The theme of the November 2018 issue of Health Affairs (Health Affairs 2018) was patient safety. There were several articles that are very valuable. But one really caught our attention. The article “A Prescription For Enhancing Electronic Prescribing Safety” (Schiff 2018) carries 2 key things we have long been advocating for. One is inclusion of the indication for each medication. The other is a mechanism for proper notification of pharmacies (and others that need to know) when a medication is discontinued, that is “e-discontinuation”.
Providing the indication for a prescription is important for more than one reason. First, there are many medications that are used for treating multiple conditions. For example, beta blockers may be used in the treatment of MI, CHF, migraine, essential tremor, hypertension, etc. Knowing the reason for the initial prescription, thus, is important when decisions about discontinuation are being pondered.
Second, seeing the indication may help a pharmacist recognize when a wrong drug has been prescribed. That is especially important when LASA (“look-alike, sound-alike”) errors are made. For example, if a prescriber erroneously clicked on “Dilaudid” instead of “Dilantin” but a pharmacist saw the indication was “for seizures”, the pharmacist would recognize a problem and contact the prescriber for clarification. As the article also points out, the same concept should be used at the time of order entry to prevent prescribing the wrong medication. In the example above, if you looked for “seizures” as an indication under the erroneously chosen “Dilaudid” you’d realize you had chosen the wrong drug.
Third, seeing the indication can help avoid wrong-dosing errors. The article includes the methotrexate problem that we’ve discussed in multiple columns. That is when methotrexate is ordered for treating an autoimmune condition, like rheumatoid arthritis, rather than for oncologic conditions. For the former, once weekly dosing is used. So, if the pharmacist saw an order for daily methotrexate and the indication was “rheumatoid arthritis”, the pharmacist might recognize the dosing error.
Regarding “e-discontinuation”, we’ve often pointed out the gap we have where a patient is told to discontinue a medication but that never gets communicated to other parties that need to know (see our May 27, 2014 Patient Safety Tip of the Week “A Gap in ePrescribing: Stopping Medications”, our March 2017 What's New in the Patient Safety World column “Yes! Another Voice for Medication e-Discontinuation!” and our August 28, 2018 Patient Safety Tip of the Week “Thought You Discontinued That Medication? Think Again”). The critical issue: stopping a medication is much different than starting one. Starting a medication requires an active process – you either write a prescription, enter one into a computer, or call the pharmacy. You are usually in a situation where you can utilize an electronic order system (CPOE or e-prescribing tool) and you may have access to the many clinical decision support tools in those systems. But discontinuing a medication is often more passive – you might get a call from your patient after hours and just tell the patient over the phone to stop it when the patient tells about a potential side effect. You don’t call the pharmacy to stop it. And, if there was no associated office visit, you might even forget to update the patient’s medication list in your EMR (or paper records) until the patient’s next office visit.
With today’s integration of the EMR to the physician’s smartphone, almost all opportunities to do e-discontinuation should be done with a formal process that should include more than just the discontinuation order. The EMR system could ask “Have you notified the patient to discontinue the medication?”, “What is the reason for the discontinuation?”, and “Do you wish to notify the patient’s pharmacy of the discontinuation?”. The system’s clinical decision support tools should then also consider whether any drug-drug interactions might be in play that would necessitate changing the dosage of another medication.
And don’t forget there is one other mechanism by which discontinued medications get inappropriately continued. Our February 28, 2017 Patient Safety Tip of the Week “The Copy and Paste ETTO” reminds us how the copy/paste function in today’s healthcare IT systems can lead to erroneous medication lists that might result in a patient being inappropriately restarted on a medication that had actually been discontinued.
The current Schiff article discusses the CancelRx, a format for sending discontinuation messages to pharmacies but notes some barriers that have delayed widespread adoption (eg. workflow issues, alert fatigue, etc.).
Of course, all the above presumes that the physician discontinuing the medication enters a discontinuation order in CPOE or an ePrescribing tool (and that those tools have a discontinuation capability). As pointed out above, the discontinuation is often made via a patient phone call at a time when the physician may not have ready access to an e-prescribing system.
