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e-prescribing

Electronic prescribing: "computer-based support for the creation, transmission, dispensing, and monitoring of pharmacological therapies " [Miller et al, 2005].

Introduction

Electronic prescribing, often abbreviated to e-prescribing or eRx, is a form of computer-based physician order entry (CPOE, also referred to as computerized provider order entry and computerized prescription order entry). CPOE systems are frequently regarded in the USA as the main technical solution to tackling medication order errors identified (for example, in the 1999 IOM report, To Err Is Human: Building a Safer Health System) as the largest source of preventable medical errors in hospitals.

The main aim of electronic prescribing systems is to reduce medication errors (incorrect dosages, and drug-drug interactions or drug-allergy interactions etc.) and adverse drug events (ADEs - problems that result from medication errors) and consequently improve standards in patient safety.

Commercial software to support e-prescribing (including drug formularies, drug-drug interaction checkers and patient elgibility checkers) is widely available, particularly in the USA. It has the advantage that it appears to be a relatively uncomplicated form of decision support to implement, and has wide political, regulatory, social and economic support at the national level. Paul Tang's 2003 letter report, Key Capabilities of an Electronic Health Record System, (reprinted in the IOM's report of the same year, Patient Safety: Achieving a New Standard for Care) states clearly: "The strongest evidence of the clinical effectiveness of CPOE is seen in medication order entry" [Tang, 2003]. The conclusions of the eHealth Initiative's 2004 report on electronic prescribing [details below - EHI, 2004] were quickly adopted by the National Committee on Vital Health Statistics (NCVHS) as the basis for formulating recommendations on e-prescribing to the US Department of Health and Human Services (HHS). Now, under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the HHS is now required to 'promulgate' uniform electronic prescribing standards by April 1, 2008.

In the UK, implementation of an electronic prescribing service forms part of the NHS Plan. In 1998, the NHS set a target for all hospitals to implement electronic prescribing, (specifically, Electronic Transmission of Prescriptions - ETP) by 2005. This target was not however met. ETP is now focused on primary care prescribing and forms a part of Connecting for Health (NHS, England, formerly the The NHS National Programme for IT). ETP pilots went live in early 2005, and the deadline for full implementation of the service in the NHS has been set at December 2007.

Negative attitudes towards e-prescribing systems are comparatively rare, but in an edition of JAMIA published in 2005 focusing on e-prescribing, Miller et al urge a degree of caution:
"Clinicians should be wary of developing a false sense of security and unrealistic expectations based on use of e-prescribing applications alone, when more complex systems may be required." [Miller et al, 2005].

But with the strong impetus from many sectors for e-prescribing and as data entry systems and electronic medical records become more sophisticated and increasingly routinely used in healthcare, eRx systems seem certain to become a commonplace part of healthcare information infrastructures.
Benefits
Electronic prescribing that integrate patient data and drug information can offer the following benefits:

  • "Computers can maintain accurate, unbiased, and up-to-date drug databases, which constitute essential tools as the number of approved medications continues to increase.
  • Prescribers can receive on-screen prompts for drug-specific dosage information, with reminders to ensure that look-alikes and sound-alikes are not confused.
  • Vital patient-specific information, such as overdose warnings, drug interactions, and allergy alerts, can be presented in the course of prescribing, so that potential ADEs that would otherwise go unrecognized can easily be avoided.
  • Computers can reduce, even eliminate, the margin for error by flagging pre-existing medical conditions or concurrent medications that would preclude use of certain drugs in individual patients.
  • Electronic prescribing can expedite refill requests, once patients are entered into the system.
  • Computers can facilitate data exchange to enhance teamwork between clinicians and professionals who represent other parts of the medication management system, such as pharmacists in retail, hospital, and online environments; pharmacy benefit managers (PBMs); and health plans.
  • Computers can enable practitioners to stay abreast of changes in formularies and insurance coverage.
  • The use of computers can reduce healthcare costs through time and efficiency savings and by encouraging prescribers to consider lower-cost drug options."

