Difference between revisions of "E-prescribing"

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Away from benefits behind incorporating clinical decision support; the electronic transfer of the prescription from clinical setting like offices of general practioners directly to community pharmacies, and the idea here finds a great acceptance from the three major stakeholders involved in prescribing process, the physician, the pharmacist and the patient [4].
 
Away from benefits behind incorporating clinical decision support; the electronic transfer of the prescription from clinical setting like offices of general practioners directly to community pharmacies, and the idea here finds a great acceptance from the three major stakeholders involved in prescribing process, the physician, the pharmacist and the patient [4].
 
Our ultimate objective is to produce a prescription with a high quality, however quality of prescription is not correlated to increased expenditure on pharmaceuticals; certainly it will be a cumulative result of safe and rational prescribing.
 
Our ultimate objective is to produce a prescription with a high quality, however quality of prescription is not correlated to increased expenditure on pharmaceuticals; certainly it will be a cumulative result of safe and rational prescribing.
 +
 +
== Improving Ambulatory Office Workflow, Efficiency and Reducing Prescribing Error Through the Use of E-Prescribing CPOE ==
 +
 +
===Problem Statement===
 +
 +
====Background====
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 +
“The current system of prescribing and dispensing medications in the United States has widespread problems with safety and efficiency”.<sup>3</sup> Yet drug therapy is an integral component of many ambulatory treatment regimens recommended for chronic and acute medical conditions. Americans made 906.5 million outpatient visits in 2000<sup>1</sup> and half of the US population takes one prescription daily, with one in six taking three or more a day.<sup>2</sup> This includes 3.27 billion prescriptions and more than 10% of the national health spending.<sup>2</sup> In the Crossing the Quality Chasm article, The Institute of Medicine challenged us to create a new system that is safe, effective, patient-centered, timely, efficient and equitable. Our current ambulatory prescribing and dispensing systems do not meet those criteria. There appears to be one glaring weak link; inadequate implementation of ambulatory computerized patient ordering entry (ACPOE) systems for medications. i.e. electronic prescribing (eRx).
 +
 +
 +
To the patient the prescriptive process seems quite simple. They are given a written prescription, take it to the pharmacy (or mail it in), pay the allotted amount due, receive and consume the medications. In all reality there is a complex and convoluted system that manages the drug industry’s transactions including the retail or mail order pharmacy, pharmacy benefit manager, payer, manufacture, wholesaler as well as technology venders for transaction networks, clinical information databases and software. This is further complicated by a serpentine economic trail of rebates and incentives. From the point a person turns in their prescription to when they pick it up, the processes are all electronic and have proven effective managing 3.27 billion prescriptions a year! Yet this process currently starts with a paper prescription process greater than 85% of the time.<sup>1</sup> This is the “weak link” where the majority of ambulatory medication errors occur. Converting the prescribing process from paper to an electronic process is often referred to as the “final mile” for ambulatory electronic medication management.<sup>2</sup>.
 +
 +
 +
Because of the immense potential seen for ePrescibing to reduce errors and cost, Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 was passed requiring the ePrescribing process adhere to specific standards.<sup>3,4</sup> Subsequently President Bush has called for linking reimbursement rendered for medical services covered by government sponsored plans to ePrescribing. A 2007 report issued by the Health and Human Services suggested that “electronic prescribing is still in its infancy” however the findings are encouraging. Although there is still work to be done implementing the remaining standards, the report encourages “interested stakeholders to fully adopt and implement electronic prescribing in order to reap its many potential benefits”.<sup>3</sup>
 +
 +
 +
