Electronic prescriptions: Return to sender

Life doesn't come with an instruction manual. Fortunately, everything I buy at IKEA does.  

In the pharmacy world, our assembly instructions come in the form of a prescription. Its singular purpose, the reason for its very existence, is to communicate to the pharmacist the prescribers' intentions. What do we do if the communication system is broken?  

Years ago, prescriptions were handwritten. If we couldn't read something, we'd call the office for clarification. Today we have electronic prescribing (e-Rxs), the savior of healthcare. It exists to reduce errors.

When I was first asked about the pure awesomeness of this new technology, the offices and software companies were taken aback by my response: “We do not have fewer errors, we have more legible errors.” Now I can clearly see the mistake that was made on the prescription.

Pharmacists used to know the handwriting of their local prescribers. We knew what their hieroglyphics meant and often didn’t need to call. Today, the errors are so bad that many e-scripts we receive cannot be filled as sent.

Whose fault?

Who is to blame? The offices. This is either a training error, which falls on the e-script service/provider that was selected, or a lack-of-learning error. This means that, despite repeated calls from pharmacies all over town, the offices are not changing their habits and continue to repeat the same mistakes.

If you go to a restaurant and order a steak medium rare and receive it well done, what do you do? You send it back. You could ask the waiter to bring you the chef, but it doesn't expedite your receipt of a new, properly cooked filet. Did the waiter enter the order incorrectly? Did the chef not cook it correctly? Either way, you aren’t likely to leave a big tip.

In the pharmacy world, even though we are not at fault for not being able to fill your prescription, we will be the ones to get yelled at.

It's the same with a prescriber's office. Did the prescriber enter the order incorrectly? Did the assistant not check the order and enter it incorrectly? I don't know. What is important is that the order is correct and I am able to fill patients’ prescriptions without wasting my time or any more of theirs. The prescribers get off without ever knowing what they did wrong.

What’s the fix?

How do we fix this? We need a Return-to-Sender button. We need a way to directly communicate with the offices.

Pharmacists have long been relegated to the refill line at many offices. This means that we have to leave a message and wait for an answer. Many times we will receive a phone call asking why we called. This is a waste of time. We need to be able to reply to the offices with a note of what needs to be fixed.

The other problem is with the software itself. Prescribers should not be allowed to make selections that do not match each other.

If the prescriber wants metoprolol, the computer should prompt her to then choose succinate or tartrate. Once that selection is made, the strength options should be given for the chosen salt.

This way, the prescriber cannot select metoprolol tartrate 200 mg. This will also result in fewer errors from prescribers selecting what they think they want as opposed to what they really want. And it will stop my local prescribers from writing gabapentin 200 mg.

I also have a suggestion that prescribers be given default quantities on unit-of-use products. This way we won’t receive prescriptions for 15 g or 30 g of mupirocin ointment when it’s only available in a 22-g size. And how many prescriptions have you received that told you to dispense 3.1415 tablets?

Short-term fixes

This issue has caused more divisiveness between professions than any other in recent memory. We as pharmacists have allowed this to happen.

There is a mindset among prescribers that it is the pharmacist's job to fix everything. It is not. If the order is entered incorrectly every time, how is that our fault? If the assembly instructions are incomplete, can the end user really be to blame for how a product was assembled?

We have to go to the source. The only way for this to happen is for us to have a direct link to the point of entry.

On my Facebook page, the community is quite helpful with idea-sharing. We offer fixes that seem to work for others around the country.

Some pharmacies print the e-script, circle the errors, then fax it to the offices.

Some call, leave messages, and then hand the incorrect copy to the patient to have him or her deal directly with the prescribing office. These are short-term fixes, not permanent solutions.

Solve the problem at its source

Here is my proposal. We need to talk with the e-script providers. We need to discuss their training methods, their software, their programming, and the ability for pharmacies to return problem prescriptions.

Prescribers should not be able to select drugs, strengths, directions, and dosage forms that do not all match.

We need a voice on this problem. Our local, state, and national organizations seem to be absent, or at least silent, on this issue. Instead of forcing a broken technology down the collective throat of us in healthcare, let’s get together and fix it. Let’s put right what once went wrong.

Pharmacists are tired of complaining about the problems with electronic prescriptions. We are tired of fighting with offices to make them correct their errors. We are tired of wasting our time and the patients’ time and the offices’ time fixing something that never should have been sent.

Call me. Let’s fix this. 

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