[ISMP White Paper, 2000]   

A list of desirable features of eRx systems is provided in Bell et al, 2004 (see abstract below).

references: reports, recommendations and white papers

Teich JM, Osheroff JA, Pifer EA, Sittig DF, Jenders RA, Panel TC. Clinical Decision Support in Electronic Prescribing: Recommendations and an Action Plan. J Am Med Inform Assoc. 2005 Jul-Aug;12(4):365-76.

[PubMed]   [JAMIA]

" Clinical decision support (CDS) in electronic prescribing (eRx) systems can improve the safety, quality, efficiency, and cost-effectiveness of care. However, at present, these potential benefits have not been fully realized. In this consensus whitepaper, we set forth recommendations and action plans in three critical domains: (1) advances in system capabilities, including a basic and advanced set of CDS interventions and knowledge, supporting database elements, operational features to improve usability and measure performance, and management and governance structures; (2) uniform standards, vocabularies, and centralized knowledge structures and services that could reduce rework by vendors and care providers, improve dissemination of well-constructed CDS interventions, promote generally-applicable research in CDS methods, and accelerate the movement of new medical knowledge from research to practice; and (3) appropriate financial and legal incentives to promote adoption. "

eHI report - Electronic Prescribing: Toward Maximum Value and Rapid Adoption: Recommendations for Optimal Design and Implementation to Improve Care, Increase Efficiency and Reduce Costs in Ambulatory Care (eRx Report). A Report of the Electronic Prescribing Initiative, eHealth Initiative. Washington, D.C. April 14, 2004

[PubMed]   [eHealth Initiative]    [eHealth Initiative]

 

(The eHI is an independent, Washington DC-based non-profit group promoting the use of information technology to improve health care.)

" Highlights of the Report

  1. Errors and adverse drug events in ambulatory care errors can be common, serious, and preventable, according to research.
  2. Electronic prescribing can improve safety, quality, efficiency, and cost. Studies suggest that the national savings from universal adoption could be as high as $27 billion.
  3. Electronic prescribing systems are available in a variety of graduated levels, Systems at the highest levels of sophistication afford much greater opportunities for benefit, although all of the middle and higher levels convey some significant benefits.
  4. Despite the benefits of electronic prescribing, adoption is still modest. Current surveys estimate that between 5% and 18% of physicians and other clinicians are using electronic prescribing. Key barriers to clinician adoption include startup cost, lack of specific reimbursement, and fear of reduced efficiency in the practice.
  5. The adoption and use of electronic prescribing should be encouraged through the deployment of appropriate incentives. These incentives will be critical to widespread adoption. Promising incentives are reviewed in the report.
  6. Continuing progress toward better-designed, more usable systems is likely to help adoption. A number of techniques and best practices are reviewed.
  7. Clinical decision support interventions should follow certain design principles for maximum acceptability and impact.
  8. Electronic communication offers numerous advantages: it is faster, more work-efficient, more secure, more reliable, less error-prone, and less prone to abuse than paper or fax prescriptions. Current barriers include expense, broadband availability, and variant standards.
  9. Software should inform but not mandate a clinicianís and patientís choice of medications and pharmacies. Patient confidentiality must also be protected.
  10. A number of enhancements in standards and vocabularies are needed to improve quality, efficiency, and to facilitate interoperability between the various electronic systems involved in the electronic prescribing process. Unifying state prescription-form standards, establishing a consistent ďdoctor-levelĒ drug vocabulary, and standardizing formulary information are among the highest needs.
  11. Careful management of the initial use period in any practice is essential. Access to registration, schedule, and prior medication information is important.
  12. Integration of electronic prescribing with an overall electronic health record adds value in a number of ways. Many lessons about adoption of electronic prescribing can be applied to the widespread adoption of robust, connected electronic health records as well."

