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A Call to Action:
Eliminate Handwritten Prescriptions Within 3 Years!

Electronic Prescribing Can Reduce Medication Errors

First in a Series of White Papers from the Institute for Safe Medication Practices

Copyright © 2000 by the Institute for Safe Medication Practices. All rights reserved.

About the Institute for Safe Medication Practices

The nonprofit Institute for Safe Medication Practices (ISMP) was formally established in January 1994, but its efforts to prevent medication errors began far earlier, in 1975. The Institute works closely with healthcare practitioners (i.e., physicians, nurses, pharmacists), regulatory agencies, healthcare institutions, professional organizations, and the pharmaceutical industry to provide education about adverse drug events. ISMP is governed by a board of trustees representing a cross-section of the healthcare community, including medicine, community pharmacy, health system pharmacy, consultant pharmacy, academia, nursing, the pharmaceutical industry, professional healthcare organizations, managed care, healthcare consumers, and healthcare administration and medical communication.

Under an agreement with the U.S. Pharmacopeia (USP) in Rockville, Maryland, ISMP provides independent review of all reports voluntarily submitted to the USP Medication Errors Reporting Program (MERP), which ISMP founded. Many journals and newsletters regularly publish ISMP error advisories and safety alerts. ISMP's own newsletter ISMP Medication Safety Alert! is distributed every 2 weeks to U.S. hospitals and 30 countries internationally. ISMP's web site (www.ismp.org) contains extensive information on medication errors, including a comprehensive bibliography.

Institute for Safe Medication Practices
200 Lakeside Drive, Suite 200
Horsham, PA 19044
(215) 947-7797
Fax (215) 914-1492
www.ismp.org

Publication Development
This publication was prepared for press by Calibre Publishing, Inc., and designed by Two Spruce Design, both of Minneapolis, Minnesota. Development and distribution were made possible through an unrestricted educational grant from Allscripts, Inc., Libertyville, Illinois.

The views expressed herein represent those of the Institute for Safe Medication Practices and not those of the publisher or sponsor; neither ISMP nor any of its employees has received any payment.

Executive Summary

Medication errors became front page news with the November 1999 release of a compelling report from the Institute of Medicine (IOM). The public may have been surprised to learn that errors involving prescription medications kill up to 7,000 Americans a year, according to the IOM, and that the financial costs of drug-related morbidity and mortality may run nearly $77 billion a year.

But the problem of medication errors is not new. In fact, research demonstrates that injuries resulting from medication errors are not the fault of any individual healthcare professional, but rather represent the failure of a complex healthcare system. System failures can be analyzed and prevented, many through emerging information technology (I.T.) solutions.

In the medication management system, errors can be introduced at multiple points. Numerous problems are related to the naming, labeling, and/or packaging of drugs or to inefficient distribution practices. Patients often contribute to errors by failing to comply with instructions. Many errors occur as prescriptions are written; these tend to be failures of communication and, in far too many cases, the underlying problem is clinicians' handwriting.

The healthcare industry has been slow to adopt new technologies, although these tools hold promise for enhancing the delivery of healthcare. Prescription writing is perhaps the most important paper transaction remaining in our increasingly digital society; it seems simplistic to note that electronic prescribing tools could minimize medication errors related to handwriting. Yet even though such devices are available for use in hospitals, ISMP estimates that less than 5% of U.S. physicians currently "write" prescriptions electronically.

The hurdles until very recently have been clinicians' reticence about computers, a lack of hardware and software that would conveniently allow prescribers to select medications electronically, and fear of the costs associated with such technology. Fortunately, the advent of wireless hand-held devices is making it increasingly possible to solve the "handwriting crisis," perhaps on all 3 counts.

Technology: Promise, Not Panacea

Easy-to-use point-of-care systems, some that offer comprehensive applications in real time, are becoming available from a number of manufacturers-and at perhaps a surprisingly low cost of entry. Such integrated programs may provide benefits for cost and risk management as well as for clinical care, and they may enhance the prescribing process beyond addressing penmanship alone. For example, hand-held devices can alert practitioners to potential drug or allergy interactions via up-to-date databases of medications that are connected with patient records. That kind of functionality should help to rapidly expand adoption of electronic prescribing among practitioners.

Of course, computerized medication management systems certainly are not a panacea. Moreover, clinicians' use of hand-held technology will not solve the broad spectrum of medication errors, for technology is but one part of a larger solution that includes such simple and low-tech strategies as separating look-alike medications in a dispensing cabinet.

