Electronic Prescribing Systems in Pediatrics: The Rationale and Functionality Requirements

Electronic Prescribing Systems in Pediatrics: The Rationale and Functionality Requirements

Gerstle RS, Lehmann CU, and the Council on Clinical Information Technology

Pediatrics 2007; 119; e1413-e1422.

This paper reviews the current state of electronic prescribing, its benefits and limitations, the advantages of its integration into an electronic medical record, the barriers towards its adoption, and presents the options physicians have for acquiring the appropriate system for their practice.

Electronic prescribing (e-prescribing) systems are computer applications designed for use by clinicians to generate paper or electronic medication prescriptions. (1) Several well recognized institutions, such as the Institute of Medicine, have endorsed these systems with the purpose of reducing medical errors. Even though the error rates and the resulting morbidity and costs in the outpatient setting has not been studied as well as in the inpatient hospital setting, the adoption of e-Prescribing by pediatricians in community has been between 5% to 18%, and is expected to increase in the next few years. For these reasons, it is important for the pediatrician to understand the benefits and limitation of these systems.

The authors presented the benefits of e-Prescribing for public health, patients, insurers, pharmacy managers, and the physician and some of its limitations. The limitations presented in this paper include the system design and the content of the program. In the case of system design, the system may eliminate errors at the transcription and administration stage; however they will not eliminate errors at the ordering stage if the system is not designed for it. The second limitation consists of the system capacity to execute what the application is intended for.

In order to educate the clinicians taking care of pediatric patient who had the intention of acquiring an e-Prescribing system, the authors offer an overview of the current state of these systems. They provide a list of all the e-Prescribing application from the electronic drug reference only, with no prescription-writing capability which is design for mobile personal assistants and have drug dosage, contraindications, and drug interactions, to e-Prescribing systems integrate with more complete EHR.

While the potential of e-Prescribing has been proven, many barriers have slowed down its adoption. These barriers include: failure of the physicians to recognize themselves as part of the system’s problems by having illegible hand writing(2); technological barriers in the office setting such as lack of access to internet connections; the cost of implementation, training, maintenance, interface and integration to new electronic health record systems; beneficiary-payer discrepancies(3); existing inherited systems at pharmacies that have not adopted e-prescribing; lack of regulation at the level of state and federal agencies; negative past user experience and lack of consolidating standards that include prescription drugs as well as “over the counter” medication.

Physicians need to be aware of the different options they have available for the implementation of e-Prescribing. They need to consider the connectivity options that are available (telephone lines versus cable). They should also think about their software and hardware options such as the use one local computer versus having the opportunity to create their own networks, consider keeping local control of their own system versus using an off site location such as application server providers (ASP) to provide the e-Prescribing service, the different computer software that offer practice management and scheduling integration to pharmacy list with up to date fax number. They also have the opportunity to explore alternative for cost sharing and the vendor’s options available in the market.

In addition, the authors presented 10 categories which the physicians should use to compare e-Prescribing systems prior to acquisition and provide a pediatric perspective to these categories. They consist of patient identification, access to patient historical data, medication selection, alerts and other message to prescribers, patient education, data transmission and storage, monitoring and renewals, transparency and accountability, prescriber-level feedback and security and confidentiality(1).

The American Academy of Pediatric believes that there is enough evidence that support e-prescribing in reduction of medical errors and enhancement of patient care and safety. The authors review why children are more prone to dosage error compare to adults. Factors such as children physiology and pharmacology, the need of weight or body surface area in dosing and the variability of organ development make the medication process for children more prone to calculation errors. (4) Although some pediatric studies were reviewed in which CPOE implementation at inpatient hospital settings has resulted in a significant reduction in medication turn around times, medication errors for selected drugs, decreased ancillary service response time, reduced provider error in order total parental nutrition, continuous infusion and chemotherapy, these systems has not proven to be completely infallible.(5,6) Physicians need to have a clear understanding of the capabilities of these systems when they are evaluating them to be implemented in their outpatient practice.

Is my opinion the this paper is an excellent resource for those physician caring for pediatric patient that are in the search for information regarding e-Prescribing system to better serve their patient and improve their practice of medicine.

References

1. Bell DS, Marken RS, Meili RC, et al. Recommendations for comparing electronic prescribing systems: results of an expert consensus process, Health Aff 2004: w4-305-w4-317.

2. Tyler C. Five obstacle to e-prescribing: five approaches to overcoming them. American Medical News. May 12,2003

3. Teich JM, Marchibroda JM. Executive Summary: Electronic Prescribing-Toward Maximum Value and Rapid Adoption. Washington, DC: eHealth Initiative; 2004.

4. American Academy of Pediatrics, Committee on Drugs, Committee on Hospital care. Prevention of medication errors in the pediatric inpatient setting. Pediatrics. 2003; 112:431-436.

5. Lehmann CU, Conner KG, Cox JM. Preventing provider errors: online total parenteral nutrition calculator. Pediatrics. 2004; 113: 748-753.

6. Lehmann CU, Kim GR, Gujral R, Veltri MA, Clark JS, Miller MR. Decreasing errors in pediatric continuous intravenous infusions. Pediatr Crit Care Med. 2006; 7:225-230.

Elisdel M. García-Bousquet, MD FAAP

11-09-2007