Electronic Prescribing Can Reduce Medication Errors White Paper from the Institute for Safe Medication Practices, 2000

[]   [ISMP]

" Medication errors became front page news with the November 1999 release of a compelling report from the Institute of Medicine (IOM). The public may have been surprised to learn that errors involving prescription medications kill up to 7,000 Americans a year, according to the IOM, and that the financial costs of drug-related morbidity and mortality may run nearly $77 billion a year.

" But the problem of medication errors is not new. In fact, research demonstrates that injuries resulting from medication errors are not the fault of any individual healthcare professional, but rather represent the failure of a complex healthcare system. System failures can be analyzed and prevented, many through emerging information technology (I.T.) solutions.

" In the medication management system, errors can be introduced at multiple points. Numerous problems are related to the naming, labeling, and/or packaging of drugs or to inefficient distribution practices. Patients often contribute to errors by failing to comply with instructions. Many errors occur as prescriptions are written; these tend to be failures of communication and, in far too many cases, the underlying problem is clinicians' handwriting.

" The healthcare industry has been slow to adopt new technologies, although these tools hold promise for enhancing the delivery of healthcare. Prescription writing is perhaps the most important paper transaction remaining in our increasingly digital society; it seems simplistic to note that electronic prescribing tools could minimize medication errors related to handwriting. Yet even though such devices are available for use in hospitals, ISMP estimates that less than 5% of U.S. physicians currently "write" prescriptions electronically.

" The hurdles until very recently have been clinicians' reticence about computers, a lack of hardware and software that would conveniently allow prescribers to select medications electronically, and fear of the costs associated with such technology. Fortunately, the advent of wireless hand-held devices is making it increasingly possible to solve the "handwriting crisis," perhaps on all 3 counts. "

Bell DS, Marken RS, Meili RC, Wang CJ, Rosen M, Brook RH; RAND Electronic Prescribing Expert Advisory Panel. Recommendations for comparing electronic prescribing systems: results of an expert consensus process. Health Aff (Millwood). 2004 Jan-Jun;Suppl Web Exclusives:W4-305-17.

[PubMed]   [Health Affairs]

" Commercially available electronic prescribing systems may differ in their effects on patients' health outcomes and on patients' ability to manage costs. An expert panel convened to recommend specific features that would enable electronic prescribing systems to advance these goals. The panel authored sixty recommendations and rated each using a modified Delphi process. Ratings identified fifty-two recommendations as clearly positive for patient safety and health outcomes and forty-three recommendations as achievable in the average clinician's office within three years. Overall, these recommendations offer a synthesis of evidence and expert opinion that can help guide the development of electronic prescribing policy. "

references: e-prescribing

Smith AD. Barriers to accepting e-prescribing in the U.S.A. Int J Health Care Qual Assur Inc Leadersh Health Serv. 2006;19(2-3):158-80.

[PubMed]   []

" PURPOSE: With the number of prescriptions rising nationally each year, it is surprising that Web-based technology is not fully embraced in the pharmacy industry as an aid to quality-assuring prescribing processes. Traditional prescription handling is done in a manual fashion with physicians hand-writing prescriptions for the patients during an office visit, giving the patient the responsibility of taking the prescription to a pharmacy or mailing the prescription to a mail order company for fulfillment. Electronic prescribing (e-prescribing) has the ability not only to streamline the prescription writing process, but also to reduce the number of errors that may be incurred with hand-written prescriptions. The purpose of this paper is to investigate these phenomena in the U.S.A. DESIGN/METHODOLOGY/APPROACH: A number of hypotheses were tested using principal-components analysis (PCA) and factor analyses. As a result, a total of 55 fully employed, professional and semi-professional service management and internet users, representing a college-educated and knowledge-based sample derived from the metropolitan section of Pittsburgh, was selected. FINDINGS: The six major constructs generated from the factor loadings in descending order of importance were: profit and risk factors, shipping and handling, saving, customer relationship management (CRM) and ethics, age, and awareness. The dependent variable chosen to be regressed against these major independent factor-based constructs was willingness to purchase prescriptions online. The overall relationship was found to be statistically significant (F = 2.971, p = 0.015) in predicting willingness to use e-prescribing options based on the various independent constructs. However, when testing the various standardized beta coefficients in the linear model, only the factor score-based construct CRM and ethics was found to significantly contribute to predicting the willingness to purchase prescriptions online (t = -3.074, p = 0.003). RESEARCH LIMITATIONS/IMPLICATIONS: Although this study appears to represent the e-prescribing process in the U.S.A., the sample size and region studied are only one slice of the general population. Practical implications - Unfortunately, the adoption of e-prescribing has been difficult to attain owing to numerous barriers throughout the industry. Such acceptance barriers include lack of technology trust, associated system costs, and risk of un-securing patient health and medical information. ORIGINALITY/VALUE: This article documents that increasing numbers of pharmacies today are building their IT-infrastructures to accept electronic prescriptions and it may soon be the preferred method for physicians to write prescriptions. It is with great anticipation that this technology will also enhance the prescription-writing abilities of prescribing physicians globally, giving them electronic access to patient medical records and resources that will assist them in prescribing the correct drug for the patient. "

