E-prescribing
The page embodies the literature I have collected on electronic prescribing (e-prescribing). This is a work in progress and I add content when it becomes available. The focus is on e-prescribing in the United States although I am starting a page on e-prescribing in other countries.
E-prescribing has been touted since the early 1990's but adoption has been slow. Many physicians see practice management (to allow for more effective medical billing) as a higher priority. Given that the benefits of prescribing accrue primarily to the payer in the form of decreased drug costs due to generic substitution, the slow uptake seems understandable. I am examining reasons adoption may be proceeding slowly especially from the perspective of actor roles and their relationships with associated caregivers. The unintended consequences of e-prescribing seem to be overlooked by e-prescribing advocates. For example, the majority of e-prescribing in the AHRQ pilot studies was done by surrogate prescribers. We should be asking why surrogate prescribers exist if best practices were codified in the intended design of e-prescribing. Another unintended consequence of e-prescribing are the perfectly legible errors of a supposedly error-free digital prescription which is evidence of e-iatrogenesis.
Overview
The Agency for Healthcare Research and Quality (AHRQ) report summarizing 2007 pilot studies is a good starting point for US e-prescribing:
Moiduddin, A, Dullabh, P, Espinosa, O, Frisse, M, Johnson, K, Woolley, R & Pearlstein, J 2007, Findings from the Evaluation of E-Prescribing Pilot Sites, 07-0047-EF, Agency for Healthcare Research and Quality (AHRQ).
AHRQ e-prescribing page (link). The 2009 National Progress Report on E-prescribing has been released by Surescripts. (link)
Articles related to AHRQ funded Research
E-prescribing (academic) journal articles based on the AHRQ pilots funded in 2007:
Grossman, JM, Gerland, A, Reed, MC & Fahlman, C 2007, 'Physicians' Experiences Using Commercial E-Prescribing Systems', Health Affairs, Vol. 26, no. 3, pp. w393-404.
Hollingworth, W, Devine, EB, Hansen, RN, Lawless, NM, Comstock, BA, Wilson-Norton, JL, Tharp, KL & Sullivan, SD 2007, 'The Impact of E-Prescribing on Prescriber and Staff Time in Ambulatory Care Clinics: A Time- Motion Study', Journal of the American Medical Informatics Association, Vol. 14, no. 6, pp. 722-30.
Lapane, KL, Dub, Catherine, Schneider, KL & Quilliam, BJ 2007, 'Patient Perceptions Regarding Electronic Prescriptions: Is the Geriatric Patient Ready?' Journal of the American Geriatrics Society, Vol. 55, no. 8, pp. 1254-9.
Lapane, KL, Waring, ME, Schneider, KL, Dubé, C & Quilliam, BJ 2008, 'A Mixed Method Study of the Merits of E-Prescribing Drug Alerts in Primary Care', Journal of General Internal Medicine, Vol. 23, no. 4, pp. 442-6.
Rothschild, JM 2007, Electronic Prescribing Using a Community Utility: The Eprescribing Gateway, Agency for Healthcare Research and Quality.
Unintended Consequences of E-prescribing
"I don't think it is so much that e-prescribing might increase errors; it is that the type of errors occurring will be different than paper," Steven Waldren, assistant director for health and information technology with Leawood, Kansas-based American Academy of Family Physicians
For more opinions and rants
There are numerous challenges to e-prescribing and many can be overcome with thoughtful government policy. Recommendations from the report "Overcoming Ambulatory E-prescribing Adoption Challenges: Governments Shaping Innovation on Behalf of Individual Stakeholders are summarized on the recommendations page.
The challenge of e-prescribing research is to look both upstream and downstream of the actual prescribing event (filling in a prescription). Looking at the big picture - end-to-end medication management is where one finds hints about role changes that will likely have some kind of impact on the adoption of e-prescribing. Go to the page diversity of sources (sub-page of e-prescribing) for details. There are two tables with the first containing citations with its journal (domain of study), research method used, and description of the sample used for e-prescribing articles alone. The second table contains the articles outside of e-prescribing.
Articles related to e-prescribing in other countries - go to the sub-page eRx Around the World. There are both news articles and journal articles from academia.
