The effect of e-prescribing on patient safety and
quality of patient care in hospital settings:
Generally, the research findings on the effect of e-prescribing on medication errors were partially attributed to their settings, the system design features, or the nature of prescribers’ work. Studies conducted on homegrown systems (vs. commercial products/systems) or on systems with manual chart review show a higher ability to detect medication errors with e-prescribing. One study stated that design features of e-prescribing such as poor drop-down menu, poor screen design, or inaccurate or incomplete patient medication lists especially in certain diseases can pose a threat to patient safety. Another study that examined the relationship between prescribing errors, use of e- prescribing technology, complexity of tasks and interruptions in healthcare settings reported that common errors that occurred include: selection of incorrect medication, dose, route, and formulation. When prescribers were interrupted when performing tasks on e-prescribing systems, they required almost three times longer to complete complex tasks when compared to simple tasks. Interruptions when using e-prescribing systems were suggested to be a possible contributing factor to medications errors when using this technology possibly due to loss of concentration by the user.
On the receiving end: community pharmacies
Patient safety is commonly thought of in health-
care settings as the freedom from medication errors and patient harm.
Studies on safety of e-prescribing in community
pharmacies are particularly important as they are the recipients of the product (e-prescriptions) of e-prescribing systems. The literature on the safety issues related to e-prescribing use in community pharmacies is sparse when compared to studies that have been conducted in hospital settings. Unlike hospital settings, community pharmacies do not have access to real-time patient information that may help them detect when incorrect information is present on the e-prescription.
Pharmacists need to understand the new kinds of prescribing errors generated using new technologies used in healthcare delivery, especially related to e-prescribing technol- ogy use, for them to be better equipped to detect and prevent errors.
Issues associated with e-prescriptions in pharmacies have been reported to be caused by omission of vital information by prescribers, poor design in pharmacies and physician office and other inherent technology limitations. E- prescribing, like other types of HIT, has the potential to improve patient safety in pharmacies but if poorly designed or implemented can pose a risk to patient safety. Issues arising from using such HIT safely are increasingly being recognized as more healthcare organizations across the health system implement these technologies.
Using HFE to improve safety in technology use in pharmacy
Human Factors Engineering(HFE) is a science focused on studying the interactions between people, work systems, environment and how all these important elements might affect safety and human performance.
Pharmacies can also proactively reduce safety
risks related to using e-prescribing technology. This can be achieved by using HFE methods to identify underlying causes of e-prescribing errors and improve shared situational awareness about issues related to using e-prescribing technology.
HFE approaches are currently being applied to
evaluate the benefits and challenges with HIT in hospital settings but have not been widely used in pharmacies or ambulatory care. Patient safety experts are increasingly obtaining guidance from HFE on how to improve usability of e-prescribing design in hospital settings but no research has looked into community pharmacy. It is clear that usability testing of any HIT is a necessity. A fundamental design principle of technology usability is transparency and visibility. Qualitative studies of use of computerized provider order entry systems in hospital settings applying HFE approaches have uncovered challenges with usability involving physicians and nurses which lead to errors. Application of HFE concepts and techniques to improve e-prescribing safety will require collaborative effort from e-prescribing vendors, prescribers, and pharmacists.
This paper has a very interesting inclusion criteria chapter.
This is an important paper
Based on: The majority of the included studies were conducted in North America (almost 64% in the United States and 4% in Canada), 16% addressed e-prescribing systems in European centuries, 9% in the Asian context, and the remaining 7% discussed e-prescribing issues in Australia.
Should we have an inclusion criteria like the studies should be conducted in UK and if there is any other country with similar to NHS system?
This is an important paper
Handwritten prescriptions have been associated with certain problems such as the risk of misinterpretation and falsification of handwritten prescriptions and the difficulties of legibility, which prompted the use of electronic prescriptions (e-prescriptions). e-Prescription systems are considered as an instrument to minimize medication errors in pharmacies. Electronically produced prescriptions are transmitted to pharmacists by the physicians over a safe network.
