US Pharm. 2013;8(38)(P&T suppl):4-7.

Electronic prescribing, or “e-prescribing,” is not new to the world of pharmacy; however, it has rapidly evolved over the last decade to accommodate the growth and complexities of health care in the United States. E-prescribing was brought into the spotlight in 2003 with the approval of the Medicare Modernization Act (MMA). The MMA included a formal definition of e-prescribing, and although it did not require providers or pharmacies to adopt e-prescribing, it did offer a set of uniform standards for appropriate implementation and use.1 In 2009, Medicare rolled out an incentive program for providers who were successfully using an e-prescribing program in their practice.2 To expand usage, the Drug Enforcement Administration approved controlled-substance e-prescribing in 2010.3

Most U.S. pharmacies and providers have integrated e-prescribing into their practice. About 91% of community pharmacies and 34% of office-based providers have electronic prescription-routing capability.4

Patient safety and prescription error reduction are major concerns in modern health care, and e-prescribing was introduced to address these issues. E-prescribing initially presented many challenges, making resistance by pharmacists and providers difficult to overcome. Many of the problems faced in previous years have been resolved through advances in technology. These advances allow e-prescribing software to screen for dosing accuracy, drug-drug interactions, and drug allergies and to alert providers to generic equivalents and formulary preferences.5-8 While e-prescribing has progressed and now provides many advantages to the community pharmacist, problems remain. The intent of this review is to summarize the benefits and challenges of e-prescribing in U.S. community pharmacies.

Pros of E-Prescribing

The proposed and confirmed benefits of e-prescribing include enhanced patient safety, reduced drug costs, increased access to patient prescription records, and improved pharmacy workflow.9-16

Patient Safety: Enhanced patient safety is of great significance. An estimated 1.5 million adverse drug events (ADEs) occur annually in the U.S., accounting for approximately $3.5 million in health care spending.17,18 Avoidable errors associated with written prescriptions include selection of an incorrect or unavailable drug, dosage form, or dosage; duplication of therapy; omission of information; and misinterpretation of the order because of illegible handwriting.11-16 These errors, if identified before the prescription is processed, often require additional communication between the pharmacist and the provider, thus delaying patient care.6,12,14 Indecipherable orders alone account for 150 million calls from pharmacists to providers in the U.S each year.19 Not all mistakes are detected, potentially resulting in patient harm and even death.20

Failure to identify drug allergies or drug-drug interactions also increases the likelihood of an ADE.11,14 Some e-prescribing software is equipped with point-of-care decision support that notifies the provider of potential prescription errors before transmission. The program prompts the provider to verify allergies, confirm dosage accuracy, and identify drug-drug interactions before the prescription is transmitted. Access to insurance information, formulary decision support (FDS), and fill status notification are supplementary features that increase the probability of the provider selecting a commercially available dosage form and a generic equivalent, if applicable.5-8

Cost Benefits: A trial evaluating the impact of point-of-care decision support software found the software to be of financial benefit for patients. Over 12 months, 26,674 new prescriptions written by providers using the software had an average cost that was $4.12 lower than expected based on a comparable number of prescriptions written by providers not using the software (P = .003). The savings were attributed to alerts that informed providers of more cost-effective therapies, suggested discontinuation of unnecessary high-cost medications, and recommended optimization of current therapies before permitting transmission of the prescription to a pharmacy.8

Access to Prescription Records: Electronic storage of prescription records is invaluable in situations in which patient safety is threatened, such as natural disasters and drug recalls. Following Hurricane Katrina in 2005, complete cessation of patient care was avoided because medical records were readily obtainable. Pharmacists and providers were able to retrieve records of evacuees’ medications through SureScripts, an e-prescribing network covering more than 90% of U.S. pharmacies.21 Similarly, drug recalls were shown to be managed more efficiently when a pharmacy had e-prescribing capability, since the software enabled pharmacists to trace certain medications to specific patients and expedite delivery of pertinent information.22,23

Clinical benefits of e-prescribing have been reported as well. A retrospective study assessed the effect of e-prescribing on attainment of cholesterol goals in 796 patients. Cholesterol-lowering agents were prescribed either traditionally or via e-prescription software equipped with FDS. After a mean of 4.6 months, patients who received an e-prescription had a higher rate of LDL goal achievement and were more likely to receive a generic cholesterol-lowering medication compared with controls (51% vs. 44% [P = .009] and 38% vs. 22.9% [P <.001], respectively). This suggests that e-prescribing software equipped with FDS may improve LDL goal attainment in patients not currently at goal.24

