Spotlight Case
E-prescribing: E for Error?
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Source and Credits
•This presentation is based on the February 2012AHRQ WebM&M Spotlight Case
–CME credit is available
•Commentary by: Elisa W. Ashton, PharmD, AssistantClinical Professor, Department of Clinical Pharmacy,University of California, San Francisco
–Editor, AHRQ WebM&M: Robert Wachter, MD
–Spotlight Editor: Bradley A. Sharpe, MD
–Managing Editor: Erin Hartman, MS
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Objectives
At the conclusion of this educational activity,participants should be able to:
•Define e-prescribing
•Describe ways in which e-prescribing can reducehealth care costs
•State how often prescriptions errors occur with e-prescribing
•Describe steps to limit errors associated with e-prescribing
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Case—Part 1: E-prescribing (1)
A 63-year-old man with multiple medical problemswas seen by his primary care doctor for a routinefollow-up appointment. Despite receivingpsychotherapy, the patient admitted that hecontinued to struggle with anxiety. In light of thesecomplaints, the primary care doctor elected toprescribe an antianxiety agent, alprazolam.
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Case—Part 1: E-prescribing (2)
The clinic had just implemented electronicprescribing—the ability to electronically transmit anew prescription to a pharmacy. The physicianreassured the patient that he didn’t need a paperprescription and could simply go to the pharmacy topick up his medications.
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Background: Electronic Prescribing
•E-prescribing is the transmission, usingelectronic media, of prescriptions orprescription-related information fromprescriber (physician, nurse practitioner, etc.)to pharmacy
•Most simple example is two-way transmissionbetween provider and pharmacy
•Intended to replace writing out, faxing, orcalling in prescriptions
See Notes for references.
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E-prescribing Benefits
•Proposed benefits include safer, more efficient, andmore cost-effective care
•Because of potential benefits, federal government hasput in place incentives for providers to adopt e-prescribing
–Significant funds as part of the American Recovery andReinvestment Act of 2009
•Incentives expected to increase rate of e-prescribingand save $22 billion in drug costs in the next decade
See Notes for references.
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Savings from E-prescribing
•Savings expected to arise from 4 factors:
–Informing providers the point of care, allowing them tochoose best and most affordable drugs
–Providing doctors with patients’ medication histories toprevent harmful drug interactions or duplicate prescriptions
–Notifying physicians of pharmacy options, including mail-order and retail drug stores, to help curb patients' out-of-pocket costs
–Reducing wait times and errors related to illegiblehandwriting by transmitting prescriptions electronically topharmacies
See Notes for reference.
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E-prescribing Improves Safety
•Will allow for clinical decision support—immediateaccess to pharmacy eligibility, benefits, andformularies at the point of care
–In Massachusetts, led to cost-savings of $845,000 per100,000 patients
–At Henry Ford Health System, clinical decision supportwas associated with increased use of generic drugs,lower administrative costs, and reductions in adversedrug events
See Notes for references.
Increase in E-prescribing
•By end of 2010, there were 234,000active e-prescribers, 34% of alloffice-based physicians in the UnitedStates
•Approximately 20% of all eligibleprescriptions were sent electronicallyin 2010 (vs. 12% in 2009)
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See Notes for reference.
![C:\Users\ehartman\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.IE5\O4QT7PU7\MP900448637[1].jpg](data/images/img4.jpg)
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Case—Part 2: E-prescribing (1)
The clinic nurse entered the medications into thecomputer system. However, while entering theprescription for alprazolam, she inadvertentlyentered an additional medication, atenolol, aprescription intended for a different patient. Quicklyrecognizing her error, she deleted the e-prescriptionin the computer, and assumed the order had beencanceled.
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Case—Part 2: E-prescribing (2)
Unfortunately, despite the nurse’s efforts to cancel theatenolol order, the e-prescription went through to thepharmacy. When the patient arrived at the pharmacy, hewas given both medications. Although he thought it was abit strange to receive two medications for his problem, hewas willing to do anything to reduce his anxiety.Consequently, he took both medications as instructed. Afew days later, during his cardiology appointment, theerror was noted, and the atenolol was discontinued.
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Unintended Consequences
•Evidence suggests that e-prescribingimproves safety overall
•However, like any new technology,e-prescribing has the potential tointroduce new errors
See Notes for references.
![C:\Users\ehartman\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.IE5\UC1P7B7N\MP900337301[1].jpg](data/images/img5.jpg)
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Errors and E-prescribing (1)
•In a large study 11.7% of all e-prescriptionshad errors, of which 35% were consideredpotential adverse drug events
•Information omitted most often wasduration, dose, or frequency
•Requiring fields to be completed may helpovercome omission errors
See Notes for reference.
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Errors and E-prescribing (2)
•Providers new to e-prescribing maymake errors initially and must use thee-prescribing system routinely to gainexperience with it
•Some pharmacies have differentcomputer systems. Thus, even thoughthe information is sent electronically, itstill needs to be manually entered intoa different system
See Notes for reference.
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Preventing Errors with E-prescribing
•Experts have recommended all e-prescribingsystems use standard nomenclature for drugs
–May reduce drug selection inefficiencies and errors
•Others recommend using a structured format forpatient instructions
–For example, if a provider prescribes a medication to betaken T.I.D., it would automatically print for the patient as“3 times a day,” instead of pharmacist having to changeinstructions manually
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Notes about Case
•The system should not have allowed nurse toprescribe on behalf of doctor, without doctor’sverification
•No mechanism in place to force final review ofprescription before sending
–Many systems require the provider to review all new,renewed, or changed medications
•E-prescribing does not replace other safemedication prescribing practices
–Patients should be informed of their medications
–Providing and reviewing current medication list should bedone at each patient visit
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Steps to Maximize Safety (1)
•Verify name and date of birth before enteringan order
•Review all new medications and intended usewith the patient
•Confirm deletion of an order entered in errorwhile reviewing the patient’s current medicationlist at the end of the visit. Provide paper orelectronic copy to the patient
Steps to Maximize Safety (2)
•Follow up with a phone call to the pharmacyto ensure that the wrong medication was nottransmitted for the wrong patient, especiallywhen a prescription is canceled or changed
•Document software design and workflowchallenges to feedback to the vendor andprovider practice for future trainingopportunities or upgrades
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Take-Home Points
•E-prescribing is the transmission, using electronicmedia, of prescriptions or prescription-relatedinformation from a prescriber to a pharmacy
•E-prescribing may lead to safer, more efficient, andmore cost-effective care
•E-prescribing can lead to unintended consequencesand new types of medical errors
•Institutions and providers should take steps to limiterrors associated with e-prescribing