Another important feature the Schiff article calls for are structured and codified prescription instructions. It points out that most instructions (the “sig” on a prescription) are transmitted via free-text and that there is tremendous variation in how those “sig” instructions are written. They note that, when using free-text, the simple instruction to “Take one tablet by mouth once daily” can be represented in 832 different ways! Using structured, codified instructions via e-prescribing has numerous workflow improvement capabilities in the pharmacy and should considerably reduce the variation in instructions on labels.
The article calls for better clinical decision support. The authors describe both the basic and advanced elements for an ideal clinical decision support system, noting that such does not just consist of alerts and reminders. See the actual article for details of all the elememts.
And, a very important concept put forward in the Schiff article is facilitating the ordering of nondrug alternatives. We know that clinical decision support alerts often fail because they do not include alternatives. Usually the alternatives we’d like to point out are other medications. But what about suggesting alternatives that are not drugs at all? The Schiff article provides an example that, when a provider attempts to prescribe a sleep medication, a message with alternative sleep hygiene interventions be presented. (See our June 3, 2014 Patient Safety Tip of the Week “More on the Risk of Sedative/Hypnotics” for a discussion on alternatives to sedative/hypnotics).
A single shared medication list is a goal that everyone wants to see. Long ago we envisioned being able to populate medication lists with data from numerous sources, such as EMR’s, hospital pharmacies, community pharmacies, payer databases, pharmacy benefit managers, etc. (see our December 30, 2008 Patient Safety Tip of the Week “Unintended Consequences: Is Medication Reconciliatin Next?”). But we found that those electronically downloaded lists may include drugs that a patient is not or never has been taking. Such medications can get on those lists for several reasons. In some cases, fraudulent activity is involved (eg. the medication is for a friend or relative) or there is medical identity theft involved. In most cases, though, it is simply due to honest mistakes taking place in the billing process. Remember, those lists are largely generated for the purpose of fulfilling the payment transaction between the pharmacy and the third-party payor. How many of you have ever had an item that you never purchased show up on your credit card statement? Probably most of you. Usually a harmless error that you can easily rectify via a phone call. Though we don’t know the frequency of such ID errors in healthcare, your ID number at the pharmacy often differs from that of one of your family members by only one digit so we would not be surprised at all if such errors are more frequent than in the credit card industry. And if such an error leads to appearance on your best possible medication history of a drug you have never taken, that can lead to problems. Shouldn’t that discrepancy be resolved when your physician goes over that list with you on admission? Certainly. But what if you are obtunded or comatose or otherwise not able to communicate on admission? You may well be started on a medication you have never taken. And you could ultimately also be discharged on that medication and have it continued indefinitely.
But the Schiff article focuses not on populating medication lists from all those sources but rather on interfacing all prescribing software with a single online database. They note a benefit would be that access to patients’ current medication lists would not be constrained by geography, institution, practice type, pharmacy, or insurance plan. And prescribers would not have to worry about which pharmacy a patient goes to, and pharmacies would be able to fill any active prescription (with checks to avoid duplicate filling). Primary care physicians would be able to readily see any changes a specialist or hospitalist has made in a patient’s regimen. Now that virtually all hospitals use CPOE and e-prescribing is mandated in most other venues, this concept is now feasible.
Note one thing missing from the Schiff article that we’d also like to see is a “reason for discontinuation”. It may be important to know whether a medication was discontinued because of:
· Side effects (dose-related or non-dose-related)
· Allergy (true allergy)
· Cost considerations
For example, I might consider prescribing a beta blocker for migraine prophylaxis and the patient tells me that he/she was once on that medication. It would be important for me to know whether it had been discontinued because it was ineffective for the initial indication (other than migraine prophylaxis) or because of an untoward side effect or true allergy.
The article by Schiff and colleagues is not just a pipedream. The concepts are feasible and, though there may be barriers, their implementation is something we ought to be able to see in the near future.
Health Affairs 2018; 37(11): November 2018. Patient Safety
Schiff G, Mirica MM, Dhavle AA, Galanter WL, et al. A Prescription For Enhancing Electronic Prescribing Safety. Health Affairs 2018; 37(11): 1877-1883
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