Improved Workflow: While much literature describes how e-prescribing benefits the patient in terms of goal achievement and prevention of drug errors, the community pharmacy also stands to gain. E-prescribing has been shown to streamline prescription processing and reduce wait times, since patients need not be present before a prescription is filled and it is no longer necessary to manually enter the prescription into the computer.11,12,14 Calls to the provider’s office to clarify illegible orders are eliminated, affording the pharmacist more time to counsel patients.25 Based on evidence confirming the correlation between the time a pharmacist spends counseling patients and the reduction of preventable ADEs, e-prescribing can help prevent ADEs.26,27 Enhanced safety, shorter wait times, expanded pharmacy consultation services, and reduced medication costs are anticipated to yield greater patient satisfaction with the services provided by a pharmacy, ultimately resulting in retention and increased revenue.14,25

Other Advantages: Besides patients and community pharmacies, beneficiaries of e-prescribing include providers, insurance companies, employers, malpractice insurers, and the community. Providers have reported less time spent verifying handwritten orders, easier access to a patient’s insurance coverage information, and peace of mind concerning transmitted orders.5,12,14 Additionally, providers may be eligible for reimbursement if they are compliant with formulary programs.11,12 Insurance companies have reported cost savings due to better formulary adherence, reduced therapeutic duplication, and prevention of ADEs.14 Employers have been shown to benefit financially from reduced health care costs and healthier employees.14 Malpractice insurers are projected to have fewer claim losses thanks to the reduction in preventable ADEs.14 A decrease in handwritten orders and the increased frequency of electronic submission are likely to result in fewer prescription forgeries.11

The implementation of e-prescribing in clinical practice has several benefits. The chief advantage of e-prescribing over written prescribing is the expansion of patient safety by reduction of ADEs. In the community pharmacy, pharmacists benefit from increased time for counseling patients, patient satisfaction, and customer retention. As technology improves, it is likely that most U.S. pharmacies that have not yet implemented e-prescribing will adopt it for the many advantages it affords.

Cons of E-Prescribing

Although e-prescribing eliminates certain errors, it potentiates new errors and reintroduces problems similar to those encountered with written prescriptions. Omitted or inaccurate information, such as incorrect drug selection, wrong patient, and incorrect directions, accounts for most errors associated with e-prescribing.28-30 Given the initial resistance and lack of acceptance on the part of providers and pharmacists, many studies have been conducted to determine the accuracy of e-prescribing.

Clarification of Inaccuracies: One of the benefits of e-prescribing—additional time for the pharmacist to provide other services—is offset by the increased amount of time required to process an e-prescription if inaccuracies exist. A study comparing traditional prescriptions with e-prescriptions found that e-prescriptions necessitated more pharmacist interaction with the provider because of missing, inaccurate, or unclear information.31 Another study reported an overall intervention rate of 3.8% for e-prescriptions in the community chain setting, with omitted information the most likely reason for the pharmacist to intervene. Verification of inaccurate doses (whether insufficient or excessive) was also common. On average, the pharmacist required 6.07 minutes per intervention, with a resultant incremental dispensing cost of $4.74 per e-prescription.16 Another analysis revealed that pharmacists intervened on 21 of 180 new electronic prescriptions versus 132 of 1,498 traditional prescriptions (faxed, handwritten, and verbal), correlating to an intervention rate of 11.7% versus 8.8%, respectively. Violation of legal requirements and excessive quantity or duration of medication were the most common reasons for intervention, resulting in a 4.7-minute intervention and a $4 increased dispensing cost per prescription.32 These findings suggest the continued need for pharmacists to intervene on e-prescriptions, leading to greater associated costs and dispensing times.

As with traditional prescriptions, errors associated with e-prescriptions are not always detected by the pharmacist, which can result in decreased safety, as well as patient harm. In a recent study, one in 10 computer-generated prescriptions received by pharmacies had at least one medication error, and one-third of the errors were potentially harmful.33 This is in contrast to previous reports suggesting that e-prescribing reduces preventable drug errors, thereby reducing patient harm. With such discrepancies, it is uncertain whether errors are decreased or increased with the use of e-prescribing software.

