E-prescribing: safer than paper?

We have just completed the roll-out of an electronic prescribing and medicines administration system (EPMA) at an 800 bed teaching hospital in the North West, going from zero to full inpatient coverage in 18 months.

We certainly don’t consider ourselves “know it alls’ in this field, but we are hoping that we can raise awareness of some of the issues that we have come across.

We hope that after reading this article, you will have a greater understanding of some of the limitations and potential misconceptions/risks of EPMA - to balance against the more bullish articles that have recently been published.

We also hope that you will be armed with the type of questions that need to be asked of electronic prescribing suppliers, so that informed decisions can be made.

We are still convinced that from a trust and pharmacy perspective there are significant benefits to switching to an electronic prescribing system. However, the EPMA systems in the market-place have significant limitations that are not widely publicised. The examples below illustrate how clinical risk remains, and that healthcare professionals need to be vigilant.

Safer? Hard to say

Prescribing safety is usually at the beginning of any business case promoting a switch to electronic prescribing. However, the question of whether electronic prescribing is safer than paper-based systems is extremely difficult to answer.

With any EPMA system, there is a process by which a medicine has to be selected; and this process, as with a handwritten system, is a source of error.

Previously, a junior doctor may have tried to scribble something unintelligible on paper if they were unsure what it was they were required to prescribe; whereas with EPMA they have to pick an actual medicine.

We have found significant problems with the prescribing of insulin, in that the myriad of products available leads to an unwieldy drop down list that can - and has - led to patients being prescribed a rapid acting insulin in place of a long acting basal. An erroneous, rapid acting insulin prescribed at night is potentially a quick way to lead to a coroner’s court!

Does this happen on paper? The answer is yes, but with paper it is perhaps unusual for a junior doctor to be able to prescribe in sufficient detail to allow the insulin to be dispensed from pharmacy, or indeed administered.

With EPMA, the detail is accurate; unfortunately it may be the wrong medicine entirely. This does present pharmacists with a new challenge, as prescribing errors can become quite subtle and difficult to spot.

The perils of drop-down boxes

The typical method used to pick a prescribed medicine is from a drop-down box, after typing the first few letters. This is another source of potential error. For example, a doctor might type in “CYC’ as a search for cyclizine; but the box would also bring up cyclophosphamide.

We have discovered a number of incidents were cyclophosphamide has been prescribed instead of cyclizine due to a picking error. Possibly more alarming was the prescribing of thalidomide instead of thiamine.

A similar theme is that it is entirely possible to prescribe ludicrously high doses of medicines, as there is limited dose checking ability in electronic prescribing systems at the moment.

We have seen medicines prescribed with a thousand fold overdose due to confusion with units. For example, the once daily Mesalazine preparation is listed in our EPMA system in grams (as it is in the BNF); so 4.8g needs to be prescribed each day, as this fits the dosing schedule better. We have seen the dose prescribed as 4800g each day, because of an assumption that mg is the unit.

A recent article in the Pharmaceutical Journal (Hospitals must embrace electronic prescribing (vol 286) 19 March 2011 pg 331) implied that EPMA would prevent a patient with a severe penicillin allergy from receiving a penicillin. However, our experience would suggest that this scenario is just as likely to occur with or without EPMA.

Firstly, allergy data still has to be entered by a human hand and this information has to be entered correctly. Depending on the EPMA system used, the entry of a drug allergy may or may not be that intuitive.

Secondly - and this is possibly the biggest failing of all electronic prescribing systems - there are far too many irrelevant pop-up warning boxes. This means that very serious warning messages have the potential to be inadvertently suppressed.

It is worth noting that there is no EPMA system in existence that can actually prevent any of the “never ever’ events currently listed by the Department of Health. In fact, the adoption of EPMA can in many instances lead to a step back in functionality.

Screen time

This is because another limitation of any electronic prescribing system is that it is not possible to fit all the relevant information onto a computer screen so that it is all visible at the same time.

Prior to electronic prescribing, our medicine chart was three sides of A4 paper, which opened out to be fully visible. With EPMA we are required to click buttons to move to new screens or have to scroll around the existing screen to be able to see all of the information that was previously available in one place.

This is a particular problem when trying to reduce the number of omitted or missed doses, in line with NPSA guidance (Rapid Response Report NPSA/2010/RRR009: Reducing harm from omitted and delayed medicines in hospital).

The nurse administering medicines can only see the previous day’s missed doses by clicking on buttons to view additional screens; and during a busy administration round it is easy for this check to be missed.

Therefore, unless there is a warning system to alert nurses or pharmacy to a patient who has missed their antiepileptic medicine, there is the potential for missed doses to go unnoticed.