Halamka J. Early experiences with E-prescribing. J Healthc Inf Manag. 2006 Spring;20(2):12-4.

[PubMed]   []

" Most physicians understand that e-prescribing will reduce medical errors and will be perceived by patients as making the prescription process easier. However, they are skeptical about a number of things. They worry whether their office processes will be improved or streamlined; e-prescribing will interface seamlessly with their existing practice management software; training and support will be available; e-prescribing data will be seamlessly transferable to an electronic health record when they implement a more advanced clinical record system for their practice; and if they will achieve a return on investment. Early adopting clinicians in Massachusetts can convince the majority of clinicians to adopt e-prescribing by sharing their motivations for adopting e-prescribing, the challenges that they needed to overcome, the hardware and software requirements, and integration into their office workflow. Finally, interaction with the physicians and practice managers in the audience makes the adoption of e-prescribing seem both reasonable and exciting. Resources such as vendor lists, questions to ask, and hardware and software requirements also need to be readily available and in a form that non-technical staff can read and understand. Physicians who know the "why" would also like to know. "

Miller RA, Gardner RM, Johnson KB, Hripcsak G. Clinical decision support and electronic prescribing systems: a time for responsible thought and action. J Am Med Inform Assoc. 2005 Jul-Aug;12(4):403-9.

[PubMed]   []

" Electronic prescribing (e-prescribing) systems can provide computer-based support for the creation, transmission, dispensing, and monitoring of pharmacological therapies. In the United States and other countries, such systems have been documented, under certain conditions, to increase the safety and quality of patient care.1,2,3,4,5 The authors applaud the initial efforts of Teich and colleagues in the Joint Clinical Decision Support Workgroup (Joint CDS WG) to outline e-prescribing desiderata, as reported in this issue of JAMIA by Teich et al.6 Their article is published as an endorsed policy of the American Medical Informatics Association (AMIA). Previously, Bell et al. published an excellent list of desiderata for outpatient e-prescribing and sorted the desiderata into functional categories.7 Subsequently, Wang et al. surveyed e-prescribing vendor systems to determine that existing systems on average met only half the desiderata, with none exceeding 64% fulfillment.8 The recommendations outlined in the tables of the Joint CDS WG provide a useful point of departure for future discussions. Of note, the Joint CDS WG guidelines were developed as a "commissioned work" with externally determined foci, time limitations, and priorities, so that those guidelines do not fully cover all relevant areas. The Joint CDS WG document therefore represents an important first step in an evolving approach to a complex set of problems.

