Key Characteristics of an Electronic Prescription Writer
By Robert Keet, MD FACP
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Robert Keet, MD FACP
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Healthcare practitioners have a professional mandate to prescribe
the most appropriate, disease-specific medication in a safe
and efficacious manner. Each year, though, this becomes more
complex. The number of new medications increases exponentially
each year with new entries for each class and new classes
for each disease. Each drug has its unique indications, contraindications,
cross reactivity, complications, and costs. Increasingly,
drug-drug interactions present a major problem, reportedly
occurring in 12% to 22% of prescribed medications.1
Providers can no longer rely on memory for necessary details about familiar medications. They must prescribe in the context of all medications a patient takes, including those prescribed by other physicians in the community. In addition to indications, contraindications, and potential side effects, they must be aware of drug-drug, drug-age, drug-allergy interactions, and which medications are covered by the patient's insurance. The cost of managing the plethora of often-modified, insurance-specific formularies is rapidly driving up the cost of care.
Several studies have shown that applying computing technology to prescription writing significantly reduces the cost of medications while increasing the adherence to specific protocols.2 3 Computerized prescription writing can provide tremendous benefit to both the healthcare provider and the patient.4 Despite the obvious benefits, the use of computerized prescription writers is not widespread.
My healthcare community, which includes 135 physician offices, is implementing an electronic prescription writer. The prescription writer is part of a project to automate the flow of clinical data between physicians and their affiliated healthcare partners. The first stage of the project involved managing the flow of incoming clinical data such as laboratory results, radiology results, and transcriptions. The data was digitized and delivered to physicians' "inboxes," and tools were provided to manage those messages. The second stage of the project automates the management of outgoing messages including authorizations, laboratory orders, and prescriptions. Lessons learned during this effort provide insight into specific issues that must be addressed by architects of automated prescription systems for healthcare providers.
A variety of papers and articles have addressed the design issues faced when implementing physician automation in a single economic entity.5 This paper addresses the myriad of issues that must be considered when designing a prescription writing system to meet the needs of physicians in multiple economic entities linked only by a common community of patients.
Cross-Community Implementation
The typical patient sees a primary care physician and several
specialists each year. An effective electronic prescription
writer must track all drugs prescribed by all physicians in
the community and must perform duplicate and interaction checking
based on all drugs prescribed for that patient by multiple providers.
The prescription writer must provide adequate security, for
example, to assure that physicians do not have access to drug
information for patients they are not managing. Finally, each
prescription must be linked to a unique patient identifier so
that data can be appropriately transmitted across the system.
Our healthcare community created a "master patient index" (MPI) that identifies each patient and provides up-to-date patient demographics, eligibility status, health plan, co-pay, and eligibility information. It also has the capability to carry key clinical information including prescribed medications and allergies. The MPI database entries are automatically generated and maintained from data included in incoming clinical messages, such as laboratory results, and from outgoing messages, such as laboratory orders and prescriptions. The database is replicated across the community and allows for rapid demographic look-up and unique identification of clinical data (including prescriptions) and for checking for duplicate and interacting medications.
Although we implemented a wide area network across the entire community to maintain the patient index and to distribute clinical messages, healthcare communities today can take advantage of the Internet and Web browser technology, thereby avoiding the high costs associated with the development of a community-wide network. Using the Internet and Web browser technology, physicians and their staffs can easily access the tools necessary to facilitate writing prescriptions. This includes linkages to expert databases, patient demographic data, and medication history. Using an e-mail metaphor familiar to physicians and their staff, prescriptions can be generated and delivered to the appropriate pharmacy.
Web technology faces two special considerations: security and speed. The U.S. Federal Government via the Health Care Financing Administration (HCFA) is currently setting standards for the Web-based delivery of clinical data.6 With encryption and appropriate authentication or identification, Web transmittal of clinical prescription data should not be a problem.
Quick Response Time
Each day the average primary care physician writes 10 to
20 prescriptions and processes a similar number of refills.
Prescription writing generally occurs at the end of a patient
encounter and must be done very rapidly. Because of this, response
time is critical in any point-of-service system. Since the speed
of a browser-based prescription writer is dependent on the data
transfer bandwidth and the speed of the loading of pages, the
prescription writer must be designed with an eye to rapid loading
and transfer of data, even if this requires compromising on
the quality of graphics.
In addition, physicians are very sensitive to the number
of "mouse clicks" and text entry required to complete
a task. The physician must be able to quickly choose the
appropriate drug and create the "Sig" (directions
for use).
Effortless, Intelligent Medication
Choice
We found that physicians generally wish to choose a medication
by name but appreciate the ability to find medications by diagnosis
and cost. Often physicians remember only the brand name, yet
wish to prescribe the generic alternative when available. Sometimes
they do not know if the drug name is brand or generic, so they
must be able to choose drugs from one master list. Spelling
is also often a problem; physicians may remember only the first
several letters of a drug name. Finally, physicians need guidance
regarding the specific strengths available for a medication.