Countries currently included are: Australia, Belgium, Canada, Denmark, United Kingdom
Central Fill/Mail Order
How does central fill impact our conceptualization of e-prescribing? Mail Order is the epitome of central fill but seems to be spreading on a localized basis. Stay tuned as I investigate ...
Central fill became a point of discussion in the early 2000's after the 1999 Anderson study broke down the time spent by pharmacists on their tasks.
Central fill to the extreme? A video from the EU.
Here is an interesting study on consumer medical information provided at the time of dispensing. Winterstein et al concluded that much of this CMI is inadequate (and 6% of pharmacies don't even provide CMI).
My Publications
Articles that I have published on e-prescribing include:
Journal Articles
King NE, Christie T, Alami K, "Process Implications of E-Prescribing Information Integration Models: United States Versus a Middle East Approach", E-service Journal, Vol 5, No. 3, Summer 2007, pp. 15-37 - Healthcare Special Issue
Reports
King NE, Overcoming Ambulatory E-prescribing Adoption Challenges: Governments Shaping Innovation on Behalf of Individual Stakeholders (pdf)
Note: The report was written for the IBM Center for Business of Government but there wasn’t any interest from government healthcare policy makers so the report was never published.
Conference Papers (Refereed)
King NE, "E-Prescribing as a Micro-Organizational Network – In Search of an Analysis Framework", IWODE09 - International Workshop on Organizational Design and Engineering, December 2009 (pdf)
King NE, “An Initial Exploration of Stakeholder Benefit Dependencies in Ambulatory E-Prescribing",15th Americas Conference on Information Systems, 2009 (pdf)
King NE, “Availability of Prescription Information for Secondary Usage – Impact of Outpatient E-prescribing”, Presentation - Summer Institute in Nursing Informatics 2008 (pdf)
AHRQ Request for Comments on Health IT Tracking Study
AHRQ was looking for comments on a planned e-prescribing study: ‘‘Health IT Community Tracking Study 2009" (see pdf from Federal Register) (Comments were due October 1). My general comments are provided here. The specific comments require the survey protocols that AHRQ sent to me.
When it comes to adopting new systems, we need to understand what is being done with the existing systems (e.g., manual prescribing with electronic adjudication). We need to ask the question from the stakeholders investing in a new system: “What’s in it for me?” I raise some of these questions in the previous section (Specific Comments). For example, why would a pharmacist pay upwards of $1 for receiving an e-script that has to be retyped anyway due to system incompatibility?
I move on to a system-oriented suggestion. The survey doesn’t address the broader issue of the allocation of benefits among e-prescribing stakeholders which is why I suggest a 9th protocol to interview policy makers. E-prescribing systems are really just one element of a broader medication management system. Fundamentally, most benefits of a fully implemented e-prescribing system, greater use of generics and reduced medication errors, accrues to the payers. To encourage adoption, the imbalance must be addressed and the system made usable. One such example is the ability of Drug-to-Drug Interaction (DDI) alert modules to detect a high payoff interaction. It seems little progress has been made over the years as the recent Weingart et al (2009) study shows. Does it make sense for the prescribing physician to deal with 331 alerts so that one adverse drug event (ADE) can be prevented? Perhaps so. Then why not pool our efforts and develop a single effective DDI module to be used by all e-prescribing (and pharmacy) systems? But perhaps it would be better for the “system” that pharmacists, with greater knowledge of DDI, be given more patient information (e.g., diagnosis not currently included on a prescription) and increase their ability to prevent ADE. These are the types of questions that I have been thinking about and hope the AHRQ Health IT Community Tracking Study 2009 will raise.
I have not received a response from AHRQ nor its study contractor.
Journal Articles for E-prescribing
E-prescribing (academic) journal articles from my collection with keywords "electronic prescribing" in title. You will note that various specialties in the medical field have published articles on e-prescribing:
Ammenwerth, E., P. Schnell-Inderst, C. Machan, and U. Siebert (2008) "The Effect of Electronic Prescribing on Medication Errors and Adverse Drug Events: A Systematic Review," Journal of the American Medical Informatics Association (15) 5, pp. 585-600.
Barber, N., T. Cornford, and E. Klecun (2007) "Qualitative Evaluation of an Electronic Prescribing and Administration System," Quality and Safety in Health Care (16) 4, pp. 271-278.