"The Joint CDS WG recommendations present a scenario of how e-prescribing features might be rolled out. The authors of this commentary would like to supplement, from what we believe is a broader perspective, the focused set of Joint CDS WG recommendations. The Joint CDS WG proposal has several strengths, including the recommendations that the United States should develop and promote shareable standards for e-prescribing and related decision support systems, a consensus should be developed on how to implement and evaluate decision support systems, and certain organizations, (such as the Office of the National Coordinator for Health Information Technology, the Agency for Healthcare Research and Quality, the U.S. Food and Drug Administration (FDA), the National Library of Medicine, AMIA, the e-Health Initiative, and the Health Information and Management Systems Society) should take leadership roles in the e-prescribing efforts. The authors note that developers and implementers should consider the variability that currently exists among users, clinical settings, information systems, and environments when determining how and when to install and support an e-prescribing system. For example, even when clinical systems provide net benefits to an institution, the implementation of electronic systems to improve the quality of care can introduce unwanted, potentially harmful side effects that must be detected, monitored, and addressed.9,10 It is therefore important to consider the potential adverse effects of e-prescribing implementation. "

Hammond WE. The role of standards in electronic prescribing. Health Aff (Millwood). 2004 Jan-Jun;Suppl Web Exclusives:W4-325-7.

[PubMed]   [healthaffairs.org]

" The focus on preventing medical errors has advanced the arguments for widespread implementation of electronic prescribing. The choice of systems as well as the variation in functionality is large. Value and return on investment depend on the functionality provided. The paper by Douglas Bell and colleagues defines the functionalities that are required and desirable to ensure patient safety and quality of care. Health data standards are a prerequisite for the interoperability to support elect ronic prescribing. This paper discusses some of the barriers and problems in producing and adopting those standards. "

Wang CJ, Marken RS, Meili RC, Straus JB, Landman AB, Bell DS. Functional characteristics of commercial ambulatory electronic prescribing systems: a field study. J Am Med Inform Assoc. 2005 May-Jun;12(3):346-56.

[PubMed]   []

" OBJECTIVE: To compare the functional capabilities being offered by commercial ambulatory electronic prescribing systems with a set of expert panel recommendations. DESIGN: A descriptive field study of ten commercially available ambulatory electronic prescribing systems, each of which had established a significant market presence. Data were collected from vendors by telephone interview and at sites where the systems were functioning through direct observation of the systems and through personal interviews with prescribers and technical staff. MEASUREMENTS: The capabilities of electronic prescribing systems were compared with 60 expert panel recommendations for capabilities that would improve patient safety, health outcomes, or patients' costs. Each recommended capability was judged as having been implemented fully, partially, or not at all by each system to which the recommendation applied. Vendors' claims about capabilities were compared with the capabilities found in the site visits. RESULTS: On average, the systems fully implemented 50% of the recommended capabilities, with individual systems ranging from 26% to 64% implementation. Only 15% of the recommended capabilities were not implemented by any system. Prescribing systems that were part of electronic health records (EHRs) tended to implement more recommendations. Vendors' claims about their systems' capabilities had a 96% sensitivity and a 72% specificity when site visit findings were considered the gold standard. CONCLUSIONS: The commercial electronic prescribing marketplace may not be selecting for capabilities that would most benefit patients. Electronic prescribing standards should include minimal functional capabilities, and certification of adherence to standards may need to take place where systems are installed and operating. "

Tamblyn R, Huang A, Kawasumi Y et al. The development and evaluation of an integrated electronic prescribing and drug management system for primary care. J Am Med Inform Assoc. 2006 Mar-Apr;13(2):148-59.

[PubMed]   []