A Call to Action

Still, while technology does not offer a perfect solution, ISMP does believe that technology, if appropriately and aggressively used, holds great promise for researching, identifying, reporting, and reducing medication errors. In particular, ISMP believes that electronic prescribing-with proper systems design, implementation, and maintenance-can contribute significantly to the prevention of medication errors today. There is no reason to wait for legislative activity or task forces to insist that this capability be utilized as fully as possible.

Put simply, handwritten prescriptions ought to be a thing of the past. Healthcare practitioners and providers across the nation should rapidly and aggressively take advantage of the electronic prescribing technology that can help prevent medication errors today. The need is urgent. As such, a serious public health problem calls for a bold goal: Let's eliminate handwritten prescriptions by 2003!

Medication Errors:
A Compelling Public Health Issue

The subject of medication errors has become front page news. President Clinton put the issue on the media map during a press conference in December 1999. The catalyst: a report from the Institute of Medicine (IOM) documenting that these errors have unacceptably high costs, in both human and economic terms, especially since medication errors are almost completely preventable.

The IOM is a nonprofit institution that provides health policy advice under a congressional charter. The report is significant because it represents the consensus of leading experts in the healthcare community. It addresses many kinds of medical errors, including diagnostic and surgical mistakes, which could cost as many as 98,000 American lives each year. In addition, medical errors cost society billions of dollars in unnecessary healthcare expenditures, not to mention the costs related to disability and lost productivity.

The report notes that medication-related errors alone constitute a sizable problem. Errors related to medication orders and prescriptions and to administration of medications kill up to 7,000 Americans annually, both in and out of hospitals. These errors actually cause more deaths each year than workplace injuries, which have long received considerable public scrutiny. One estimate places the annual national cost of drug-related morbidity and mortality in the outpatient setting as high as $76.6 billion.

Not a New Phenomenon

Understandably, such dramatic statistics inspired immediate responses from the media, the federal government, and a wide range of healthcare interests. But despite this recent outcry, the problem of medication errors is not at all new. Healthcare researchers have been examining the causes of these errors for a quarter-century, and they have been identifying ways to minimize inadvertent and, thus, preventable errors. Many healthcare groups have called attention to the issue (see table 1). For instance, the Institute for Safe Medication Practices (ISMP) began its work with preventing medication errors in 1975; thus, the Institute is pleased that the issue has finally come to fuller public attention. Indeed, at the pivotal White House press conference on December 7, 1999, the president of ISMP joined President Clinton and the president of the American Hospital Association in corroborating the IOM conclusions. The two organizations also unveiled a new partnership, one designed to create an inventory of best practices for reducing medication errors in hospitals and healthcare systems.



Table 1.

Medication Safety Resources
The following organizations offer additional information on the causes of and preventive strategies for medication errors.
Agency for Healthcare Research and Quality www.ahrq.gov
American Hospital Association www.aha.org
American Pharmaceutical Association www.aphanet.org
American Society for Healthcare Risk Management www.ashrm.org
American Society of Health-System Pharmacists www.ashp.org
Food and Drug Administration www.fda.gov
Institute for Healthcare Improvement www.ihi.org
Institute for Safe Medication Practices www.ismp.org
Institute of Medicine www.iom.edu
Joint Commission www.jointcommission.org
Massachusetts Coalition for the Prevention of Medical Errors http://www.macoalition.org/
National Coordinating Council for Medication Error Reporting and Prevention www.nccmerp.org
National Patient Safety Foundation www.npsf.org
U.S. Pharmacopeia www.usp.org



Hospitals represent one critical area where errors occur, but medication errors among outpatients are an even more insidious concern. The President launched a number of initiatives that should help address both arenas. In particular, he assigned a task force to identify ways to accommodate the IOM recommendations; by the end of February 2000, he had approved its "national action plan." Among the key features: a $20 million Center for Quality Improvement in Patient Safety to serve as a clearinghouse on medical errors, a requirement that hospitals participating in Medicare have patient safety programs in place, and a challenge to the Food and Drug Administration (FDA) to develop new standards for drug packaging and labeling.

Both the IOM report and the task force findings suggest that curtailing medication errors will demand a variety of approaches. Certain initiatives, such as whether to rely on mandatory vs. voluntary reporting systems, will be debated for some time to come. Others will take time to implement fully but show tremendous potential; in this context, the promise of information technology (I.T.) as a means of reducing errors deserves greater attention. Indeed, in his February remarks, the President referred to computerized systems for generating prescriptions-a capability generally referred to as electronic prescribing.

