Electronic prescribing

Electronic prescribing or e-prescribing is the electronic transmission of prescription information from the prescriber's computer to a pharmacy computer. It replaces a paper prescription that the patient would otherwise carry or fax to the pharmacy. It is believed to improve patient safety by reducing the possibility of a prescribing error due to various causes including poor handwriting or ambiguous nomenclature. Examples of universal ePrescribing clearinghouses in the US include RxHub and Surescripts. Many EHRs send their eprescriptions through these interfaces to the end pharmacy.

How it works

Electronic prescribing is a form of computerized physician order entry. In the US, e-prescribing health information technology is based on standards set forth by NCPDP. The prescriber must have access to computer software developed for this purpose. For example, most electronic medical record systems include e-prescribing features. Orders are usually placed in the exam room while seeing the patient.

1. The prescriber logs on to the system and authenticates their identity. This important step ensures that no one may impersonate an authorized prescriber and generate illegal prescriptions. Authentication requires two of the following.
   1. Presenting something you know, such as a password
   2. Presenting something you are, such as a fingerprint, retinal scan, or other biometric identification
   3. Presenting something you have, such as a magnetic card or physical security token
2. The prescriber looks up the patient in the system
3. A drug is chosen, with parameters including strength, quantity, directions, days supply, and number of refills
4. The patient's active medication list and known allergies are reviewed for potential adverse drug reactions
5. The software may suggest alternative drugs that are either more effective or less costly
6. Select a pharmacy that will process the order, and place the order
7. The order flows over an encrypted connection to the pharmacy. The connection may be direct peer-to-peer, but usually it is indirectly routed over a commercial network of pharmacies such as SureScripts or eRx Network. Orders take the form of standardized electronic messages that both the prescriber's system and the pharmacist's system must implement.
8. The order appears in the pharmacists computer system, where it may be filled.
9. The patient shows up at the pharmacy to pick up and pay for their medications.

New prescription orders are not the only type of message that can flow over the network connection. Other types of messages may include:

• Notice from the pharmacist that the order has been filled or refilled
• Request from the pharmacist for additional refills, and response from the doctor either authorizing or denying the request
• Change the prescription parameters
• Cancel the prescription
• Check that the patient's insurance coverage will pay for the medications

Benefits

In 2000, the Institute of Medicine identified medication errors as the most common type of medical error in health care, estimating that this leads to several thousand deaths each year. Causes of medication errors include mistakes by the pharmacist incorrectly interpreting illegible handwriting or ambiguous nomenclature, and lapses in the prescriber's knowledge of desired dosage of a drug or undesired interactions between multiple drugs. Electronic prescribing has the potential to eliminate most of these types of errors. The computer can ensure that clear and unambiguous instructions are encoded in a structured message to the pharmacist, and decision support systems can flag lethal dosages and lethal combinations of drugs.

E-prescribing also has the potential to improve beneficiary health outcomes. For providers who choose to invest in e-prescribing technology, the adoption could improve quality and efficiency and could show promise in reducing costs by actively promoting appropriate drug usage; providing information to providers and dispensers about formulary-based drug coverage, including formulary alternatives and co-pay information; and speeding up the process of renewing medications. E-prescribing also may play a significant role in efforts to reduce the incidence of drug diversion by alerting providers and pharmacists of duplicative prescriptions for controlled substances.

According to some estimates, almost 30 percent of prescriptions require pharmacy callbacks. This translates into less time available to the pharmacist for other important functions, such as educating consumers about their medications. A potential benefit of e-prescribing in preventing errors is that each prescription can be checked electronically–and quickly–at the time of prescribing.

Disadvantages

A new technology is not without its drawbacks. Some of the more notable issues include:

• Accidental data entry errors such as selecting the wrong patient or clicking on the wrong choice in a menu of dosages. Software vendors should continually review user feedback and follow best practices in user interface design.
• Inadvertently divulging protected health information on the internet through inadequate security practices. Hospitals and clinics should be protected with firewalls, use strict computer permission settings, and remain vigilant toward signs of an intrusion.
• Inability to use electronic prescribing when the power is out, when the exam room computer has failed, or when providing treatment outside of a standard health care setting.

Government incentives

In the United States, the HITECH Act promotes adoption of this technology by defining e-prescribing as one meaningful use of an electronic medical record. Standards for transmitting, recording, and describing prescriptions have been developed by the National Council for Prescription Drug Programs, in particular the SCRIPT standard, which describes data formats. Elsewhere in the world, health care systems have been slower to adopt e-prescribing standards.

See also

• Clinicians Guide to e-Prescribing