E-PRESCRIBING - TELEPHARMACY

E-PRESCRIBING - TELEPHARMACY S.G. PETROPOULOU 1, M.P. BEKAKOS 2 and G.A. GRAVVANIS 2 1 Health Informatics Laboratory, Department of Nursing, National and Capodistrian University of Athens, Hellas; email: pstavroula@freemail.gr 2 Department of Electrical & Computer Engineering, School of Engineering, Democritus University of Thrace, Hellas; email: {mbekakos, ggravvan}@ee.duth.gr Abstract: Advances in information and communication technology and in particularly the development of new mobile devices with user-friendly interfaces, broadband communication and wireless networks technology, offer new approaches to encouraging physician adoption of new technology applications. According to the Institute of Medicine (IOM) study To Error is human: building a safer health system, over one million preventable medication errors are made each year. A significant number of these errors result in serious complications in citizen health status and death. Thus, prescriber s handwriting is frequently cited as a common cause of medication errors. As a result, there is high level of interest in the development of electronic prescribing. E-prescribing, as a basic component of a telepharmacy system, is an electronic data entry system will not only replace the traditional manual ordering and prescriptions management system but it will also complicate the automation of medication dispensing process. Upper goal of such a system is the automation of inpatient and outpatient prescribing process by reengineering of pharmaceutical care provision in order to reduce the cost and risk of the medication errors. The Institute for Safe Medication Practices (ISMP) supports strongly electronic prescribing. A recent, very important initiative is referred to the application of Computerized Physician Order Entry (CPOE) system in hospitals. CPOE is a computerized physician orders management system, which support physician operations, such as prescribing. Three major companies like Advance PCS, Merck Medco and Express Scripts have been parts of the RxHub Consortium to develop standards and to facilitate the communication between physicians and pharmacies through the electronic transmission of prescriptions and medication information. Keywords:E-prescribing, telepharmacy. 1. INTRODUCTION Advances in sciences and technology are changing the healthcare delivery worldwide. About 15000 websites contain primarily health information and 1

an estimated 70 million people only in the United States have used the Internet to search for medical information. Moore s Law states that microchip computing power doubles every eighteen months [1]. Thus, it is estimated that the half-life of medical knowledge is less than eighteen months and this has created a huge challenge for healthcare professionals and systems with respect to channeling new information and technology to the front lines of the care delivery system. According to the Institute of Medicine (IOM) study To err is human: building a safer health system, over one million preventable medication errors are made each year [31]. A significant number of these errors result in serious complications and death. New challenges and important opportunities are arising for electronic delivery of health services as citizen become more informed and more patients are consulting physicians remotely and they are interested in healthcare services provision at a distance. Pharmacists too, are using information technologies and automated dispensing systems to make their dispensing and clinical operations more efficient. Pharmacists have been challenged for many years with the need to dispense an increasing number of prescriptions while coping with a pharmacist storage and expanding their practices to include more patient care activities. Four technology trends rapid software development to support health care services, increased extent of information systems integration, shortened computers life cycle, and increased use of electronic data interchange have been notable in recent years. These trends are leading to new possibilities for telemedicine applications like telepharmacy, computerized health records, electronically - based prescribing (eprescribing), and integrated pharmacy information systems, including automated dispensing systems. The term electronic prescribing suggests that the physician is able to electronically fill and send the pharmacy a prescription, similar to how we use fax or e-mail. If this were the extent of e-prescribing, its advantages would be limited to eliminating the problem of interpreting illegible handwriting. However, e- prescribing has the potential to do much more. Telepharmacy is a telemedicine application that specifically involves the provision of medications, medication information, and pharmaceutical care from a distance. Some telepharmacy services, include the management of patients databases, adhering checking, inventory control, and the processing of claims and bills. All of these electronically designed pharmacy management systems use technology to prevent medication errors and improve patient care. In disease management clinics, pharmacists are monitoring laboratory test results, adjusting medications, and providing information to physicians via the communication networks. An example of telepharmacy is a pharmacist reviewing a patient s record and prescription order and then signaling a dispensing machine at a distant location to deliver the medication. Providing medications and pharmaceutical care in this manner increases access to care for patients, especially those in rural areas, and improves continuity of care. In the 2

