Electronic Prescribing

1. Electronic Prescribing Jill Mulderig

2. Objectives: • Describe Electronic Prescribing • Discuss tools and information system needed • Evaluate the Nurse Informaticist role in EMR/Electronic Prescribing • Discuss safety, ethical and confidentiality issues • Discuss Advantages/Disadvantages with Electronic Prescribing

3. Electronic Prescribing or E-Prescribing is: • Computer based mode of communication • Electronic mode of generating prescriptions • Part of the growing Electronic Medical Record (EMR) • Designed for improved communication with pharmacies and to reduce errors. • Commercially available software- can be used with or without EMR. (Finkelstein, 2006)

4. Main Goals of E-Prescribing: • Reduce medication errors • Improve patient safety • Increased access to medical information • Improved reporting ability • Cost and time effectiveness ( Barber, Cornford, Klecun 2007)

5. Hardware for E- PrescribingCan be used with : • Laptops • Desktop PC’s • Pocket PC’s • Tablet PC’s • PDA’s utilizing a wireless network

6. Personal Digital Assistant (PDA) • Handheld computer with many similar functions • Works with an operating system • Personal computer needed for syncing data and updating. • Organizing while mobile • Compatible with innumerous programs and software titles. (Carmack, Freudenrich, 2003)

7. PDA’s in E-Prescribing • Valuable tool to have all information needed at hand • Information can be saved to sync with office computer • Software easily compatible with PDA’s • Time saving • Helps eliminate written errors • Great start for streamlining to the EMR • Electronic communication between physicians and pharmacists

8. Software for E-Prescribing • Commercially available software • Physician or provider chooses based on preference • Many assist with patient tracking, ICD-9 codes, interactions, pricing, and warnings. • Work with desktop computers, laptops, PDA’s, and tablet pc’s. • Accurate drug databases in tune with health insurances • (nationalerx, nd)

9. Commercial Software Vendors • SureScripts • RxHub • ProxyMed • MedicWare • National E Rx

10. eRX Software: • National ePrescribing Patient Safety Initiative (NEPSI) was enacted due to the large number of medical errors in the healthcare system. • Free program to all physicians and medication prescribers • Created through an advocacy initiative – with • Claims to be simple, safe, and secure • Designed to increase patient safety and reduce errors. • Designed from funding to assist physicians in the advanced technology without the high costs to them. • (nationalerx, nd)

11. E RX software is designed to: • Eliminates handwriting issues and error • Creates electronic records to ensure prescription information is saved. • Reduces healthcare costs by improving efficiency and identifying generic drug options • Checks for allergies, drug interactions, dosing errors, and many other patient specific factors • Maintains an comprehensive drug database • Expedites prescription refill requests and saves staff time • Provides up-to-date formulary and insurance information • Improves data exchange between pharmacists and prescribers • (nationalerx, nd)

12. Included in the free program: • Partnership with ALLSCRIPTS and PocketScript • Six months of connectivity available (cell data exchange or high speed internet access available • Cell phone and WAN option available • Installed access area - connected to either DSL or cable high-speed internet • (Mandel, Boulter, nd)

13. Usability of Software: • The system appears to be user friendly for both beginners and experts with minimal training. • Pilot program in 2001 for physicians to evaluate • Two pilot projects confirmed better ease of use and usability for physicians. • There is an iterative design – which can cause less anxieties. • There are icons and visual aids for the users to see. • Workarounds possible but less likely • Cognitive work analysis- program was developed under influence of physician’s concerns. • (Mandel, Boulter, nd)

14. Evaluations on Usability • A pilot study with a focus group was enacted before release. • Collaborative is staffed by members of involved organizations for feedback. • Forums and meetings for prescriber education and training (cognitive walkthrough). • Evaluation after pilot to discuss and change • Study found a decrease in ER visits and reduction in safety errors. • Positive feedback received would indicate positive usability. • Qualitative evaluations done via studies to evaluate • (Mandel, Boulter, nd)

15. Information System • E-prescribing is an information system that is available as a stand alone configuration. • It is also part of a larger information system- Electronic Medical Record (EHR) • Many use e-prescribing as a starter or part of the electronic transition into the EMR.

16. Clinical Information System: EMR • EMR is an electronic record with ability to generate a complete record of a clinical patient & supporting care related activities through an computerized interface. • Use specific software to personalize specific needs.

17. Electronic Medical Records:Medicware • Clinical information system • EMR and components are used by physicians, nurses, hospitals, support staff, billing departments, and other personnel • Available in many configurations such as workstations, Tablet PC’s, and servers. • Networking capabilities • Some information available on PDA

18. Electronic Medical Records • Computer-based • Systematic documentation of a clients health status and health care in a secure format • Can be processed, stored, transmitted, and accessed by authorized professionals for the purpose of supporting efficient, high quality health care and accurate sharing of information across the continuum (McGonigle, Mastrain, 2009)

19. MedicWare EMR Software System • Clinical Information System • Centralized computerized patient medical record software • Streamlined diagnostic and treatment processes • Available online or via software purchase • Houses data and information regarding the health status of a client • (Medicware, 2008)

