1. Spotlight Case E-prescribing: E for Error?

2. 2 Source and Credits This presentation is based on the February 2012 AHRQ WebM&M Spotlight Case –See the full article at http://webmm.ahrq.govhttp://webmm.ahrq.gov –CME credit is available Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical 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

3. 3 Objectives At the conclusion of this educational activity, participants should be able to: Define e-prescribing Describe ways in which e-prescribing can reduce health care costs State how often prescriptions errors occur with e- prescribing Describe steps to limit errors associated with e- prescribing

4. 4 Case—Part 1: E-prescribing (1) A 63-year-old man with multiple medical problems was seen by his primary care doctor for a routine follow-up appointment. Despite receiving psychotherapy, the patient admitted that he continued to struggle with anxiety. In light of these complaints, the primary care doctor elected to prescribe an antianxiety agent, alprazolam.

5. 5 Case—Part 1: E-prescribing (2) The clinic had just implemented electronic prescribing—the ability to electronically transmit a new prescription to a pharmacy. The physician reassured the patient that he didn’t need a paper prescription and could simply go to the pharmacy to pick up his medications.

6. 6 Background: Electronic Prescribing E-prescribing is the transmission, using electronic media, of prescriptions or prescription-related information from prescriber (physician, nurse practitioner, etc.) to pharmacy Most simple example is two-way transmission between provider and pharmacy Intended to replace writing out, faxing, or calling in prescriptions See Notes for references.

7. 7 E-prescribing Benefits Proposed benefits include safer, more efficient, and more cost-effective care Because of potential benefits, federal government has put in place incentives for providers to adopt e- prescribing –Significant funds as part of the American Recovery and Reinvestment Act of 2009 Incentives expected to increase rate of e-prescribing and save $22 billion in drug costs in the next decade See Notes for references.

8. 8 Savings from E-prescribing Savings expected to arise from 4 factors: –Informing providers the point of care, allowing them to choose best and most affordable drugs –Providing doctors with patients’ medication histories to prevent 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 illegible handwriting by transmitting prescriptions electronically to pharmacies See Notes for reference.

9. 9 E-prescribing Improves Safety Will allow for clinical decision support—immediate access to pharmacy eligibility, benefits, and formularies at the point of care –In Massachusetts, led to cost-savings of $845,000 per 100,000 patients –At Henry Ford Health System, clinical decision support was associated with increased use of generic drugs, lower administrative costs, and reductions in adverse drug events See Notes for references.

10. Increase in E-prescribing By end of 2010, there were 234,000 active e-prescribers, 34% of all office-based physicians in the United States Approximately 20% of all eligible prescriptions were sent electronically in 2010 (vs. 12% in 2009) 10 See Notes for reference.

11. 11 Case—Part 2: E-prescribing (1) The clinic nurse entered the medications into the computer system. However, while entering the prescription for alprazolam, she inadvertently entered an additional medication, atenolol, a prescription intended for a different patient. Quickly recognizing her error, she deleted the e-prescription in the computer, and assumed the order had been canceled.

12. 12 Case—Part 2: E-prescribing (2) Unfortunately, despite the nurse’s efforts to cancel the atenolol order, the e-prescription went through to the pharmacy. When the patient arrived at the pharmacy, he was given both medications. Although he thought it was a bit strange to receive two medications for his problem, he was willing to do anything to reduce his anxiety. Consequently, he took both medications as instructed. A few days later, during his cardiology appointment, the error was noted, and the atenolol was discontinued.

13. 13 Unintended Consequences Evidence suggests that e-prescribing improves safety overall However, like any new technology, e-prescribing has the potential to introduce new errors See Notes for references.

14. 14 Errors and E-prescribing (1) In a large study 11.7% of all e-prescriptions had errors, of which 35% were considered potential adverse drug events Information omitted most often was duration, dose, or frequency Requiring fields to be completed may help overcome omission errors See Notes for reference.

15. 15 Errors and E-prescribing (2) Providers new to e-prescribing may make errors initially and must use the e-prescribing system routinely to gain experience with it Some pharmacies have different computer systems. Thus, even though the information is sent electronically, it still needs to be manually entered into a different system See Notes for reference.

16. 16 Preventing Errors with E-prescribing Experts have recommended all e-prescribing systems use standard nomenclature for drugs –May reduce drug selection inefficiencies and errors Others recommend using a structured format for patient instructions –For example, if a provider prescribes a medication to be taken T.I.D., it would automatically print for the patient as “3 times a day,” instead of pharmacist having to change instructions manually

17. 17 Notes about Case The system should not have allowed nurse to prescribe on behalf of doctor, without doctor’s verification No mechanism in place to force final review of prescription before sending –Many systems require the provider to review all new, renewed, or changed medications E-prescribing does not replace other safe medication prescribing practices –Patients should be informed of their medications –Providing and reviewing current medication list should be done at each patient visit

18. 18 Steps to Maximize Safety (1) Verify name and date of birth before entering an order Review all new medications and intended use with the patient Confirm deletion of an order entered in error while reviewing the patient’s current medication list at the end of the visit. Provide paper or electronic copy to the patient

19. Steps to Maximize Safety (2) Follow up with a phone call to the pharmacy to ensure that the wrong medication was not transmitted for the wrong patient, especially when a prescription is canceled or changed Document software design and workflow challenges to feedback to the vendor and provider practice for future training opportunities or upgrades 19

20. 20 Take-Home Points E-prescribing is the transmission, using electronic media, of prescriptions or prescription-related information from a prescriber to a pharmacy E-prescribing may lead to safer, more efficient, and more cost-effective care E-prescribing can lead to unintended consequences and new types of medical errors Institutions and providers should take steps to limit errors associated with e-prescribing