Previous research has shown that health professionals play a vital role in adoption and assessment of HIS . Medication errors are frequent in prescriptions, which are one of the most important outputs in health sector. 20% of medical negligence treatment claims result from medications errors. Prescription errors bring extra costs for individuals and have financial impacts on the government. These errors can occur in various stages such as prescription, transcription, dispensing and drug administration and the effects of these errors have varying levels of severity. In parallel to the developments in technology, e-prescription, which has been developed to prevent errors, involves direct transmission of prescriptions from the working environment of physicians to pharmacies via computers. e-Prescription systems record all format information of a prescription in electronic environment. Health institutions, pharmacy, refunding institution and other individuals/stakeholders can access prescription data to the extent they are authorized to, and thus all operations regarding the supply, refund, register and follow-up of medications can be performed in electronic environment. In other countries such as the United Kingdom, e- prescription can be made in two methods: 1) a mechanism in which prescribers can download a prescription automatically from a central network or a mechanism in which the prescribers can produce an e-prescription. However, the system uses paper in prescription infrastructure. 2) A mechanism in which the prescribers can produce an electronically coded signature and can electronically transmit the prescription to the pharmacy rather than physical transport made by the patient. Although verbal prescriptions or those sent by facsimile are legal in the United States, only electronic or handwritten prescriptions are valid in countries like United Kingdom and Holland. Pharmacists can save time by processing the prescriptions which they do not have to manually enter pharmacy information system.[Top]
This is an important paper
‘Electronic prescription’. ‘e-prescription’ or ‘e-prescribing’
is a computer based application which utilizes the internet to create, broadcast and fill out a medical prescription form. It has taken the place of paper based prescription or fax based prescriptions.
The purpose of this latest technology in the medical field is
to provide patients with an efficient, safe and time saving mode of administering prescriptions. This technology directly transmits the prescription to the pharmacist ensuring there are no errors in understanding the prescribed drug. The use of e? prescription also ensures better health care for the patients as it helps the doctors in many ways to diagnose and prescribe the patient more effectively. This technology has many options that help doctors like the option of providing complete prescription history and other medical conditions of the patients at a click and giving warnings and alerts to the doctor in cases of prescriptions that the system checks are against the medical history of the patient.
It ensures that precious time is saved of the physicians
clarifying their drugs to the pharmacists resulting in more time for the doctor to serve his patient. The purpose of E? Prescription is not just to help the patient but to help everyone associated with the medical industry: the option of automated refill request ensures that hospitals do not lack any necessary medications and their refill process is completed before time. The purpose of this technology is also to serve societal issues and in cases of drug recalls this technology has an option of maintaining the records of patient who were prescribed a particular medicine and by just a click all those patients with that prescribed medicine can be contacted easily and informed about the drug fall out. The use of this technology is not limited to patients and doctors only, it also serves the insurance and other regulatory bodies in assessing records of patients much quicker than the manual systems. In short, the purpose of this innovation is to serve many aspects of patient health care and other related issues at the same time.
Patient security is important for the healthcare industry.
Adverse drug effects happen across the world on a daily basis, which is why health is an important part of a community’s budget.
E-prescription avoids errors which used to appear with
paper based prescriptions: e.g. a wrong drug or an out of stock drug, a wrong quantity of dosage, repeating medicines, exclusion of information or badly written prescriptions. Such problems mean the pharmacist must call up the medical authorities to confirm the prescription details. This delays the process of providing proper healthcare at the proper time to the patients. They increase expenses as well as time spent on correcting mistakes. Not all mistakes are noted, which may result in harm or even death. Most e-prescription applications have a built in ‘point of care decision’ which detects many errors in the prescription before sending it out. It asks the user to confirm about allergies, verify dosage precision and point
out out the possible reactions between the prescribed drugs before the e-prescription is sent out.
The difficulties in evaluation fall into three areas: defining appropriate measures of benefit, disentangling the effects of the system from other factors, and bias.
When defining appropriate measures, it is unrealistic to expect a clinical data system to improve patient outcomes directly (in the manner of a drug) because it is merely improving data management. Therefore, some investigators have settled for measuring clinical attitudes to such systems, or the accuracy and completeness of data. Others concentrate on clinical functions such as usage rates or time to enter data. To measure the effects of systems, the methods include surveys of system users and patients and “work sampling” to evaluate changes in work patterns. Measurement of direct effects on data management is more difficult. One suggestion is to adopt Shannon’s definition of information as the absence of uncertainty, and assess physicians’ uncertainty by asking them to make predictions whose accuracy is measured subsequently.  Most interesting of all, however, are those few assessments of the impact of systems on clinical processes known to improve outcomes (eg, screening rates for hypertension) or on clinical outcomes themselves.
Whichever measure is adopted, the reasons for any observed effects can be hard to disentangle, For example, installation of a hospital?wide clinical data system is a major project requiring teamwork, consultation, training, and even re?engineering of working relationships. Any changes observed may be due to these components rather than to the information system itself.
