Research in Social and Administrative Pharmacy
Original ResearchAnalysis of pharmacists’ interventions on electronic versus traditional prescriptions in 2 community pharmacies
Introduction
Studies have suggested that up to 11% of all new outpatient prescriptions have been found to have at least one problem that requires intervention by a pharmacist.1, 2, 3, 4, 5, 6, 7 Electronic order entry (e-prescribing), which has been promoted as a potential mechanism for increasing patient safety (ie, reducing prescription errors) and increasing prescribing efficiency, has been shown to decrease the amount of medication errors in the inpatient setting by more than 80%.8, 9, 10, 11, 12, 13, 14, 15, 16, 17 However, relatively little is known about how e-prescribing impacts outpatient prescribing errors. Some researchers believe that the implementation of e-prescribing to the outpatient setting will yield similar effects to those of inpatient settings. However, effects remain unknown.18, 19, 20
E-prescribing in the United States is defined as “the transmission, using electronic media, of prescription or prescription-related information, between a prescriber, dispenser, pharmacy benefit manager (PBM), or health plan in either direction or through an intermediary, including an e-prescribing network. It includes, but is not limited to, two-way transmission between the point of care and the dispenser.”21 In other countries, such as the United Kingdom, electronic prescriptions can occur in 2 methods: (1) a mechanism whereby prescribers can download medication data or generate an electronic prescription automatically from the core network, but the system still uses a paper prescription infrastructure or (2) generate an electronic encrypted signature and be allowed to transfer the prescription electronically as opposed to having the patient take the prescription to the pharmacy.22 The first method has been adopted since the 1990s, whereas the second method is still currently being implemented. E-prescribing in England, Denmark, and Scotland has demonstrated that one of the biggest benefits to prescribers addressing legibility concerns is a significant time-saver and offers the potential to use decision support capabilities.23
The Institute of Medicine has recommended that by 2010, all prescriptions should be written electronically,24, 25, 26 and public and private initiatives are encouraging ambulatory prescribers to implement and use e-prescribing.27 E-prescribing has the potential to minimize interruptions in the pharmacy that are created from verbal and fax conveyances.28, 29, 30, 31, 32, 33 Although faxed and verbal prescriptions are legal in the United States, in other countries such as the United Kingdom and the Netherlands, only electronic and handwritten prescriptions are valid.22 Pharmacists also may save time processing prescriptions that do not have to be entered into pharmacy computer systems manually.33, 34, 35 However, e-prescribing adoption in the ambulatory care setting remains less than optimal; it is estimated that 12% to 20% of prescribers in the ambulatory setting are currently using e-prescribing.36, 37, 38 One reason for the low implementation rate of e-prescribing may be provider attitudes concerning expected productivity loss and lack of time to learn about new systems.39 Additionally, other concerns include increased costs, the effort needed to adapt office systems, and technical difficulties.40
E-prescribing impacts pharmacists as well as prescribers. Anderson and Malone41 found that pharmacists express concerns about e-prescribing similar to those of prescribers, although the majority (54%) agreed that e-prescribing was inevitable. Murray et al42 evaluated the impact of e-prescribing on pharmacist work patterns in the outpatient pharmacy of a hospital, and the results demonstrated important changes in work-related activities and functions after e-prescribing began: pharmacists spent 12.9% more time correcting prescription problems and 2.2% less time in discussions with others (ie, any interactions with one or more people, including telephonic conversations). Additionally, pharmacists spent 34% less time filling prescriptions, 45.8% more time in problem-solving activities involving prescriptions, and 3.4% less time providing advice.43
It is essential to understand the rate and type of prescriptions requiring intervention by a pharmacist to assess the potential impact of strategies such as e-prescribing. As e-prescribing becomes more common, examining the types of problems pharmacists identify on e-prescriptions will become more important. Comparing these data with problems identified with other prescription conveyance methods will help researchers identify systems problems and offer solutions.44
Current literature includes studies that compare pharmacists’ traditional prescription and e-prescription intervention time and costs separately.43, 44, 45 However, no study has directly compared the interventions of all forms of prescribing in the community pharmacy setting. The objectives of this study were to (1) measure the incidence of prescription problems that required the pharmacist to intervene, (2) determine the types and relative frequencies of prescription conveyance that contain problems that require intervention by the pharmacist, and (3) estimate the pharmacy personnel time and related practice expenses for prescriptions requiring intervention.
