Technology in the healthcare field is rapidly advancing, from the diagnosis, to surgery, all the way to sending the prescriptions to the pharmacy. As equipment and procedures become modernized, the healthcare field is shifting its focus on accuracy and efficiency. Pharmacies are now becoming more and more automated, where they days of receiving written prescriptions are slowly becoming numbered. As a matter of fact, New York has already mandated that prescriptions electronically prescribed for both controlled and non-controlled medications (Gilligan, et al., 2011). With a high possibility of other states to follow, this begs the question “are electronic prescriptions safer and more efficient than traditional handwritten prescriptions?”
Before answering that question, understanding the common issues that pharmacists are faced with on a regular basis will help identify the advantages that electronic prescriptions possess. When a patient drops off a prescription to the pharmacy, it must be entered into the computer. After verifying the correct patient information, the next step is to select the medication. Most of the time, there is no issue at this point, but sometimes, on a prescription for hydralazine for example, it may be seen as hydroxyzine. Without getting into too much detail, it is evident with the results of this mistake can be. Fortunately, electronic prescriptions virtually eliminate errors due to an illegible handwriting. From a patient safety perspective, this will decrease medication errors and overall adverse drug events. Illegible handwriting accounts for 20% of errors, and electronic prescribing can improve clarity and indications for therapy when sent to pharmacies (Odukoya, et al., 2014).
Electronic prescriptions also increase efficiency in the pharmacy because there is no need to call the physician to verify or doublecheck an incoming prescription. Although it takes a longer time for the physician, on average of 20 seconds longer to electronically send a prescription, this time is offset by the time saved because less clarification is needed (Porterfield, et al., 2014). Therefore, at the pharmacy, filling and dispensing prescriptions is simplified. As far as efficiency, physicians have an added tool called medication decision support or MDS (Horsky, et al, 2013). This tool increases patient safety by cross-checking for drug-drug interactions, drug-allergy, and drug-disease interactions. It also provides physicians recommendations for medication dosing across all patient populations, ranging pediatrics to geriatrics (Horsky, et al, 2013). MDS can check formularies within insurances, therefore decreasing phone calls to the provider when a nonformulary drug is prescribed and an alternative is required. This provides a cost saving benefit for patients, which results in increased patient medication adherence, reduced doctor visits due to adverse drug events, and overall improved health outcomes. For added support, some software includes clinical decision support (CDS) systems when resulted in fewer preventable errors over traditional handwritten or verbal prescriptions (Horsky, et al, 2013). As an added bonus, most physicians can add notes indicating diagnosis, medication calculations, and even billing information. As of date, many pharmacies have software that allows for automated processing, further streamlining the dispensing productivity. From a medication safety standpoint, error rates and near misses were decrease nearly 7-fold, from 42.5% to 6.6% after 1 year of adoption (Velo, Minus, 2009). According to the study findings, illegibility errors were completely eliminated by electronic prescribing, along with a decrease in rule violations (Velo, Minus, 2009).
The importance of adopting electronic prescribing goes beyond face value, it is a step towards incorporating electronic medical records into the office of physicians. It offers opportunities to streamline prescription renewal requests, to be entered by clinicians or queued up by office staff, to selecting medications that were covered by insurances, and to improve patient satisfaction by demonstrating the doctors use of cutting-edge technology and saving patients an extra trip to the pharmacy (Weingart, et al., 2009). Physicians can keep track of what was prescribed, and therefore reconciliation of medication will not be needed as physicians receive feedback when they are received at the pharmacy. With this process, there will be a decrease in the amount of lost prescriptions from the patient when they are sent directly to the pharmacy. With the increased regulations of controlled substances, this will allow for better monitoring of what has been prescribed (Weingart, et al., 2009). With this technology, pharmacies can request refills and send physicians information regarding prior authorizations online through the same system without having to pick up the phone and call the physician.
Even with this technology, the pharmacist clearly is not of the hook, pharmacists are still responsible about being vigilant regarding all incoming prescriptions. Most physicians select drugs from the drop-down menu, so selecting the incorrect drug can easily occur. This is where pharmacist need to read the directions and make sure it corresponds with the drugs selected. Considering the previous example of hydralazine in hydroxyzine, one me realize that hydralazine is given for hypertension. But if the Direction state as needed for itch, this may indicate that the wrong drug was selected, and a call must be made to the physician for clarification. Physicians are also subjected to “alert fatigue” which can happen when presented with several alerts as prescriptions are being entered (Gagnon, et al., 2014). When presented with loads of alerts when each prescription is entered, prescribers tend to stop reading the alerts and just quickly scroll through them. This can lead to missing important drug-drug, drug-allergy, or even drug-disease interactions and now the pharmacist is the last chance to catch those errors, which usually results in a phone call made to the physician for clarification. These are just two examples of many where the pharmacist’s intervention is still needed on prescriptions that show up on the screen for verification.
There are also several other issues that are presented with the implementation of electronic prescribing. Many of these issues can become deterrents to physicians when deciding on incorporating electronic prescribing. When it comes to wireless the transmission of patient protected health information (PHI), an important concern to address is privacy protection of PHI. This requires all computers and internet access at any clinic or institution be protected with up to date firewalls and antivirus to prevent intruders from entering and accesses and PHI. Studies have shown that most breaches occur internally, therefore proper training of all employees is required (Gagnon, et al., 2014). Many physicians have mixed attitudes toward the implementation of electronic prescribing. Both physicians and nurses are not adequately trained, therefore it may change their current workflow (Gagnon, et al., 2014). There are also unrealistic expectations presented on the physicians, which is expected improved speed and “fool-proof” application. Many physicians have tried electronic prescribing and resulted in discontinuation of its use due to hardware issues (12.4%), workflow issues (27.9%), software problems (34.0%), and other issues (25.5%) (Porterfield, et al., 2014). Another major factor in the implementation of electronic prescribing is cost. The average cost of a new system is an average of $42,332 with an average annual operating cost of $14,725 (Porterfield, et al., 2014). This is due to requiring proper training, privacy protection, and information technology support to keep the program running. Maintaining monthly and yearly logs of electronically prescribed control substances is very costly, adding to the already high overhead. These policies and financial rewards do not provide physicians, especially those with smaller clinics, sufficient incentives for them to adopt. Adding to the already difficult task of choosing whether or not to add electronic prescribing to an office or clinic, different vendors and technology make it hard to choose which best suits the needs of physicians. Also, so companies do not wish to share their information with vendors, this decreases its effectiveness for support software such as MDS Gagnon, et al., 2014).
So back to the original question of “are electronic prescriptions better than traditional handwritten prescriptions?” the obvious answer to this question is yes, but they do come with their limitations. There are many limitations, of which cost is the most prohibitive factor for physicians, especially ones that operate out of a small clinic Patient safety and the use of electronic prescribing increase legibility and decreases the time required to prescribe prescriptions, and with MDS and CDS, there are more tools to help guide physicians in the decision making of prescribing new prescriptions (Horsky, et al., 2013). Although they do minimize the amount of hands that touch the prescription or the need for deciphering what the doctor actually wanted to prescribe, as we move toward a more digital future, pharmacists must still use their clinical judgment and intervene when necessary on any prescription, electronic or handwritten (Warholak, Rupp, 2003).