintheproviders’EMRs,andtheinformationwithinanationalprescriptiondatabase[17,32].Overall,whileseveralsourcesforprescriptionanddis-pensinginformationregardingapatientareavailable,theintegrationofthisinformationintoacompletemedicationhistoryremainsatechnicalandorganizationalchallenge.Thus,aneasilyaccessibleandcompletemedicationlist   isnotavailableinmany   countries.ThisisalsotrueforAustria,whereprescriptionsarestillissuedinpaper-basedformandwherenoregionalornationalprescriptionordispensingdatabase,coveringbothinpatientandoutpatientmedications,hasbeenavailableuntilnow.In2009,Austrialaunchedthepilotproject“e-Medikation”thataimedatprovidingaccesstoa   completenationalmed-icationhistoryandthatincludesmedicationsafetychecks.Followingthe   visionoftheU.S.NationalLibraryofMedicine,theobjectivewasto“bringthe   medicationsan   individualiscurrentlytakingtothedoctor’sattentionatthetimeimpor-tantdecisionsaboutnewprescriptionsarebeingmade”[33].Tobetterunderstandthepotentialimpactandfeasibilityof e-Medikation,andtosupportthe   decisionabouta   nationalrollout,anevaluationstudywasconducted.Theobjectiveofthispaperis   toreportontheresultsandlessonslearntfromtheevaluationofthee-MedikationpilotprojectinthreepilotregionsinAustria.Thefocusofthisevaluationwas   threefold:usersatisfaction;potentialimpactofe-Medikationonpatientsafety,asseenfromthepointof viewoftheparticipatinggroups;andtechnicalfeasibilityof e-Medikation. 2.   Methods 2.1.   The    Austrian   e-Medikation   system Thee-Medikationpilotprojectwasa   publicnationalservicelaunchedinMarch2009.E-Medikationmanagedthe  i   nternat   i   o   nalj   o   u   r   na   lofm   ed   i   ca   linfo   rmati   cs   8   3(   201   4   )   655–669 657 Fig.1–Technicalinfrastructureofe-Medikationduringthepilotproject.Thee-Medikationsystemconsistedofseveraldatabases,includingprescriptiondatabase,dispensingdatabase,moduleforautomaticcentralchecks,andtheSISdrugdatabase. medicationlistofa   patient.Thislistcomprisedallmedica-tionsprescribedand/ordispensedinthelastsixmonths,theirdosages,aswellastheirstartandstopdate.ItalsoincludedselectedOTCdrugsthathadbeendefinedbya   nationalexpertgroupasbeingespeciallyrelevantinthecontextofdrug–drug interactions.E-Medikationwas   oneofthefirstservicestobeprovidedaspartofAustria’snationaleHealthstrategy[34,35].Thedefinedaimsofe-Medikationweretoincreasepatientsafetyandtoimproveeffectivenessandefficiencyofprescrip-tionanddispensingprocesseswhilemaintainingdatasecurity[36].   E-MedikationwasbuiltupontheAustriane-Cardnetwork[35]thatprovidessecuredatainterchangeofhealthdataanduniqueidentificationofpatients.Allinsuredcitizensownane-Cardtoidentifythemselveswhenengaginghealthservices;thee-Cardcouldthusbeusedtoidentifypatientsparticipating inthepilotproject[37].Thee-Medikationinformationwasstoredin   a   databaseandwascollectedautomaticallyfromthefollowingsources:prescriptionsdocumentedintheEMR   systemsofgeneralprac-titionersandspecialists;prescriptionsatdischargeissuedbyselectedhospitals;andinformationondispenseddrugs(includingselectedOTCdrugs)frompharmacysystems[36].Toobtainthisinformation,ane-Medikationclientwas   inte-gratedintothelocalEMR   systemsofphysicians,pharmacies,andhospitals.Overall,11EMR   vendors,allofthemAus-triancompanies,participatedinthepilotprojectandofferedtheirusersane-Medikationclient.AllvendorsimplementedtheirownuserinterfacetofollowtheirindividualEMRstyleguide.Fig.1showsthetechnicalinfrastructurethatwas   usedinthepilotproject: 2.2.   Workflow   of    e-Medikation Whenvisitedbyapatient,thephysicianfirstobtainedthepatient’sconsentforaccessingthemedicationhistoryinthee-Medikationsystem.Theconsentremainedvalidfor12h.   