Additionally, the complex number of medicine charts for insulin, warfarin, syringe drivers and heparin and so on is very difficult to include in an EPMA package, and invariably results in both paper and electronic systems co-existing with further risk of missed doses.

Developments such as DVT pathways and post op pain management protocols are also difficult to translate into EPMA, which can mean that in the short term adopting EPMA can lead to a perceived backwards step in medicine management or adherence to NPSA/NICE guidance.

Wards and discharge issues

Possibly the biggest misconception that exists with the current incarnations of EPMA is the assumption that when a medicine is prescribed it will automatically appear on the ward, by pharmacy being informed of the newly prescribed line.

Unfortunately the mechanics of this interface are quite complicated and I am yet to see an EPMA product that has a practical and functional interface between prescribing and stock control.

The result is that when a new medicine is prescribed or stock runs low of an existing medicine, a message still has to be sent to pharmacy in some way.

You may find it hard to believe that this may have to be done by a handwritten note to pharmacy (accompanied with all of the inbuilt transcribing risks). This can be a real problem as the supply of medicines as with paper still depends on someone to initiate.

It is also widely accepted that there is no perfect EPMA system that can be used across all inpatient settings and this can lead to mistakes happening at the interface between EPMA and non-EPMA wards.

This is a particular problem during roll-out, but it is ongoing in places like critical care, where the array of infusions makes EPMA problematic and the continual transfer to and from wards can lead to prescribing errors. From many years of working with paper based prescribing systems, pharmacists have become proficient at spotting errors and ensuring patient safety.

Looking at the discharge process, a typical EPMA package allows a junior doctor to select from the inpatient medicine list those medicines that are required for discharge.

The hope was that errors on discharge prescriptions would no longer occur. Unfortunately, this hope has not come to fruition, as producing the discharge prescription for most patients is not simple.

Questions such as how long should antibiotics be continued, should the steroids be stopped, should the antihypertensive held at admission due to low blood pressure be restarted and so on still need to be answered; and, if anything, are more important when using an EPMA system as the process to select medicines for discharge is turned into a simple mouse click.

Therefore, any thought that the advent of electronic prescribing will lead to cost savings from the pharmacy service couldn’t be further from the truth. The demands on pharmacy time when using electronic prescribing increase significantly, as the verification of medicines becomes more time consuming and the EPMA system itself requires constant attention.

It is very important that board members and finance departments are not under the illusion that EPMA will lead to any overall cost savings.

Benefits – and questions to answer

These examples are just a few of the generic limitations to EPMA, and each system is likely to have its own list of specific short comings. Errors still frequently occur with any electronic prescribing system.

To date, much of the evidence supporting the use of EPMA is based on small scale trials or from looking at secondary endpoints from studies that were not designed to review the use of EPMA. The use of EPMA on one ward using one or two medical staff is very different to a trust-wide deployment.

Rolling out EPMA as it exists at the present time to an entire hospital leads, in my opinion, to similar levels of prescribing errors to a paper based system.

Then, there are the many other issues like hardware, networks, training and support. For example, just how will a new locum doctor or bank nurse fulfil their duties if presenting for one shift without EPMA training and what will happen if the EPMA system goes down?

You might be under the impression that we have regret that our trust has moved to electronic prescribing. However, that is not necessarily the case. There are real benefits: true transcribing errors are all but eliminated; for the first time a robust audit trail is recorded with clear lines of accountability; and there can be no doubt that everything is legible.

Additional benefits are possible if you have departmental IT skills to be able to interrogate the EPMA database. For instance, we have been able to develop reports to direct our clinical teams to new patients requiring medicines reconciliation.

I do believe that given time the existing EPMA systems can be developed and may one day be the safer systems that we all hope they can be. If any of the current EPMA suppliers would like to know how to build a safer EPMA system, they should listen to a hospital pharmacist for some good advice.

The message to all trusts contemplating EPMA should be one of caution. To rush headlong into deploying electronic prescribing systems in their current form could be no safer than continuing with the inherent but known risks of a paper-based system.

However, dipping your toes in the water now, as long as you have your eyes wide open, may mean that you can help develop systems for the future and place greater pressure on software companies to develop their packages for the real world and towards perfection.

My final piece of advice would be that if you are contemplating entry into the EPMA market place, you should critically review your chosen product by visiting a trust that has fully deployed EPMA (I would suggest a week’s observation should be the minimum considered).

The sales pitch and product claims employed by EPMA companies are not always practical in a clinical setting. While things may look beautiful on a PowerPoint presentation, use in the real world can be very different. Any identified product shortcomings in your chosen product should be stipulated by contract as required fixes before payments for the product are released.