A Call to
Eliminate Handwritten Prescriptions Within 3 Years!
Electronic Prescribing Can Reduce Medication
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
Fax (215) 914-1492
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
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'
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
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!
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
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
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,
- 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.
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
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
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
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
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.
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
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
- 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
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.
Hand-held Electronic Prescribing Products
||NO. PHYSICIAN USERS*
|Autros Healthcare Solutions
|| Toronto, Canada
||Santa Ana. CA
||Mountain View, CA
||San Mateo, CA
|ParkStone Medical Information Systems
||Fort Lauderdale, FL
|Way Over the Line, LLC
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).
1. Touching the screen for a patient's name calls up the record.
2. Touching the screen for a diagnosis selects the patient's
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
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
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
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.
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
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
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!
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