September 25, 2018

It’s Time to Put Away the Puzzle: Improving Patient Safety by Enhancing Medication Management Accuracy

Last fall, my colleague, Stacy Ward-Charlerie, wrote about the complex nature of medication management. She compared the practice to solving a puzzle, one that requires all the right pieces to arrive at the solution: an accurate picture of a patient’s therapy regimen.

As Stacy stated in her piece, “So, where are all of the pieces to the puzzle? And in a digitized society, why is it even a puzzle in the first place? Can we deliver better information to pharmacists—we call it actionable intelligence—to improve prescription accuracy and patient safety? It starts with the provider’s decision to stop or change a therapy. She needs to declare this intent clearly and conspicuously to communicate to all other stakeholders involved in the patient’s care, including the pharmacist who may be miles away.”

This is where the NCPDP SCRIPT CancelRx transaction plays a critical role. A CancelRx Request message is sent to the pharmacy when a prescriber discontinues a medication in the Electronic Health Record (EHR) system, thereby providing a crucial piece of actionable intelligence that is distinct from other new e-prescription (NewRx) orders.  This transaction plays an essential role in prescribers’ workflows, as they expect timely receipt and efficient processing of their electronic medication orders, including cancellation orders, to ensure optimal patient care.  Unfortunately, this critical tool is currently underused.  

As we found in our study published  in the August 2018 Journal of the American Medical Informatics Association, prescribers are using unorthodox electronic workarounds in text fields of new e-prescriptions, with potentially dangerous implications, instead of using CancelRx to safely discontinue or replace prescriptions.

We analyzed a nationally-representative sample of 1.4 million NewRx transactions during a seven-day period and quantified how those “workarounds” were used to cancel or replace a medication therapy. Instead of using CancelRx, some prescribers modify NewRx transaction by entering free-text instructions to "STOP" or "Cancel"  regimens. Or, they replace a previous regimen with a different product, strength, or dosage, in the Notes, Drug Description, or patient directions (SIG) field.  

When prescribers use free-text fields to communicate cancellation instructions, the possibility that pharmacists will miss the instructions increases for two reasons. One, these fields may be laden with other information that can make the cancellation orders difficult to detect. Two, pharmacists don't expect these fields to contain cancellation instructions, as they were not intended by the NCPDP SCRIPT standard to accommodate such information.

The consequences of missed instructions can be severe, as patients may experience adverse drug events when cancelled medications are erroneously dispensed.  The safety issues are further magnified when prescriptions involve high-alert, or look-alike-like-sound-alike medications as identified by the Institute for Safe Medication Practices (ISMP). 

Our study identified nearly 10,000 opportunities per week to prevent these unnecessary patient risks. In one year, that’s nearly 10 million additional opportunities, across 1.4 billion NewRx transactions, to reduce potential for patient harm and to improve the efficiency and clarity of e-prescriptions.

There are signs of progress, however. Over the past few years, EHR vendors have increased their adoption and implementation of CancelRx. In fact, Surescripts has processed more than 6.3 million CancelRx transactions as of August 2018, up from 3.8 million in 2017. Meaningful Use requirements for the enablement of this functionality as well as prescribers’ preferences for efficient electronic communication may have helped increase use, as CancelRx is a safe and clear electronic message that is more expedient than phone calls or faxes. Plus, the American Medical Association has encouraged greater use of electronic solutions to cancel prescriptions.

However, the successful utilization of CancelRx requires both EHRs and pharmacies to implement it. So far, adoption is spread unevenly across the prescription spectrum. Consequently, prescribers may have to maintain separate workflows for pharmacies that can process CancelRx and those that still depend on phone calls or faxes. But here lies an opportunity for partnership across the Surescripts Network Alliance: increased adoption on the part of pharmacies can spur greater deployment on the part of EHRs, and vice versa.

Our study findings can serve as a catalyst for the wider use of CancelRx and more meaningful use of NewRx. Let’s leverage the tools that have been afforded to the industry by the NCPDP SCRIPT Standard v10.6 since 2010. And let’s quickly implement the latest functionalities in the upcoming new SCRIPT version 2017071, especially mandatory ones, like CancelRx. Concurrently, let’s educate end-users on how to best use newly-implemented e-prescribing functionalities and avoid misuse of the familiar ones.  Such collaboration and commitment from the industry can help shift medication management away from the current paradigm of a puzzle that needs to be solved to the efficient, accurate, and safe care experience that patients, prescribers, and pharmacists deserve.

To learn more about what Surescripts is doing to enhance patient safety by improving prescription accuracy, visit Intelligence in Action.

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