[MUSIC] Hello, this is Bruce Darrow, and the topic for this section is on Prescription Management. So, when we think about the different components of care that an electronic medical record system needs to be able to handle, one of the key ones is the ability to prescribe medications. And while it may seem pretty straightforward, this is actually a topic with a lot of detail and a lot of thought behind it. And I thought it would be a good topic to go in-depth a little bit. Just to look at some of the nuance behind this. So what I show you here in this slide is a picture of a paper prescription. This happens to be a piece of paper for my prescription. I've taken out my license number, but otherwise it appears the way that it would if you came to see me in the doctor's office and I hand wrote your prescription. New York State became the first state in the country in March of 2016, to make it required that all prescriptions from a doctor's office be electronically prescribed directly to a pharmacy. So, this is a piece of paper that I do not use much anymore. When you think about the components of this piece of paper, and they go back historically for decades. In this case, this is a special piece of paper. It is issued by the state of New York. Although in other states and previously, it would be possible to go to a printing shop and get them printed. This one has a serial number for quality control and tracking. It is bar coded. There is printed information on it. So in this case the printed information includes my name, my degree, my street address and phone number, my license number, and it has these prompts to put in other pieces of information. But let's think about everything that is missing from this piece of paper. You do not have the name of the medication, the strength of that per unit, the route that it's to be delivered, whether it be by mouth, or subcutaneously, or transdermally. It doesn't tell you how often the medication is supposed to be taken. Directions, as in take it with food or without food. A duration, take this for one week or two weeks or every day. The number of pills that the pharmacy should be dispensing, the maximum number of pills that you can take in a given day. If there's a discrepancy or some latitude for how you're supposed to take it. It doesn't include the number of refills and it doesn't include my signature. Any piece of information that is not on this pharmacy or prescription piece of paper, that I don't put in in the process of writing that prescription, is a potential source of error. An additional source of error is, I might be able to write all of this information there, but it might not be legible. And the history of jokes about the legibility of doctors' handwriting precedes me by a great many years. So, not only does the information have to be present and correct, but it has to be readable. So, now that you know how to write a prescription, let's talk a little bit about how not to write a prescription. So TIME Magazine has an article in 2007, which was entitled, Doctors' sloppy handwriting kills more than 7,000 people annually. This is a somewhat provocative statement. But it is meant to show the possibility that if you make errors in writing a prescription in terms of how many pills to take, how often to take it, or even an error in the way that the pharmacist reads the name of that medication, it can have a drastic impact on the health of your patient receiving that medication. In 2010, there was a study looking at the rate of errors in prescriptions written in an ambulatory practice. And they estimated that out of every 100 prescription written, 42.5 prescriptions had some sort of error with them. Either it was an omission and inappropriate abbreviation, so something that was meant to be written for daily consumption would have an abbreviation that was not acceptable by The Institute of Safe Medical Practices. The dose might be missing, the frequency, the duration, specific directions, the strength of the medication or the amount. These are all things that have to be there for the prescription to be complete, but even leaving out questions of legibility, a substantial number of prescriptions did not have this information. When you went from a process where the prescriptions were handwritten, to one where you converted it to an electronic prescriptions system, the error rate decrease substantially from more than 42% down to 7% of the time. So, in an ambulatory setting, there are a lot of reasons why the quality of prescribing will improve if you do an electronic process. And this is theoretically one of the key safety features behind health information technology and medication prescription management. First of all, legibility is guaranteed. You don't have to worry about the doctor's handwriting anymore. Second of all, standard doses can be recommended. If I have a piece of paper in front of me, if aspirin normally comes in 81 milligrams or 325 milligrams, there is nothing to stop me from taking that piece of paper and writing aspiring 83.2 milligrams. I can write it, but the pill doesn't exist. However, in an electronic prescribing system, you can default or you can put guard rails that if I'm only prescribing aspirin, the choices that I have are 81 or 325. I am not allowed to come up with a non-existent dose of that medication. Third, existing pill strengths can be offered. So this is similar in terms of standard doses. Standard doses have to do with the fact that an 81 milligram pill may be the strength of the pill, but you