Healthcare has lagged behind other industries in adopting digital tools, but in the past 2 to 3 years, the emerging field of healthcare informatics has produced an array of new applications that could streamline healthcare delivery on many fronts. Computerized solutions are being developed not only for scheduling appointments and tracking billings, but also for exchanging medical records (including laboratory results and diagnostic data such as x-rays), enhancing clinical decision-making, and improving patient education. I.T. has not as yet been uniformly embraced, however, partly because a lack of technical standards has slowed data exchange and partly because many hospitals and clinics are wary of the costs and/or logistical challenges posed by connecting or upgrading their existing networks and workstations.

Nevertheless, the shift toward technology is under way in healthcare. With regard to medication errors, computers are being called upon to solve problems related to drug distribution, naming, packaging, labeling, and storage. Hospitals and pharmacies increasingly are taking steps to automate the dispensing of drugs and minimize errors through technology, including the implementation of system-wide networks, bar coding, and even robotics. Prescription fulfillment systems have been in place in some hospitals for several years, although usage still is not widespread.

One of the key pieces missing in the fight to prevent medication errors has been automation of the prescribing function itself. Electronic prescribing represents a class of technology that could improve patient safety at the point of care, especially as hand-held wireless devices are harnessed for this purpose. That is one reason, though not the only one, why ISMP feels strongly about bringing this solution to the public consciousness. Electronic prescribing, if used appropriately, can have a powerful impact on medication errors in the short term.

What Is a Medication Error?

In order to evaluate the potential of electronic prescribing, it is important to first go through the reasons for medication errors. A few definitions are in order: The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) defines a medication error as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice; healthcare products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use." In other words, a medication error is any deviation from an order for a drug as prescribed by a licensed clinician, such as a physician, physician's assistant, or nurse-practitioner. The error can be one of planning (for example, if an improper dosage is selected) or one of execution (the prescriber's intentions are misunderstood). Errors can be made at any point during the process of prescribing and executing a prescription.

A medication error may or may not result in an adverse drug event, which is an injury to a patient resulting from the medical intervention itself, not from the underlying condition for which the intervention was prescribed. It is crucial to note two truths:

  • Most medication errors have little potential for harm, and
  • most adverse drug events (ADEs) are not preventable, given what we know today.

Nevertheless, as the IOM report makes plain, every error is potentially tragic and costly, not only for the patient but for the healthcare professionals involved. This is particularly true, of course, when the error could have been prevented.

Disconcerting Statistics

To date, most research on the prevalence of medication errors and ADEs has focused on error rates in acute-care settings. One noteworthy study found that adverse drug events occurred at a rate of 6.5 per 100 admissions.(1) And a study of two prestigious teaching hospitals determined that 2 of every 100 patients admitted experienced a preventable adverse drug event, resulting in average increased hospital costs of $4,685 for each affected patient.(2) Annualized, that figure represents $2.8 million for a 700-bed hospital. If these findings are generalizable to the nation, the increased hospital costs of preventable ADEs affecting inpatients alone are about $2 billion a year.

Moreover, these figures exclude medication errors that lead to hospitalizations and outpatient events. After all, inpatients represent a small proportion of patients at risk; many more patients are seen in ambulatory care settings such as physicians' offices, clinics, urgent care centers, nursing homes, and home health services. Thus, these expense estimates probably only modestly reflect the toll of medication errors. Further research is needed to understand the scope of the situation.

Indeed, one of the few studies to investigate outpatient error rates suggests that the number of outpatients who suffer medication errors may be on the rise.(3) An examination of U.S. death certificates during a 10-year period ending in 1993 found that fatal medication errors had increased 2.6-fold. Among outpatients, the number increased 8.5 times. Such statistics are especially disturbing since the cause of death may be attributed solely to whatever physiological outcome was produced by the error and not to the error itself.

In addition, there is evidence to suggest that ADEs generate a considerable number of admissions to hospitals, perhaps as many as 11%, but it is difficult to know how many of these can be traced to medication errors. It is an understatement to say we need additional research on the epidemiology of medication errors. Yet it is not difficult to believe consumer advocates such as Thomas J. Moore, author of Prescription for Disaster, who claims that Americans are 10 times more likely to be hospitalized by a prescription drug than by an automobile accident.

