Doctors’ Orders

Better Electronic Prescribing Systems Could Improve Care

By Douglas S. Bell and C. Jason Wang

Douglas Bell is an associate natural scientist at RAND and an assistant professor in the department of medicine, David Geffen School of Medicine, University of California, Los Angeles (UCLA). Jason Wang is a doctoral fellow at the Pardee RAND Graduate School and a National Research Service Award fellow and pediatrician at UCLA.

In December 2003, a physician inadvertently prescribed daily dosages of a powerful cancer drug for a 79-year-old woman with arthritis. The drug, methotrexate, can indeed be used to relieve arthritis — but for arthritis, the medication should be taken once or twice a week, not daily. The error was discovered only after the woman had taken the drug for nine consecutive days. That was too late. She subsequently died.

Such errors are all too common. Medical patients today are at serious risk of injury from medication errors. Typical errors include dispensing the correct medication in the wrong dosage or frequency, as described above, or dispensing an incorrect medication whose name sounds similar to the correct one.

Fortunately, the use of a new technology, called electronic prescribing, has the potential to reduce medication errors substantially and to improve the efficiency of health care. With electronic prescribing, doctors use computers containing extensive drug information to help them select and prescribe proper medications for particular conditions. Electronic prescribing systems are part of a new trend in health care toward the adoption of electronic medical record systems, or computerized versions of paper health records.

A number of electronic prescribing systems are in operation around the world today. However, no attempt has been made to standardize how they work or to ensure that they fulfill their promise of minimizing the risk for medication errors, maximizing patient safety, and helping consumers manage their drug costs.

The Medicare Modernization Act of 2003, which enacted a prescription drug benefit for Medicare recipients, also mandated that safety standards and other guidelines be developed for electronic prescribing systems. Accordingly, we at the RAND Corporation convened an expert panel that created a set of 60 proposed guidelines — or recommendations for guidelines. We then used the recommendations to test how well some of the electronic prescribing systems are working today in typical doctors’ offices.

Our key findings are as follows:

• Electronic prescribing systems could greatly reduce medication errors, thereby maximizing patient safety and health.
• Computerized menus that aid in selecting appropriate medication doses and other medication characteristics are important tools for maximizing patient safety and health.
• Currently, electronic prescribing systems vary widely in their features and capabilities and might not produce the best results for patient safety and health. Nonetheless, hospitals and physicians’ offices should be able to implement about two-thirds of our recommendations for better systems within the next three years.

Many Preventable Errors

The medical term for an injury that results from medication is an “adverse drug event” (ADE). ADEs caused by errors are called “preventable ADEs.” Estimates of the likelihood of suffering a preventable ADE vary from a low of 1 in 200 hospitalized patients to a high of 1 in 33 patients seen at doctors’ offices. The percentage of preventable ADEs considered serious, life threatening, or even fatal also varies — from about 10 percent in one study to 100 percent in another. Such high risks underscore the need for a system that can prevent medication errors.

Errors can occur at various steps in the process of obtaining a prescription medication. Prescribing begins with the health care provider making a diagnosis and determining what medication or treatment to prescribe. The process continues with the provider issuing a written prescription and either the patient delivering the prescription to a pharmacy or the provider’s staff transmitting the prescription (by phone or fax) to a pharmacy. The provider, office staff, or pharmacist may then provide the patient with oral or written information about how and when to take the medication and about possible side effects. For some prescriptions, the provider may subsequently order lab tests to monitor the patient for improvement or adverse events. Finally, the provider will follow up to check on the patient’s response.

Errors could occur at each step along the way, but electronic prescribing systems may be able to prevent many of the errors. For example, the life of the woman who died because her physician had written erroneous dosage frequency information on her arthritis prescription might have been spared had an electronic prescribing system provided a menu of appropriate dosage choices for her condition.

It is also possible, however, that flawed electronic prescribing systems could unintentionally introduce new kinds of errors into the process. For example, if pharmacists or pharmacy technicians assume that computer-generated prescriptions are free of errors, they could be more likely to fill the prescriptions blindly, without checking them.

An Evolving Technology

Electronic prescribing systems are one form of a technology called “computerized physician order entry.” This technology has not been greeted with universal praise.

In 1993, doctors at a major university hospital on the East Coast staged a work action to protest a physician order entry system that they felt interfered with the way they routinely practiced medicine. Only a series of meetings among senior hospital managers and doctors to address the barriers created by the new system enabled it to be accepted.

Ten years later, in 2003, physician complaints about compromised patient safety led the largest private hospital in the West to shut down its physician order entry system. Doctors had complained about premature or delayed dispensing of prescription medications (although none of the incidents had led to patient harm). Doctors had also complained about inconveniences, such as the difficulty in learning to use the system and the length of time it took to enter an order.

For years, the only electronic prescribing systems that were evaluated were noncommercial or “homegrown” systems — those built by medical researchers and operated only in their teaching hospitals (the hospitals associated with medical schools). With a few notable exceptions, these systems were found to increase efficiency, greatly reduce medication errors, and lower costs.

Until recently, though, none of the commercial systems being used in doctors’ offices had been thoroughly evaluated. Despite the existence of at least 50 commercially available systems, we at RAND were the first to try to assess how well they are working in the average doctor’s office.

