December 19, 2013

Dr First

Should the E-prescribing Industry Require Mandatory Standards?

To follow on to my introductory blog post regarding prescription quality, this blog series is dedicated to examining current quality issues in the e-prescribing industry in order to help foster cross-industry conversations about some of the most pressing dilemmas in the field today.
In this blog, let’s examine the broader question of mandating specific fields for prescriptions such as days supply, diagnosis and structured and codified sig, and how this move could impact the broader industry.
The question is this: should the e-prescribing industry standardize specific, mandatory fields beyond what is traditionally encompassed in the current script standard? This would be a contentious step for the industry. Ease of use, flexibility, and limitations of software are just some of the reasons that point-of-care vendors cite when discussing the issue of making certain fields mandatory.
It’s wise to guard against industry developments that have the potential to stifle or otherwise limit innovation, but there are areas where we can make improvements, without placing arbitrary or unnecessary obstacles in the way of providers. For example, we can add some additional fields to ensure that patients are getting the right medications and know how to take them. However, I believe that there should be limits on how much emphasis we as vendors place on mandates, given the realities of a complex and dynamic clinical environment: the fact is, not all prescriptions fit into a nice neat box.
For instance, we know that current standards require quantity but do not require a stipulated days supply. I think the two go hand in hand. Why require days supply? Well, for pain medications, it allows the pharmacist to know whether the medication is to last a certain number of days, and to notify the prescriber for a possible overuse situation. For creams and ointments, it allows the pharmacist to know how long the patient should use the medication. This is important, for example, for corticosteroid topical agents, as long term use can have negative consequences. The days supply aids the pharmacist’s understanding and therefore aids proper patient counseling.
In addition to adding in a stipulated days supply, it would be highly beneficial to the healthcare industry if we finally began moving toward a structured and codified sig. This has been discussed for a long time by many leaders across the e-prescribing industry, but we have always delayed moving forward with the structured and codified sig over concerns regarding the complexity involved in implementing it. Continuing to delay implementing this initiative is detrimental to the industry’s long-term interests. My suggestion is that we begin with an interim solution, with the e-prescribing industry building in some segments of the structured and codified sig while gradually building toward the completed product. All participants should implement a minimum of two segments and up to at least 6 segments.
Certain specialties require prescriptions that are fine tuned for each patient, which generally means that the medications require tapered directions or titration instructions. At DrFirst, we are routinely asked when the industry will support prescriptions of this nature. Adjustments should also be made to account for the difficulty of placing some drugs neatly into boxes. Drugs like Azithromycin packs and Medrol dose packs, or even GI preps do not fit neatly into simple structured directions. These types of products have multiple day directions over several days. Other pharmaceutical products, such as GI preps, are even more distinct since they also include custom directions by GI specialists. And, while some Latin abbreviations are slowly being phased out due to the ease of e-prescribing applications, we still see providers using these abbreviations. It is time to rethink their continued utility within the field.
Finally, patient diagnosis information should be required for all prescriptions sent or printed from providers to pharmacists. This step has the potential to add an entirely new level of clinical benefits to e-prescribing because including patient diagnosis information will allow for far more meaningful consultations between patients and pharmacists, which further supports the information that the prescriber has given the patient. As a pharmacist, I am frustrated by the lack of information regarding patients’ conditions over the course of routine consultations, because there are so many drugs that have multiple indications and are prescribed to treat a variety of different symptoms, ailments, and conditions. For example, I would have a very different conversation with a patient who is taking metformin for polycystic ovarian disease (PCOS) versus one taking the medication for type 2 diabetes. In general, having access to provider diagnosis can aid pharmacists in helping patients understand their medication and the importance of adhering to their medication regimens.
I challenge my colleagues across the e-prescribing industry to begin thinking about how mandatory standards like these can help minimize many of the most common errors, and to join me in considering how best to implement these new standards. And don’t worry about rocking the boat or proposing something that may cause some initial alarm within the broader healthcare community. I remember when the quantity field was first made mandatory. Providers were upset because in the past, they relied on the pharmacist to figure out the quantity. We all have a responsibility to ensure that the right patient has the right drug, with the right directions, at the right time. These proposed improvements in e-prescribing would provide very real, positive impacts for pharmacists, providers, and most importantly, to patients.
Now, I’d like to turn this discussion over to my readers and industry colleagues. What do you think? Are these proposals worthwhile? Are there other standards you would like to see?

  1. E-Prescription Quality: An Industry Issue
  2. Should the E-prescribing Industry Require Mandatory Standards?
  3. Change the way we determine certification requirements?
  4. Force usability standards or specific workflows?
  5. Attempt to alter provider behavior to reduce common errors? If so, how?
  6. Require that vendors mandate more rigorous training regimens for providers and their staff prior to authorizing the use of their specific e-prescribing solution?