Original Research
Analysis of pharmacists’ interventions on electronic versus traditional prescriptions in 2 community pharmacies

https://doi.org/10.1016/j.sapharm.2011.12.005Get rights and content

Abstract

Background

Relatively little is known about how e-prescribing impacts outpatient prescribing errors. Comparing these data with problems identified with other prescription conveyance methods will help researchers identify system problems and offer solutions.

Objectives

The objectives of this study were to (1) measure the incidence of prescription problems that required pharmacist intervention, (2) determine the types and relative frequencies of prescription conveyance that contain problems that require pharmacist intervention, and (3) estimate the pharmacy personnel time and related practice expenses for prescriptions requiring intervention.

Methods

This study used an observational prospective design examining data from 2 community chain grocery store pharmacies. The primary outcome was number of interventions for each prescription conveyance type. Variables of interest included (1) the type of medication(s) involved in the intervention, (2) how the pharmacist was alerted to the potential problem, (3) reason for the intervention, (4) pharmacists’ actions based on the intervention, (5) time spent during the resolution of the intervention, and (6) costs based on pharmacy personnel time. Chi-square analysis with a Bonferroni correction was used to compare percentage intervention rates between prescription conveyances. E-prescribing was used as the reference group to compare across interventions. A Kruskal-Wallis rank test was used to compare the time on task values for the interventions.

Results

Pharmacists reviewed 1678 new prescriptions and intervened on 153 (9.1%) during 13 days of data collection. A total of 11 hours and 58 minutes were required to perform all interventions for an overall average of 4.9 (standard deviation = 0.34) minutes per intervention. The most common reasons for pharmacists’ intervention on e-prescriptions were excessive quantity/duration (18.2%) and violating legal requirements (18.2%). The percentages of interventions were significantly different between e-prescribing (11.7%) and both faxed (3.9%) and verbal (5.1%) orders (P < .0001 and P < .01, respectively), with faxed and verbal interventions occurring less frequently. The difference in the intervention rates between e-prescribing (11.7%) and handwritten (15.4%) prescription conveyances were not statistically significant.

Conclusion

When comparing e-prescribing with handwritten prescriptions requiring interventions, no significant differences existed. Results suggest that pharmacists must intervene on e-prescriptions as at the same rate as handwritten prescriptions.

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)

  • M.T. Rupp et al.

    Prescribing problems and pharmacist interventions in community practice

    Med Care

    (1992)
  • M.T. Rupp

    Value of community pharmacists’ interventions to correct prescribing errors

    Ann Pharmacother

    (1992)
  • R.L. Dobie et al.

    Documenting the value of pharmacist interventions

    Am Pharm

    (1994)
  • H. Buurma et al.

    Evaluation of the clinical value of pharmacists’ modifications of prescription errors

    Br J Clin Pharmacol

    (2004)
  • T.S. Lesar et al.

    Factors related to errors in medication prescribing

    JAMA

    (1997)
  • G.D. Schiff et al.

    Building the electronic infrastructure for better medication usage

    JAMA

    (1998)
  • D.W. Bates et al.

    Reducing the frequency of errors in medicine using information technology

    J Am Med Inform Assoc

    (2001)
  • E. Oren et al.

    Impact of emerging technologies on medication errors and adverse drug events

    Am J Health Syst Pharm

    (2003)
  • W.J. King et al.

    The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients

    Pediatrics

    (2003)
  • D.W. Bates et al.

    The impact of computerized physician order entry on medication error prevention

    J Am Med Inform Assoc

    (1999)
  • K. Colpaert et al.

    Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial

    Crit Care

    (2006)
  • A.L. Potts et al.

    Computerized physician order entry and mediation errors in a pediatric critical care unit

    Pediatrics

    (2004)
  • D.W. Bates et al.

    Effect of computerized physician order entry and a team intervention on prevention of serious medication errors

    JAMA

    (1998)
  • R. Shulman et al.

    Medication errors: a prospective cohort study of hand-written and computerized physician order entry in the intensive care unit

    Crit Care

    (2005)
  • J.M. Teich et al.

    Effects of computerized physician order entry on prescribing practices

    Arch Intern Med

    (2000)
  • Centers for Medicare and Medicaid Services (CMS). 2009 fee schedule review. Available at:...
  • Van Dijk LV, De Vries H, Bell DS. Electronic prescribing in the United Kingdom and the Netherlands. AHRQ Publication...
  • D. Protti et al.

    Primary care computing in England and Scotland: a comparison with Denmark

    Inform Prim Care

    (2006)
  • Aspden P, Wolcott JA, Bootman JL, Cronenwett LR, eds. Preventing Medication Errors [prepublication copy; uncorrected...
  • T.K. Gandhi et al.

    Outpatient prescribing errors and the impact of computerized prescribing

    J Gen Intern Med

    (2005)
  • 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.

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