E-Prescribing: Should Physicians Write it Off?

Have you heard the one about the Physician who hand-wrote his prescriptions? One of them was mistaken for Cuneiform and is on display at the Smithsonian, one's being used by astronomers to chart the movements of Jupiter's moons, and another was played in concert by the London Philharmonic. Now, I'll give you a few minutes to contain your chortling and we can move on. Seriously though, doctors and (corny) penmanship jokes once came joined at the hip, but with the advent of technology, the phenomenon could very well go the way of alchemy, blood-sucking leeches and other archaic medical methods.

You see, a little over a decade ago, the Institute of Safe Medication Practices (ISMP) published a report which condemned the practice of hand-written prescriptions as a relic of times gone and urged physicians and pharmacies to make the jump to a novel new process known as "E-prescribing." With an eye on efficiency and error-free medical service, the paper sought to demonstrate the superiority of a new Electronic service by highlighting its features and functions.

In a nutshell, E-prescribing (or e-Rx) utilizes computer software to generate, transmit and fill medical prescriptions. Moreover, it replaces paper and faxed prescriptions and freely allows authorized physicians, nurse practitioners or physician assistants to submit new prescriptions and renew existing prescriptions with a community or mail-order pharmacy.

Additionally, qualified e-prescribing systems come equipped with numerous time-saving features. Among other things, these systems purport to generate a complete active medication list, pooling electronic data received from applicable drug plans, to review a patient's current medication list and history, to connect to various databases and to file through a series of drug "safety checks" before a prescription is sent.

Regardless of the ISMP's praises of E-prescribing's benefits, small and mid-level practice physicians should conduct a point-counterpoint analysis, a thorough investigation of the system's attributes and limitations, before adopting the new technology full-force.

E-Prescribing's Benefits

E-prescribing's ostensible benefits aren't puny, nor are they difficult to identify. For busy physicians with stacked appointment schedules, the prospect of zipping a prescription directly from the point of care facility to a pharmacy via a millisecond mouse-click counts as an immeasurable luxury.

"Streamlining" is the name of E-Rx game, and workflow efficiency for physicians and pharmacies comes as a dramatic effect. For one, it scratches out issues like illegibility and the subsequent bewilderment many pharmacists experience when trying to decipher a harried, handwritten prescription. While it may seem like a negligible issue, Shawn Riley's The Benefits of E-Prescribing for Today's Physician indicates that over 900 million annual prescriptions require some sort of "clarification callback" from a pharmacy, whether it's due to dosage inaccuracies or un-decodable chicken-scratch. By routing prescriptions through a secure online channel, E-Prescribing alleviates a pharmacy's telecom burdens, reduces wasted work hours and ultimately lets pharmacists be pharmacists...not cryptolinguists.

Simplifying the workload goes part-and-parcel with E-prescribing's "green" design. Since prescribing occurs instantly through a digital channel, cumbersome paperwork is rendered obsolete and physician offices and pharmacy desks stay a little less cluttered, while a few swaths of leafy rainforest stay lush and living. In the long run, patients cut a trip out of their own equation because, being sent electronically to pharmacists, their medications can be collected at their own convenience.

Though E-Prescribing's major claim to pharmacy fame is its insistence on simplifying, it lends a great big dollop thoroughness to the prescribing process. Rather than a physician simply scribbling out a recommendation and sending a patient out into the lone and dreary wilderness, E-prescription utilizes advanced "Drug Utilization Review" (DUR) programs. These programs cross check new prescriptions with a patient's earlier medications, detect allergies and identify applicable drug interactions. By automatically accounting for patient factors like age, body weight, sex and contraindications, E-prescribing software will immediately warn a physician of an inappropriate prescription or a better alternative.

These warning systems, along with general patient information, are entered into an online database that's accessed and shared among hospitals and clinics worldwide. These databases are frequently maintained, updated and equipped with on-screen memos for physicians, keeping them on schedule for prescription refills, changes in drug information and appointment reminders.

Bells, whistles and automated flourishes accounted for, perhaps the most potent advantage of E-prescribing development might also be the most controversial. E-prescribing promises to reduce prescription errors and maximize accuracy. No longer subject to shaky hands, hasty ballpoint malfunctions and the indefinably cryptic cursive once standard practice in the medical community, crystal clear digital text erases the possibility of patients or pharmacists misreading the way a "delete" key erases a college term paper. Liability dangers of wrongful prescriptions used to land doctors up to their eyeballs in legal trouble (nearly 7000 deaths in the United States occur because of prescription and medication errors according to a health news article by Tom Harrison) but E-prescribing cuts them back and everyone's happy...right?

The Disadvantages of E-Rxing

The simple answer is "not quite." Studying 3,850 automated prescribing systems over a four week period, the American Medical Association concluded that E-prescribing's claims of higher accuracy may be a tad unfounded. Of all the electronic prescriptions made, 452 of them (roughly 12%) contained errors, and of these errors, 163 of them could have resulted in serious harm. According to the article Electronic Prescribing Systems Don't Reduce Common Errors by Kate H. Gamble, adverse reactions like diarrhea, headaches and rashes became present in 58% of these E-prescribing errors, and more serious side effects like low blood sugar, reduced heart rate and fainting in about 42% of them. While none ultimately fall under the umbrella of "life threatening," they're certainly major inconveniences to patients.

These studies of E-prescribing technology find that of the mistakes made by physicians, the most likely are errors of omission. This includes mis-prescribing key information like proper dosages, how long to take a particular medication and the number of times a day said medicine should be taken.

