WASHINGTON — E-prescribing can help reduce medication errors, lower practice costs, and save physician time, but it's important to understand the limits and problems of this rapidly evolving technology, according to Dr. Kevin Johnson.

“There are enormously great advantages to using e-prescribing systems. [However,] there are issues that you need to be aware of,” said Dr. Johnson, vice chair of the biomedical informatics department at Vanderbilt University Medical Center in Nashville.

The primary reason for adopting e-prescribing is to prevent errors. “If all you ever did was just switch to Microsoft Word, you will decrease your risk [of prescription errors] by 15%,” Dr. Johnson said at the annual meeting of the American Academy of Pediatrics. Illegibility is one of the prime drivers of prescription errors, along with dose errors and unclear abbreviations. Dose errors in particular play a big role in pediatric medication errors.

Dr. Johnson cited the 10-fold error as an example of a common one. A pediatrician may include a trailing zero in the dose but if the pharmacist doesn't see the period, the dose will be increased 10-fold. “Believe it or not, that dose is probably a completely valid dose, depending on the age of the child,” he said. A similar mistake can occur with leading zeros. Another common error is the calculation of a dosage using the wrong units. For example, a pediatrician might use weight in pounds to calculate a dosage, when weight in kilograms should be used.

“These are all things that e-prescribing can potentially help in terms of making sure that the communication is clear between us and the pharmacy,” he said.

Other errors associated with paper-based prescriptions include omissions, dose or direction errors, unclear quantity to be dispensed, prescriptions for nonprescription products, incomplete directions, and unfulfilled legal requirements (J. Fam. Pract. 1989;29:290-5).

E-prescribing systems also can provide clinical decision support (such as drug-drug interaction checking), pharmacy benefit eligibility checking, formulary compliance, drug reference, medication history reporting, and prescription routing to retail or mail order pharmacies.

Electronic prescribing systems offer potential cost savings to both physicians and pharmacies by eliminating handwriting issues, reducing overtime and callback problems, and speeding up refill requests, according to Dr. Johnson.

However, if you're considering an e-prescribing system, he recommended considering an electronic health record system as well. “My opinion is that EHRs are as important as e-prescribing.” EHRs provide valuable patient information for e-prescribing, such as allergies and medication history, and solve some workflow issues.

Electronic prescribing systems can be integrated into existing electronic medical record systems or can be used as a stand-alone option. Stand-alone systems can involve either an application service provider or locally installed software. The use of an application service provider means that the system exists on the Web. Internet access is all that is needed to access the system. Physicians need to think about what setup will work best for them, said Dr. Johnson.

Connectivity is a key element of e-prescribing. For example, SureScripts is an e-prescribing network that is connected with approximately 95% of pharmacies in the United States, according to its Web site. This connectivity allows physicians and pharmacists to electronically exchange prescription information. Physicians can transmit new prescriptions and refill requests electronically to a pharmacy. Both pharmacists and physicians have access to aggregated information across the system about a patient's medication history and often can view formulary information from a patient's drug plan. In the future, “there will be some competitors, but at this moment there aren't,” he noted.

Reliability of prescription transmission remains a problem for some e-prescribing systems that rely on fax to transmit prescriptions. Although such a system may provide the physician office with confirmation that a prescription has been sent to a pharmacy, “on the pharmacy end, more than 20% of the time that prescription may not be received,” said Dr. Johnson. This can sometimes result in multiple prescriptions or multiple documentations in an e-prescribing system.

Another downside to e-prescribing is the number of alerts that a physician can receive, based on how many automatic checks have been activated. Physicians often end up turning off drug-drug interaction or drug allergy checks to decrease the number of alerts sent by the system. If all checks are activated, “it is actually not uncommon that almost every prescription generates something.”

Disclosures: Dr. Johnson reported that he receives royalties from ICA Corp.

Online Resources

The eHealth Initiative provides a set of guides and reports on e-prescribing (

www.ehealthinitiative.org/electronic-prescribing-resources.html

For more information on preventing pediatric medication errors, see the Pediatric Pharmacy Advocacy Group's 2001 publication, “Guidelines for Preventing Medication Errors” (J. Pediatr. Pharmacol. Ther. 2001;6:426-42;

www.ppag.org/attachments/files/111/Guidelines_Peds.pdf)

MDs Need to Understand E-Prescribing Benefits, Concerns