System Failures Cause Errors

Members of the public typically surmise that medical errors are the fault of an individual (and incompetent) physician, nurse, or pharmacist. But as the IOM report makes clear, medication errors are not the fault of any one healthcare professional, but rather represent the failure of a complex healthcare system. Accidents tend to result from a series of failures in the medical management system (see figure 1), rather than from negligence on the part of a single practitioner.

The very title of the IOM report-To Err Is Human: Building a Safer Health System-suggests we need a systems approach for addressing medication errors. As President Clinton pointed out: "Ensuring patient safety is not about fixing blame. It's about fixing problems in an increasingly complex system, about creating a culture of safety."

The good news is that system failures can be analyzed and addressed, as evidenced by successes in the aviation and automobile industries. ISMP has promoted the use of an error-prevention technique called failure mode and effects analysis (FMEA), which has long been used in these other industries. The goal is to pinpoint areas in the process of medication therapy where the system is most likely to fail, so that the effects of failures can be predicted and effective safeguards implemented. Important areas of scrutiny are the processes, tasks, training, and conditions within the system that make errors more likely.

A System in Overload

Many factors complicate the seemingly straightforward process of prescribing and taking medications. First and foremost is the sheer number of drugs, which has grown 500% in just the last decade. The FDA approved a record-breaking 122 chemical compounds in the last 3 years, and that figure does not include new indications for existing drugs. There are more than 17,000 trade and generic names for pharmaceuticals marketed in North America, and the number of new entities in the R&D pipeline continues to climb. Furthermore, drug labeling changes constantly. Thousands of pages of detailed drug information are released every month across the United States. The FDA can post as many as 20 safety-related changes a month.

The situation is exacerbated by poor nomenclature practices. An astonishing number of prescription medications have names that are spelled ("look alikes") or pronounced ("sound alikes") in similar ways, yet they have completely different pharmacologic actions. Inadvertently mixing them up can have serious implications for a patient. Consider this example: Celebrex, indicated for arthritis; Celexa, prescribed for depression; and Cerebyx, an epilepsy drug. And we now have two products whose names are pronounced exactly the same: Lamicel and Lamisil. The first is a cervical dilator, and the latter is an antifungal agent.

Packaging is another source of confusion. Many drugs are distributed in packages and/or containers that have similar shapes, color schemes, or type faces. Such similarities can confound workers operating in healthcare environments already laden with stressors. Ergonomic factors such as poor lighting, interruptions, and noise and other distractions set the stage for a wrong drug to be pulled mistakenly from a crowded inventory shelf. We do not know the true frequency of such errors because, in current systems, many are never detected.

The scenario is worsened by the trend in many institutions to reduce staffs and budgets. The personnel who are left must care for more-and sicker-patients. Doctors themselves have been facing increased pressures from managed care organizations or from their own office managers to see more patients in less time.

The volume of prescriptions also exacerbates the situation. Figures from the National Wholesale Druggists' Association show that in 1998, nearly 2.5 billion prescriptions were dispensed by U.S. pharmacies. The National Association of Chain Drug Stores estimates the number will reach 4 billion by the year 2005.

Why are prescriptions increasing? Pharmaceuticals are, on the whole, beneficial; they can be lower-cost alternatives to surgery and hospital care. With the aging of America, more and more patients are taking multiple drugs for chronic conditions. Plus, younger patients are taking drugs for longer periods of time; many of these are the so-called lifestyle drugs used, for example, to curb cholesterol, treat depression, or improve sexual function. Direct-to-consumer advertising of prescription products now tops $1 billion a year, driving demand for specific brand name products.

Patients themselves often are involved in medication errors, simply by failing to comply with their instructions. They may choose not to fill a prescription or fail to take it as directed. They may stop taking a drug before the entire course has been completed. Noncompliance is a profound problem; estimates vary, but somewhere between 50% and 90% of all patients do not take their medications according to recommended instructions. Close to 20% of all prescriptions are never filled.

A Handwriting Crisis

One fundamental source of medication errors arises out of the very act of handwriting prescriptions. These errors tend to be failures of communication between the prescriber and the nurse and/or pharmacist who must fill the order. In far too many cases the underlying problem is clinicians' handwriting (see figure 2). Many jokes have been made about doctors' sloppy penmanship, but illegibility is no laughing matter. Virtually all of the prescriptions issued each year in the United States are written by hand. Indecipherable or unclear prescriptions result in more than 150 million calls from pharmacists to physicians, asking for clarification, a time-consuming process that could cost the healthcare system billions of dollars a year in wasted time. At the very least, that process can delay the time until patients receive their medications. At worst, a misread order can lead to injury or even death.