Errors in the medication process include prescribing, transcribing, dispensing, consuming and monitoring. Estimates suggest there are 8.8 million ambulatory adverse drug events (ADE) a year, of which 2.1 million are preventable and 130,000 are life threatening.<sup>3</sup> Preventable prescribing and transcribing errors include illegible written prescriptions, incorrect dosing, drug/allergy, drug/drug and drug/condition errors. Estimates vary on just how many of these ADE would be averted depending significantly on the software functionalities and human factors.<sup>1</sup>
 +
 +
 +
Unfortunately making a business case for implementation of health information technology in an independent primary care office has been difficult. The vast majority of the savings from ePrescribe go to the purchasers and payers of health services, not the physician.<sup>1,3</sup> Physicians will, however, migrate to eRx when they perceive the benefit to their practice outweigh the costs. The primary physician office benefits and costs are in the financial, productivity, service and hassle areas. It is anticipated that as eRx systems are able to meet these needs, adoption will increase.
 +
 +
*Aim: Our mission is to improve the office workflow efficiency and safety within the ambulatory prescription process of a primary care office within six months.
 +
*Goals
 +
*#Reduce total telephone calls by 25%
 +
*#Reduce drug/allergy prescribing errors to zero
 +
*#Increase patient satisfaction to medication refill times by 50%
 +
*#Develop and implement a staff satisfaction survey tool
 +
 +
These address the efficiency, safety, and patient-centered goals of the IOM quality improvement initiative.
 +
 +
===Processes and Prioritization===
 +
*Process affected:  Office workflow and efficiency
 +
*Measure:  Phone calls
 +
*Process affected: Prescriptive safety
 +
*Measure:  Cancelled prescriptions
 +
*Process affected: Patient satisfaction
 +
*Measure: Patient satisfaction to medication refill times
 +
 +
====Intervention====
 +
*Plan: Get baseline measure of phone calls, plot flow diagram of current workflow process and idealized workflow for patient refills
 +
*Do:  Reengineer office workflow so that prescription refills initate at the pharmacy
 +
*Study: Measure phone calls after reengineering and plot phone calls before and after reengineering on p chart.
 +
*Act: Institute reengineered workflow and initiate e-prescribing
 +
*PDSA 2 - Reiterate above, but in addition, measure cancelled rx thru e-prescriptive process
 +
*PDSA 3 - Reiterate, and institute patient satisfaction tool
 +
 +
===References===
 +
BIBLIOGRAPHY
 +
 +
The following websites were accessed for information and references:
 +
 +
*www.ahrg.gov
 +
*www.ihi.gov
 +
*www.mpro.org/doquit
 +
*www.ncbi.nlm.nih.gov (pubmed)
 +
 +
1. Johnston,DS,Pan,E,Walker,J,Bates,DW, Middleton,B, Patient Safety in the Physician’s Office: Assessing the Value of Ambulatory CPOE, I-Health Reports April,2004.
 +
 +
2. Sarasohn-Kahn, J., Holt, M, The Prescription Infrastructure: Are We Ready for ePrescribing? I-Health Reports, January,2006.
 +
 +
3. Findings From The Evaluation of E-Prescribing Pilot Sites; AHQR Publication No. 07-0047-EF, April, 2007
 +
 +
4. Johnson,KB,Fitzhenry,F, Case Report:Activity Diagrams for Integrating e_Prescribing Tools into Clinical Workflow, JAMIA 13(4) 2006: 391-96.
 +
 +
5. Papshev,D,Peterson,AM, Electronic Prescribing in Ambulatory Practice:Promises,Pitfalls, and Potential Solutions, AmJManagCare 7(7)2001: 725-36.
 +
 +
6. Bell,DS,Friedman,MA, E-Prescribing and the Medicare Modernization Act of 2003, Health Affairs 24(5) 2005: 1159-69.
 +
 +
7. Wang,CJ,Marken,RS,Meili,RC,Straus,JB,Landman,AB,Bell,DS, Functional Characteristics of Commercial Ambulatory Prescribing Systems: A Field Study, JAMIA 12(3) 2005: 346-56.
 +
 +
8. Tamblyn,R, et al, The Development and Evaluation of an Integrated Electronic                                        Prescribing and Drug Management System for Primary Care, JAMIA  13(1): 148-59.
 +
 +
9. Gandhi,TK, Weingart,SN,Seger,AC, et al, Outpatient Prescribing Errors and the Impact of Computerized Prescribing, J Gen Int Med 20()  2005: 837-41.
 +
 +
10. West,DR,Westfall,JM et al, Using Reported Primary Care Errors to Develop and Implement Patient Safety Interventions: A Report from the ASIPS Collaborative,
 +
Advances in Patient Safety Vol 3.
 +
 +
11. Feifer,RA,Nevins,LM,McGuigan,KA,Paul,L, Lee,J, Mail-Order Prescriptions   
 +
Requiring Clarification Contact with the Prescriber:Prevalence, Reasons, and Implications, JMCP 9(4) 2003: 346-52.
 +
 +
 +
[[category:BMI537-F-07]]
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Revision as of 14:56, 11 October 2011

