A Rx to improve medication safety

The casual scribbles that pass for handwriting and the extensive use of abbreviations, acronyms, and shorthand dose designations in many doctors’ offices are more than just a nuisance for patients. Rather, these medical hieroglyphics often are to blame for routine miscommunications with pharmacists—miscommunications that too often lead to medication errors related to the drug name, proper dosage, and instructions.

Making matters worse, more than 12,000 prescription drugs are on the market, and many have look-alike and sound-alike names, a long list of potential contraindications, and multiple formulation and dosage options. With all this information synthesis complexity, it's not uncommon for additional problems to crop up.

Enter electronic prescribing. E-prescribing systems enable prescribers to use laptop or desktop computers, PDAs, or smart phones to set up both new and refill prescriptions in a uniform, electronic format, and to transmit all prescriptions to the patient's pharmacy of choice—with just the push of a button.

And, to promote greater medication safety, such systems routinely include embedded decision-support functionality, which enables physicians to retrieve and review patients’ clinical information (for instance, to verify whether specific tests are up to date) and the complete prescription history (to see what other medications the patient is taking). Such systems also provide routine alerts when the physician's drug of choice presents problems in terms of potential drug-drug or drug-allergy interactions or insurance formulary eligibility.

By eliminating reliance on potentially illegible handwritten prescriptions, and inherently error-prone and inefficient phone- and fax-based communication, today's e-prescribing systems provide an effective antidote to the many shortcomings of the traditional approach to prescribing.

Wake-up Call

Statistics on medication-related errors and adverse drug events (ADEs) are alarming:

• According to the Center for Information Technology Leadership, roughly 8 million Americans experience outpatient ADEs each year, roughly 3 million of which are preventable, most by electronic prescribing.

• According to the Institute of Medicine, preventable prescription medication errors injure more than 1.5 million Americans and contribute to the deaths of 7,000 each year—the equivalent of one plane crash every week.

• According to a recent report from the National Council on Patient Information and Education, only about 50% of Americans faithfully take their medicines as prescribed, resulting in roughly $177 billion annually in direct and indirect costs to the U.S. economy in terms of increased incidence of hospitalization, death, and disability.

• According to a September 2007 report in the Archives of Internal Medicine, during calendar years 1998 through 2005 there was a nearly three-fold increase in both the number of serious ADEs (from 34,966 to 89,842) and fatal ADEs (from 5,519 to 15,107) that were reported voluntarily to the FDA. The study authors reported that serious events increased four times faster than the total number of outpatient prescriptions written during the study period.

Nearly 65% of Americans take at least one prescription drug, and studies show that the average senior citizen is taking a half dozen or more. In 2006, Americans spent more than $250 billion on prescription drugs. With more than 3 billion prescriptions dispensed in the United States each year (a figure projected to rise to more than 4.1 billion by 2010), it's easy to see that these problems underscore the need for an improved prescribing process.

Deploying Technology

Today's e-prescribing systems improve patient safety and satisfaction in several ways:

• By using uniform, formatted electronic communications to create new prescription orders and authorize refill requests, and transmit them to pharmacies. This reduces medication errors by allowing prescribers to create complete, accurate, legible prescription orders, and by eliminating miscommunications related to verbal and faxed communications.

• By giving physicians electronic access to accurate drug and dosing information (among other things), as well as up-to-date information about potential drug-drug and drug-allergy reactions. Such insight allows physicians to prescribe safer alternatives before the patient has left the office and, in doing so, to reduce the likelihood of ADEs and unpleasant side effects.

• By giving prescribers real-time access to the status of a given drug on the patient's insurance formulary, right at the point of care. This enables the prescriber to maximize formulary adherence, reducing both the patient's out-of-pocket expenses and overall costs for insurance plans.

With critical information right in the palm of their hands, today's e-enabled physicians are able to make more informed prescribing decisions at the point of care. Such informed prescribing is able to reduce unwanted side effects and excessive costs for patients so their likelihood of adhering to prescribed drug therapies increases.

