E-Prescriptions: A good thing?

As we move into the future of computers and the internet (I know, that started a long time ago, but it's a long process, especially when lawmaking is involved), it is becoming more and more common for doctors to send prescriptions to pharmacies online.  Originally, the only way to transmit a prescription was via a hand-carried piece of paper or a direct phone call.  Then, faxing prescriptions became commonplace.  This is still one of the most widely-used methods of transmission, especially for refills.  But now, doctors can instantly send prescriptions to be filled without depending on outdated facsimile technology or encountering the possibility of a hard-copy prescription being lost (or modified) on the way to the pharmacy.  Seems like a good idea, right?  It is.  But there are quite a few issues with the system.

The first issue is the ease at which a doctor can submit a prescription.  They can pick a drug from a menu, enter directions, and press "send."  They can also approve refill requests with the press of a button.  These things that make it easier and faster for the doctor also increase the possibility for error.  I received an e-prescription last week that was for a routine medication for a patient that had been on it for a long time.  I started to enter it, but then looked at the date.  It said it was written 07/24/2009.  The patient was due for a refill and the doctor had sent five or six other prescriptions at the same time (with the correct date), but I called to verify the prescription.  The nurse said they didn't receive our request for that refill and that she did not send authorization.  Yet somehow, I had, in my hand, a prescription sent 11/17/2011, but written over two years earlier.  It seems they inadvertently pushed a "refill" button on an old prescription and unknowingly sent it to us.  I caught it because of the date, but if the date had been auto-entered as today, I surely would not have noticed anything out of the ordinary and it could have resulted in a prescription being dispensed that the doctor did not mean to request. 

The other issue with the ease of use is drug selection.  I haven't seen it as much recently (maybe they have made some improvement to this part of the process), but sometimes we get an e-script for a drug that seems really odd.  When we call to verify, they say they actually meant to order the drug that is listed one line earlier or later, alphabetically.  They can apparently pick drugs from drop-down menus and if they simply click a little too high or low, it could result in a major error.

The second issue is the lack of clarity in directions.  This is sometimes a source for a good laugh, but is also sometimes worrisome.  Most of the time, the directions are clear enough that we can interpret them, but they're not what they say they are.  I'll give an example of an eyedrop e-script I got last week: the directions said to insert 4 capsules in the right eye four times a day for a week.  It also said I was to dispense 1,000 mL.  I can't imagine inserting a capsule in my eye, let alone 16/day.  Plus this is the first time I have heard of dispensing a liter of eye drops at once (they usually come in sizes from 2.5-15mL).  It got a good laugh out of everyone in the pharmacy and I could make sense of what they probably meant, but if they can make an error this big without noticing, it must be very easy to make a smaller error that may not be caught and ultimately result in harm to the patient.

E-prescriptions are also supposed to be a step towards becoming less dependent on paper.  However, we are required to keep paper copies of all the prescriptions we fill, so it doesn't do the "paperless society" much good for the doctor to save a piece of paper when we just have to print it out anyway.  Also, there's a feature where we can import the data from the e-script right into the pharmacy software, but by the time you correct all the little errors it is faster just to enter it from scratch.  For example, directions that intend to say "take one tablet daily" may come across as "1 PO QD by oral route daily (tablet)" which you have to clear completely out and enter directions that can be easily read.  Also, when you correct something, it clears what used to be there, so you have nothing to refer to if you forget what it said originally.  Thus, printing it out is necessary for one more reason and no paper has been saved.

E-prescriptions are a good idea and are an improvement over faxes in many ways.  They are not dependent on cleanliness of the scanner or quality of the printer, and don't have to wait for an open phone line, so can be transmitted much faster and reliably.  However, we still have a long way to go in improving software and designing better safety measures and double-checks to ensure that what is being dispensed is just what the doctor ordered.