Electronic prescribing (e-prescribing) is the use of a computerized system to enter and generate a prescription rather than writing it on paper.

Introduction

Electronic prescribing or e-prescribing improves patients safety and satisfaction by providing legible prescriptions. This results in decreased call backs to provider offices for clarification and faster prescription fulfillment. One study estimates that pharmacists make 150 million calls a year to physicians to clarify prescriptions (Kilbridge, 2001). Electronic prescribing can also help reduce medication spending by providing information on generic or other low-cost alternatives (Steinbrook, 2008).

In the United States, 3.5 billion prescriptions were filled in 2007 (Steinbrook, 2008). Medication prescriptions accounts for 13% of health care expenditures annually in the U.S. (Eslami et al., 2007). The Institute of Medicine announced in July 2006 their recommendation that all prescriptions be written electronically by 2010 (eHealth Initiative 2008). Medicare also announced that all Medicare Part D prescriptions must be transmitted electronically by January 1, 2009 (Surescripts, n.d.). The prescription is then sent to the pharmacy over a secure network (Lapane et al., 2008). Prescriptions that have been created through an EHR then printed or faxed are not considered e-prescriptions (Steinbrook, 2008). This technology has the potential to reduce preventable ADEs by alerting providers to drug interactions and drug allergies (Lapane et al., 2008).

Many medication errors are a result of illegible handwriting, unclear abbreviations and unclear or ambiguous orders (eHealth Initiative, 2008).

Electronic prescribingadoption has had a slow but steady growth. In March 2008, about 40,000 physicians in the U.S. were writing e-prescriptions and nearly 73% of retail pharmacies were receiving them (Steinbrook, 2008).

In 2007, approximately 35 million prescriptions were transmitted electronically through the Pharmacy Health Information Exchange operated by Surescripts(Surescripts 2007). The eRX Collaborative, another e-prescribing program, reported 5 million prescriptions transmitted in 2007. They also reported that approximately 104,000 e-prescriptions (2.1%) were changed or cancelled as a result of a safety alert by the system (eHealth Initiative, 2008).

The eHealth Initiative and the Center for Improving Medication Management documented the phases and functions of e-prescribing to demonstrate its benefits and key features. Some of the benefits are the ability to access medication history and receive notifications when a medication has been picked up or left unfilled. Another benefit is providers can receive drug safety alerts when prescribing medications. However, a study in 2008 concluded that providers override the drug dose alerts and drug-drug alerts most of the time. Approximately 1 in 4 providers override drug dose alerts most of the time or always and 40% override drug-drug interactions most of the time or always. When asked about drug-allergy alerts, they were least likely to override the alert stating that the alerts are helpful, useful and a good reminder. Providers noted that drug-drug alerts are beneficial but, at times, unnecessarily excessive or trivial (Lapane et al., 2008).

Benefits of electronic prescribing

Electronic prescribing has major benefits for providers and patients. Providers will benefit from decision support tools to assist them in prescribing medications and a decrease in the number of phone calls from pharmacies requesting clarification. Patients will receive lower costs, increased safety, and greater efficiency.