For new medications, physicians often remember that a new drug is available in a specific class or for a specific diagnosis but do not remember the specific name. Presenting the physician with drugs sorted by FDA-approved diagnoses solves this problem. In short, choosing a medication should require minimal data entry and not be dependent on knowledge of the drug's exact name or whether the name is a generic or brand name. Once chosen, the physician should be presented with available strengths and guided to the appropriate direction for use.
Formulary Linkage
Managed care has introduced a new dimension to prescribing
a medication—selecting one that is covered by the patient's
insurance. Because formulary management directly impacts patient
satisfaction and office efficiency, it is of increasing concern
to clinicians. Healthcare providers now spend more money on
medications than they do for primary medical care. This is an
issue of significant economic importance.
Unfortunately, there is no single formulary of medications to use for a specific diagnosis. Instead, the physician usually has several possible choices with costs related to the insurance carrier's contracted rates. The appropriate drug choice thus depends on the patient's insurance and that company's current contracts—a rapidly moving target. Providers should be warned when they prescribe a drug not on the patient's insurance plan and should be presented with a list of alternative, plan-approved choices in the same drug class. Providing this information at the time the prescription is written saves physicians, patients, and pharmacies significant effort in changing non-formulary drugs to appropriate alternatives.
Physicians tend to prescribe a subset of medications repeatedly. In addition, they usually prescribe the same number of tablets with the same directions and number of refills. The electronic prescription writer should allow rapid completion of the prescription form for each physician's frequently prescribed drugs.
Expert Database Linkage
The complexity of prescription writing requires that clinicians
have rapid access to expert knowledge. The prescription writer
should automatically check for drug duplicates and interactions
as prescriptions are written. Duplicate checking includes checking
for the same drug as well as for similar drugs in the same class.
We have found that physicians wish to be warned but do not want
that process to interfere with the completion of the prescription.
Often they are aware of the potential problem and do not want
more details. When interested, the physician would like the
complete detail of the potential interaction including scientific
reference.
Prescription writers linked to expert databases such as Medi-Span allow this checking. Expert drug databases can also provide physicians with specific prescribing details including the usual dosage, route of administration, relationship to food, contraindications, and potential reactions. Average wholesale price data is useful for choosing among otherwise equivalent drugs. Providing physicians with details of drug cost leads to cost-effective improvement in prescribing patterns.7
Directions for Use and Patient Education
The ideal prescription writer provides defaults for appropriate
usage directions. These defaults can come from the physician's
personal list for frequently prescribed drugs or from an expert
database and can be easily changed. The directions for use should
drive other automation within the prescription process. For
example, the prescription writer can use the dose, strength,
units prescribed, number of refills, and the directions for
use to calculate the date that the drug would normally require
renewal. This date can drive other processes including the renewal
process and the tracking of patient compliance.
Finally, drug databases can provide drug-specific patient education in multiple languages. This includes information about proper usage of the drug, contraindications, warnings, and precautions and can be printed before the patient leaves the office.
Renewal Process
Our workflow analysis showed that the refill process is
one of the most cumbersome and expensive processes in a primary
care physician's office. A typical primary care physician may
receive 20 or more requests for refills each day. These requests
come from patients and pharmacies via phone, fax, and mail.
For each request, the office staff must obtain the chart, check and update the medication list, confirm the dose, and present the data to the physician for approval. Once approved, the staff must update the chart and transmit the refill approval to the patient or pharmacy by fax, phone, or mail. In a paper-based system, it is cumbersome to determine if the drug is being refilled too soon and impossible to determine if it isn't being refilled soon enough. Medication lists often become outdated or contain incorrect information regarding dose or directions for use. For critical drugs such as Coumadin, this can lead to significant risk to the patient.
An automated prescription process must allow the staff to enter renewal requests for approval by the physician. By choosing a drug from the prescribed list, a staff member should be able to initiate a renewal with a single mouse click. The original dose, number, refills, and directions for use should be carried forward to a new prescription with the date modified. This preliminary renewal request can then be deposited in the physician's electronic inbox for approval.
If the system can calculate the expected renewal date based on the dose, strength, number, refills, and directions for use, the staff and physician can quickly determine if the refill is occurring too soon or there if evidence of non-compliance. If the dates of the patient's last visit and laboratory tests are also available, refill checking can be even more comprehensive.
