Are You Ready for E-Prescribing?

Are You Ready for E-Prescribing?

The arguments for electronic prescribing (e-prescribing) are compelling, as noted in the article on this topic in this issue (page 1). Indeed, the potential benefits are so great that the problems—and before getting carried away in our enthusiasm, there are indeed some problems—seem minor in comparison. Much of my job relates to dealing with errors—identification of errors, and then prevention with system changes, education, and when all else fails, work-arounds. If our goal is to prevent prescription errors, then our discussion is reduced to how e-prescribing is implemented, or when, but not whether.

What can e-prescribing do for us? And by extension, what do we need to concentrate on until e-prescribing is fully implemented as a nationwide phenomenon? In other words, don’t hold your breath, you’re not going to see the “real thing” anytime soon. When it finally happens, we’ll have to give up using e-prescribing as the scapegoat for the consequences of our behaviors that lead to medical errors (eg, “I wouldn’t have to write legibly if only our hospital, practice manager, system would buy e-prescribing).

First, a caveat—I am not an information technology guy, which means I may not know what I am talking about, but being a physician, there is a better chance that you will understand what I am trying to say.

Potential Benefits of Universal E-Prescribing

• Memory crutch. It is a needed crutch for our poor memories. Who can possibly keep track of drug adverse reactions, interactions, and dose alterations? Nearly all patients over age 65 seem to be taking at least 5 drugs, and if not, they probably should be but they just don’t know about it yet. Until then, download ePoctrates onto your personal digital assistant; I can’t remember the last time I consulted my big, red Physicians’ Desk Reference.
• Avoid duplication. As the number of drugs continues to expand, we seem to be running out of names that have x’s and z’s, and each name tends to sprout different delivery systems (ie, ER, XL, SR, TDS). Sincere efforts to economize, by using generic formulations or prescribing the cheapest equivalent, can lead to duplication of drugs, with patients taking both the generic and the brand name drug or 2 different drugs with the same action. A case in point is one of my patients who is currently in the hospital for pulmonary edema; she was taking both carvedilol (Coreg), which was prescribed by her cardiologist, and atenolol (Tenormin), which was prescribed by her primary care physician. So until we have e-prescribing, we have to be very careful in reviewing our orders every time patients are transferred to our care, and always ask all patients to bring in their “brown bag,” so we or our office staff can review all their medications.
• Eliminate illegibility. Illegibility of doctors’ handwriting is a standing joke, but one’s humor flags when put in the position of the pharmacist or nurse trying to decipher a hastily written prescription. Until then, give us a break: write slowly, print, or exercise your ego some other way. Illegibility is just asking for medical and/or legal trouble.
• Transfer form. E-prescribing is an invaluable aid for the most dangerous times in patient care— the hand-offs. When patients are transferred from the hospital to home or to a nursing home, from provider to provider, or from primary care to consultant, the accuracy of the list of medications is paramount. Omission of a beta-blocker can precipitate a myocardial infarction; an incorrect dose of a psychotropic can lead to readmission for change in mental status. The capacity of e-prescribing to produce a printout of drugs for the patient or the transfer form will save time and reduce errors for everyone involved.

Until then—there really is no “until then” strategy except to recognize that hand-offs occur all the time now. No longer is anyone the patient’s “womb-to-tomb provider”—hand-offs are not only a fact of life, they can improve care. So, we have to adapt and be especially conscientious when care is transferred to other doctors or our nonphysician colleagues.

If It’s So Great, Why Don’t We Have It Already?

• Compatibility. The Veterans Association can make a systemwide change just happen (and bill the government!). In the real world, however, information systems vary from “third world primitive” to dazzling high-tech. But to be truly effective, e-prescribing has to be able to cross all these barriers to send the prescription to wherever your patient is cared for, across different systems, platforms, and insurance company formularies. The complexity is dazzling.
• Cost. Software does not come free. Even on the Internet, the free lunch must now be paid for by banners, cookies, and blinking ads.
• Physicians. Availability means that you will have to use it. Physicians are not the most progressive group—smart, yes, innovative, not so fast. If it really is available and actually works, then you will have to use it! On the other hand, we are fierce critics, so if it is not perfect, woe be the software developer.
• Efficiency. It must be user-friendly and proven better. Nothing could be physician-friendlier than the pad of prescription blanks and our latest drug-company-lurid pen. To convince us rather than coerce us, e-prescribing has to be more efficient or demonstrably better than what we have now. Otherwise, good luck in convincing physicians to use it without edict or reward.