Introduction

The emergence of electronic health records (EHR) has subsequently led to the emergence of other electronic systems to be used in the clinical settings, as anyone might think the primary goal of theses systems is to harmonize the electronic workflow in the clinical settings, but these systems have proven to have an important role in improving the service provided and subsequently the health care in general.

One of these systems are ePrescribing systems, which by the use of clinical decision support systems have made a significant change in the way the service is provided which we will discuss later in this paper, but let's first explore the benefits of ePrecribing systems in various types of clinical settings.

Why ePrescribing?

In a report of eHealth initiative[1] it was estimated that ePrescribing could save up to $29 bn for the US healthcare systems, $27 bn can be saved directly by sending the prescription electronically to the pharmacy, detecting medication duplication in prescription when different doctors prescribe the same medication and alerting prescribers to a cheaper generic alternatives, The other $2 bn may be saved indirectly through decreasing prescription error and subsequently additional intervention and visits cost.

ePrescribing when combined with clinical decision support systems at point of care can improve the safety of prescription as demonstrated in many studies, one of these studies was a randomize controlled trial (RCT) intended to evaluate the use of handheld systems with a clinical decision support to improve the safety of Non steroidal anti-inflammatory agents prescriptions [2] and concluded that the use of such systems led to a fewer unsafe treatments.

As many of the medical errors are medication errors, ePrescribing can help in reduction of these errors by appropriately offering timely decision support capabilities, proactively detect errors such as drug-drug interactions and drugs that is known to stimulate hypersensitivity reactions for an individual by making use of her/his electronic health record, Also the use of automated prescribing mechanism will lead to preventing the use of unacceptable abbreviations as a potential source of medication errors.

More above avoiding errors is Rational prescribing and the, Rational prescribing is the alignment of prescribing practice and evidences, and a study here shows how an electronic intervention (as one of many other interventions) improved he quality of prescription (of antihypertensive medications).

Another potential benefit of ePrescribing is to do some tasks for physicians, one of the most prominent task is dose calculation specially for children and some drugs where the dose is weight dependent, previously these calculations were done manually and were liable to human error, the study here shows the great benefit of using ePrescribing in ambulatory settings to calculate pediatric dose [3].

Away from benefits behind incorporating clinical decision support; the electronic transfer of the prescription from clinical setting like offices of general practioners directly to community pharmacies, and the idea here finds a great acceptance from the three major stakeholders involved in prescribing process, the physician, the pharmacist and the patient [4]. Our ultimate objective is to produce a prescription with a high quality, however quality of prescription is not correlated to increased expenditure on pharmaceuticals; certainly it will be a cumulative result of safe and rational prescribing.

Improving Ambulatory Office Workflow, Efficiency and Reducing Prescribing Error Through the Use of E-Prescribing CPOE

Problem Statement

Background

“The current system of prescribing and dispensing medications in the United States has widespread problems with safety and efficiency”.3 Yet drug therapy is an integral component of many ambulatory treatment regimens recommended for chronic and acute medical conditions. Americans made 906.5 million outpatient visits in 20001 and half of the US population takes one prescription daily, with one in six taking three or more a day.2 This includes 3.27 billion prescriptions and more than 10% of the national health spending.2 In the Crossing the Quality Chasm article, The Institute of Medicine challenged us to create a new system that is safe, effective, patient-centered, timely, efficient and equitable. Our current ambulatory prescribing and dispensing systems do not meet those criteria. There appears to be one glaring weak link; inadequate implementation of ambulatory computerized patient ordering entry (ACPOE) systems for medications. i.e. electronic prescribing (eRx).


To the patient the prescriptive process seems quite simple. They are given a written prescription, take it to the pharmacy (or mail it in), pay the allotted amount due, receive and consume the medications. In all reality there is a complex and convoluted system that manages the drug industry’s transactions including the retail or mail order pharmacy, pharmacy benefit manager, payer, manufacture, wholesaler as well as technology venders for transaction networks, clinical information databases and software. This is further complicated by a serpentine economic trail of rebates and incentives. From the point a person turns in their prescription to when they pick it up, the processes are all electronic and have proven effective managing 3.27 billion prescriptions a year! Yet this process currently starts with a paper prescription process greater than 85% of the time.1 This is the “weak link” where the majority of ambulatory medication errors occur. Converting the prescribing process from paper to an electronic process is often referred to as the “final mile” for ambulatory electronic medication management.2.


