August 3, 2009

Gaps and Opportunities in E-Prescribing
By Jonathan Teich, MD
For The Record
Vol. 21  No. 15 P. 4

E-prescribing has been indispensable in helping providers prevent adverse drug events, streamline prescription renewals, achieve disease management goals, deliver the right information to the right provider, and reduce costs through formulary adherence and reduced administrative expenses.

However, studies have shown that the technology, used to its fullest capability, can have an even greater impact on safety, quality, and cost. For example, the Center for Information Technology Leadership concluded that the widespread use of e-prescribing systems could prevent 130,000 medication errors annually. The e-prescribing systems that will reach that potential—now and in the future—are those that pay the most attention to continuing developments in clinical decision support (CDS), formulary management, enhanced communication, EHR interoperability, and easy updating to stay current as clinical and administrative details evolve.

CDS Targets
Many e-prescribing benefits involve the effective use of CDS, which has been shown to have a significant impact on improving drug safety and quality of care through tools such as standard dose lists, error checks and alerts, drug and dose recommendations based on indication and patient status, and disease management guidance. By taking advantage of these tools, a clinician can identify and remedy errors of commission, such as drug-allergy or drug-condition conflicts, and—if the e-prescribing system includes problem lists or is part of a more comprehensive EHR—also detect and manage omissions, such as ensuring that a patient with hypercholesterolemia has a statin prescription.

In 2004, Health and Human Services asked 70 experts to consider CDS targets that should be required of certified e-prescribing systems. (See the report of the American Medical Informatics Association’s Joint Clinical Decision Support Workgroup at www.amia.org/files/cdswhitepaperforhhs-final2005-03-08.pdf or in the Journal of the American Informatics Association at www.jamia.org/cgi/content/short/12/4/365.) The list spanned a range from commonly available functions such as drug-drug and drug-allergy interactions and patient instructions to newer, high-impact functions, including drug-lab test result interactions, drug-problem list interactions, disease management and preventive care medication alerts, drug-monitoring reminders, and dose adjustments for renal failure and age. Some of these newer functions have now appeared in many commercial e-prescribing systems, while others are still relatively uncommon.

Ultimately, more advanced CDS systems should be able to provide drug and dose recommendations based on a wide range of factors to allow clinicians to order by indication, contraindication, guideline, or algorithm. Systems should routinely indicate when prescription renewals are due and deliver drug selection and use reference information matched to the most frequently asked questions through information buttons and quick-reference tools. Finally, in a few years, e-prescribing systems will need to consider genomic adjustments of drug and dose to optimize treatment effectiveness and minimize adverse events.

Financial CDS
CDS also improves care through financial management by ensuring that patients can better afford their medications by delivering just-in-time formulary and cost information to both providers and consumers. Studies have shown that patients often do not fill prescriptions with expensive out-of-pocket costs; thus formulary and cost checking provide safety and quality benefits, in addition to financial gains.

Providers must do their utmost to support this by ensuring that each patient’s drug plan is properly identified. In turn, e-prescribing vendors and prescribing networks must always provide updated formulary drug data, including information on preferred drugs, restrictions, and copays. Equally important are utilization review and workflow features within e-prescribing systems, such as pointers to preferred alternatives, overrides, and prior authorization forms, to make it as quick and easy as possible both to identify and to remedy a drug-cost concern.

Communication Flow
Effective e-prescribing requires an easy flow of information among the patient, the physician, the pharmacy, and the health plan or pharmacy benefit manager. Physicians and pharmacies interact through phoned-in or faxed prescriptions, as well as callbacks for corrections or changes. Physician practices also phone or fax approval requests to health plans, which send coverage information back to the practice. Pharmacies also exchange claims and approvals with health plans. Patients present prescriptions and refill requests to pharmacies in exchange for dispensed medications, and so on down the chain.

E-prescribing systems and prescribing networks need to support this intricate web of communication. This capability has been growing significantly in recent years, although some parts of the country have more complete communication networks than others. E-prescribing systems in physician practices should contain a list of pharmacy and pharmacy benefit manager contacts and direct communications functions to reach other parts of the network.

Interoperability
In addition, “communication” to other parts of the patient record and other practices makes medication management safer, more efficient, and more patient specific. Access to diagnoses, problem lists, and lab results from the EHR, as well as medication information from other practices, enhances the value of e-prescribing’s disease management and quality improvement benefits. It also boosts drug safety through implicit communication. For example, a primary care physician needs to know if a patient’s cardiologist has already prescribed and then discontinued a statin due to an adverse event such as muscle pain. Otherwise, the well-meaning primary doctor may cause the same problem again by represcribing the offending drug.

An increasingly important capability of e-prescribing is medication reconciliation, which ensures that important medications are not lost at the start and end of hospital admission. In recent years, The Joint Commission has made this a point of focus and featured it prominently in its patient safety goals.

Maintenance
As noted above, it is important to keep a patient’s plan information, medication list, and problem list current in order for safety and quality functions to work properly. Standard dictionaries and knowledge bases in the e-prescribing system need to be kept current as well. Medication dictionaries should be updated frequently—ideally every month, but at least every three months—while urgent recalls or changes should trigger immediate removals from the list. Just as important is rapid integration of new CDS rules and knowledge as guidelines and quality measures evolve. A practice needs to build and maintain a culture of quality and safety and then must perform the routine tasks necessary to keep both human and computer systems tuned to support that environment.

The majority of e-prescribing systems provide features such as basic prescription writing, dose and allergy checking, and formulary displays. But the real benefits—quality improvement, cost savings, and a reduction in medical errors—will be fully realized only when vendors provide a strong collection of implementable, usable, and valuable advanced CDS options and caregivers utilize these tools to their fullest potential.

— Jonathan Teich, MD, chief medical informatics officer for Elsevier, is a practicing emergency physician and an assistant professor of medicine at Harvard Medical School.