Electronic prescribing refers to the use of computing devices to enter, modify, review, and output or communicate drug prescriptions. In a basic electronic prescribing system, clinicians review, enter, manage, and sign prescriptions using a computer, instead of writing them on paper. Systems are available in a variety of graduated levels from basic electronic reference only to full integration into an EMR. Systems at the higher levels afford much greater opportunities for quality improvement, reduction in errors and improved workflow efficiency.
In addition to basic prescription entry capability, the definition of electronic prescribing includes a number of important capabilities, including:
• Clinical decision support, including alerts and reminders to promote guideline compliance, prevent prescribing errors, and advice about formulary compliance.
• Integration of other patient data from an electronic medical record, such as medical conditions, current and prior medications, allergies, laboratory results, and personal preferences, to enhance efficiency, improve documentation, and increase the potential impact of clinical decision support.
• Fax or electronic communication between clinicians, pharmacies, and health plans, in order to transmit prescriptions, conduct eligibility and benefit transactions, exchange messages, and process renewal requests.
• Provision of educational materials for patients and clinicians.
Given the large volume of prescriptions (more than 3 billion per year), even a small improvement in quality can translate into significant healthcare cost and safety benefits. Electronic prescribing helps deliver relevant patient information and clinical knowledge to the prescriber, reducing the risk of faulty prescriptions, and can help eliminate nearly 2.1 million ADE’s per year in the U.S. It can also decrease prescription clarification calls for the approximately 5 percent of prescriptions that are somehow incompletely specified or unclear.
Electronic prescribing can help track patient medication use to assist in efforts to improve compliance and also to decrease risk of abuse by prescriptions obtained from multiple providers and pharmacies.
Electronic prescribing maximizes cost-effective drug selection through easier compliance with formularies and generic substitutions.
Although considerable progress has been made, handwritten prescriptions remain the norm rather than the exception, but momentum for electronic prescribing is building through support from public and private sectors.
Stakeholders in Electronic Prescribing
There are a variety of stakeholders involved in the electronic prescribing process. Each constituency plays a critical role in the complex process of prescription creation and management.
• Practicing clinicians.
• Practicing pharmacists and associated staff, in store-based and mail-order pharmacies.
• Healthcare information technology producers/suppliers (“vendors”).
• Health systems, practice organizations, and hospitals.
• Patients and family caregivers.
• Employers, health plans, government and other purchasers.
• Pharmacy Benefit Management (PBM) organizations.
• Pharmaceutical and medical device manufacturers.
• Public health organizations.
• Research and academic institutions.
• Professional and lay societies representing each of the above.
Figure 1- Levels of e-prescribing systems
Figure 2- Features and benefits of e-prescribing levels
Electronic prescribing systems are available in a variety of graduated levels as shown in figure. Different commercially available systems may provide different combinations of these feature levels, although most current commercial systems at least provide significant features at levels 2, 3, and 4. Benefit can be seen at all levels; however, systems at the higher levels of sophistication afford much greater opportunities for quality improvement, reduction in errors, and improved workflow efficiency, primarily by including more relevant information about the patient and better communication among the stakeholders and data sources in the prescribing chain. A summary of the features and benefits of each level is contained in Figure 2:
|1. Electronic Prescription Reference||“Reference handbook” information is available in one system and links drug information, general formulary information, and interactions checkers.||Information is available in one place and integrated to facilitate handwriting of prescriptions. May prevent errors passively if user opens it at the relevant moment. Improves convenience.|
|2. Standalone Prescription Writer||Allows one to search for a particular drug and create a prescription. Generally-used dosages are included.||No patient-specific information on allergies, drug history, health plan, or medication history is included. Safety enhanced through legibility and standard dosages.|
|3. Patient-specific Prescription Creation or Refilling||Includes some combination of demographics, formulary, allergies, and plan information.||Allows tailoring of prescription to patient unique needs and desires. Provides safety benefits from clinical decision support for allergies. Enables consideration for elderly or pediatric patients. Also reduces callbacks. Formulary checking improves cost and compliance.|
|4. Medication Management||Access to prior medication history and current regimen is available, either though prior entries or through linkage to an external database, or both.||Significantly enhanced safety levels from warnings for drug-drug interactions, therapeutic duplications. Allows efficient refills and renewals, possibly including reminders.|
|5. Connectivity||Transmission of a “clinically certified” prescription to the dispensing site requested by the patient. Enhanced linkages between all parties involved in patient medication management.||Additional assurances that the medication order is consistent with the clinical intent, dosing guidelines, and health plan design. Reduces transcription errors, speeds dispensing. Allows for additional interaction checks and lowers administrative costs.|
|6. Integration with EHR||Medication ordering automatically linked to the comprehensive health record used to provide clinical care. Includes access to lab and test results, problem lists, diagnoses.||Many enhancements to quality: problem-based ordering, disease management reminders, drug-lab result conflicts, renal dosing, drug monitoring needs. Integrates medication ordering into the overall process of medical care delivery.|
Still other capabilities on the spectrum of electronic prescribing add to this core set and may provide additional advantages in safety, quality, and cost. These include but are not limited to:
• Direct patient access to review personal medication regimen, suggest corrections and changes, and submit refill and renewal transactions.
• Aggregate databases to support the greater understanding of the impact of prescription drugs on public health.
• Additional communications regarding benefits changes, formulary updates, drug utilization reviews, and other important information.