Because of the immense potential seen for ePrescibing to reduce errors and cost, Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 was passed requiring the ePrescribing process adhere to specific standards.3,4 Subsequently President Bush has called for linking reimbursement rendered for medical services covered by government sponsored plans to ePrescribing. A 2007 report issued by the Health and Human Services suggested that “electronic prescribing is still in its infancy” however the findings are encouraging. Although there is still work to be done implementing the remaining standards, the report encourages “interested stakeholders to fully adopt and implement electronic prescribing in order to reap its many potential benefits”.3


Errors in the medication process include prescribing, transcribing, dispensing, consuming and monitoring. Estimates suggest there are 8.8 million ambulatory adverse drug events (ADE) a year, of which 2.1 million are preventable and 130,000 are life threatening.3 Preventable prescribing and transcribing errors include illegible written prescriptions, incorrect dosing, drug/allergy, drug/drug and drug/condition errors. Estimates vary on just how many of these ADE would be averted depending significantly on the software functionalities and human factors.1


Unfortunately making a business case for implementation of health information technology in an independent primary care office has been difficult. The vast majority of the savings from ePrescribe go to the purchasers and payers of health services, not the physician.1,3 Physicians will, however, migrate to eRx when they perceive the benefit to their practice outweigh the costs. The primary physician office benefits and costs are in the financial, productivity, service and hassle areas. It is anticipated that as eRx systems are able to meet these needs, adoption will increase.

  • Aim: Our mission is to improve the office workflow efficiency and safety within the ambulatory prescription process of a primary care office within six months.
  • Goals
    1. Reduce total telephone calls by 25%
    2. Reduce drug/allergy prescribing errors to zero
    3. Increase patient satisfaction to medication refill times by 50%
    4. Develop and implement a staff satisfaction survey tool

These address the efficiency, safety, and patient-centered goals of the IOM quality improvement initiative.

Processes and Prioritization

  • Process affected: Office workflow and efficiency
  • Measure: Phone calls
  • Process affected: Prescriptive safety
  • Measure: Cancelled prescriptions
  • Process affected: Patient satisfaction
  • Measure: Patient satisfaction to medication refill times

Intervention

  • Plan: Get baseline measure of phone calls, plot flow diagram of current workflow process and idealized workflow for patient refills
  • Do: Reengineer office workflow so that prescription refills initate at the pharmacy
  • Study: Measure phone calls after reengineering and plot phone calls before and after reengineering on p chart.
  • Act: Institute reengineered workflow and initiate e-prescribing
  • PDSA 2 - Reiterate above, but in addition, measure cancelled rx thru e-prescriptive process
  • PDSA 3 - Reiterate, and institute patient satisfaction tool

References

BIBLIOGRAPHY

The following websites were accessed for information and references:

  • www.ahrg.gov
  • www.ihi.gov
  • www.mpro.org/doquit
  • www.ncbi.nlm.nih.gov (pubmed)

1. Johnston,DS,Pan,E,Walker,J,Bates,DW, Middleton,B, Patient Safety in the Physician’s Office: Assessing the Value of Ambulatory CPOE, I-Health Reports April,2004.

2. Sarasohn-Kahn, J., Holt, M, The Prescription Infrastructure: Are We Ready for ePrescribing? I-Health Reports, January,2006.

3. Findings From The Evaluation of E-Prescribing Pilot Sites; AHQR Publication No. 07-0047-EF, April, 2007

4. Johnson,KB,Fitzhenry,F, Case Report:Activity Diagrams for Integrating e_Prescribing Tools into Clinical Workflow, JAMIA 13(4) 2006: 391-96.

