People often joke about doctors’ handwriting not being easy to read. Perhaps it is not true but what is true is that any transaction carried out on the basis of handwritten documents is likely to be prone to errors. Prescription are no exception. Studies show that there can be as many as 37 errors in 100 prescriptions while only 7 such errors are found if these transactions are electronic. It is a non-trivial problem with over 7,000 deaths in the USA are caused by prescription errors, some of which could be avoided by using electronic prescriptions. Presented as such, one is forced to confront why are we still using paper prescriptions at all!
The answer to this is the usual “It is a bit more complicated than that”. To understand electronic prescriptions (ePrescription) it is important to note that to merely digitise the process of doctors sending instructions to dispense to pharmacists would be too simplistic and would be an opportunity lost. An e-Prescribing system contains not only the information related to decision support software, electronic medication administration records, robots, automated pharmacy systems, bar coding, smart IV pumps, electronic discharge prescriptions and targeted patient information.
While reducing prescription errors and consequent patient harm is solid argument for why we must have electronic prescribing, it also seems true that non-adherence among patient can be reduced by using systems with more ‘touch points’ for users. in one study non-adherence went from 22% to only 7-13% when electronic prescribing system was employed.
In addition to the clinical argument for using e-prescribing there are operational arguments as well. Anyone familiar with ERP systems in other industries will instantly recognise the additional value of such a system. Information, once entered, can be used by nurses to dispense medicines, pharmacies to manage inventories and ordering, administrators and researchers to gather data on drug use and in some cases on adherence and outcomes. However, with all the features and integrations with existing systems makes the product a lot more complex and each implementation becomes riddled with discussions around standards and costs and who will pay for them.
In the USA alone, medication errors kill 7,000 patients a year
Despite all these marvellous benefits of e-prescribing systems, progress has been slow. Some places have gone on and installed all singing and dancing e-prescribing systems only to then print out prescriptions electronically and sending them to the pharmacy to be filled. This points to the lack of desire or understanding the downstream value of e-prescribing above and beyond that of the thousands of year old paper version. There are issues of changing behaviours and incentives.
Where are we now?
Generally, e-Prescribing adoption levels are consistent with the levels of e-health practice, and the leading regions are the Western industrialised economies in the EU and, the USA where at least some elements of e-prescribing exist. What makes it hard to pin down e-prescribing penetration is the fact that it has so many modules and providers often count themselves as e-prescribers even if only a few of these modules are functional. For example in the EU, majority (16) reported it as an element of their national eHealth strategy plan.
Perhaps, it is best to count countries that have adopted fully operational ePrescribing office practise such as Denmark, Estonia, Iceland, and Sweden which means that the entire prescribing sequence, from issuing one in a GP to transfer and dispensation, is done electronically.
There are signs of progress. A couple of recent developments come to mind. Following the change in regulation in 2013, most of UK primary care physicians now offer electronic prescriptions to be sent to patients’ ‘nominated’ dispenser eg their local pharmacy. It is not perfect but it work. For example you cannot issue a prescription unless you nominate a specific pharmacy. You have to change this if you want to pick it up from a different dispenser. And Schedule 1, 2 or 3 of the Misuse of Drugs Regulations 2005 cannot be dispensed using e prescription. Both of these restrictions will be lifted at a later date making the implementation complete. However, e-prescribing in UK hospitals is still patchy (data from 2013 showed only 1 out of 101 hospitals had fully integrated e-prescribing across specialties)
Incidentally, following change in Vermont law on prescribing of controlled substances being brought in line in August 2015, e-prescribing of controlled substances including schedule 2 painkillers such as oxycodone, hydrocodone, and morphine can now be routed via electronic prescriptions to pharmacies across the USA.