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Like his peers, Joel Gallant, MD, MPH, used to prescribe medications by pulling a pad from his pocket, writing the script, and handing the piece of paper to his patient. Today, while he continues to handwrite an occasional prescription, Gallant has switched to e-prescribing, and says he would never want to go back to relying on the old paper prescription pad.

Gallant, associate professor of medicine and epidemiology at The Johns Hopkins University School of Medicine in Baltimore, simply walks over to the exam room computer, pulls up the patient's name on the screen, and either clicks "refill" or chooses from menus of options to create a new prescription. The automated system sends the prescription, by fax with an electronic signature, to the patient's pharmacy.

"That way patients do not have to wait around for the drug when they arrive at the pharmacy, and there is no question of misreading handwriting. The doses of the drugs are shown to me as options, so I am not going to put down the wrong dose," Gallant says. He notes that the system can also alert physicians to possible drug interactions, a particularly important benefit for patients who are taking multiple medications.

Physicians prescribing electronically generally do so either through a handheld personal digital assistant (PDA) or from a computer terminal. Some e-prescribing systems, like Gallant's, transmit physicians' prescriptions directly to pharmacies, using e-mail or fax. Others electronically generate prescriptions but have not yet been set up to send scripts directly to pharmacies. 

Michael Saag, professor of medicine and director of the AIDS Center at the University of Alabama at Birmingham, has been using a form of e-prescribing since August 2004. At UAB, an electronic medical record system checks for errors and drug interactions and electronically prints prescriptions that doctors hand to patients.

"We have not yet gone to e-mailing pharmacies, but that is a relatively straightforward thing once we get it set up," Saag says.

Eliminating errors

The American Pharmacists Association is behind e-prescribing, according to Susan Winckler, RPh, vice president for policy and communications at the Washington D.C.-based trade organization. When transmitted by e-mail, prescription information can populate the pharmacy's dispensing software, eliminating data entry and the potential for transcription errors on the pharmacy's end, she says.

Gallant says there is no more guessing about handwritten or verbally delivered drug names that look and sound similar and are a major reason for prescribing mistakes (see chart, page 58). The problem of handwritten abbreviations is also eliminated by the e-option. "In an e-prescribing system you would look up the generic or brand name and it would be printed out, with no handwriting problems," he says. 

The fact that many systems alert physicians to possible drug interactions should also serve to cut down on prescribing errors.

Saag says that while he cannot say that switching to e-prescribing has saved anyone's life, he feels better about the decreased likelihood he will miss any potential drug interactions.

"It's a nice reminder about interactions," he says. "Every time we prescribe a new medicine, [our] system compares the new medicine to all other medicines that the patient is currently taking and will alert the provider to the nature of the interaction and the degree to which the interaction is a danger."

Promotes communication

Saag likes the idea that the system is educational for physicians.

"Every time one of those interactions comes up, it reinforces for the provider that the threat of interaction exists," he says.

Saag also appreciates that the system he uses scans for any conflict between a new medication and a patient's drug allergies or intolerance, and will not allow such prescriptions to be written without a physician override.

Some systems also offer educational information for patients. "If I'm writing a new prescription for a drug, I can click on that drug name and [receive a printout of] patient-oriented information that I can hand to the patient," Gallant says. 

As a convenience to patients and physicians, some e-prescribing systems will check health plan formularies to determine on the spot whether a drug is covered under a patient's plan.

Used correctly, e-prescribing could facilitate communication between pharmacists and physicians by providing more time for information sharing and reducing time spent on data entry, according to Winckler. "Prescribers should not assume that because they have e-prescribing they cannot call their pharmacist. If they have that clinical question, it is OK [to call]," she says.   

Here to stay

E-prescribing is not foolproof. "It actually introduces new sources of error, but it addresses some existing sources," Winckler says.

A recent study in the Journal of the American Medical Association looked at computerized physician order entry (CPOE) systems in facilitating medication errors. (E-prescribing generally refers to doctors prescribing from their offices, whereas CPOE is hospital-based and systemwide.)

The study found that a widely used CPOE system increased risk for 22 types of medical errors, including human-machine interface flaws, such as selecting the wrong patient file because names are listed close together, and selecting the wrong medications. According to Winckler, mistakes could also start at the software development stage if the wrong information about a drug or dosage is programmed into the system. An error like that could lead to not just one person getting the wrong dose, but widespread misprescribing.

As a result, experts say, physician and pharmacist diligence and clinical review are just as important with regard to e-prescribing as with handwritten prescriptions. Physicians need to keep updated patient medication lists so that they don't inadvertently renew inactive prescriptions. Users also should not assume that their systems provide services such as checking for drug interactions.

Health plans and the government are starting to push for e-prescribing, according to Peter R. Kongstvedt, MD, an internist and vice president at Capgemini Health, a healthcare consulting company based in New York City. "In the Medicare Modernization Act that was passed last year, there is a requirement that at some point in the future ... any company administering drug benefits for the new Medicare drug benefits [program] will have to have e-prescribing," Kongstvedt says. "Some health plans ... actually have programs to fund getting e-prescribing out there to the doctors."

Lisette Hilton can be reached at editor@physicianspractice.com.

This article originally appeared in the May 2005 issue of Physicians Practice.