" OBJECTIVE: To develop and evaluate the acceptability and use of an integrated electronic prescribing and drug management system (MOXXI) for primary care physicians. DESIGN: A 20-month follow-up study of MOXXI (Medical Office of the XXIst Century) implementation in 28 primary care physicians and 13,515 consenting patients. MEASUREMENT: MOXXI was developed to enhance patient safety by integrating patient demographics, retrieving active drugs from pharmacy systems, generating an automated problem list, and providing electronic prescription, stop order, automated prescribing problem alerts, and compliance monitoring functions. Evaluation of technical performance, acceptability, and use was conducted using audit trails, questionnaires, standardized tasks, and information from comprehensive health insurance databases. RESULTS: Perceived improvements in continuity of care and professional autonomy were associated with physicians' expected use of MOXXI. Physician speed in using MOXXI improved substantially in the first three months; however, only the represcribing function was faster using MOXXI than by handwritten prescription. Physicians wrote electronic prescriptions in 36.9 per 100 visits and reviewed the patient's drug profile in 12.6 per 100 visits. Physicians rated printed prescriptions, the current drug list, and the represcribing function as the most beneficial aspects of the system. Physicians were more likely to use the drug profile for patients who used more medication, made more emergency department visits, had more prescribing physicians, and lower continuity of care. CONCLUSION: Primary care physicians believed an integrated electronic prescribing and drug management system would improve continuity of care, and they were more likely to use the system for patients with more complex, fragmented care. "

Taylor LK, Kawasumi Y, Bartlett G, Tamblyn R. Inappropriate prescribing practices: the challenge and opportunity for patient safety. Healthc Q. 2005;8 Spec No:81-5.

[PubMed]   []

" Adverse clinical events related to inappropriate prescribing practices are an important threat to patient safety. Avoidance of inappropriate prescribing in community settings, where the majority of prescriptions are written, offers a major area of opportunity to improve quality of care and outcomes. Electronic medication order entry systems, with automated clinical risk screening and online alerting capabilities, appear as particularly promising enabling tools in such settings. The Medical Office of the Twenty First Century (MOXXI-III) research group is currently utilizing such a system that integrates identification of dosing errors, adverse drug interactions, drug-disease and allergy contraindications and potential toxicity or contraindications based on patient age. This paper characterizes the spectrum of alerts in an urban community of care involving 28 physicians and 32 pharmacies. Over a consecutive nine-month period, alerts were generated in 29% of 22,419 prescriptions, resulting in revised prescriptions in 14% of the alert cases. Drug-disease contraindications were the most common driver of alerts, accounting for 41% of the total and resulting in revised prescriptions in 14% of cases. In contrast, potential dosing errors generated only 8% of all alerts, but resulted in revised prescriptions 23% of the time. Overall, online evidence-based screening and alerting around prescription of medications in a community setting demands confirmation in prescribers' clinical decision making in almost one-third of prescriptions and leads to changed decisions in up to one-quarter of some prescribing categories. Its ultimate determination of clinical relevance to patient safety may, however, have to await more detailed examination of physician response to alerts and patient outcomes as a primary measure of utility. Patient safety is an increasingly recognized challenge and opportunity for stakeholders in improving health care delivery. It involves many issues, including delayed diagnosis and treatment, as well as inappropriate undertreatment and overtreatment. The common denominators, however, are that care and outcomes could be better, and there is a role for patients, providers and policy makers in making improvements. "

Shah NR, Seger AC, Seger DL et al. Improving acceptance of computerized prescribing alerts in ambulatory care. J Am Med Inform Assoc. 2006 Jan-Feb;13(1):5-11.

[PubMed]   []

" Computerized drug prescribing alerts can improve patient safety, but are often overridden because of poor specificity and alert overload. Our objective was to improve clinician acceptance of drug alerts by designing a selective set of drug alerts for the ambulatory care setting and minimizing workflow disruptions by designating only critical to high-severity alerts to be interruptive to clinician workflow. The alerts were presented to clinicians using computerized prescribing within an electronic medical record in 31 Boston-area practices. There were 18,115 drug alerts generated during our six-month study period. Of these, 12,933 (71%) were noninterruptive and 5,182 (29%) interruptive. Of the 5,182 interruptive alerts, 67% were accepted. Reasons for overrides varied for each drug alert category and provided potentially useful information for future alert improvement. These data suggest that it is possible to design computerized prescribing decision support with high rates of alert recommendation acceptance by clinicians. "

Tamblyn R. Improving patient safety through computerized drug management: the devil is in the details. Healthc Pap. 2004;5(3):52-68.