5. Papshev,D,Peterson,AM, Electronic Prescribing in Ambulatory Practice:Promises,Pitfalls, and Potential Solutions, AmJManagCare 7(7)2001: 725-36.

6. Bell,DS,Friedman,MA, E-Prescribing and the Medicare Modernization Act of 2003, Health Affairs 24(5) 2005: 1159-69.

7. Wang,CJ,Marken,RS,Meili,RC,Straus,JB,Landman,AB,Bell,DS, Functional Characteristics of Commercial Ambulatory Prescribing Systems: A Field Study, JAMIA 12(3) 2005: 346-56.

8. Tamblyn,R, et al, The Development and Evaluation of an Integrated Electronic Prescribing and Drug Management System for Primary Care, JAMIA 13(1): 148-59.

9. Gandhi,TK, Weingart,SN,Seger,AC, et al, Outpatient Prescribing Errors and the Impact of Computerized Prescribing, J Gen Int Med 20() 2005: 837-41.

10. West,DR,Westfall,JM et al, Using Reported Primary Care Errors to Develop and Implement Patient Safety Interventions: A Report from the ASIPS Collaborative, Advances in Patient Safety Vol 3.

11. Feifer,RA,Nevins,LM,McGuigan,KA,Paul,L, Lee,J, Mail-Order Prescriptions Requiring Clarification Contact with the Prescriber:Prevalence, Reasons, and Implications, JMCP 9(4) 2003: 346-52.


Refrences

  1. Janice Hopkins Tanne, Electronic prescribing could save at least $29bn, electronic communication and health care News. Report can be accessed www.ehealthinitiative.org
  2. ETA S. BERNER, EDD, et al, Improving Ambulatory Prescribing Safety with a Handheld Decision Support System: A Randomized Controlled Trial, J Am Med Inform Assoc. 2006
  3. T Porteous, C Bond, R Robertson, et al, Electronic transfer of prescription-related information: comparing views of patients, general practitioners, and pharmacists, British Journal of General Practice, March 2003.

References

  1. American National Standards Institute (ANSI). n.d.. Robert Kolodner Named National Coordinator for Health Information Technology. Retrieved August 21, 2008.

http://www.ansi.org/news_publications/news_story.aspx?menuid=7&articleid=1475.

  1. eHealth Initiative. June 2008. The consumer’s guide to e-prescribing.

http://www.thecimm.org/PDF/eHI_CIMM_Consumer_Guide_to_ePrescribing.pdf

  1. eHealth Initiative. June 2008. Electronic prescribing: becoming mainstream practice.

http://www.thecimm.org/PDF/eHI_CIMM_ePrescribing_Report_6-10-08.pdf

  1. Eslami, S., de Keizer, N.F., Abu-Hanna, A. 2007. The impact of computerized physician medication order entry in hospitalized patients – A systematic review. International Journal of Medical Informatics. 77: 365-376
  2. Kilbridge, P.M., Welebob, E.M., Classen, D.C. 2006. Development of the Leapfrog methodology for evaluating hospital implemented inpatient computerized physician order entry systems. Qual. Saf. Health Care. 15: 81 - 84.
  3. Lapane, K.L., Waring, M.E., Schneider, K.L., Dube, C., Quilliam, B.J. 2008. A mixed method study of the merits of e-prescribing drug alerts in primary care. Journal of Gen Intern Med. 23(4): 442-446.
  4. McGlynn, E.A., Asch, S.A., Adams, J., Keesey, J., Hicks, J., DeChristofaro, A., et al. 2003. The Quality of Health Care Delivered to Adults in the United States. New England Journal of Medicine.
  5. Steinbrook, R. 2008. The (slowly) vanishing prescription pad. New England Journal of Medicine. 359: 115-117
  6. White House: Office of the Press Secretary. April 24, 2004. President Unveils Tech Initiatives for Energy, Health Care, Internet. Retrieved August 19, 2008. [1]