Increased patient adherence is an important public-policy goal, not only because it increases the patient's chance of experiencing positive therapeutic outcomes (particularly for chronic conditions such as diabetes, high cholesterol, hypertension, and so on), but because it saves the overall healthcare industry a tremendous amount of money by reducing the need for unnecessary medical interventions, emergency room visits, extended hospitalizations, and premature death.

One Nationwide Network

E-prescribing in the United States is conducted via the Pharmacy Health Information Exchange, a neutral electronic network operated by SureScripts. The SureScripts network enables the transparent, two-way electronic exchange of prescription-related information between physicians’ offices and pharmacies that use e-prescribing software applications that have been certified to connect to the network. E-prescribing software applications (ranging from stand-alone packages to more comprehensive electronic medical records) from roughly 60 vendors, and pharmacy-management software systems from roughly 20 vendors, are certified to connect to the SureScripts network.

Because pharmacy-management software tools are so widely used by both chain pharmacies and independent drugstores, more than 95% of all retail pharmacies in the United States are able to handle prescription orders electronically. By contrast, the pace of adoption among prescribers has not been as swift. Despite a growing body of anecdotal and empirical evidence validating the many clinical advantages, safety improvements, financial benefits, and administrative/efficiency gains that come from using e-prescribing systems, only 6% of the 563,000 office-based physicians in the United States are using them. Traditional barriers include overall resistance to new technology, the perceived cost of the hardware, software and training required, and concerns about the potential work-flow disruptions that may be associated with moving from paper-based to computer-based prescribing. Slow physician adoption rates represent a tremendous missed opportunity for the entire healthcare industry.

To help promote more widespread use of this inherently safer approach to prescribing, an array of public- and private-sector initiatives, involving state governments, insurers and other payer organizations, medical associations, and individual technology vendors, are under way (see https://www.surescripts.com/Initiatives/default.aspx?ptype=physician for a periodically updated list of these initiatives).

A New Advocate

Last August, a coalition of stakeholders representing family physicians, physician practices, pharmacies, health insurers, and technology providers launched The Center for Improving Medication Management (https://www.theCIMM.org). The co-founding members include the American Academy of Family Physicians, Medical Group Management Association, Blue Cross Blue Shield Association, Humana, Inc., Intel Corporation, and SureScripts.

The Center will conduct research, develop programs, and disseminate best practices to help physicians, pharmacists, and patients exploit the full range of capabilities that today's health IT tools provide. The overarching goal is to help stakeholders take better advantage of e-prescribing, pharmacy interoperability, and transparent health information exchange to improve the way in which medications are prescribed, dispensed, and consumed to improve patient safety and maximize desired therapeutic outcomes.

The Center will bring medication management to the next level and have a meaningful impact on accelerating the employment of technology to improve the safety of the prescribing process. With more effective implementation comes wider adoption. Thanks to e-prescribing's proven ability to streamline the prescribing process, reduce costs for prescribers and pharmacists, reduce medication errors, and increase patient adherence, wider adoption offers a more-automated, safe, and efficient means of managing medications for patients.

Specific studies to be undertaken by The Center will evolve over time. Initial projects being considered will aim to:

• demonstrate and enhance the advantages of e-prescribing and EMR technology, in terms of their ability to improve medication safety, encourage medication adherence, and reduce labor and overhead costs for both physicians and pharmacists;

• determine how comprehensive information related to a patient's medication history can be best used to improve the relevance of drug-drug and drug-allergy alerts, and evaluate the impact of a non-adherence alert for specified patient popula-tions; and

• evaluate how technology can be leveraged to improve outreach to patients to increase drug adherence (through the use of refill reminders, personalized educational materials, periodic messaging alerts, etc.).

The Center also plans to develop online discussion forums to foster the more efficient exchange of information and support among healthcare providers, technology providers, and other stakeholders.

The Center is committed to being more than just a think tank. It is focused on creating pragmatic, action-oriented results and recommendations that can advance and accelerate the adoption of technology to improve both patient safety and the effectiveness of medication management. We encourage our colleagues in behavioral healthcare to share their ideas with us.

SureScripts was established in 2001 by the nation's two major pharmacy associations: the National Association of Chain Drug Stores, which represents more than 38,000 chain pharmacies, and the National Community Pharmacists Association, which represents more than 24,000 community pharmacies.