Thephysicianwas   thenallowedtoretrievethefullmedicationhis-toryfrome-Medikation(Fig.2)andto   downloadittothe   localEMR   system.Foreachnewprescription,e-Medikationsafetycheckswereperformedbasedonthe   completemedicationlist.Inthe   caseofawarning,thephysiciancouldadapttheprescriptionandrepeattheprocedureuntilanyconcernswerecleared.Thefinalprescriptionwas   thenstoredinthee-Medikationsystemandhandedtothepatientinprintedform.Thepharmacistequallyfirstobtainedthepatient’scon-sentforaccessingthemedicationhistoryinthee-Medikationsystem.Thepharmacistthencheckedallprescribedmedica-tionsinthesystemandadaptedthemifnecessary.Thefinalmedicationwasstoredinthepatient’smedicationlistandthecorrespondingdrugsweredispensedtothe   patient.Inaddi-tion,thepharmacistaddedrecentlypurchasedOTCdrugstothepatient’smedicationlist.Byfollowingthisworkflow,e-Medikationalwayscontaineda   completelistofallmedicationsprescribedand/ordispensedfora   givenpatient.Allphysiciansandpharmacieshadaccesstothisinformationuponconsentofthepatient.Itshouldbenotedthate-Medikationdidnotcomprisee-Prescription;whileallprescriptionswereenteredin   thehealthcareprovider’sEMRandcommunicatedtoe-Medikation,thepatientstillreceiveda   print-outofthe   prescriptionandtookthispaper-basedprescriptionto   a   pharmacy.A   patientportalwasnotavailableforthepilotprojectbutisplannedtobeavailableforthefuturenationalrollout.Dur-ingthepilotproject,participatingpatientshadthepossibilityofobtaininga   printoutoftheirmedicationhistoryfromtheirhealthcareprovider. 2.3.   Medication   safety   checks   in   e-Medikation Uponaddinga   medicationtothemedicationlist(eitherbythephysicianor   thepharmacist),thee-Medikationsystemconductedautomaticcentralchecksonallnewlyentereddrugs.Thesecheckscomprisedchecksfordrug–druginterac-tion(“interactioncheck”),checksforduplicateprescriptions(samedrugoratleastactiveagentalreadytakenbypatient–“duplicationcheck”),andcheckswhetherthepatientstillshouldhavea   sufficientamountofthisdrugathome(“inven-torycheck”).ThecheckingalgorithmwasbasedontheSIS-DatabasewhichincludesalldrugsadmittedinAustriaaswellastheirpotentialinteractions[37].  658   i   nter   na   ti   o   naljou   r   nalo   fme   di   c   ali   nf   o   r   mat   i   cs   83(2014)   655–669 Fig.2–Printoutofthecompletemedicationlistofapatient,asprovidedbye-Medikation.“BezogenerezeptierteArzneimittel”:prescribedanddispenseddrugs;“bezogenerezeptfreieArzneimittel”:OTCdrugspurchasedatapharmacy;“offeneRezepte”:prescriptionsnotyetdispensedbyapharmacy.Alsoshowninadditionto   thenameofthedrugarethedosagesandthedesignatedstartandendofintake.Thespecificimplementationofthislistin   theEMRsofpharmaciesandphysiciansdependedonthesoftwareused. Resultingwarningswerepresentedtothephysicianorpharmacistandcouldleadtochangesinprescriptionordis-pensing.Todocumenttherespectivereactiontoa   warning,alistofpossiblereactionswasofferedtothe   userforselection.Apharmacist,for   example,couldstatethatthewarningwasirrelevant,thathe/sheconsultedtheprescribingphysician,clarifiedthesituationwiththe   patient,ordidnotdispensethemedication. 2.4.   