Handwriting picture
Figure 2.
In far too many cases of medication errors, the underlying problem is prescribers' handwriting. In this example, the physician prescribed Avandia, a diabetes drug. But it was read as Coumadin, a blood thinner. Many jokes have been made about doctors' sloppy penmanship, but illegibility is no laughing matter. Virtually all of the 3 billion prescriptions issued each year in the United States are still written by hand.

An incorrect understanding of the intended drug, dosage, or route or frequency of administration can quite obviously produce a medication error-not to mention an adverse drug event. Given some doctors' hurried scribbles, it may be hard for dispensers to tell whether a zero is preceded by a decimal point or not; if the decimal is misread, the dose ultimately given may be off by an order of magnitude, and the result could be a 10-fold overdose. Poor handwriting can blur critical abbreviations for weights, volumes, or units; mg may be confused with mg, again leading to an overdose. An order marked as "qd" (once a day) might be read as "qid" (4 times a day). A complete table of frequently misunderstood (hazardous) abbreviations is available.(4)

Enter: Electronic Prescribing

While the medical community has made efforts to curb the odds of misinterpretation of handwritten prescriptions, prescription writing remains one of the last and perhaps most important paper transactions in our increasingly computerized society. Most clinicians still write prescriptions by hand, utilizing memory for drug names, dosage strengths, and directions. It is an archaic system, and it is time to change it-by automating the prescribing function.

Indeed, several recent studies in hospitals have shown that physicians who use a computer order entry program witness improvements in medication error rates. One noteworthy example found a 55% reduction in errors with potential for harm; the program greatly reduced the need for transcription, and it minimized misinterpretations caused by illegibility.(5) In a study of intensive care patients, a computerized system helped physicians reduce the incidence of allergic drug reactions and excessive drug dosages by more than 75%; the average time patients spent in the unit dropped from 4.9 days to 2.7, slashing costs by 25%.(6) Yet another study concluded that medication errors, though common, result in relatively few ADEs, but those that do result in ADEs are preventable-through physician computer order entry.(7)

Not Just for Handwriting

In light of such promising results with inpatients, it is logical to assume that many additional medication errors could be avoided if clinicians harnessed electronic prescribing tools for their ambulatory care practices as well. It is highly likely that the poor handwriting that causes ADEs would be eliminated, and proper terminology would more likely be used.

But computerized order entry is only part of the solution. To be truly effective in reducing medication errors, electronic prescribing must offer even more capabilities and stop errors at additional points in the medication management system. With so many drugs available and so many patients taking concurrent medications, the opportunity for ADEs has never been greater, especially when some patients see a variety of specialists who may be unaware of what their colleagues have already prescribed.

Integrating patient and drug information for electronic prescribing offers invaluable benefits to practitioners and other healthcare constituents, such as pharmacists and managed care providers. Among these benefits are the following:

  • Computers can maintain accurate, unbiased, and up-to-date drug databases, which constitute essential tools as the number of approved medications continues to increase.
  • Prescribers can receive on-screen prompts for drug-specific dosage information, with reminders to ensure that look-alikes and sound-alikes are not confused.
  • Vital patient-specific information, such as overdose warnings, drug interactions, and allergy alerts, can be presented in the course of prescribing, so that potential ADEs that would otherwise go unrecognized can easily be avoided.
  • Computers can reduce, even eliminate, the margin for error by flagging pre-existing medical conditions or concurrent medications that would preclude use of certain drugs in individual patients.
  • Electronic prescribing can expedite refill requests, once patients are entered into the system.
  • Computers can facilitate data exchange to enhance teamwork between clinicians and professionals who represent other parts of the medication management system, such as pharmacists in retail, hospital, and online environments; pharmacy benefit managers (PBMs); and health plans.
  • Computers can enable practitioners to stay abreast of changes in formularies and insurance coverage.
  • The use of computers can reduce healthcare costs through time and efficiency savings and by encouraging prescribers to consider lower-cost drug options.

