Upgrading e-prescribing system can bump up error risk

Some of those risks can put patients in jeopardy in the first few weeks of implementation, a study finds.

By Pamela Lewis Dolan — Posted June 13, 2011

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Switching to new or upgraded electronic-prescribing systems may pose patient safety risks during the transition period, despite the advanced clinical decision support tools offered by the newly implemented technology.

Many hospitals and physician practices are upgrading or switching their e-prescribing systems to meet meaningful use incentive requirements. Physicians from Weill Cornell Medical College and New York-Presbyterian Hospital, both in New York, authored a report published online April 16 in the Journal of General Internal Medicine that identified challenges associated with switching to new e-prescribing technology. Some of those issues may pose safety threats during the first few weeks after implementation, the study found.

Researchers examined prescribing errors that occurred from February 2008 through August 2009 at an academic-affiliated ambulatory clinic that switched from an older electronic medical record system to a new one with advanced clinical decision support for e-prescribing. They measured errors that occurred with the old system prior to implementing the new system, 12 weeks post-implementation of the new system and errors that took place one year later.

The report showed that the largest number of errors occurred before implementation, when the old system was still in use. The number of overall errors dropped from 36% to 12% one year later.

The most common errors, those caused by improper abbreviations, fell from 24% to 6% in one year. But the number of non-abbreviation errors, such as those associated with directions, frequency and dosage mistakes, increased in the first 12 weeks of implementation of the new system.

Study co-author Rainu Kaushal, MD, MPH, chief of the Division of Quality and Medical Informatics at Weill Cornell Medical College, said she knew the transition from paper to electronic was difficult for most physicians. She was surprised to learn that even for experienced e-prescribers, the move to a new system can be challenging. Dr. Kaushal, who was involved in the transition studied for the report, said she found the experience to be "exceedingly difficult."

"We thought it would be more of a seamless transition because people were already accustomed to sitting in front of a computer, entering in orders and so on, so they didn't have to get used to that piece," she said. "But each electronic system has its nuances and learning how to utilize it and optimize the physician-computer interaction takes time. Every time a switch is made there are important issues that arise."

Meaningful use incentives push change

An annual progress report by the e-prescribing network operator Surescripts found that there are many health care organizations going through a transition period because of the meaningful use incentive program. The report, released in May, found the number of new e-prescriptions and replies to pharmacies' electronic renewal requests increased 72% from 191 million in 2009 to more than 326 million in 2010.

The report also found more physicians are using advanced functions of the systems, such as medication histories. The number of medication histories delivered to prescribers grew 184% in one year.

The authors of the Journal of General Internal Medicine report say physicians should be better educated on the benefits technology can provide and the potential dangers when not used correctly. Interviews that researchers conducted of physicians involved with the transition to a new e-prescribing system revealed most doctors did not think the new technology would improve safety. The prescribers also said the enhanced clinical decision support led to alert fatigue and routine overriding of alerts.

Challenges and risks exist for organizations implementing for the first time and those upgrading older systems, said Shelly Spiro, director of the Pharmacy e-Health Information Technology Collaborative, a group of several pharmacy and medical associations that advocates and studies best e-prescribing practices and standards. Involving physicians and others who use the systems in the customization and optimization of them can be an important step toward reducing the risks, she said.

Also important, Spiro said, is working with vendors to ensure that the e-prescribing systems that practices adopt have standards and functions to help reduce errors. One standard is "structured and codified sig," which standardizes the instructions physicians intend to give patients for use of a drug. The system would use codes that correspond to specific sets of directions, as opposed to free text, which can sometimes be misinterpreted or not understood by the pharmacy.

Another standard is RxNorm, a standardized nomenclature for clinical drugs developed by the U.S. National Library of Medicine.

Spiro said vendors need to explain the data fields in the electronic systems that are prepopulated. Physicians should know which fields default to certain data being entered and how to change the fields if that information doesn't apply to a particular patient.

Dr. Kaushal said many practices and hospitals prefer to do training in groups to save time and money, but one-on-one training is ideal when implementing a new system. No matter how training is handled, it should be mandatory for everyone regardless of experience, she said.

Despite the initial hurdles, Dr. Kaushal said the promised patient safety improvements eventually were delivered for the practice that was studied.

"What made those weeks more tolerable ... was understanding that this transition would ultimately have large benefits," she said.

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External links

"Transitioning Between Electronic Health Records: Effects on Ambulatory Prescribing Safety," Journal of General Internal Medicine, published online April 16 (link)

"The National Progress Report on e-prescribing and Interoperable Healthcare," Surescripts, May (link)

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