Section snippets
Methods
This study was an observational prospective study of pharmacists’ prescription interventions at 2 chain grocery store pharmacies located within the Phoenix metropolitan area. These 2 chain grocery store pharmacies were from the same corporation; therefore, pharmacy software systems and setup were identical. Convenience sampling was used to select the participating pharmacies. In this study, pharmacies had to dispense more than 100 new prescriptions daily, including 5 or more electronic
Results
Interventions performed by community pharmacists during the dispensing process to correct prescribing-related issues were documented during 117 hours of direct observation during December 2009. Observations were performed at 2 grocery chain community pharmacies in the Phoenix metropolitan area. The new prescription orders were categorized according to form of delivery (ie, handwritten, fax, verbal, and e-prescribed).
During the study period, pharmacists reviewed 1678 new prescriptions and
Discussion
In this study, an 11.7% intervention rate was observed for e-prescriptions. This indicates that the e-prescribing process has ample room for improvement. These results are in line with other evaluations of e-prescribing interventions.44 In their study of self-reported community pharmacists’ interventions on e-prescribing, Warholak and Rupp44 concluded that although e-prescribing can improve safety and effectiveness in patient care, still-emerging technology can pose threats to medication safety
Conclusion
When comparing e-prescribing with handwritten prescriptions requiring interventions, no significant differences existed. Results from this study suggest that pharmacists must intervene on e-prescriptions as at the same rate as handwritten prescriptions. Potential solutions for enhancing electronic prescribing include increasing clarity from prescribers regarding quantity units on prescriptions, improvement in signa (SIG) codes', increasing prescriber-side e-prescription completion checking (ie,
References (60)
Evaluation of prescribing errors and pharmacist interventions in community practice: an estimate of “value added.”
Am Pharm
(1988)- et al.
The development and evaluation of an integrated electronic prescribing and drug management system for primary care
J Am Med Inform Assoc
(2006) - et al.
e-Prescribing, efficiency, quality: lessons from the computerization of UK family practice
J Am Med Inform Assoc
(2006) - et al.
Beyond the basics: refills by electronic prescribing
Int J Med Inform
(2010) - et al.
Perceptions of e-prescribing efficiencies and inefficiencies in ambulatory care
Int J Med Inform
(2011) - et al.
The impact of e-prescribing on prescriber and staff time in ambulatory care clinics: a time motion study
J Am Med Inform Assoc
(2007) - et al.
Correlates of electronic health record adoption in office practices: a statewide survey
J Am Med Inform Assoc
(2007) - et al.
Analysis of community chain pharmacists’ interventions on electronic prescriptions
J Am Pharm Assoc (2003)
(2009) - et al.
Documenting outpatient problem intervention activities of pharmacists in an HMO
Med Care
(1981) - et al.
Documenting prescribing errors and pharmacist interventions in community pharmacy practice
Am Pharm
(1988)
Prescribing problems and pharmacist interventions in community practice
Med Care
Value of community pharmacists’ interventions to correct prescribing errors
Ann Pharmacother
Documenting the value of pharmacist interventions
Am Pharm
Evaluation of the clinical value of pharmacists’ modifications of prescription errors
Br J Clin Pharmacol
Factors related to errors in medication prescribing
JAMA
Building the electronic infrastructure for better medication usage
JAMA
Reducing the frequency of errors in medicine using information technology
J Am Med Inform Assoc
Impact of emerging technologies on medication errors and adverse drug events
Am J Health Syst Pharm
The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients
Pediatrics
The impact of computerized physician order entry on medication error prevention
J Am Med Inform Assoc
Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial
Crit Care
Computerized physician order entry and mediation errors in a pediatric critical care unit
Pediatrics
Effect of computerized physician order entry and a team intervention on prevention of serious medication errors
JAMA
Medication errors: a prospective cohort study of hand-written and computerized physician order entry in the intensive care unit
Crit Care
Effects of computerized physician order entry on prescribing practices
Arch Intern Med
Primary care computing in England and Scotland: a comparison with Denmark
Inform Prim Care
Outpatient prescribing errors and the impact of computerized prescribing
J Gen Intern Med
Cited by (0)
We, Adrienne M. Gilligan, Kimberly Miller, Adam Mohney, Courtney Montenegro, Jacob Schwarz, and Terri L. Warholak, declare that we have no proprietary, financial, professional, or other personal interest of any nature or kind in any product, service, and/or company that could be construed as influencing the position presented in, or the review of, this manuscript. This study had no funding support.