Overcoming e-Prescribing Quality Issues

January 12, 2015

When I was a practicing pharmacist in Minnesota, I handled plenty of rumpled and stained paper prescriptions and chased more than a few patients down weeks after their recorded office visits.  With paper prescriptions, the patient holds the burden of transporting a small piece of paper from point A to point B. And while e-prescribing does speed up the time it takes information to reach the pharmacy and eliminates the need to protect against coffee spills or physical damage, we are always looking for ways to improve the process.

The National Community Pharmacists Association (NCPA) takes member feedback on satisfaction with e-prescribing seriously, and our relationship with Surescripts has resulted in a few initiatives designed with that feedback and quality assurance in mind: a quality reporting helpline for independent pharmacies, a quality problem reporting project, and reliable communications to software vendors when a programming problem pops up. The National Council for Prescription Drug Programs’ (NCPDP) SCRIPT Standard was adopted by Surescripts in 2003 to ensure high quality e-prescriptions, but user behavior is still a significant factor to overcome.

The perfect e-prescription is currently attainable and there are many prescribers who use this technology well.  However, the efficiencies and safety improvements that prescribers, pharmacists and patients want suffer when e-prescriptions require clarification from the prescriber because of errors or ambiguities in drug selection, quantity, directions (Sig), prescription notes or prescriber ID (supervising physician ID is needed for some midlevel practitioners).

The most common error reported in research conducted by Surescripts and twelve independent pharmacies in the summer of 2014 occurred in the Sig/Notes field.  This included directions that didn’t make sense for the drug selected as well as prescriptions including two conflicting sets of directions: one in the Sig field (where it belongs) and one in the Notes field. 

Here are some examples of instruction mistakes we’ve encountered:

  1. Notes: “Take 1 tablet by mouth as directed take 1 tablet twice a day to three times a day”
  2. Notes: “Take 1 mL to each cheek three times a day” for nystatin ointment (Nystatin ointment is not intended to be administered to the cheeks of an infant to treat thrush!)
  3. Sig: “Take 1 tablet two times daily” Notes: “Take 2 tablets at bedtime.  If symptoms persist, add 1 tablet every morning starting day 3.  If symptoms persist, add 1 tablet every evening starting day 4.”

Improved user training and greater awareness of the biggest problems will go a long way.  In addition to confusion of where Sig information belongs, another issue is prescriptions not containing all the information required by a state board of pharmacy to be valid. I frequently hear from pharmacy owners in Texas who receive e-prescriptions from mid-level practitioners without the supervising physician’s identification, which makes such prescriptions invalid in Texas. 

So, what can prescribers do to ensure the quality of their e-prescriptions? Proofread.  Previously, a prescriber’s hand moved the pen that applied the ink to a prescription.  Now there are dropdown menus, quick picks and defaults that sometimes cause confusion and result in quality issues.  A learning curve is to be expected when using a new technology, but prescribing medication calls for great attention to detail. As trusted medical professionals, prescribers owe it to patients to write clear, valid prescriptions. Surescripts requires EHR software to show a confirmation screen to the prescriber much the way most online retailers have an order summary screen prior to charging a credit card. Prescribers should review this screen carefully. The costliest errors could result in the patient getting a prescription that is potentially harmful. 

Lastly, prescribers and pharmacies need to know how to report problems when they arise, and the person taking that report needs to be able to provide actionable feedback.  I suspect that problems, local and nationwide, would be resolved faster if end-users, the pharmacies and prescribers, believed reports or complaints to the IT department or their software vendor would make a difference.  Software vendors and company IT professionals both rely on complaints, but they sometimes don’t know a small issue is a big issue or a widespread issue unless everyone reports all problems.

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