Finally, there is bias. For example, if patients are randomized to use of a clinical data system in a trial, staff may learn better data organisation from the system which may spill over to control cases (“contamination”). This can be partly overcome by randomizing staff to use the system, but this disrupts teamwork and can alienate control staff. It is better to randomize teams or departments, but the sample must be large enough to compensate for random variations. Thus, many studies so far have been before/after designs, though in a handful staff or teams have been randomized.
Characteristics of data systems:
- completeness of data
- availability of data
- use of clinicians’ time
- Effects on clinical process and outcomes
The characteristics above fit the risk factors of Standardization in patient safety: the WHO High 5s project academic paper.
This is an important paper
Person-centered care recognizes the patient’s full autonomy as a person in society who happens to need health-related services, and moves away from a hierarchical relationship. The Person-centered health system has recently been defined as one that “supports people to make informed decisions and to successfully manage their own health and care and to invite others to act on their behalf … Person-centered care sees patients as equal partners in planning, developing and assessing care”
The advent of Patient Portals, whereby the patient may access his/her medical or health record, would seem to offer an important contribution to improving the patient-practitioner knowledge balance, and to make the patient fully aware of the facts related to his/her condition and its treatment. In turn, this would appear to empower the patient as a participant in the negotiation of their own care to ensure that it is integrated and fits their preferences wherever possible. However, we find that the evidence of this effect is worryingly sparse, due in particular to the lack of effective evaluation of patient portals.
I can link the above with the studies that show that EHR didn’t have much effect on patients medication intake. see notes here
The sharing of responsibility between diagnosed patients and providers leading to improved coordination and integration of care is not a new idea. For those patients with chronic or enduring conditions, there has been recognition of the expertise they build up about the condition which they have permanently, but which the clinician sees only occasionally, such that the concept of the “Expert Patient” was coined more than a decade ago, accompanied by a related policy program, which still endures in English NHS policy. There is a strong belief that many of today’s patients are increasingly in search of more information about their health and are keen to establish a closer engagement with medical providers about the way their care is undertaken and managed. Research evidence consistently shows that patients want to be kept involved and regularly informed about decisions related to their medical care.
Patient information needs should not be limited to obtaining general knowledge. There should be opportunity for patients to access their medical records and the content within them. Providing patients with access to personalized health information is believed to be a means of improving communication between patients and providers, contributing to more accurate information, and helping patients to prepare for upcoming clinical visits and cope with the potential anxiety. This notion has been supported by evidence which shows that the failure to fully inform patients can lead to poor treatment adherence.
Overall, patient portals may offer one or more of the following functionalities:
- Access to EMR data of the patient
- Access to test results
- Printing or export of the portal data
- Medication refills
- Appointment scheduling
- Ability to obtain referrals
- Access to general medical information such as guidelines
- Secure messaging between the patient and the institution
Advanced patient portals are still a very new and innovative ICT application, whose impact on health care delivery, outcomes, and patient engagement is neither very well known nor understood.
Personal health records
Another, rather different, means of involving patients is personal health records (PHRs). PHRs are “a set of computer-based tools that allow people to access and coordinate their lifelong health information and make appropriate parts of it available to those who need it”. PHRs allow the patient to document health-related information and to make them available to others, for example to their health care providers or families. PHRs are typically owned and administered by the patients themselves. Microsoft’s HealthVault is one platform which can be used to maintain a PHR. It also offers connectivity to devices and apps to enhance tracking of health information. The Apple Health app is yet another platform that can be used as a central repository to aggregate information from other health apps.
Understanding features and functions of the technology, and their context of use, helps us understand what works and how.
The four mechanisms identified by Otte-Trojel, seem to focus on the “what” level. The policy aims of governments, payers, and consumers of patient portals form one part of the “why” mechanism.
Consumer health portals should be developed and evaluated with the understanding of their contexts of use, and based on a theoretical framework such as, for example, the theory of planned behaviour, by which the functions of the portal can perceive the behaviour control to be influenced, as a means of optimising and coordinating care. Evaluation studies which are based on such a scientific theory, and that compare variants of theoretical mechanisms (e.g. providing personalised information versus general patient information) and different contexts (e.g. patient portals used in young, well educated patients such as in vitro fertilisation clinics versus the same patient portals used in elderly patients with dementia) will provide knowledge on what works for who, in what circumstances, in what respect and how.[Top]