Hand-held Technology at the Point of Care

Still, electronic prescribing has not yet become standard operating procedure in offices and clinics, partly because clinicians have been notoriously slow to embrace digital applications for any purpose and partly because providers have feared the high costs typically associated with technology. In addition, until very recently, appropriate hardware and software simply did not exist to allow practitioners to electronically select medications as a natural part of their workflow. However, that has changed with the advent of wireless technologies.

The hand-held electronic prescribing units that now are available typically utilize radio frequency, cellular, or infrared signals to communicate with an on-site server or a PC-based Internet connection. Patient and drug information is available confidentially to practitioners in real time. An electronic prescription can be entered directly into a computer, then electronically transmitted to a pharmacy-at the hospital, in a local retail store, to a mail order outlet, or to a virtual pharmacy on the Internet-or perhaps be provided right in physicians' offices. The entire process is far less time-consuming than the current paper-based system.

Portability is a distinct benefit of such devices. Physicians, in particular, are mobile, so they need a system that allows them to input prescriptions at the point of care. Wireless devices allow clinicians to bring computers into their workflow, as opposed to reengineering the workflow to suit the technology. It also helps that most of the units are easy to use.

Electronic tools are being put to use for all manner of clinical tasks, including but not limited to automating and integrating the prescription-generating process. Other applications include provisions for medical histories, ICD-9 coding, clinical alerts, drug utilization reviews, and formulary compliance. Some programs allow prescribers to order laboratory tests, capture charge information, or refer patients to specialists, while ensuring security and privacy of records.

That kind of functionality should help to rapidly expand adoption of electronic prescribing among practitioners. ISMP is heartened by recent estimates from industry analysts that suggest 10% to 15% of physicians are trying hand-held computers, with the number higher (perhaps 60% to 70%) among doctors in training who have come of age in a computer-oriented culture.

Not Science Fiction

Hand-held technology and electronic prescribing systems are in the early stages of adoption, yet they are an important and viable tool available to prescribers right now. Widespread adoption could well prevent many medication errors.

A number of companies are bringing hand-held electronic prescribing systems to market. The first company to introduce this technology to the clinical setting was Allscripts, Inc. Other vendors with hand-held products in development, beta testing, or roll-out include Autros Healthcare Solutions, DocPlanet.com, ePhysician, iScribe, Notre, ParkStone Medical Information Systems, Way Over the Line, LLC, and Wireless MD (see table 2). The IOM report will, no doubt, spur even greater activity and innovation.

Vendors of Hand-held Electronic Prescribing Products
COMPANY NO. PHYSICIAN USERS* HEADQUARTERS WEB ADDRESS
Allscripts, Inc. 2,000 Libertyville, IL www.allscripts.com
Autros Healthcare Solutions ** Toronto, Canada www.autros.com
DocPlanet.com *** Santa Ana. CA www.docplanet.com
ePhysician *** Mountain View, CA www.ephysician.com
iScribe *** San Mateo, CA www.iscribe.com
Notre >100 Philadelphia, PA www.notre.net
ParkStone Medical Information Systems >300 Fort Lauderdale, FL www.parkstonemed.com
Way Over the Line, LLC *** Montgomery, OH www.wayovertheline.com
Wireless MD *** Woodstock, GA www.wirelessmd.com
*
As of 12/31/99
**
In-patient application only;
no U.S. installations yet
***
Scheduled for release in 2000

The products introduced so far share certain characteristics, although they also have distinguishing features. They tend to utilize accepted hardware such as Casio's Cassiopeia, the Hewlett-Packard Jornada, or 3Com Corporation's PalmPilot line. The typical operating system is Windows CE or Palm OS. (The Palm series is not real time-enabled, however.) The devices also tend to be easy to use. Many prescribers can master the basics in half an hour, largely through point-and-click software. (In the past, a deterrent for many doctors has been their unwillingness to type.) One illustrative system permits prescriptions to be generated in as few as 3 keystrokes (see figure 3).

Figure 3.

1. Touching the screen for a patient's name calls up the record.

2. Touching the screen for a diagnosis selects the patient's illness.

3. Touching the screen for the medication completes the prescription.

Hand-held computers offer clinicians-for the first time-the ability to harness technology right at the point of care. Many can master the basics in half an hour due to point-and-click software. In this example, a prescription can be generated in as few as 3 touches; the process takes less than 15 seconds.

It should be noted that hand-held solutions do not constitute the only approach to electronic prescribing. Very recently, a number of newly launched Internet companies have introduced online pharmacy fulfillment services containing, in part, a prescribing feature linking practitioners to dispensing facilities across the country. They are not considered in this document because it is too early to gauge how practical these systems will be.