can have as a standard dose, 162, if you want them to take two of those pill. You can set upper and lower doses. So, if your maximum daily dose of a pill should be no more than, say, two grams. You can make it so that if there is an attempt to prescribe more than that, either your system does allow it, or it gives you some sort of feedback saying this is above the recommended dose. You can also recommend standard frequencies. If you're taking an antibiotic that is meant to be taken twice a day, then when you order that antibiotic, it can default to giving it twice a day. In comparison, if were handwriting that prescription, when you write it, you have the opportunity to make that mistake and say, once a day or three times a day, instead of twice. You can enable the checking of drug drugging and drug allergy for that patient. So if you were prescribing a medication, say an antibiotic for which that patient is allergic, or an antibiotic that would react with an existing medication that a patient takes, those checks can be built into your system in a way that you can never replicate. With paper you'd have to remember I have to check the allergy list. I have to check manually all of the other medications. You can offer formulary support. So if a patient is being offered a blood pressure medication, and within that class of blood pressure medication there's one medication that is on formulary and cheaper in terms of copay for the patient, you can be steered to that by your electronic system. You can offer decision support if you were using medication for a patient with kidney problems. The system can potentially recognize that and recommend that you adjust the dose of that medication based on the kidney problem. You create a longitudinal patient prescription record. In a way that you can never do so with paper prescriptions, you can in an electronic system, reference back and see three years, five years, ten years later, what you're prescribing history is. This becomes important when you're doing longitudinal care, and you want to make sure that you are potentially either choosing a medication that the patient previously, because it's time for them to take it again, and you know they took it. Or potentially avoiding a medication that a patient took in the past, and you know the patient did not do well with that option. When you have the information digitally, you can support research and quality. So you can see for example, of the patients that I saw in the last year who have a history of heart attack, how many of them were prescribed aspirin? And you can use login password and enhanced user ID like two-factor authentication to prevent the improper use and theft, or misuse of prescription pads. And these are true whether the prescription is done electronically and routed to a prescription paper printer, or if it's routed directly to a pharmacy. Some additional advantage of electronic prescription when you look at an in-patient setting, is, first of all, you can setup a pharmacy loop. So, if you are paper prescribing, then that paper order has to go to pharmacy with a highly manual process. Whereas, if you're doing it electronically, it can go automatically into a pharmacy verification cue. And that can be an automatic cue where are things that fall within normal guidelines get approved automatically, or get fast tracked for pharmacy approval. You also have the ability to say, well, this is a medication that is an institute for safety medical practices, we'd say high risk medication, so we're going to put a higher degree of scrutiny on that one. You can do bar code and close loop medication administration. This refers to the fact that once you prescribe medication, you can set it up in your system so that you have determined who the right patient is, and what the right medication is. And if you have a barcoding or a positive patient identification system in place, you can check the patient and then check the medication, and verify that that medication is the right pill, the right dose, the right composition for the correct patient. And then finally, you create a medication administration record automatically. So you know at any given time in the hospital stay, what medications were prescribed, when they were prescribed, for how long they were prescribed. Which medications were given, when they were given. While there is definitely a lot of safety built into the electronic prescribing practice, and overall this is good for patients. It is important to recognize that when you create a new system, you not only fix old errors, but you potentially create new ones. One example of this can be illustrated by what a physician by the name of Bob Wachter, a hospitalist out in California wrote about in his book, The Digital Doctor. And I list here the link for an excerpt called, How Medical Tech Gave a Patient a Massive Overdose. And in this example, he goes into detail about a patient in a hospital, who received a substantially higher number of pills of a particular antibiotic, than was intended by the prescribing doctor. This is one of the few errors that arguably is more likely to happen in a tech-enabled process, than would be done in a paper-enabled process. So overall, a stronger and safer system, but one that creates a new category of fortunately rare, but definitely present error. So, electronic prescription order entry, clearly safer than handwritten, but not 100% safe. And the goal of what we do in healthcare informatics is to continue to increase that margin of safety. [MUSIC]