20. Components to Medicware include: • Clinical Data Repository (CDR) • Clinical Decision Support System (CDSS) • Electronic Prescribing with Alert messages • Medical Vocabulary • Evidence-based decision support with outcome reporting • Billing and scheduling • HIPAA compliant • Automated task management • Nurses notes • Patient Education materials • Quality management and control • HL7 interface • (Medicware, 2008)

21. Data Standards for Medicware: • American National Standards Institute (ANSI) • Healthlevel 7 (HL7) • Continuity of Care Record (CCR) • (Medicware, 2008)

22. Classifications compatible with Medicware: • ICD-9, ICD-10 - International Statistical Classification of Diseases • CPT – Current Procedure Terminology • SNOMED – Systemized Nomenclature of Medicine • HCPCS - Healthcare Common Procedure Coding System • NANDA – used only for nursing SOAP notes • (Medicware, 2008)

23. EMR advantages to Nursing: • Promoting standardized nursing language and terminology • Error reduction • Improve medication safety • Fast, clear access to patient information • Time saving

24. E-Prescribing Advantages • Cost saving (over time) • Time saving • Error reduction • Medication Tracking • Easy access • Better formulary compliance • Provider/Nurse mobility • Improved quality of care

25. E-prescribing Advantages: • Possible Medicare bonuses for e-prescribing

26. Disadvantages/Barriers to e- prescribing • Staff resistance • Cost • Security concerns • Lack of IT staff • Technology Mistrust • Possible reduction in staff (Anderson, 2007)

27. Ethical & Legal Issues: • Security • Privacy Concerns – HIPAA • Legal barriers (Anderson, 2007)

28. Informatics Competencies Required for Eprescribing and EMR: • Health information literacy • Privacy and confidentiality knowledge • Technical security knowledge • Basic computer literacy skills • Informatics skills – acquiring, processing, and sharing knowledge • * Above required by the Professional Nurse • (McGonigle, Mastrain, 2009) • (Miller et al, 2005).

29. Informatics Nurse Role:Eprescribing and EMR • Education • Lead projects • Assist in implementation, access and support of eprescribing leading to the expansion to the EMR. • Ensure security processes are correct and in place • Clinical resource person • Facilitates the integration of data, information, and knowledge to support patients, nurses, physicians, and staff. • Assist and lead research • Tech support • (McGonigle, Mastrain, 2009) • (Miller et al, 2005).

30. SUMMARY With proper implementation eprescribing can: • Reduce medication errors • Increase access to medical information • Reduce cost and increase time effectiveness • Ease into the transition to Electronic Medical Records • Improve patient safety • Increase direct care time to patient • Space Savings • Legibility of Notes – reduce errors cause by

31. Summary Cont: • Accessibility of Charts • Transcription Costs Savings • Space Savings • Eliminate Staff • Eligibility for Pay-for-performance • Multiple Users Use a Chart Simultaneously • Automatic laboratory and radiological reports • Electronic Prescriptions • System Recovery • Drug to Drug Interaction and allergy interaction checking

32. REFERENCES • Finkelstein, J (2006).E-Prescribing first step to improved safety. Journal of the National Cancer Institute. 98, 1763-1765 • Barber, N, Cornford, T, & Klecun, E (2007). Qualitative evaluation of an electronic prescribing and administration system. Quality and Safety in Health Care. 16, 271-78. • Anderson, J (2007).Social, ethical and legal barriers to e-health. International Journal of Medical Informatics. 76, 480-83. • Miller, MD, R, Gardner, PhD, R, Johnson, MD, MS, K, & Hripcsak, MD, MS, G (2005). Clinical decision support and electronic prescribing systems: A time for responsible thought and action. Journal of the American Medical Informatics Association, 12, 403-09 • Carmack, C, Freudenrich (2003, 06, 12). How PDAs work. Retrieved September 30, 2008, from HowStuffWorks.com. Web site: http://communication.howstuffworks.com/pda.htm • Retrieved September 30, 2008, Web site: http://www.nationalerx.com/ • Anderson, J (2007).Social, ethical, and legal barriers to E-health. International Journal of Medical Informatics. 76, 480-83.

33. REFERENCES • Mandel, MD, BCBSMA, B, Boulter, MD, P, E-Rx collaborative, E-Prescribing: A bridge to the 21st century. Retrieved October 5, 2008, from www.HCTProject.com Web site: http://www.HCTProject.com • What is HN7?. Retrieved October 26, 2008, from What is Web site: http://www.hl7.org/ • Conn , J (2007, February 13). Standards rivals’ collaboration could have major impact. Retrieved October 26, 2008, from EMRAdvice Web site: http://emradvice.wordpress.com/category/continuity-of-care-record • 2008, September). Retrieved October 26, 2008, from Center for Disease Control Web site: http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm • von Krogh, G, Dale, C, & Naden, D (2005). A framework for integrating NANDA, NIC, and NOC terminology in electronic patient records. Journal of Nursing Scholarship. 37, 275-81 • (McGonigle, Dee., & Mastrain, Kathleen. (2009). Nursing Informatics and the Foundation of Knowledge. Sudbury, Massachusetts: Jones and Bartlett Publishers) • Medicware Electronic Medical Records. Retrieved November 15, 2008, from Medicware.com Web site: http://www.medicware.com/emr-software.html