Bell, D. S., S. Cretin, R. S. Marken, and A. B. Landman (2004a) "A Conceptual Framework for Evaluating Outpatient Electronic Prescribing Systems Based on Their Functional Capabilities," Journal of American Medical Informatics Association (11) 1, pp. 60–70.
Bell, D. S., R. S. Marken, R. C. Meili, C. J. Wang et al. (2004b) "Recommendations for Comparing Electronic Prescribing Systems: Results of an Expert Consensus Process," Health Affairs (1) w4.305-w4.317.
Buckles, M. A. (2001) "Electronic Formulary Management and Medicaid: Maximizing Economic Efficiency and Quality of Care in the Age of Electronic Prescribing," Specialty Law Digest. Health Care Law (264pp. 9-32
Council on Clinical Information Technology (2007) "Electronic Prescribing Systems in Pediatrics: The Rationale and Functionality Requirements," Pediatrics (119) 6, pp. e1413-1422.
Crosson, J. C., N. Isaacson, D. Lancaster, E. A. McDonald et al. (2008) "Variation in Electronic Prescribing Implementation Among Twelve Ambulatory Practices," Journal of General Internal Medicine (23) 4, pp. 364-371.
Cusack, C. M. (2008) "Electronic Health Records and Electronic Prescribing: Promise and Pitfalls," Obstetrics and Gynecology Clinics of North America (35) 1, pp. 63-79.
Devine, EB, Wilson-Norton, JL, Lawless, NM, Hansen, RN, Hazlet, TK, Kelly, K, Hollingworth, W, Blough, DK & Sullivan, SD 2007, 'Characterization of Prescribing Errors in an Internal Medicine Clinic', American Journal of Health System Pharmacy, Vol. 64, no. 10, pp. 1062-70.
Devine, EB, Hansen, RN, Wilson-Norton, JL, Lawless, NM, Fisk, AW, Blough, DK, Martin, DP & Sullivan, SD 2010, 'The Impact of Computerized Provider Order Entry on Medication Errors in a Multispecialty Group Practice', Journal of the American Medical Informatics Association, Vol. 17, no. 1, pp. 78-84.
Donyai, P., K. O'Grady, A. Jacklin, N. Barber et al. (2008) "The Effects of Electronic Prescribing on the Quality of Prescribing," British Journal of Clinical Pharmacology (65) 2, pp. 230-237.
Eguale, T., R. Tamblyn, N. Winslade, and D. Buckeridge (2008) "Detection of Adverse Drug Events and Other Treatment Outcomes Using an Electronic Prescribing System," Drug Safety (31) 11, pp. 1005-1016.
Elson, B. (2001) "Electronic Prescribing in Ambulatory Care: A Market Primer and Implications," Journal of Managed Care Pharmacy (Vol. 7) No. 2
Fischer, M. A., C. Vogeli, M. Stedman, T. Ferris et al. (2008a) "Effect of Electronic Prescribing With Formulary Decision Support on Medication Use and Cost," Archives of Internal Medicine (168) 22, pp. 2433-2439.
Fischer, M. A., C. Vogeli, M. R. Stedman, T. G. Ferris et al. (2008b) "Uptake of Electronic Prescribing in Community-Based Practices," Journal of General Internal Medicine (23) 4.
Goedert, J. (2002) "Electronic Prescribing: Is It Just What the Doctor Ordered?," Health Data Management (10) 6, pp. 14.
Goldblum, O. M. (2001) "Electronic prescribing: criteria for evaluating handheld prescribing systems and an evaluation of a new, handheld, wireless wide area network (WWAN) prescribing system," e.healthrecord.news (2) 4, pp. 17-31.
Greenberg, M. D., M. S. Ridgely, and D. S. Bell (2004) "Electronic Prescribing and HIPAA Privacy Regulation," RAND Health (41pp. 461-468.
Jani, Y. H., M. A. Ghaleb, S. D. Marks, J. Cope et al. (2008) "Electronic Prescribing Reduced Prescribing Errors in a Pediatric Renal Outpatient Clinic," The Journal of Pediatrics (152) 2, pp. 214-218.
