November 2006

Moving beyond hospitals: e-prescriptions

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Introduction
In 1993, the American healthcare community was jolted by Institute of Medicine’s study which claimed that the mortality rate due to medical errors in United States is more than breast cancer, AIDS or motor vehicle accidents. Subsequently, many studies were conducted to assess the impact of medical errors and majority of these concluded that preventable adverse events represent one of the leading causes of morbidity and mortality in patients. Today, as many as 100,000 lives are lost, with a cost of at least USD 2 billion every year for medical errors, as said by T.A. Brennan, et. al. in New England Journal of Medicine.

Although many approaches can be used to improve safety, IT has increasingly found a place in the healthcare delivery system as vital tool for reducing the frequency of medical errors. One of the most profound impacts has been due to the use of Computerized Physician Order Entry (CPOE) systems in outpatient and inpatient settings, and in particular, because of electronic prescribing.

Reducing medication error rates
In a clinical scenario, a physician uses computers for three primary reasons – accessing and updating patients’ electronic medical records, entering prescription information and communicating with other professionals involved in the patient care process. Amongst all clinical computer applications, CPOE systems deliver perhaps the maximum benefit by increasing productivity, reducing costs and helping control medical error rates. The reason CPOE is so important is that most actions occur as the result of an order.  In a study conducted in 1995, our research group found that there were about 20.7 ordering errors for every 1000 orders. Out of these, Adverse Drug Events (ADEs) occurred in 1% of orders and potential ADEs were found in 10% of orders.  In one study, CPOE reduced the serious medication error rate by 55%, and in another study reduced the overall medication error rate by more than 80%. Thus, CPOE systems play an important role in controlling these errors.

e-Prescribing is the process of medication prescribing in an outpatient setting, using an ambulatory Computerised Physician Order Entry systems application linked with clinical decision support that can in addition electronically send prescriptions or prescription-related information directly with the pharmacies or pharmacy benefit managers

CPOE systems facilitate the process of entering prescriptions into the computer. They are usually linked to Electronic Patient Records and are developed with inbuilt Clinical Decision Support (CDS) algorithms. The CDS systems attempt to both suggest optimal choices, and also catch any errors in prescription orders that do occur. They alert the prescriber about allergies, contradications or noteworthy issues. Even without CDS, CPOE standardises the prescriptions and ensures that the orders are legible and complete. However, in a recent study on outpatient prescribing errors and the impact of computerised prescribing by it was shown that only the CPOE systems with advanced features like dose and frequency checks were able to prevent a high proportion of potential ADEs.

In general, CPOE systems are slowly becoming more pervasive in hospitals, although penetration is only 5-15% currently. The rate seems likely to increase rapidly; in 2006, the Healthcare Information and Management Systems Society (HIMSS) published a study of Healthcare CIOs, listing CPOE systems as among the most important applications that they would like to implement by 2008. 

Together, the CPOE and CDS systems greatly improve the safety, quality and cost effectiveness of providing medications to patients and can reduce medication costs both for the hospital and for society. In the inpatient setting, CPOE systems are directly linked to the hospital pharmacy systems.  In the outpatient setting, however, CPOE systems are usually standalone without any network connecti-vity to pharmacies or pharmacy benefit managers. The CPOE system with decision support provides the physicians with access to patient’s medication history, drug information including drug-drug interac-tions, allergies, formulary information and refill management. The physician can also track the previous medications the patient has taken or is concurrently taking.

Even though the use of CPOE systems has shown to decrease errors, many medication errors happen during the process of dispensing, transcribing or administration. Our hospital implemented a CPOE system in 1993 and on a subsequent evaluation, we found that the serious medication errors were reduced by half in inpatient setting but since majority of errors occur after the prescription ordering stage, a need was felt to link the CPOE systems to dispensing units in pharmacies.

e-Prescriptions – Definition and scope
e-Prescribing is the process of medication prescribing in an outpatient setting, using an ambulatory CPOE systems application linked with clinical decision support that can in addition electronically send prescriptions or prescription-related information directly to the pharmacies or pharmacy benefit managers. Every year, more than 3 billion prescriptions are written in the United States. Any technological intervention that makes a small improvement in the medication prescribing process could thus lead to large benefits. By avoiding the cost associated with preventable illnesses, accurate and appropriate use of medications is the single most cost-effective technological solution to improve patient care, according to J. Avorn, author of ‘The prescription as final common pathway’.

Over seventy five percent of office visits to internists are either due to continuation or initiation of medication. e-Prescribing has the potential to make this process much easier by seamlessly linking the various steps between prescription writing to dispensing – medication prescribing, data transmission, dispensing, administration and monitoring. Not only do manual prescription refill orders take up nursing and physician time, about 10% of handwritten prescriptions are not legible to the pharmacist. A lot of time is also wasted due to communication between pharmacies and physician practices for clarifications. Center of Information Technology Leadership (CITL) calculated that e-Prescribing systems could save over USD 2.7 billion annually by reducing clarifying phone calls.

e-Prescribing can also lead to better tracking of patient’s compliance by physicians and insurance companies. The physicians can get updates when the patients get their prescriptions refilled. This helps to prevent non-compliance which is one of the major causes of ineffective treatment. Use of e-Prescription on a wider level could also be used as a valuable public health surveillance tool to monitor abnormal patterns in prescription dispensing in real time. This could be used to raise flags for example if there are increased prescribing rates for drugs used to treat upper respiratory infections. Physicians could also potentially report any previously undocumented adverse drug events in the e-Prescription system which can be directly routed to the appropriate authority.