Software Design Issues: The design features of e-prescribing software may increase the likelihood of the errors described above. Drop-down menus, poor screen design, and automatic filling functions have been identified as potential sources of errors and consequently as threats to patient safety.29,34 Additionally, these design features may contribute to workflow challenges, as they dictate manual entry and editing of prescriptions and potential follow-up with providers to resolve gaps, errors, or lack of clarity.12 Delays in the arrival of new e-prescriptions can result in patient discontent and increased waiting times, as patients may arrive at the pharmacy before an order has been received.12,30 Also, e-prescriptions may be transmitted not at once, but at different times. These delays impact the pharmacy’s workflow, as a call to the provider’s office is necessary to confirm transmission and to verify that the order was sent to the correct pharmacy. Bundling—the transmittal of a large number of e-prescriptions at once—creates potential workplace tension, as pharmacy personnel are required to dispense accurate prescriptions in a timely manner.29

System failures and incompatibilities between technology designs may prove to be problematic and create workflow inefficiencies.28 The negative impact of e-prescribing on pharmacy workflow has been shown to negatively affect patient care.28,29 Reasons for this include a pharmacy’s capability for receiving large numbers of prescriptions faster than was previously possible with handwritten orders; the adaptation required by the pharmacist in order to process e-prescriptions; and the lack of formal training to efficiently utilize e-prescribing software. Finally, as previously discussed, an unclear or inaccurate prescription requires pharmacy personnel to put dispensing on hold and verify the information with the provider, thereby delaying workflow for that prescription and other prescriptions being filled.29

Cost Disadvantages: Other limitations of e-prescribing include costs associated with use: start-up, maintenance, and transaction fees.12,35 Although large chain pharmacies are able to negotiate lower transaction fees, smaller chain and independent pharmacies pay more to utilize e-prescribing software. Additionally, not all community and mail-order pharmacies have the ability to receive new prescriptions electronically.12

Conclusion

E-prescribing, like any new technological development, comes with advantages and disadvantages. Some of the most appealing benefits include enhanced patient safety and decreased medication errors, reduced drug costs with FDS software, increased access to patient medication records, and improved pharmacy workflow. Some of the most notable disadvantages are introduction of prescription errors, poor design features of e-prescribing software, and disruptions in pharmacy workflow.

E-prescribing can potentially yield cost savings and improve efficiency and patient safety. Cost savings are seen more frequently when providers use systems equipped with FDS; however, savings are negated if the pharmacist is losing valuable time verifying incomplete or inaccurate orders. It is anticipated that, with continued advances in technology, these problems will be resolved and e-prescribing will yield more benefits than risks for patients, providers, and pharmacists. Utilization of technologically advanced e-prescribing software is projected to improve pharmacy workflow and efficiency while reducing prescribing errors, and to ultimately enhance patient safety.