[PubMed]   []

" Electronic prescribing and computerized drug management can improve the safety, quality and cost-effectiveness of prescribing. However, if the problems that lead to avoidable adverse events are not addressed by information technology, there is a risk of making considerable investment without the expected return of error reduction and improved patient safety. Improving the safety of prescribing is particularly important in ambulatory care, where most drugs are prescribed. To improve patient safety, IT solutions should be developed that provide: (1) access to the list of all currently active drugs, (2) alerts for relevant prescribing problems (therapeutic duplication, excess dose, dose adjustment for weight (children, elderly) and renal impairment, drug-disease, drug-drug, drug-age and drug-allergy contraindications), (3) the capacity to electronically submit medication stop orders to the dispensing pharmacy and (4) integration of electronic prescriptions (e-rx) into pharmacy software to avoid transcription errors. To improve quality of prescribing, IT solutions should be capable of providing physicians with reminders and alerts for evidence-based preventive care and disease management based on patient-specific drug, disease, therapeutic intent and other relevant clinical information. To improve the cost-effectiveness of prescribing, IT solutions should be developed to provide the cost of medication at the time the prescription is written, and evidence-based alerts for drugs of choice recommendations when appropriate. "

Bates DW, Teich JM, Lee J at al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc. 1999 Jul-Aug;6(4):313-21.

[PubMed]   [PubMed Central]

" BACKGROUND: Medication errors are common, and while most such errors have little potential for harm they cause substantial extra work in hospitals. A small proportion do have the potential to cause injury, and some cause preventable adverse drug events. OBJECTIVE: To evaluate the impact of computerized physician order entry (POE) with decision support in reducing the number of medication errors. DESIGN: Prospective time series analysis, with four periods. SETTING AND PARTICIPANTS: All patients admitted to three medical units were studied for seven to ten-week periods in four different years. The baseline period was before implementation of POE, and the remaining three were after. Sophistication of POE increased with each successive period. INTERVENTION: Physician order entry with decision support features such as drug allergy and drug-drug interaction warnings. MAIN OUTCOME MEASURE: Medication errors, excluding missed dose errors. RESULTS: During the study, the non-missed-dose medication error rate fell 81 percent, from 142 per 1,000 patient-days in the baseline period to 26.6 per 1,000 patient-days in the final period (P < 0.0001). Non-intercepted serious medication errors (those with the potential to cause injury) fell 86 percent from baseline to period 3, the final period (P = 0.0003). Large differences were seen for all main types of medication errors: dose errors, frequency errors, route errors, substitution errors, and allergies. For example, in the baseline period there were ten allergy errors, but only two in the following three periods combined (P < 0.0001). CONCLUSIONS: Computerized POE substantially decreased the rate of non-missed-dose medication errors. A major reduction in errors was achieved with the initial version of the system, and further reductions were found with addition of decision support features. "

Bell DS, Cretin S, Marken RS, Landman AB. A conceptual framework for evaluating outpatient electronic prescribing systems based on their functional capabilities. J Am Med Inform Assoc. 2004 Jan-Feb;11(1):60-70.

[PubMed]   [PubMed Central]

" OBJECTIVE: Electronic prescribing (e-prescribing) may substantially improve health care quality and efficiency, but the available systems are complex and their heterogeneity makes comparing and evaluating them a challenge. The authors aimed to develop a conceptual framework for anticipating the effects of alternative designs for outpatient e-prescribing systems. DESIGN: Based on a literature review and on telephone interviews with e-prescribing vendors, the authors identified distinct e-prescribing functional capabilities and developed a conceptual framework for evaluating e-prescribing systems' potential effects based on their capabilities. Analyses of two commercial e-prescribing systems are presented as examples of applying the conceptual framework. MEASUREMENTS: Major e-prescribing functional capabilities identified and the availability of evidence to support their specific effects. RESULTS: The proposed framework for evaluating e-prescribing systems is organized using a process model of medication management. Fourteen e-prescribing functional capabilities are identified within the model. Evidence is identified to support eight specific effects for six of the functional capabilities. The evidence also shows that a functional capability with generally positive effects can be implemented in a way that creates unintended hazards. Applying the framework involves identifying an e-prescribing system's functional capabilities within the process model and then assessing the effects that could be expected from each capability in the proposed clinical environment. CONCLUSION: The proposed conceptual framework supports the integration of available evidence in considering the full range of effects from e-prescribing design alternatives. More research is needed into the effects of specific e-prescribing functional alternatives. Until more is known, e-prescribing initiatives should include provisions to monitor for unintended hazards. "

