AHRQ WebM&M: Morbidity & Mortality Rounds on the Web
E-prescribing: E for error?
Commentary by Elisa W. Ashton, PharmD
A 63-year-old man with multiple medical problems was seen by his primary care doctor for a routine follow-up appointment. Despite receiving psychotherapy, the patient admitted that he continued to struggle with anxiety. In light of these complaints, the primary care doctor elected to prescribe an antianxiety agent, alprazolam. The clinic had just implemented electronic prescribing—the ability to electronically transmit a new prescription to a pharmacy. The physician reassured the patient that he didn't need a paper prescription and could simply go to the pharmacy to pick up his medications.
Electronic prescribing (e-prescribing) is the transmission, using electronic media, of prescriptions or prescription-related information from a prescriber (physician, nurse practitioner, etc.) to a pharmacy. The information may flow to a number of parties in addition to the pharmacy, such as a pharmacy benefit manager, health plan, or an intermediary, such as an e-prescribing network (a large centralized system to process electronic prescriptions). In its simplest form, as in this case, e-prescribing involves two-way transmissions between the point of care and the pharmacy.(1) E-prescribing is intended to replace writing out, faxing, or calling in prescriptions, and its many proposed benefits include safer, more efficient, and more cost-effective care.(2)
Because of these potential benefits, the federal government has put in place major incentives for providers to adopt e-prescribing (3) (Medicare Modernization Act, 2003) and to adopt electronic health records (EHRs) (4) through the meaningful use incentives (American Recovery and Reinvestment Act, 2009). According to a health information technology (IT) stimulus report published in 2009, the health IT incentives included in the federal stimulus law will significantly increase the rate of electronic prescribing and save $22 billion in drug and medical costs in the next decade.(5) The authors report that the e-prescribing savings would come from (i) informing doctors at the point of prescribing about the cost and clinical characteristics of medication options and letting doctors select the best and most affordable drugs, including more generic prescriptions; (ii) providing doctors with patients' medication histories to prevent harmful drug interactions and duplicate prescriptions; (iii) notifying physicians of pharmacy options, including mail-order and retail drug stores, to help curb patients' out-of-pocket costs; and (iv) reducing wait times and errors related to illegible handwriting by transmitting prescriptions electronically to pharmacies. The report also estimates that the increase in e-prescribing could prevent 3.5 million medication errors and 585,000 hospitalizations by 2018.
A recent literature review shows substantial evidence that e-prescribing can improve the safety, efficiency, and cost-effectiveness of patient care.(2) Several previous studies demonstrated the benefits of integrated clinical decision support, which requires the availability of accurate and complete pharmacy eligibility, benefit, and formulary information at the point of care. The availability of insurance coverage and copay information at the point of care can reduce the number of calls to providers seeking information for changes in medications to covered agents or requests for prior authorization information. Furthermore, the copay information offers an opportunity for providers to engage patients in their own care by involving the patient in deciding what agent the patient will receive based on cost and benefits. In addition, studies showed that clinical decision support systems change prescribing behavior and significantly lower prescription drug costs. In a Massachusetts study, the cost savings had a potential of reaching $845,000 per 100,000 patients.(6,7) A study at the Henry Ford Health System found that e-prescribing was associated with an increase in the prescribing of generic drugs, lower administrative costs, and reductions in adverse drug events.(8)
While these benefits have been realized in many locations, successful e-prescribing on a truly broad scale has not been achieved. More widespread adoption depends on the coordinated actions of many stakeholders and the continuing evolution of standards, capabilities, and competencies to ensure that robust and accurate transmission of e-prescribing data and workflow processes are the rule rather than the exception.
Across the United States, the number of prescribers sending electronic prescriptions has increased since 2008. Recently, with the initial rollout of the meaningful use standards and incentive payments, this growth has been accelerated by adoption of EHRs. Standalone e-prescribing systems, which can create and refill prescriptions for individual patients, manage medications and view patient history, connect to a pharmacy or other drug dispensing site, and integrate with an electronic medical record (EMR) system, have actually dropped slightly, likely due to movement toward EHRs. The Surescripts National Progress Report is the primary source of information for e-prescribing adoption and use.(9) By the end of 2010, the Report found that there were 234,000 active e-prescribers, representing 34% of all office-based physicians in the nation. About 20% of eligible prescriptions were sent electronically in 2010, versus 12% in 2009. Drug Enforcement Administration regulatory changes that give prescribers the option of issuing prescriptions for controlled substances electronically should drive future growth of e-prescribing
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