Traditional I.T. vendors also have entered this market, largely with PC-based solutions that work within the framework of a larger suite of clinical application modules. Such systems currently require practitioners to return to a workstation to input orders and, as a result, are less convenient because it is harder to use them at the point of care. Furthermore, in many cases these solutions rely on proprietary software, which may limit their value in an ever-changing technology scene.

Some suppliers offer electronic prescribing solutions via multiple platforms. The most desirable systems should offer both the best speed and applications that fit most seamlessly into prescribers' natural workflow. Coming enhancements should enable the creation of clinical data repositories that will allow more sophisticated analyses of drug utilization and therapeutic outcomes. Electronic prescribing may even help improve patient compliance; using computers, it might be possible to track whether patients fill and actually take prescribed medications.

Cost Considerations

While it is beyond the scope of this document to consider cost in great depth, it is probably safe to say that clinicians can obtain electronic prescribing capability at what may be a surprisingly low cost of entry. Moreover, in ISMP's view, the cost of such technology is far outweighed by the benefits hand-held devices offer in preventing the tragic human toll and devastating financial costs associated with medication errors.

Creative strategies are in development for helping providers and healthcare institutions deal with the cost issue. One successful model involves a relatively low monthly subscription fee for access to a broad range of electronic prescribing capabilities. This fee may well be offset entirely by other savings realized through use of the technology, such as reducing the number of call-backs from pharmacists and streamlining the dispensing process. Another model might be to have the use of electronic prescribing tools underwritten by a third-party stakeholder, such as a pharmacy, PBM, or pharmaceutical manufacturer. These strategies are worth exploring if they lead to more prescribers embracing the technology without lessening their control of the prescribing process.

Managing Risks

Even the greatest technology is of no value if it is not used. It is likely that clinicians, given their reticence about computers and the related costs, will need a clear incentive to spur greater use of electronic prescribing. An appropriate incentive may well be the potential ability of this technology to address long-standing concerns in the area of malpractice.

According to the Physician Insurers Association of America, the average indemnity payment for claims related to medication errors between 1985 and 1992 was nearly $100,000. Medication error claims settled out of court may involve much higher amounts. In October 1999, a cardiologist in Texas was ordered to pay $225,000 to the family of a patient who died after receiving Plendil instead of Isordil; the pharmacist could not read the prescription. Medication errors related to misinterpreted physicians' prescriptions were the second most prevalent and expensive claim listed on 90,000 malpractice claims filed over a recent 7-year period; the same report noted that computers are playing a major role in solving the "handwriting problem." For that reason alone, electronic prescribing could well help mitigate malpractice risk. In fact, if technological solutions to aid in prescription writing indeed exist, is it a stretch of the imagination to assume that courts might soon begin challenging physicians to explain why they are not using the available technology to improve the safety of the prescription process?

Another potential incentive is related to formulary management. Formularies play a role both in preventing medication errors and in curbing costs. Prescribing formulary medications ensures that all healthcare workers within a particular institution are familiar with the medications and, thus, less likely to make errors dispensing or administering them. However, because patients belong to so many different health plans, it is difficult for prescribers to stay abreast of which formulary a specific plan has. A possible solution lies in the fact that electronic prescribing systems can maintain multiple lists of approved medications, while also suggesting less expensive generic or therapeutic alternatives. (In one of the few outpatient assessments so far, Ernst & Young analyzed a physician practice management company in San Antonio, Texas, and reported savings of more than $80,000 in total pharmacy costs in just one clinic through electronic prescribing.)

No Perfect Solutions

There are no perfect solutions for any area of human endeavor, and computerized medication management systems certainly are not a panacea. Clinicians' use of hand-held technology will not solve the broad spectrum of medication errors, for technology is but one part of a larger solution that includes such simple and low-tech strategies as separating look-alike medications in a dispensing cabinet.

To put it bluntly, computers cannot be a foolproof solution, because they are only as good as their designers and end users. This was amply demonstrated in a study conducted by ISMP in 1998; pharmacists nationwide were asked to process a hypothetical prescription using their hospitals' computer systems. The sobering result: Up to 67% of the computer systems functioning in those hospitals processed a series of fatal overdoses without any on-screen warnings. And the human factor will always be present, even if such warnings appear. Experience shows that even with computer assistance, problems in prescribing still occur. For instance, clinicians may overlook warnings. They may choose to ignore or "de-select" certain options or choose to rely on their own experience instead of taking guidance from the computer. Or the clinical data itself may not be updated in the computer as often as necessary.