Another common error committed by E-prescribing physicians is the bungling of proper terminology and drug abbreviations. Some actual reported errors in an article by Pharmacy Times include cases of improper drug selection due to "stemming" (physicians failing to read past the first few letters of a drug and hurriedly selecting the wrong one), because the full name wasn't visible on the monitor screen or because the software contained an improper "sig" for medication.

But why so many errors? Many hold the E-prescribing design to blame, citing accusations of "poor design" and "underdevelopment." While a godsend to some, certain physicians, particularly those from an earlier generation less comfortable with computer technology, may struggle with the alien interface. The software is slow to develop, and according to the aforementioned Pharmacy Times article, the gains throughout haven't been fully realized.

Furthermore, with an innovation that encourages a speedy walkthrough and strips the more "hands on" element of a procedure, quick and careless errors become an increasing reality. Stray mouse clicks, drop-down menu mix-ups and skipped lines of text work their way into the mix, and the over-burdened physician may not spot the error until too late.

Conclusion

Negative statistics aside, E-prescribing's benefits are too great to ignore. Though still in its infancy, the technology has the potential to become the norm within the small and mid-level practice realm. With that knowledge comes the fact that antidotes for E-prescribing errors are very simple...but extremely crucial.

Physicians must be sure to thoroughly check over a prescription made on a computer. Drug names and dosage units made by hand are less likely to contain errors, but an incorrect mouse click is harder to detect. Reading over a prescription (out loud if necessary) before sending, can catch a small error before the metaphorical train leaves the station.

New technology often ushers in the need for re-evaluation and training of staff. While this also includes time and monetary expenses, competently trained staff and physicians, specifically prepared for the ins, outs and nuances of E-prescribing technology, will slow the effect and proliferation of their errors.

Finally, physicians and staff must be willing and able to communicate with pharmacies directly if needs be. While E-prescribing can minimize the phone calls and trips, physicians must report errors immediately, especially when they involve close calls and potentially hazardous situations.

With over 3 Billion prescriptions written annually in the USA (both by hand and electronically), 385 Million of these prescriptions contain errors and according to Jeffrey Rothschild, MD, MPH at Brigham and Women's Hospital in Boston "128 million have the potential to cause harm."

While E-prescribing certainly diminishes the burden in some areas, it's not without its risks nor is it an electronic cure-all for sloppy handwriting. With this in mind, and an eye out for simple errors, willing physicians can adopt the technology and give their practice the efficient upgrade it needs.

References
Gamble, Kate H. "Study Finds E-prescribing Systems Don't Reduce Common Errors."
Pharmacy Times, 1 July 2011. Web. 12 July 2012. 
<http://www.pharmacytimes.com/news/Study-Finds-E-prescribing-Systems-Dont-Reduce-Common-Errors>.

Gaunt, Michael J. "Continued Efforts Needed to Design Safer E-Prescribing Systems."
Pharmacytimes.com. Pharmacy Times, 13 Jan. 2011. Web. 12 July 2012.
<http://www.pharmacytimes.com/publications/issue/2011/January2011/MedSafety-0111>.

Harrison, Tom. "Medication Errors Cause 7,000 Deaths Per Year." Dailynewscentral.com.
Daily News Central, 21 July 2006. Web. 12 July 2012.
<http://health.dailynewscentral.com/content/view/0002352/53/>.

Maguire, Jim. "E-Prescribing: Opportunities for Specialty Pharmacy Efficiencies."
Pharmacytimes.com. Pharmacy Times, 18 May 2011. Web. 12 July 2012.
<http://www.pharmacytimes.com/publications/specialty-pt/2011/May2011/E-Prescribing-Opportunities-for-Specialty-Pharmacy-Efficiencies>.

MedRunner. "E-Prescribing." MedRunner.com. MedRunner, 2009-2011. Web. 12 July 2012.
<http://www.medrunner.ca/learn-more/eprescribing/>.

Naji, Karen C., Jeffrey M. Rothschild, Claudia Salzberg, Carol A. Keohane, Katherine
Zigmont, Jim Devita, Tejai K. Gandhi, Anuj K. Dalal, David W. Bates, and Eric G. Poon. "Errors Associated with Outpatient Computerized Prescribing Systems."-- Nanji Et Al. Bmj.com, 2 May 2011. Web. 12 July 2012. 
<http://jamia.bmj.com/content/early/2011/06/09/amiajnl-2011-000205.short>.

Neumiller, Joshua J. "Pharmacy Times CE: E-prescribing: Improving Pharmacy Efficiency
with Emerging & Existing Technology." Pharmacy Times. Emdeon, 30 Jan. 2011. Web. 12 July 2012. 
<https://secure.pharmacytimes.com/lessons/201102-03.asp>.

Riley, Shawn. "The Benefits of E-prescribing for Today's Physician."HealthTechnica.com.
Health Technica, 12 Nov. 2010. Web. 12 July 2012.
<http://www.healthtechnica.com/blogsphere/2010/11/12/the-benefits-of-e-prescribing-for-todays-physician/>.

 

Dylan J. Chadwick

 

Dylan Chadwick is a graduate of Brigham Young University where he earned a Bachelor of arts in English and a minor in Spanish. Though spending his formative years in Cardiff Wales, he came to adolescence in Elizabethtown Kentucky, and considers it his home. He received the Eagle Scout Award, served a voluntary humanitarian mission to inner-city Los Angeles from 2007 to 2009, and once met Alan Alda on a golf course. He's an avid writer who cut his teeth contributing to student papers and continues writing for various print magazines, blogs and web resources. A ravenous fan of baseball, rock music and Dan Aykroyd-era Saturday Night Live, he plans on one day utilizing these interests in a Masters degree in American Studies and Literature. He also maintains a freelance illustration company on the side.