The Massachusetts Experience: eRx Gateway
In the United States, every medication prescribed by a physician for a patient has to be in accordance with the patient’s insurance company requirements, which vary substantially from insurer to insurer with the result that no physician can remember the drugs that will be least expensive for an individual patient.

There are a variety of approaches
for communicating prescriptions to pharmacies or chemists. These could be printed on a paper and physically carried by the patient, faxed or emailed where they are put together for dispensing. In Massachusetts, we have embarked on an initiative to link all physicians, pharmacies and pharmacy benefit managers to a central hub, which would route all prescription information. The hope is that this will become the primary gateway to route prescription transactions to retail and mail order pharmacies and would process requests for new prescriptions, modified prescriptions or cancel prescriptions, refill requests and eligibility checks.

In Massachusetts, the stakeholders have come together to create the foundation standards for e-Prescribing transactions, assess issues and design improvements through a community utility called Rx Gateway. The idea is to develop a stan-dards based, open source, middleware messaging engine that connects physicians using e-Prescribing applications with the providers of e-Prescribing services i.e. eligibility checking, formulary enforce-ment, prescription routing and medication history retrieval. These include Pharma-cies, Pharmacy Benefit Managers and Insurance companies. eRx gateway would serve as the foundation for connecting the entire state of Massachusetts and later offered for trial at other sites across US. Using this system, any physician in the state could securely, accurately and instanta-neously transmit electronic prescription information to any pharmacy in the state. Once successfully implemented, the software would be offered free of charge to any organisation that wishes to accelerate connectivity between existing prescribing applications and providers of e-Prescribing services. This middleware would eliminate the problem of interfacing any new e-Prescribing application with multiple existing ones. 

As with any new implementation of a technology, some problems have arisen.  For example, only about 60% of the state’s pharmacies are currently accepting electronic prescriptions.  Even among the pharmacies that do receive them, there is variation regarding whether they capture them electronically in coded form, or print them out to be re-entered by the pharmacy.  Still, this effort represents one of the leading statewide efforts to implement e-Prescribing in US.

While implementation of e-Prescription can reduce the prescribing error rate, it had little impact on dispensing errors. Dispensing errors can occur in two ways – one, when the pharmacist incorrectly reads the prescription, prepares an incorrect label and dispenses incorrect drug; the second is when the pharmacist reads the prescription accurately, prepares the correct label but dispenses incorrect medication. In the second case, it might not be possible to ascertain the mistake unless the pills are called back and checked for error. The first kind of error is controllable if the pharmacist uses automatic label generator and has linked his/her internal systems to the e-Prescription system. The second type of error can only be completely prevented using robotic dispensing units but even there, there is always a chance of inaccurate filling of robotic dispenser.

ePrescribing: Global developments
There cannot be a blanket CPOE system for different countries. Each system either has to be developed according to the country’s specific needs or customized according to the local processes and pharmacopeia information. Nonetheless, there are encouraging trends towards adaptation of e-Prescription technology. Recently, the European Union adopted an “e-Health action plan” which mandated development of e-Prescriptions amongst the member countries. The estimates are that by 2010 e-Health spending could increase to 5% of the national health budgets; a growth of 500% in 10 years. Similarly, OECD countries are starting initiatives to promote e-Prescriptions among member countries.

Sweden has been leading the world in healthcare IT adoption. According to Harris poll conducted in 2002, Sweden has EMR adoption rate of 90%, compared with about 17% in US. In April 2005, the European e-Government news reported that 45% of all prescriptions in Sweden were e-Prescriptions. The Swedish state owned pharmacy Apoteket has kept a target of 80% e-Prescription penetration by 2010. About one million e-Prescriptions are transmitted each month in Sweden.

The National Health Services (NHS) in the UK has also recently started Electronic Prescription Service at some pharmacies. Under Connecting for Health initiative, the NHS plans to provide e-Prescription access to every GP surgery and community pharmacy by 2007. Subsequently, they would integrate the e-Prescribing systems with this service. The plan is to first extend the usage of e-Prescri-ptions to hospitals, ambulatory care centers, other pharmacies and the reimbu-rsement authority over the next few years.

The European Union countries are also exploring possibility of cross-border e-Prescribing. In a survey published in Aug 2006, lack of common standards between national systems and interoperability was cited to be the most important impediment to implementation of pan European

e-Prescribing system.  The eRx Gateway being implemented in Massachusetts could help in overcoming such obstacles.

Conclusion
e-Prescription systems are at the ascending curve of the technology adoption cycle. While it will be a while before these become widespread, progress can be expected to be rapid in a number of other countries. Nonetheless, if the launch of the Massachusetts eRx Gateway is successful as expected, many other states can be expected to emulate it. Those countries with nationalised healthcare system will have an advantage in rollout of these systems because they can mandate a uniform standard across all of health care. The potential benefits in terms of safety and efficiency are substantial.

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