The widespread lack of evaluation of the commercial systems prompted us to convene our expert panel. Drawn from the fields of medicine and medical information systems, the expert panel recommended its 60 guidelines for electronic prescribing systems. Each recommendation corresponds to one or more steps of the prescribing process. Of the 60 recommendations, 52 can help to enhance patient safety and health. The table shows 14 of the recommendations, arranged according to key steps of the prescribing process.

Using the 60 recommendations as criteria, we evaluated ten commercial electronic prescribing systems in common use in doctors’ offices. We chose systems that were being used in outpatient settings rather than in hospitals because far more patients visit their doctors than are ever admitted to the hospital. Five of the systems were part of larger electronic medical record systems, and five were stand-alone systems.

Market Needs Guidance

We found that the ten commercial systems were implementing, on average, about half of our recommendations. Because full access to a patient’s medical record was required to satisfy a number of the recommendations, those electronic prescribing systems that were part of a larger electronic medical record system tended to implement more of the recommendations (an average of 60 percent) than did the stand-alone systems (an average of 35 percent).

Some of the simpler recommendations were implemented by most or all of the systems. One example is Recommendation 41: allowing the prescriber to transmit prescriptions to a patient’s pharmacy of choice. But a more sophisticated recommendation — alerting the prescriber when a medication is selected that is contraindicated or that calls for significant precaution based on a patient’s allergies, current medication, medical conditions, and/or laboratory test results (Recommendation 27) — was implemented fully by only one of the systems (see the figure).

The recommendation to help patients manage their costs (Recommendation 21) was implemented less often than those designed to increase patient safety. And a recommendation to reduce the underuse of medications — notifying the prescriber when a prescription or refill is not dispensed and delivered to the patient within a time interval specified by the prescriber (Recommendation 48) — was not implemented at all. This is unfortunate, because reducing underuse of medication could have as beneficial an effect on health as reducing inappropriate medication.

Overall, we found that the commercially available electronic prescribing systems currently fail to offer many capabilities that could provide significant benefits with respect to improving the health of patients and reducing their costs. Thus, the commercial market for these products might not be selecting the functional features that would be most important for helping patients.

Working Out the Kinks

The panel found that some of the recommendations with the greatest expected benefits are probably not achievable within the average physician’s office for at least three years. These recommendations include those for helping patients manage their costs and for reducing the underuse of highly effective medications. The latter is a major quality problem for elderly Medicare beneficiaries.

The main barrier to meeting these recommendations is the lack of integration among information systems used by physicians, pharmacies, laboratories, hospitals, payers, and others responsible for patient care in a given community. As of yet, these entities have little incentive to share data. Policy initiatives are needed to encourage community-wide integration of health information systems. The U.S. Department of Health and Human Services is beginning to fund efforts toward such integration, but these efforts will likely need to be sustained and expanded.

The panel also expressed concern that the increasing commercial sponsorship of electronic prescribing systems could lead to inappropriate influences — by pharmaceutical companies, insurance companies, or health maintenance organizations — on the medication options offered by the electronic prescribing systems. For this reason, federal design standards for the systems should aim to curb potential conflicts of interest, to ensure that patient safety is the paramount priority, and to provide doctors who might purchase the systems with instructions to help them choose among the myriad of designs.

Design flaws in electronic prescribing systems can introduce new safety hazards, but little is known about which specific design features create the hazards. The growing awareness of the potential hazards has given rise to two conflicting impulses: the desire to design systems for greater control by prescribers (to circumvent potential system errors) versus the desire to move control away from prescribers (to prevent human errors). Further research is needed to balance the safety risks from system inadequacy on the one hand and from human fallibility on the other.

Some studies suggest that doctors have been slow to embrace the idea of electronic prescribing or the addition of computerization to medical practices in general. Researchers need to learn more about doctors’ concerns and about how best to address them in order to smooth the integration of these new technologies into daily clinical practices.

Under the Medicare Modernization Act, limited federal grants to encourage the adoption of electronic prescribing systems are not scheduled to begin until 2007, but commercial efforts are already under way. As medical practices increasingly adopt the systems, their performance should be monitored to determine whether the recommendations derived from expert opinion help to promote safety and cost management among patients. In this way, our initial recommendations could yield to new federal guidelines based on clinical evidence.

Related Reading

“A Conceptual Framework for Evaluating Outpatient Electronic Prescribing Systems Based on Their Functional Capabilities,” Journal of the American Medical Informatics Association, Vol. 11, No. 1, January/February 2004, pp. 60-70, Douglas S. Bell, Shan Cretin, Richard S. Marken, Adam B. Landman.

“Functional Characteristics of Commercial Ambulatory Electronic Prescribing Systems: A Field Study,” Journal of the American Medical Informatics Association, Vol. 12, No. 3, May/June 2005, pp. 346-356, C. Jason Wang, Richard S. Marken, Robin C. Meili, Julie B. Straus, Adam B. Landman, Douglas S. Bell.

“Recommendations for Comparing Electronic Prescribing Systems: Results of an Expert Consensus Process,” Health Affairs–Web Exclusive, May 25, 2004, pp. W4305-W4317; Douglas S. Bell, Richard S. Marken, Robin C. Meili, C. Jason Wang, Mayde Rosen, Robert H. Brook, and the RAND Electronic Prescribing Expert Advisory Panel.