Enthusiasm for e-prescribing is turning into a fervor. A new industry group has formed to promote the practice, much to the delight of the Electronic Health Initiative, a non-profit group dedicated to encouraging the use of health information technology. The national health information technology coordinator, David Brailer, includes it in his proposals. And the Centers of Medicaid and Medicare Services is actively promoting the practice, both by studying best practices and by upcoming changes in reimbursement policy.
The ability for doctors to transmit prescriptions straight from an examining room to a pharmacist promises a litany of benefits. The Institute for Safe Medication Practices estimates that indecipherable or unclear prescriptions require more than 150 million calls from pharmacists asking doctors for clarification. And each year, an estimated 7,000 deaths are attributed to medication errors, a figure that does not include unnecessary pain and suffering or simply inconvenience.
But conventional wisdom tells us that the solution to one set of problems inevitably brings new ones. It stands to reason that if we foresee the consequences of e-prescribing, we may not have to face them. “I dont think it is so much that e-prescribing might increase errors; it is that the type of errors occurring will be different than paper,” Steven Waldren, assistant director for health and information technology with Leawood, Kan.-based American Academy of Family Physicians told me. “So that brings up the question, Are there systems of checks and balances for e-prescribing” as there are for traditional prescribing?
Researchers at RAND Health and the Department of Medicine at UCLA have developed a conceptual framework for anticipating the effects of using various e-prescribing systems, cataloging them into 14 functional capabilities. “Doctors and even patients must be vigilant for unintended consequences,” said principal investigator Douglas Bell. “Of course, the greatest danger would probably come from problems that we havent anticipated.”
Their work was published in the Journal of the American Medical Informatics Association this year. According to the study, if a primary care provider had 3,000 patients, there would be 45 to 90 preventable adverse drug events among them each year, with about half due to prescribing errors.
While the researchers say electronic order entry has dramatically improved safety in hospital settings, they conclude the effects for outpatients are still unclear.
In the long run, Bell is convinced e-prescribing can reduce medical errors, but more importantly it will lead to more effective prescribing. For example, he said, drugs that prevent disease, like lipid-lowering agents, are currently underused, while antibiotics are often prescribed for viral infections against which they have no use.
When selecting an e-prescribing system, physician offices should consider a variety of unfortunate possibilities:
- Doctors might pick the wrong patient on a selection menu. In many cases, such an error would cause additional work. However, if a prescription is mailed to the wrong patient, the consequences could be much more serious.
- Doctors using computerized entry might also slip on menus for selecting a diagnosis or medication regimen, particularly if drug names are similar.
- Forcing doctors through a series of menu choices can increase the time it takes to write the prescriptions, perhaps causing them to rush other tasks.
- If a system uses the same codes for both diagnosis and billing, clinically important distinctions might not be recorded or, worse, doctors may be tempted to select diagnoses that will ensure a prescription is accepted more quickly.
- Decision support systems and dose calculations could prevent doctors from prescribing a drug that might endanger a particular patient. However, systems that send out false alarms or rely on data that is available only intermittently will either be ignored by physicians or could even suggest prescriptions that could harm patients.
- In addition, systems might limit the choice of drugs with formulary lists or, for physicians that dispense medications from their offices, with in-house inventory.
The study also suggests additional uses of e-prescribing systems. One way is to increase support of outpatient drug administration, perhaps by printing out personalized dosing schedules for patients. Another is monitoring patients compliance and reactions, perhaps by alerting pharmacies when a prescription has not been refilled, or automatically soliciting feedback on reactions to a drug.
Bell cautions that early versions of e-prescribing will mask their ultimate potential. “There could be a difficult period of transition as physicians struggle to cope with changes in their work and as technology vendors struggle for market share. Performance of the system might suffer during this transition,” he said.
Bell and his colleagues recently published a list of recommended features for e-prescribing. At the top of the list? The ability to integrate data to show physicians all the medication their clients are taking.
That list was published in Health Affairs. For an abstract, click here.
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