Nursing Informatics in Prescribing Medications

      Medication errors became front page news with the November 1999 release of a compelling report from the Institute of Medicine (IOM). The public may have been surprised to learn that errors involving prescription medications kill up to 7,000 Americans a year, according to the IOM, and that the financial costs of drug-related morbidity and mortality may run nearly $77 billion a year. But the problem of medication errors is not new. In fact, research demonstrates that injuries resulting from medication errors are not the fault of any individual healthcare professional, but rather represent the failure of a complex healthcare system. System failures can be analyzed and prevented, many through emerging information technology (I.T.) solutions.

      In the medication management system, errors can be introduced at multiple points. Numerous problems are related to the naming, labeling, and/or packaging of drugs or to inefficient distribution practices. Patients often contribute to errors by failing to comply with instructions. Many errors occur as prescriptions are written; these tend to be failures of communication and, in far too many cases, the underlying problem is clinicians' handwriting.
      The healthcare industry has been slow to adopt new technologies, although these tools hold promise for enhancing the delivery of healthcare. Prescription writing is perhaps the most important paper transaction remaining in our increasingly digital society; it seems simplistic to note that electronic prescribing tools could minimize medication errors related to handwriting. Yet even though such devices are available for use in hospitals, ISMP estimates that less than 5% of U.S. physicians currently "write" prescriptions electronically.
      The hurdles until very recently have been clinicians' reticence about computers, a lack of hardware and software that would conveniently allow prescribers to select medications electronically, and fear of the costs associated with such technology. Fortunately, the advent of wireless hand-held devices is making it increasingly possible to solve the "handwriting crisis," perhaps on all 3 counts.
      Easy-to-use point-of-care systems, some that offer comprehensive applications in real time, are becoming available from a number of manufacturers-and at perhaps a surprisingly low cost of entry. Such integrated programs may provide benefits for cost and risk management as well as for clinical care, and they may enhance the prescribing process beyond addressing penmanship alone. For example, hand-held devices can alert practitioners to potential drug or allergy interactions via up-to-date databases of medications that are connected with patient records. That kind of functionality should help to rapidly expand adoption of electronic prescribing among practitioners. Of course, computerized medication management systems certainly are not a panacea. Moreover, clinicians' use of hand-held technology will not solve the broad spectrum of medication errors, for technology is but one part of a larger solution that includes such simple and low-tech strategies as separating look-alike medications in a dispensing cabinet. Hand-held Technology at the Point of Care
      Still, electronic prescribing has not yet become standard operating procedure in offices and clinics, partly because clinicians have been notoriously slow to embrace digital applications for any purpose and partly because providers have feared the high costs typically associated with technology. In addition, until very recently, appropriate hardware and software simply did not exist to allow practitioners to electronically select medications as a natural part of their workflow. However, that has changed with the advent of wireless technologies.
      The hand-held electronic prescribing units that now are available typically utilize radio frequency, cellular, or infrared signals to communicate with an on-site server or a PC-based Internet connection. Patient and drug information is available confidentially to practitioners in real time. An electronic prescription can be entered directly into a computer, then electronically transmitted to a pharmacy-at the hospital, in a local retail store, to a mail order outlet, or to a virtual pharmacy on the Internet-or perhaps be provided right in physicians' offices. The entire process is far less time-consuming than the current paper-based system.
      Portability is a distinct benefit of such devices. Physicians, in particular, are mobile, so they need a system that allows them to input prescriptions at the point of care. Wireless devices allow clinicians to bring computers into their workflow, as opposed to reengineering the workflow to suit the technology. It also helps that most of the units are easy to use. Electronic tools are being put to use for all manner of clinical tasks, including but not limited to automating and integrating the prescription-generating process. Other applications include provisions for medical histories, ICD-9 coding, clinical alerts, drug utilization reviews, and formulary compliance. Some programs allow prescribers to order laboratory tests, capture charge information, or refer patients to specialists, while ensuring security and privacy of records.
      That kind of functionality should help to rapidly expand adoption of electronic prescribing among practitioners. ISMP is heartened by recent estimates from industry analysts that suggest 10% to 15% of physicians are trying hand-held computers, with the number higher (perhaps 60% to 70%) among doctors in training who have come of age in a computer-oriented culture.

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