E-Prescribing: Boon or Bain?

Note: This entry was written by my co-author, Linda Thede, for this blog. It addresses "unintended consequences" resulting from use of technology. The technical and process issues discussed are relevant to principles of database concepts.

The U.S. government has been pushing e-prescribing as a way to reduce medication errors by eliminating the problems with handwritten prescriptions. There is a tendency to equate e-prescribing with computerized provider order entry (CPOE). CPOE, although not perfect, when it is a part of a coordinated electronic healthcare system, has been shown to reduce medication errors from many causes including, poor handwriting, bad drug interactions, and the wrong dosage.

E-prescribing, however, is NOT CPOE. Nor, to date is there much evidence of its role in reducing medication errors. There are many e-prescribing vendors, but the percentage of physician participants is low. This is despite the fact that the federal government is going to reward its use. The differences between CPOE and e-prescribing are worth noting.

CPOE	E-PRESCRIBING
Is part of an overall electronic system with access to the patient's healthcare record	A stand alone system.
The agency creating the CPOE can verify that all parts of the system work together, e.g., drug allergies, drug interaction problems can be averted.	No connection with any patient information.
Maintained by the same group. Quality can be reinforced and appropriate training as well as remediation provided when needed.	The provider has no control over either what the pharmacist sees when s/he sends the prescription, or the training the pharmacist receives.

As things stand today there are technical and process issues. We are all familiar with the difficulties when two disparate electronic systems try to communicate. If there are differences in the field names or length, information may be either lost or truncated. Formularies differ so that what is ordered may not be what is received. Additionally, patient information about when and how to take can be lost.

When a healthcare provider writes a prescription he expects that the pharmacist will see what is written, whether it is sent as a piece of paper, or with e-prescribing. Unfortunately, with the latter method, this is not always so. Additionally, give a list of drugs and dosages, it is too easy for a provider to select the wrong one. The pharmacist, not having any information to the contrary, would then fill what he or she sees on their screen, which may not be what the provider intended. With a poorly written prescription, the pharmacist can see that there is a problem and contact the physician. The patient, who may have read the prescription, can provide a secondary review.

In e-prescribing, a prescription must be sent to a specific pharmacy, not just a chain. If either the healthcare provider accidentally clicks the wrong pharmacy, or the customer goes to a different pharmacy, the prescription must be tracked down, which at 10PM may be impossible. Interestingly, in Canada, the prescription is sent to a central database and whichever pharmacy the customer goes to retrieves it from that database.

To my knowledge, Ohio is the only state that has made an attempt to regulate the vendors of e-prescribing to try and alleviate some of the above problems. Under Ohio law the Ohio Board of Pharmacy must approve not only the vendor, but also the receiving pharmacy. They also perform verification of both the sent and received messages to determine if there are mistakes, or missing pieces.

This information is based on the presentation "E-prescribing: New Source of Medication Errors ?" by Timothy R Lanese at the Northern Ohio Health Information Management Systems Society Fall Conference on Friday, December 4, 2009 at Embassy Suites, Independence, Ohio. The presentation slides may be found at http://www.nohimss.org//Fall2009Presentations/Fall2009Presentations.html