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The Patient Safety Digest

E-Prescribing: New Opportunities, New Patient Safety Risks

In the old days, prescribing was easy. I would write down the patient’s name and drug information on a piece of paper and hand it to the patient. As I knew most of my patients and their medical conditions, the main risks were that my handwriting may be hard to read and I may have forgotten to fill all relevant fields. 

Following the encounter, the patients would take the prescriptions to their local pharmacist who would, in turn fulfill that prescription. The neighborhood pharmacist also knew most of the patients and their family, their medical conditions and chronic medications, and thus became an additional critical layer of safety, making sure the prescriptions I wrote were not unintentionally harmful to the patients. 

The intimate familiarity between the patient, the physician and the pharmacist was essential in ensuring patients are treated appropriately and are not harmed by their medications. The safeguards developed at that time to ensure safe prescribing consisted of clinical knowledge bases including dosage and drug-interaction guidelines, the blind-spot for many prescribers.

Today, some of the critical safeguards from the past are becoming extinct in today’s practice. As medical care becomes more fragmented, prescribers are less familiar with their patients and their chronic conditions. The local pharmacies are vanishing from our neighborhoods and are replaced by chains with pharmacists who may be less acquainted with the history of the patients they are treating. Without these safety nets - patients today are at a higher risk of medication related harm. 

In addition, although e-prescribing technology is empowered by dosage and drug-interaction decision support systems, it has introduced new and dangerous types of risks that decision support tools of the past are unable to catch, such as the ease by which prescribers can select the wrong drug from the medication list and prescribe the wrong drug by mistake, or as frequently happens (i.e. Telehealth), the prescriber prescribes when the patient is not present and may prescribe the drug to the wrong patient by mistake. 

Such dangerous errors did not exist in the past when we specifically wrote the name of the drug and physically handed the script to the patient. Moreover, current decision support tools are unequipped to mitigate these risks and thus these new emerging risks are unmitigated. 

E-prescribing has become the standard for most healthcare providers. With the COVID-19 pandemic, telehealth experienced massive growth. In 2019, only 11 percent of US patients used telehealth services according to McKinsey research. In 2020, 46 percent used telehealth technologies and 76 percent of patients are interested in using the technology going forward, as their normal engagement with physicians. Like many advancements seen in the last year, the trend towards virtual healthcare is expected to continue beyond the current pandemic. The $3 billion the United States is spending on virtualized healthcare is expected to grow to $250 billion before the COVID-19 pandemic is over.

One aspect of this trend is in how medications are prescribed, sent, and filled. While moving from manual prescriptions to e-prescriptions has the potential to reduce, if not eliminate, prescription errors, we are not yet at that point. E-prescription technology, coupled with smart and novel clinical decision support systems (CDSS) can minimize if not eradicate the new types of errors that e-prescribing creates.

E-Prescription Risks to Patient Safety

The efficiencies gained and advancements in healthcare technology demonstrate that there are a number of prescription errors that e-prescribing will aid in preventing. However, the new technology also presents new risks and eliminates many of the safety nets inherent to manual prescriptions. Here are a few of the main concerns healthcare providers will still be required to address:

Less Patient Interaction

Overall, telehealth creates less direct patient engagement  as providers see patients virtually instead of in the office. Moreover, providers are at times less acquainted with the patients they are treating virtually and don’t have the capacity and bandwidth to review their complete historical medical record to fully assess which medications are appropriate and which may be dangerous to these patients. To mitigate this risk, next generation decision support tools should be able to identify a wide variety of personalized medication related risks, taking into account the full medical record of the patient.

As the telehealth encounters are in many cases a “one off”, providers are lacking smart tools to enable automatic monitoring of the patients ensuring adverse drug events or emerging contraindications do not pose additional risks in their patients throughout the duration of therapy of the medications they prescribed.

Human Errors

A study of medication errors that are new or likely to occur more frequently with electronic medication management systems found the most commonly reported error types were “human factors” and “unfamiliarity or training”, accounting for 70 percent of errors. Writing an e-prescription comes with the increased potential for human errors ranging from clicking the wrong drug on a dropdown menu, making a typo, or mixing up patient information. 

This risk increases when physicians are unfamiliar or untrained with the e-prescription system. According to the study, lack of physician experience prescribing a specific medication caused three times as many prescription errors compared to prescribers with more experience with the medication.

Lack of Personal Pharmacy Care

Just a few years ago, it was common practice to fill your prescriptions with your local pharmacist who knew you, your family, and your medical history. If the prescription did not fit your usual treatment plan, your pharmacist could call the prescribing physician to confirm. He or she would be able to catch any irregularities in a prescription and correct any medication errors. This level of personalized medication delivery and inherent safety net is rarely found today and as such, pharmacists and providers are becoming more dependent on tools to fill in any knowledge gaps regarding medication safety and medication appropriateness. Today, most of us fill our prescriptions at big chain retailers that dispense hundreds if not thousands of prescriptions a day. The fact that pharmacists used to have a greater understanding of their customers’ medical history served as the “last mile”  of medication safety—ensuring the appropriate script was dispensed to the correct patient. This gap in patient safety must be replaced by a new safety net.

Lack of a Personalized Safety Net

In our current ecosystem medication delivery and access, the bulk of the responsibility pertaining to medication safety and medication appropriateness falls on the e-prescribing technology and drug-drug interaction (DDI) knowledge bases. Unfortunately, these solutions lack patient- and physician-specific context and are unable to provide oversight beyond the ordering or dispensing event. Even within the ordering workflow, the most sophisticated DDI solutions fail to catch typo errors or “right drug-wrong patient” errors.

With the technology supporting e-prescriptions and telemedicine becoming more complex and lack of interoperability within and across complex care environments, technology is too often part of the problem rather than part of the solution. Case in point: a common prescription error type is cross-encounter or hybrid system errors, found in 22 percent of medication-related incidents. As care environments become more decentralized, there will be an increased reliance on tools like e-prescribing and telemedicine to bridge the gap from traditional, qualitative in-person visits to quantitative, tech-enabled remote provider-patient visits. 

Need for Provider-Empowering Patient Safety Technologies

Rapid pharmacology advancements, a decentralized healthcare ecosystem, and overburdened providers can benefit from human-enabled technologies that empower clinical care teams to close the new patient safety gaps that are developing. Current solutions are static and based on limited rules and warning signs. In order to respond to e-prescribing risks that are more multidimensional, safeguards must learn and evolve as the patient’s health evolves.

The goal of a safety layer within the EHR, e-prescribing technology, and other health information systems should be to identify hard-to-anticipate risks. For example, if a physician has less experience working with the e-prescribing tool or prescribing the specific medication selected, this safety net can identify these additional risk factors and use them to create more personalized, accurate, and actionable alerts. As this additional data provides a deeper understanding of overall practices and prescription errors, more intelligent patient safety technologies can personalize the interventions to the patient and provider. 

Any healthcare technology advancement will create new opportunities while also creating new risks to patient safety. Rather than rely on existing rules and safety measures, next-generation clinical decision support systems need to learn the human side of these risks to help reduce errors.

Learn more about physician-related risks to patient safety such as fatigue and work overload, and how AI-enabled CDSS can help, in our latest eBook, “Understanding the Association Between Physician Fatigue and Prescription Errors.”


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