Provider Workgroups
Provider groups often centralize the process of prescription
management and refills. An automated prescription writer must
function in the context of a group of healthcare providers and
staff who work together to manage this complex task. Provider
workgroups can simply be call groups or may comprise all the
clinicians in an economic entity. Thus, the prescription process
must take into account the fact that providers often act clinically
on behalf of each other. One clinician may write a prescription
for another clinician's patient or may refill medications on
behalf of a colleague who is out of town. While prescriptions
must be signed by the generating provider, the regularly treating
provider must have information about all drugs prescribed for
his patients. It is this provider who takes responsibility for
the ongoing management of the patient's medication.
Because staff members generally work with multiple providers, the refill process must allow staff to generate prescriptions with direction to a specific provider for approval. Legally, an automated prescription writer should allow only physicians or, where legal, mid-level providers to complete (sign) prescriptions; however normal workflow mandates that prescriptions be prepared by the office staff.
Linking All Players
In an ideal world, physicians, pharmacies, and patients
would all be electronically linked. While pharmacies often have
automated systems to track drugs and refills, clinicians typically
deal with multiple pharmacies with dissimilar systems. In recent
years, online pharmacies have been proliferating on the Web,
yet no simple technology exists to link these services to provider
or patient.
An automated prescription writer should have the ability to link to a variety of other computer systems. Refill requests from the pharmacy should be delivered electronically to the responsible provider. Even the patient could be brought into the loop with standard e-mail and Web tools. However, electronic prescriptions must also easily interface with the world of paper, fax and e-mail. Incorporating prescription writing into a standard communication infrastructure allows for maximum functionality now, with a growth path for the future. Electronic prescriptions can easily be converted to fax and paper, thereby meeting the general needs of the current work environment.
Implementation Process
The critical success factor for any new system is that it
can be adopted in a gradual, non-disruptive manner. In our healthcare
community, we found that, wherever possible, it is best to introduce
automation first with the office staff. Once time savings are
demonstrated, providers can gradually adapt to the new process.
Automating the time-consuming and expensive refill process first
provides the most obvious gain for the effort. A few key staff
can be trained to enter refill requests from pharmacies and
patients into the system. The physicians can approve or reject
these requests "online" in a process that requires
minimal adjustment from current procedures.
Once the system has been primed with most of the drugs for each of the patients, clinicians can gradually transform their prescription writing practice to one that is online. Providing automated alerts for drug duplicates, interactions, and formulary non-compliance will encourage clinicians to use the system.
Conclusions
Prescription writing is one of the most complex tasks performed
by physicians, demanding both detailed knowledge of the patient's
care and of drug usage. Treatment protocols are increasingly
complex, and providers are responsible for assuring that medications
are prescribed appropriately and without adverse interactions.
Several factors are coming together that will move physicians to more automated systems. First, the complexity of medical care is increasing, making it difficult for physicians to maintain the knowledge base necessary to provide quality care to their patients. Second, as computers have become more common and less expensive, clinicians have begun to use them in their day-to-day work. A recent Gartner Group survey found that 78% of physicians use the Internet. Finally, Internet and e-mail technologies are increasingly sophisticated, and complex management tools can be built within this familiar environment to assist in the delivery of healthcare.
Systems that give physicians immediate and direct feedback during the prescription process are most effective in changing behavior and improving quality.8 Using tools built on communication platforms, professionals can work together across a community to care for patients. Combining systems that generate prescriptions, track medications, provide communication between providers, and link to expert databases allows providers and their staffs to automate this process in the context of their usual workflow.
Dr. Keet has practiced Internal Medicine and Geriatrics in Santa Cruz, California for more than 20 years. During the last four years, he served as chairman of the Steering Committee of physicians overseeing the development of an automated clinical messaging network in his community. He consults with Axolotl Corp. where he assists in the company's ongoing effort to provide clinical automation tools.
- Linnarsson R, Drug interactions in primary health care. A retrospective database study and its implications for the design of a computerized decision support system, Scand J Prim Health Care 1993 Sep 11:3 181-6
- Grams RR, A primary care application of an integrated computer-based pharmacy system; J Med Syst 1996 Dec; 20(6) : 413-22
- Donald JB, Prescribing costs when computers are used to issue all prescriptions; BMJ 1989 Jul 1;299 (6990) : 28-30
- Schiff GD, Computerized prescribing: building the electronic infrastructure for better medication usage, JAMA 1998 Apr 1;279(13) : 1024-9
- Chin HL, Implementation of a comprehensive computer-based patient record system in Kaiser Permanente's Northwest Region, MD Comput 1997 Jan-Feb 14:1 41-5
- HCFA Internet Security Policy, Nov 24, 1998
- Donald JB, Prescribing costs when computers are used to issue all prescriptions, BMJ 1989 Jul 1 299:6690 28-30
- Soumerai SB, McLaughlin TJ, Avorn J, Quality assurance for drug prescribing, Qual Assur Health Care 1990 2:1 37-58
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