The    Austrian   e-Medikation    pilot    project Totestthefeasibilityandpotentialimpactofe-Medikationandtodecideona   nationalrollout,a   pilotprojectwas   conductedinthreeAustrianregions(TyrolWest;Wels-GrieskircheninUpperAustria;andtwodistrictsin   Vienna)betweenApril2011andDecember2011.Theseregionswereselectedbecausetheyrepresentbothruralandurbanregions.Physiciansandpharmacistswereinvitedto   participatevoluntarily.Overall,97physiciansand58pharmacies(witharound230phar-macistsworkingthere)decidedtoparticipateinthepilotproject.Thephysicianswereeithergeneralpractitionersorspecialists,allworkingindependentlyintheirownpractice.Theparticipatingpharmacistseitherownedorworkedinindependentpharmacies.Theparticipatingphysiciansandpharmaciesrepresentedaround13%ofallproviderswithinthepilotregions.Inaddition,onehospitalparticipatedin   eachpilotregion.Allofthesehospitalswereabletoreadmedicationinformationfrome-Medikation.Onlyonehospitalwas   alsoabletowritedischargeprescriptionsintoe-Medikation.Dueto   lowusagepatternsinthesehospitals,evaluationresultsfromhospitalsarenotreportedinthispaper.Patientscouldvolunteerto   participate;theyeitheractivelyaskedforparticipationorwererecruitedbyparticipating physiciansandpharmacists.Intheend,atotalof5431patientsparticipatedin   the   pilotprojectduringtheevaluationperiod. 2.5.   Evaluation   study   design   and   evaluation   questions An   independent,scientificevaluationstudywasconductedbya   teamofhealthinformaticsspecialistswho   hadnotbeeninvolvedinthedesignandimplementationofe-Medikation.Thestudywasapprovedbythe   UMITEthicalResearchCom-mittee.ThestudystartedinJuly2011,to   accountforimplemen-tationandtrainingtime,andlasteduntiltheendofthe   pilotprojectinDecember2011.Theevaluationwasconductedasan   observationalandformativestudy.Themajorevaluationquestionswereasfollows:1.Howmanyprescriptionsanddispensingsweredocu-mented?Howoftenwerethemedicationlistsretrieved?2.Howmanymedicationsafetywarningswereissuedbye-Medikation?Forwhichtypeofdrugs?Whatwerethereactionstothesewarnings?3.Howsatisfiedarethephysiciansandpharmacistswiththetechnicalandorganizationalaspectsofe-Medikation?Whatshouldbe   improvedregardingsoftware,hardware,ororganizationofintroduction?  i   nternat   i   o   nalj   o   u   r   na   lofm   ed   i   ca   linfo   rmati   cs   8   3(   201   4   )   655–669 659 4.Whatisthepotentialimpactofe-Medikationregarding medicationsafetyfromthepointofphysiciansandphar-macists?Whatbenefits,whatrisksdotheysee?Dothephysiciansandpharmacistssupportandrecommendanationalrolloutofe-Medikation?5.Howsatisfiedare   theparticipatingpatientswithe-Medikation?6.   Summarizing,fromthepointofviewofphysiciansandpharmacists,cane-Medikationbe   seenassuccess?7.Whatarethelessonslearntandrecommendationsforanationalrolloutthatcanbederivedfromthepilotproject? 2.6.   Methods    for   data   acquisition   and   data   analysis Theevaluationstudyuseda   combinationofquantitativeandqualitativemethods(methodologicaltriangulation)andincludeddifferentdatasourcesfromvariousparticipating groups(datatriangulation).A   longitudinalanalysisoflogfilesofthee-Medikationsystemwasconductedtoanswerevaluationquestions1and2.Withinthe   logfiles,datawerecollected,among otherthings,withregardtothefollowingparameters:(a)participationofpatients,(b)accesstoandprintoutofthemedicationlists,(c)checksperformedandwarningsraised,(d)numbersofprescriptionsanddispensings,(e)numbersofdifferentprovidersperpatient,herebydistinguishingtherolesofprescribersanddispensers.Thedataweredeliv-eredonaweeklybasisinaggregatedandanonymizedformconcerningthe   patients,physicians,andpharmacists.Thedatawere   processedwiththestatisticalsoftwarepackageSAS ® .Toanswerevaluationquestions3–5,a   standardizedsur-veyoftheparticipatingpatients,physicians,andpharmacistswas   conducted.Eachoftheparticipatinggroupsreceivedanindividualquestionnaire.ThequestionnairesweredevelopedbasedonUTAUT[38],   theDeLone&McLeanInformationSuc-cessModel[39],   