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NY Times Featured Article: Chicken Scratches vs. Electronic Prescriptions

As e-mail and texting have become our favored means of written communication, handwriting has almost disappeared. Penmanship is becoming a modern form of hieroglyphics, intelligible only to literary scholars.
But one place where handwriting persists is on medical prescriptions, and that’s unfortunate. Sloppy writing or inappropriate directions can lead to what doctors delicately refer to as preventable A.D.E.’s, or adverse drug events. These can encompass minor but still avoidable problems, like rashes or diarrhea, and much more serious events like, well, death.
Studies show that errors are much less likely if a doctor clicks to select medications from an onscreen list and sends the prescription data via computer to the pharmacy. Rainu Kaushal, a professor of medical informatics at Weill Cornell Medical College, led a study published in 2010 in which she and four colleagues followed prescriptions issued by a sample of providers in outpatient settings in New York. (Providers included physicians, physician assistants and nurse practitioners.) Some were prescribing electronically for the first time, and some continued to use paper.
The researchers found an astonishing 37 errors for every 100 paper prescriptions, versus around 7 per 100 for those who used e-prescribing software.
These errors didn’t even include legibility issues, when the pharmacist couldn’t read the handwriting with confidence and called the provider to clarify.

Earlier, when the participants who would switch to e-prescribing were still using paper, they had almost 88 legibility errors per 100 prescriptions. (Some prescriptions had more than one error.) An illegible prescription requires time to sort out with the provider. “In the case of an urgent medication,” Dr. Kaushal says, “the delay can result in patient harm.”
Previous studies of prescriptions in hospital settings have suggested error rates of about 5 per 100 paper prescriptions. Most were not serious, but about 7 percent had potential for harm. The Institute of Medicine has estimated annual costs for preventable A.D.E.’s in hospital settings alone at about $2 billion in the United States.
Yet only about 36 percent of all prescriptions were delivered electronically in the United States in 2011, according to a report to be published in May by Surescripts, which maintains an e-prescribing network.
E-prescribing comes as part of the switch to electronic health records, which can cost a medical practice tens of thousands of dollars. The stimulus package passed in 2009 included provisions that theoretically ease the financial burden for doctors, but the payments are tied to Medicare and Medicaid reimbursements that are spread out over five years. So the upfront costs remain substantial.
In addition to those costs, the other large obstacle to adopting electronic records is their impact on office work flow, Dr. Kaushal says. More hours may have to be added to the workday to enter data. “These systems are far from plug and play,” she says.
The number of hospitals using e-prescribing is growing rapidly, but still only about 30 percent have made the switch, says David W. Bates, chief of the division of general internal medicine and primary care at Brigham and Women’s Hospital in Boston and a professor at the Harvard Medical School.
Even when they install the technology, hospitals often leave e-prescribing as an option for providers but don’t require it. “What one sees often is about two-thirds of prescriptions are generated electronically” at these hospitals, Dr. Bates says, “but it’s hard to get that remaining third converted.”
In Australia, handwriting has been largely eliminated from prescribing. Johanna I. Westbrook, director of the Center for Health Systems and Safety Research at the University of New South Wales, says that about a decade ago, “the government provided financial incentives for family physicians to introduce computers into the practice.” Today, about 90 percent of those practices are computerized, but most pharmacies don’t receive prescriptions electronically. So the provider uses a computer and printer to prepare a neat prescription in paper form that the patient drops off at the pharmacy.
Reducing prescription errors can mean more than eliminating handwriting. Software is needed to integrate prescriptions with a patient’s electronic health record and to check for adverse interactions. This “decision support” software can have its own issues. It must be vigilant in looking for potential problems, but not overzealous. “Decision support is leading to ‘alert fatigue,’ ” Professor Westbrook says. “The consequence is providers ignore the alerts and the system then can’t prevent all of the medication errors that it could.”
On balance, though, it’s clear that e-prescriptions help prevent errors.
Such prescriptions were not unknown even in the 1990s, so clicks have long seemed to be on the verge of replacing scribbles. Perhaps it won’t take another 20 years before the prescription pad is placed next to the jar of leeches as an exhibit in the Museum of Medical Curiosities.
Learn how DrFirst can get you started down the road from a Paper Chart to fully Electronic Practice.
 
Randall Stross is an author based in Silicon Valley and a professor of business at San Jose State University. E-mail: stross@nytimes.com.