Jeannette Y. Wick, RPh, MBA, FASCP
Electronic prescribing has the potential to make pharmacy workflow more efficient and help reduce adverse medication events, but its uptake has been complicated and delayed by the health care system’s complexity.
Since the 2003 Medicare Modernization Act was passed, with its recommendation that the United States move toward automated prescribing, boosters and critics have described electronic prescribing, or “e-prescribing,” in terms ranging from panacea to disaster. The intent of e-prescribing is to deal with the US health care system’s rapid growth and inherent complexities and to help reduce errors and improve patient safety. The reality is that our health care system consists of many different systems cobbled into a super-structure. This unwieldy structure, along with other barriers, has complicated and delayed the uptake of e-prescribing.
The Medicare Modernization Act formally defined e-prescribing and provided uniform standards for appropriate implementation and use. It did not, however, require providers or pharmacies to adopt e-prescribing. Health care providers’ initial receptions were often skeptical. In 2009, Medicare created an incentive plan to encourage prescribers to buy in, and in 2010, the Drug Enforcement Administration’s endorsement of controlled-substance e-prescribing offered further motivation. Today, more than 90% of community pharmacies and approximately one-third of office-based providers can file or fill prescriptions electronically
Today’s best e-prescribing software screens for dosing accuracy, drug-drug interactions and drug allergies. It can also help prescribers identify less costly generic alternatives and advise them as to whether an agent is covered by the patient’s insurance. It can tell prescribers whether patients have filled or refilled previous prescriptions appropriately. In addition, it takes a major threat to patient safety—illegible handwriting
, which used to generate 150 million phone calls between pharmacists and prescribers annually as well as an unknown number of adverse medication events—out of the process.
In the pharmacy, e-prescribing can improve record keeping (by eliminating the need to transcribe orders by hand or electronically) and workflow (by transmitting prescriptions/orders in real time, as opposed to having patients physically transport them). This leads to shorter wait times and should allow more time for pharmacists to counsel patients. It also gives patients and health care providers better access to records during disasters. The expectation is that patient satisfaction will improve as e-prescribing expands.
Insurance companies report that e-prescribing has reduced costs and improved formulary adherence. They have also seen less therapeutic duplication and fewer adverse drug reactions. Over time, e-prescribing may reduce liability as well. Some experts predict that patients will file fewer malpractice claims since preventable errors and adverse drug reactions are expected to be less frequent. And, with no paper prescription, forgeries are expected to fall as well.
Perfection is Elusive
E-prescribing’s advantages and accomplishments are remarkable, but some issues persist. “User error” accounts for most problems, with errors often related to inaccurate or missing information; for example, providers may select the incorrect drug, patient, or directions from drop-down tables. (Anyone who has ever placed an online order for a consumer good and inadvertently selected the wrong item, color, or size can understand how this happens.) In addition, studies have shown that inaccuracies in e-prescriptions tend to take longer to correct than those related to paper prescriptions.
E-prescription errors sometimes slip through and end up being dispensed as written, so patient harm is possible. One study reports that 10% of e-prescriptions contain errors that need pharmacist attention, and these errors may or may not be caught. Information system incompatibilities are also a problem, causing other workflow inefficiencies. When this is the case, the pharmacy staff bears the burden of clarifying the problems and ensuring the patient’s prescription is filled.
Good software design (screen layout and clarity, drop-down menus, filling function, and delivery speed) is critical. The best systems can be difficult for small or independent pharmacies to afford, but they are well worth the cost. Systems that transmit prescriptions immediately as opposed to those that batch or bundle prescriptions and send them later ensure the prescription arrives at the pharmacy before the patient does. These systems also distribute the workload more evenly rather than sending work in potentially overwhelming bursts.
Informatics and pharmacy researchers are watching e-prescribing closely. As its uptake increases, these experts will determine whether it is living up to its promise. They’ll also identify ways to make it even more efficient and decrease the likelihood of error.
Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.
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