Kaufmann MD. Focus on: information technology. Electronic prescribing: an update. J Drugs Dermatol. 2005 Jan-Feb;4(1):106-7.

[PubMed]   []

" Electronic prescribing has been gaining momentum with the passage of recent federal legislation. This article attempts to present the current status of e-prescribing. "Electronic communications between physicians and pharmacists is being recognized as the new standard of practice in the health care industry," said Kevin Hutchinson, SureScripts president and CEO. I am not sure I would go that far yet, but electronic prescribing has come a long way since 1998 when Drs. Schiff and Rucker wrote in the American Medical News: "Physicians should never again write a prescription. Given the explosion of scientific information and advances in computer technology, prescribing medications on a blank piece of paper will soon seem as antiquated as ordering tinctures of botanicals in Latin." The benefits of electronic prescribing have been, and continue to be, touted in many articles written, even in lay literature. "

Bell DS, Friedman MA. E-prescribing and the medicare modernization act of 2003. Health Aff (Millwood). 2005 Sep-Oct;24

[PubMed]   [Health Aff]

" Provisions of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 are intended to foster electronic prescribing by requiring standards for interoperability and by permitting third parties to offset implementation costs. Although physicians have been slow to embrace e-prescribing, adoption may increase in 2006, when a new tide of pharmacy messages will arrive from patients entering multi-tier drug coverage under Medicare. However, the e-prescribing systems selected may lack the advanced features needed to improve patient safety and chronic disease control. To optimize the return on Medicare drug spending, the government should consider additional incentives to spur the uptake of more advanced systems. "

links
 bullet  National ePrescribing Patient Safety Initiative (NEPSI)  bullet  eHealth Initiative  bullet  US Institute for Safe Medication Practices  bullet  Medicare Modernization Act (Centers for Medicare & Medicaid Services)  bullet  Medication Errors (FDA)  bullet  MOXXI-III project: Medical Office of the Twenty First Century  bullet  First Set of Recommendations to the US HHS on E-Prescribing Standards (02 September 2004) (NCVHS/HHS)  bullet  Second Set of Recommendations to the US HHS on E-Prescribing Standards (04 March 2005) (NCVHS/HHS)  bullet  Connecting for Health (NHS England)  bullet  the NHS Plan (England and Wales)  bullet  Electronic Transmission of Prescriptions (ETP) - NHS (England and Wales)  bullet  eprescribingnews.com/
applications
USA  eRxNOW: Web-based electronic prescribing system from Allscripts [OC]  
commercial links (non-exhaustive)
 USA  Allscripts Healthcare Solutions  USA  Caremark (iScribe)  USA  Epocrates  USA  Facts and Comparisons  USA  HEALTHvision  USA  Medi-Span  USA  Ovid  USA  PEPID  USA  RxHub  USA  SureScripts  USA  ZixCorp  Australia  IBA Health  Canada  Purkinje
links: conferences
 bullet   ePrescribing & Medication Management: Final Programme and Book of Abstracts ePrescribing & Medication Management - Improving patient safety and healthcare efficiency by implementing interoperable ePrescribing services across Europe and worldwide: EHTEL International Conference, Ljubljana, Slovenia: 19-20 June 2006 (i2-Health project)  
acknowledgements
 
page history
Entry on OpenClinical: 3 August 2005
Last main update: 31 August 2005




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