A Call to Action

Still, while technology is not a perfect solution for the problem of medication errors, ISMP does believe that technology, if appropriately and aggressively used, holds great promise for researching, identifying, reporting, and reducing medication errors. In particular, ISMP believes that electronic prescribing-with proper systems design, implementation, and maintenance-can contribute significantly to the prevention of medication errors.

In October 1999, shortly before the IOM report was released, the American Society of Health-System Pharmacists reported the results of a telephone survey showing that 61% of respondents worried about being given the wrong medication and 58% worried about drug interactions. As healthcare business leaders, legislative and regulatory health policymakers, insurers, healthcare practitioners and providers, and healthcare advocates, we must all work together to address these very real fears. We can allay patients' fears only by taking action, both over time and in the short term. We can take a significant action today by fully utilizing the technology available to us.

We do need more research into the epidemiology of medication errors, and we hope that various initiatives to reduce errors will gain strength from the recent surge of public interest. In the meantime, we can help reduce errors right now by fully adopting technological advances. It is tragic and costly to delay.

Put simply, handwritten prescriptions ought to be a thing of the past. Healthcare practitioners and providers across the nation should rapidly and aggressively take advantage of the electronic prescribing technology that can help prevent medication errors today. According to the IOM, it would be irresponsible to expect anything less than a 50% reduction in medical errors over the coming 5 years. The need is urgent, and such a serious public health problem calls for a bold goal: Let's eliminate handwritten prescriptions by 2003!

References

1. Bates DW, Cullen DJ, Laird N, et al: Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995;274:29-34

2. Bates DW, Spell N, Cullen DJ, et al: The costs of adverse drug events in hospitalized patients. JAMA 1997;277:307-311

3. Phillips DP, Christenfeld N, Glynn LM: Increase in U.S. medication-error deaths between 1983 and 1993. Lancet 1998;351:643-644

4. Cohen MR (ed): Medication Errors. American Pharmaceutical Association, Washington, DC, 1999

5. 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

6. Evans RS, Pestotnik SL, Classen DC, et al: A computer-assisted management program for antibiotics and other anti-infective agents. N Engl J Med 1998;338:232-238

7. Bates DW, Boyle DL, Vander Vliet MD, et al: Relationship between medication errors and adverse drug events. J Gen Intern Med 1995;10:199-205

Selected Readings

Bates DW, Miller EB, Cullen DJ, et al: Patient risk factors for adverse drug events in hospitalized patients. Arch Intern Med 1999;159:2553-2560

Bates DW, Teich JM, Lee J, et al: The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999;6:313-321

Berwick DM, Leape LL (eds): Special theme issue on patient safety and medical error. BMJ 2000;320:March 18

Brodell RT, Helms SE, KrishnaRao I, et al: Prescription errors: legibility and drug name confusion. Arch Fam Med 1997;6:296-298

Cabral JD: Poor physician penmanship. JAMA 1997:278;1116-1117

Classen DC, Pestotnik SL, Evans S, et al: Adverse drug events in hospitalized patients. JAMA 1997:277;301-306

Cohen MR: Drug product characteristics that foster drug-use-system errors. Am J Health-Syst Pharm 1995;52:395-399

Evans RS, Pestotnik SL, Classen DC, et al: Preventing adverse drug events in hospitalized patients. Ann Pharmacother 1994;28:523-527

Johnson JA, Bootman JL: Drug-related morbidity and mortality: a cost-of-illness model. Arch Intern Med 1995;155:1949-1956

Kohn LT, Corrigan JM, Donaldson MS (eds): To Err Is Human: Building a Safer Health System: a report from the Committee on Quality of Healthcare in America, Institute of Medicine, National Academy of Sciences. National Academy Press, Washington, DC, 1999

Leape LL: A systems analysis approach to medical error. J Eval Clin Pract 1997;3:213-222

Moore TJ: Prescription for Disaster: The Hidden Dangers in Your Medicine Cabinet. Simon & Schuster, New York City, 1998

Schiff GD, Rucker TD: Computerized prescribing: building the electronic infrastructure for better medication usage. JAMA 1998;279:1024-1029

Tierney WM, Miller ME, Overhage JM, et al: Physician inpatient order writing on microcomputer workstations. JAMA 1993;269:379-383

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