E-prescribing: Using Technology to Prevent Errors

It is well-known that adverse drugevents (ADEs) are among the leadingcauses of death in the United States.Several studies have reported thatbetween 44,000 and 98,000 deaths eachyear are the result of some form of medicalerror.¹ Medication-related errors arethe number-1 contributor to thesedeaths.²

Former President Bill Clinton said in1999, "Our health care system does wonders,but first must do no harm." ³ To minimizemedical errors and the further lossof life due to them, Former President BillClinton called for the following changesin 1999:³

• A $20-million Center for Quality Improvementto serve as a clearinghouseon medical errors
• A 50% reduction in medical errorsover the next 5 years
• Patient safety programs to be installedand implemented in all hospitals
• New packaging and labeling standardsto be developed by the FDA

Yet, when the Institute of Medicinereleased its latest report on preventingmedication errors in July 2006,⁴ the findingswere alarming, as the number ofADEs had actually increased and becomemore costly. Although there hasbeen no accurate study to calculatethese costs, they are estimated to beabout $3.5 billion a year, including losttime and lost productivity at work.

The IOM researchers examined manystudies and found that ~400,000 ADEsoccur in hospitals every year, all of whichare preventable. In long-term care settings,>800,000 drug-related injuries havebeen reported each year, and amongoutpatient Medicare patients ~530,000such injuries occur.

The IOM investigators recommendedseveral steps to lower the number ofmedication errors and their relatedinjuries. They advocated the use of availabletechnologies and proposed that by2010 all health care providers should useelectronic prescribing systems.⁴

What Is E-prescribing?

Electronic prescribing (e-prescribing)refers to the practice of using a personalcomputer (PC), laptop, Tablet PC, personaldigital assistant (PDA), or Smartphoneto write and generate a prescription atthe point of care.⁵ Handheld technologycan offer a solution to the problems ofillegible handwriting and overlooked druginteractions. This method of prescribingis growing in acceptance. It is increasinglyreplacing the "old-fashioned" methodof doctors writing prescriptions on paperslips that are given to patients to betaken to the pharmacy for processing.⁵

E-prescribing is gaining popularityamong health care providers because ofits many benefits to all parties involved.Physicians, personnel with health careplans, third-party payers, pharmacies,and pharmaceutical companies, andespecially patients can benefit from theease, the efficiency, and, most importantly,the absence of errors from using thistechnology.

Figures 1, 2, and 3 show examples of amobile e-prescribing system for physiciansthat uses a PDA. The technology isable to send prescriptions from the pointof care to pharmacies via wireless transmissionsuch as LAN, WiFi LAN, EVDO,and other wireless services, such asGPRS and EDGE technology.^2,5,6

Characteristics of E-prescribing

Health care providers, by adopting andusing e-prescription systems, will be ableto generate legible copy of prescribedmedications that can be sent to the pharmacyelectronically, faxed, or printedwith minimal error. They also can checkfor potential drug interactions, patientdrug allergies, and possible drug duplicationsbefore the prescriptions are processed.E-prescribing is safer, faster, andmore efficient than handwriting paperprescriptions because it eliminates theproblem of illegible handwriting. It givesthe prescriber the ability to perform formularycompliance by using decisionsupportsystems, as well as an enhancedability to transfer prescriptions.⁵

Other ways that e-prescribing can playa critical role in reducing medicationerrors are as follows:

• Drug selection
• Screening for interactions (drug-drug, drug-laboratory, drug-disease)
• Links between laboratory and pharmacy
• Dosing calculations and scheduling
• Coordination between team members,particularly concerning patienteducation
• Monitoring and documenting ADEs
• Postmarketing surveillance of therapyoutcomes⁷

Advantages of E-prescribing

As mentioned earlier, e-prescribing isefficient, fast, and reliable, and, mostimportantly, it is accurate. For physicians,e-prescribing will do the following:

• Streamline the process of prescribingby providing important informationabout potential ADEs, drug interactionsand allergies, duplicate medications,and formularies
• Help reduce routine problem orders
• Offer instant access to patient medicationprofiles in the doctor's office
• Offer access to treatment guidelines
• Enhance the refill-authorizationprocess
• Help lower medical malpracticeinsurance premiums
• Allow the physician to retrieve informationon specific medications prescribedto patients in the event of alegal matter^2,5,7

Other benefits include dose checking,more legible orders, industry-wide standardization,and documentation of interventionsin the event of ADEs.⁵

Drawbacks of E-prescribing

Although e-prescribing has greatpotential to reduce medication errors,some health care providers and prescribershave noted some concerns.Some of the questions that need to beaddressed are as follows:

• Will a procedure that usually takes 15seconds to complete be exchangedfor one that takes about 50 seconds?
• Will providers select the pharmaciesto which the prescriptions are sent?
• What if a prescriber's office lacksWeb access or high-speed wirelessservices?
• What about variations among states' medical practice regulations?
• Will patients accept leaving an officewithout an Rx?^2,5

Technical Obstacles to E-prescribing

The idea of using technology to reducemedication errors is viable and feasible.Yet, health care providers need to beaware of some of the technical obstaclesto e-prescribing so that they can be betterequipped to overcome them. Theseobstacles include the following:

• A lack of standards for systems tocommunicate among themselves
• Lack of interfaces to current practice-management systems
• Lack of electronic data interchangeinfrastructure between prescribersand pharmacies
• Too many software vendors, with noregulations yet
• Differing hardware setups
• Physicians' lack of interest
• Anticipated costs that involve newinvestments and training^2,5,7

Key Components of an Ideal E-prescribingSystem

The key to success in reducing medicationerrors is to have all relevant databasespertaining to patients available topractitioners at the point of care. Such asystem should interact with the followingdatabases:

• Patient-specific data: allergies,International Classification of Diseasescodes, medication history, etc
• Patient's laboratory work
• Insurance companies and third-partypayers
• Current Procedural Terminologycodes and diagnosis
• Drug information and clinical guidelines
• The patient's electronic medicalrecords
• Billing functions
• Patient scheduling system^2,5

Final Words

The development of standards for eprescribingis an important step forwardto ensure that all health care providerswill be at ease using such a system. Theindustry is moving toward a commonsystem for physicians that will make itpossible for all practitioners to communicatewithout the need for many differingsystems on hand.⁸ The goal is to developone system that can be universally usedby doctors, insurance companies, andpharmacists. Also, health care providersare working toward the development ofcompatible interoffice technology, aswell as interoperability across healthcare settings.

A greater emphasis should be placedon the importance of uniform standardsthat will make the system able to accessall clinical databases and allow e-prescribingto take place within one effectivesystem and not several subsystems.The future of e-prescribing is exceptionallypromising in regard to helping reducemedication errors and allowing pharmaciststo focus more on improving clinicaloutcomes for patients.⁷

Dr. Mahrous is an associate professorof pharmacy administration and preclinicaleducation at MidwesternUniversity's College of Pharmacy-Glendale and Arizona College ofOsteopathic Medicine in Arizona. Mr.Dalbik is a PharmD candidate atMidwestern University's College ofPharmacy-Glendale.

For a list of references, send a stamped, self-addressedenvelope to: References Department,Attn. A. Rybovic, Pharmacy Times, AscendMedia Healthcare, 103 College Road East,Princeton, NJ 08540; or send an e-mailrequest to: arybovic@ascendmedia.com.