ande-Prescribingsurveys[26,40].Furtherideasforsurveyitemscamefromtheprojectdocumentationaswellasfrompressreleases,reflectingtheurgenttopicsonbenefitsandchallengesofthee-Medikationdiscussions.Allquestionnairesweredevelopedinaniterativeprocesswithfeedbackobtainedfromphysicians,pharmacists,ande-MedikationITstaff,takingintoaccountthe   limitationsof surveylength.Attheend,thequestionnaireswerepretestedwithtwophysiciansandfourpharmacistsbutnotformallyvalidated.Toallowcomparabilityofresults,the   question-nairesofphysiciansandpharmacistsweredesignedsimilarly,withfewdifferencesin   wording.Thesurveysforphysiciansandpharmacistscontained30standardizeditems(4-pointLikertscale)onperceivedusabilityandperceivedimpact,eightstandardizeditemsonusagepatterns(e.g.“howoftenaremedicationlistsprinted”,“howmany   patientsparticipate”),fouropen-endedquestions(“whatarebenefitsofe-Medikation”,“whatareproblemsofe-Medikation”,“whatneedstobe   improved”,“whichpatientgroupswouldbenefit”)andfivefurtheritems(e.g.“reasonsforparticipationinthepilotproject”,“usedEMRsystem”).Thepatient’ssurveycontainedtwenty   standardizeditems(4-pointLikertscale)onperceivedusefulnessandeightstandardizeditemsonfurtherissues(e.g.“numberofphysiciansconsulted”,“reasonsforparticipation”,sex,age).InOctober2011,allphysiciansandpharmacistspar-ticipatinginthepilotprojectreceivedupto100patientquestionnairesandwereaskedtodistributethemtoe-Medikationpatients.A   totalof9125questionnairesforpatientsweredistributedinthisway.InDecember2011,allparticipatingphysiciansandpharmacistsreceivedtheirownquestionnairebymail.Thestandardizeditemsofthesurveywereanalysedusing descriptivestatistics.Theopen-endedquestionswereana-lysedusinginductivequantitativecontentanalysisthatwasperformedbytworesearchersandsupportedbythesoftwareMAXQDA10 ® .Toanswerevaluationquestion6,theresultsofthesurveywereaggregatedaccordingtotheDeLone&McLeanInforma-tionSystemSuccesscategories[39](seeAppendixforthe detaileditemsineachcategory).Themeansforeachcategorywerecalculatedboth   forphysiciansandpharmacists.Toanswerevaluationquestion7,allevaluationresultswerediscussedwithallevaluationteammembersinthreeworkshopsandwiththee-Medikationprojectmanagement.Resultsfromthe   workshopswereaggregatedintolessonslearntandrecommendationsfora   nationalrollout. 3.   Results 3.1.   Participants   and   return   rate Duringtheevaluationperiod,92physicians,58pharmacies(withapprox.230pharmacists),and5431patients(represent-ing1.3%ofthe   populationinthepilotregions)participatedinthepilotproject.Inthesurvey,61physicians(returnrate66%),68pharmacists(returnrate30%),and553patients(returnrate10%)providedvalidresponses.Allresponding physiciansandpharmacistswereactiveparticipantsin   thepilotprojectandthususede-Medikationintheirdailyroutine.Inthesurvey,theparticipantswereaskedfortheirreasonsforparticipation.Physiciansmostlyanswered,“Iwanttoseemyselfthe   strengthsandweaknessesofe-Medikation”(74.6%)and“Iwant   tousethepossibilitytoparticipateinitsdesign”(57.6%).Pharmacistsmostlystated“Theideaofe-Medikationmakessensetome”   (75.4%)and“I   see   a   possibleclinicalben-efit”(63.1%). 3.2.   Unexpected   events   during   the   study Thee-Medikationpilotprojectwasinfluencedbyconcernsonthe   partoftheAustrianChamberofPhysiciansregarding thebenefits,risks,andcostsofe-Medikation.Afterintensivediscussionsandcriticismoverseveralmonths,theAustrianChamberofPhysiciansannouncedaformalboycottofthepilotprojectstartinginmid-July2011.Thisboycottledtoa   strong reductionofactivitiesin   the   pilotproject(compareFig.3)byphysiciansandpharmacists.TheboycottendedinSeptember2011.Thepilotprojectwascontinuedas   planneduntilendof December2011.
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