Johnson, K. B. and F. FitzHenry (2006) "Activity Diagrams for Integrating Electronic Prescribing Tools into Clinical Workflow (Case Report)," Journal of American Medical Informatics Association (13) 4, pp. 391-395.
Lipton, H., R. Miller, and J. Wimbush (2003) "Electronic Prescribing: Ready for Prime Time?," Journal of Health Information Management (17) 4, pp. 72-79.
McMullin, S. T. (2005) "Standardization is necessary in the methods to assess the value of electronic prescribing systems.," Journal of Managed Care Pharmacy (11) 7, pp. 594-595.
Mcmullin, S. T., T. P. Lonergan, and C. S. Rynearson (2005) "Twelve-Month Drug Cost Savings Related to Use of an Electronic Prescribing System With Integrated Decision Support in Primary Care.," Journal of Managed Care Pharmacy (11) 4, pp. 322-332.
Miller, R. A., R. M. Gardner, K. B. Johnson, and G. Hripcsak (2005) "Clinical Decision Support and Electronic Prescribing Systems: A Time for Responsible Thought and Action," Journal of the American Medical Informatics Association (12) 4, pp. 403-409.
Motulsky, A., N. Winslade, R. Tamblyn, and C. Sicotte (2008) "The Impact Of Electronic Prescribing On The Professionalization Of Community Pharmacists: A Qualitative Study Of Pharmacists' Perception," Journal of Pharmacy & Pharmaceutical Sciences (11) 1, pp. 131-146.
Papshev, D. and A. M. Peterson (2002) "Extent of Electronic Prescribing Implementation as Perceived by MCO Pharmacy Managers," Journal of Managed Care Pharmacy (8) 1, pp. 41-47.
Peel, D. (2007) Electronic Prescribing is No Panacea, in Government Health IT.
Pizzi, L. T., D.-C. Sah, J. Barone, and D. B. Nash (2005) "Factors Reated to Physicians' Adoption of Electronic Prescribing: Results from a National Survey," American Journal of Medical Quality (20) 1.
Rosenbloom, S. T. (2006) "Approaches to Evaluating Electronic Prescribing," Journal of the American Medical Informatics Association (13) 4, pp. 399-401.
Ross, S. M., D. Papshev, E. L. Murphy, D. J. Sternberg et al. (2005) "Effects of Electronic Prescribing on Formulary Compliance and Generic Drug Utilization in the Ambulatory Care Setting: A Retrospective Analysis of Administrative Claims Data," The Journal of Managed Care Pharmacy (11) 5, pp. 410-415.
Schwartz, R. H., A. A. Zuckerman, and M. Martin (2007) "Electronic Prescribing Holds both Promises and Problems," Infectious Diseases in Children) October.
Seidling, H., A. Al Barmawi, J. Kaltschmidt, T. Bertsche et al. (2007) "Detection and Prevention of Prescriptions with Excessive Doses in Electronic Prescribing Systems," European Journal of Clinical Pharmacology (63) 12, pp. 1185-1192.
Shelley, S. (2007) "Electronic Prescribing — What’s in It for Drug Makers and PBMs? ," Pharmaceutical Commerce ) Nov/Dec
Spiro, R. F. (2008) "Electronic Prescribing in Long-term Care: An Overview of Five Pilot Projects," Consultant Pharmacist (23) 1, pp. 16-26.
Tamblyn, R., A. Huang, Y. Kawasumi, G. Bartlett et al. (2006) "The Development and Evaluation of an Integrated Electronic Prescribing and Drug Management System for Primary Care," J Am Med Inform Assoc (13) 2, pp. 148-159.
Teich, J. M., J. A. Osheroff, E. A. Pifer, D. F. Sittig et al. (2005) "Clinical Decision Support in Electronic Prescribing: Recommendations and an Action Plan: Report of the Joint Clinical Decision Support Workgroup," Journal of the American Medical Informatics Association (12) 4, pp. 365-376.
Wang, C. J., R. S. Marken, R. C. Meili, J. B. Straus et al. (2005) "Functional Characteristics of Commercial Ambulatory Electronic Prescribing Systems: A Field Study," J Am Med Inform Assoc (12) 3, pp. 346-356.