REFERENCES

1. Medicare Prescription Drug, Improvement, and Modernization Act, Pub L No. 108-173, 117 Stat 2066 (2003).
2. Medicare Improvements for Patients and Providers Act, Pub L No. 110-275, 112 Stat 2066 (2008).
3. 75 FR 16236 No. 61. Electronic prescriptions for controlled substances; final rule. March 31, 2010. www.deadiversion.usdoj.gov/fed_regs/rules/2010/fr0331.pdf. Accessed April 30, 2013.
4. The National Progress Report on E-prescribing and Interoperable Healthcare, 2009. Arlington, VA: Surescripts; 2010.
5. Cooke CE, Xing S, Lee HY, Belletti DA. You wrote the prescription, but will it get filled? J Fam Pract. 2011;60:321-327.
6. Crosson JC, Etz RS, Wu S, et al. Meaningful use of electronic prescribing in 5 exemplar primary care practices. Ann Fam Med. 2011;9:392-397.
7. Curtiss FR. Why e-prescribe and the future of transforming data into information. J Manag Care Pharm. 2005;11:418-419.
8. McMullin ST, Lonergan TP, Rynearson CS. Twelve-month drug cost savings related to use of an electronic prescribing system with integrated decision support in primary care. J Manag Care Pharm. 2005;11:322-332.
9. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280:1311-1316.
10. Evans RS, Pestotnik SL, Classen DC, et al. A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med. 1998;338:232-238.
11. Gerstle RS, Lehmann CU; American Academy of Pediatrics Council on Clinical Information Technology. Electronic prescribing systems in pediatrics: the rationale and functionality requirements. Pediatrics. 2007;119:e1413-e1422.
12. Grossman JM, Cross DA, Boukus ER, Cohen GR. Transmitting and processing electronic prescriptions: experiences of physician practices and pharmacies. J Am Med Inform Assoc. 2012;19:353-359.
13. Kaushal R, Kern LM, Barrón Y, et al. Electronic prescribing improves medication safety in community-based office practices. J Gen Intern Med. 2010;25:530-536.
14. Kilbridge P. E-prescribing. Oakland, CA: California HealthCare Foundation; 2001.
15. Molitor R, Friedman S. Electronic prescription errors in an ambulatory pharmacy. J Manag Care Pharm. 2011;17:714-715.
16. Warholak TL, Rupp MT. Analysis of community chain pharmacists’ interventions on electronic prescriptions. J Am Pharm Assoc (2003). 2009;49:59-64.
17. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
18. Institute of Medicine Committee on Quality of Health Care in America. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
19. Institute for Safe Medicine Practices. A call to action: eliminate handwritten prescriptions within three years! www.ismp.org/newsletters/acutecare/articles/whitepaper.asp. Accessed June 26, 2013.
20. Gandhi TK, Burstin HR, Cook EF, et al. Drug complications in outpatients. J Gen Intern Med. 2000;15:149-154.
21. Markle Foundation, American Medical Association, Gold Standard, Rx Hub, SureScripts. Lessons from KatrinaHealth. www.surescripts.com/media/660511/katrinahealthlessons.pdf. Accessed June 26, 2013.
22. BlueCross BlueShield of Illinois. E-prescribing collaborative program. www.bcbsil.com/provider/pharmacy/eprescribing.html. Accessed April 5, 2013.
23. Pennell U. What is e-prescribing and what are the benefits? www.emrconsultant.com/education/e-prescribing. Accessed April 5, 2013.
24. Michelis KC, Hassouna B, Owlia M, et al. Effect of electronic prescription on attainment of cholesterol goals. Clin Cardiol. 2011;34:254-260.
25. Harvey J, Avery AJ, Waring J, Barber N. The socio-technical organisation of community pharmacies as a factor in the Electronic Prescription Service Release Two implementation: a qualitative study. BMC Health Serv Res. 2012;12:471.
26. Murray MD, Loos B, Tu W, et al. Effects of computer-based prescribing on pharmacist work patterns. J Am Med Inform Assoc. 1998;5:546-553.
27. Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166:565-571.
28. Odukoya OK, Chui MA. E-prescribing: a focused review and new approach to addressing safety in pharmacies and primary care. Res Social Adm Pharm. 2012; October 10.
29. Odukoya OK, Chui MA. Relationship between e-prescriptions and community pharmacy workflow. J Am Pharm Assoc (2003). 2012;52:e168-e174.
30. Rupp MT, Warholak TL. Evaluation of e-prescribing in chain community pharmacy: best-practice recommendations. J Am Pharm Assoc (2003). 2008;48:364-370.
31. Astrand B, Montelius E, Petersson G, Ekedahl A. Assessment of ePrescription quality: an observational study at three mail-order pharmacies. BMC Med Inform Decis Mak. 2009;9:8.
32. Gilligan AM, Miller K, Mohney A, et al. Analysis of pharmacists’ interventions on electronic versus traditional prescriptions in 2 community pharmacies. Res Social Adm Pharm. 2012;8:523-532.
33. Nanji KC, Rothschild JM, Salzberg C, et al. Errors associated with outpatient computerized prescribing systems. J Am Med Inform Assoc. 2011;18:767-773.
34. Smith M, Dang D, Lee J. E-prescribing: clinical implications for patients with diabetes. J Diabetes Sci Technol. 2009;3:1215-1218.
35. Lander L, Klepser DG, Cochran GL, et al. Barriers to electronic prescribing: Nebraska pharmacists’ perspective. J Rural Health. 2013;29:119-124.

To comment on this article, contact rdavidson@uspharmacist.com.