future, health care access using similar mechanisms will expand globally as patients ask for medical resources across continents. 2. BASIC CONCEPTS Medication prescribing is one of the most frequently used, powerful, therapeutic tools available to physicians, while drug therapies are not well-managed or deployed in ways that can create risk of adverse drug events. Electronic Prescribing, as also referred e- prescribing, means the Information and Communication Technology (ICT) support to all prescribing and medication management processes. E-prescribing, combined with genericfirst line therapy and point of care dispensing, creates a powerful mechanism for payer, provider and patient to reassert the right to provide the right medication, to the right patient, at the right time. According to National Association of the Boards of Pharmacy (NABP), telepharmacy means the provision of pharmaceutical care through the use of telecommunications and information technologies to patient at a distance. Still a relatively new discipline, telepharmacy is being explored in areas of pharmaceutical practice, such as increasing formulary compliance, simplifying pharmacy administration and reducing dispensing or other errors related to illegible handwritten prescriptions [3]. The Veteran Health Association (VA) and rural hospitals like Allen Memorial in Moab, United States, are just some of the healthcare organizations that have begun to adopt telepharmacy as a means of reducing cost and linking centrally located pharmacists to remote patients. Telepharmacy has also been used to provide nighttime pharmaceutical services at a community hospital. Another area in which telepharmacy is being applied, is in the development of Internet pharmacies, which sell and deliver prescription and medication as well as provide pharmaceutical care to patients over internet. Medications ordered through these pharmacies are delivered through various delivery services. 3. E-PRESCRIBING 3.1 Operational considerations of E- prescribing process The prescribing process begins with the clinician s assessment of a patient s condition and needs. The assessment is traditionally based on history, taking during patient s interview, physical examination and review of any laboratory or other diagnostic studies. The clinician arrives at a presumptive clinical diagnosis and selects a course of treatment that may include medications. Having made a therapeutic decision and selected a class of drug, taking into consideration possible allergy, drug, and disease interactions the physician writes the prescription. With e-prescribing, the clinician is generally able to access the patient s demographic data and using the suitable prescribing application selects a specific medication, dose, route, and therapy duration. This can generally be done using a handheld device or voiceactivated prescribing on a mobile. The application checks for adherence to any 3

applicable formulary and alerts the clinician to any potential allergic or other drug interactions. When all requisite checks have been completed, the clinician submits the prescription for dispensing. Depending on the system, the prescription may then be printed and given to the patient to fill, faxed to the patient s pharmacy or transmitted electronically to online pharmacies or Internet pharmacies. When a medical practice installs an e- prescribing system, the basic configuration is as follows: the physician s office computer is linked to a central computer server provided by an e- prescribing vendor. It contains formularies, drug interaction files and a drug information database. The server is used to update this information regularly in the physician s practice management office computer. The system also allows for the physicians to access information and to write prescriptions from a handheld prescribing device, like a PDA that is linked to the office computer. In Figure 1, a typical e-prescribing scenario is shown. In the ideal e-prescribing system, the physician will be able to use a handheld device to the following functions: First, select the patient, and view all his demographic and insurance information. Select a medication from the drug database viewing all information specific to the patient s health profile and insurance plan. Then check for allergies and drug interactions against the list of the previously prescribed drugs and specify the drug dose, suitable quantity, directions and refills. Digitally sign the prescription, and send it electronically to the patient s pharmacy. Print the prescription if an actual signature is required and save the prescription in the patient s record for generating rapid renewals in the future. In today s standard practice model, drug-drug interactions, drug-allergy interactions, non-formulary medication and patient eligibility issues are often not identified until the time of claim adjudication in the pharmacy. As a result, prescriptions frequently need to be changed. Several types of clinical applications contain e- prescribing functionality for the outpatient environment. These include ambulatory health record systems and mobile e-prescribing systems. Figure 1. Typical E-prescribing Scenario 3.2 Potential Benefits In a typical e-prescribing scenario, improvements in efficiency, accuracy and convenience of medication prescribing would yield a variety of benefits to patients, physicians and third parties. In table 1 below are included the potential benefits of the e-prescribing systems implementation. 4

Patients Potential BENEFITS Patients convenience and flexibility. Fewer difficulties over prescription insurance coverage. Prescriptions or medications ready for pickup. Therapy starts without delay. Improved patient safety through generation of legible, accurate prescriptions that have been checked for harmful interactions. Improved patient satisfaction through rapid prescription filling. Potential for most cost-effective therapy with subsequent cost savings. Pharmacists Fewer handwriting problems or issues; fewer mistakes because of misreads. More time spent helping physicians and patients with drug therapy matters and disease-state management. Competitive advantage over pharmacists who do not adopt e-prescribing. Physicians Online notification of drug interactions. Online access to patient s information, decision support and health information sources at the point of care. Less time to create an e-prescription. Formulary adherence through checking against health plan formularies at the point of prescribing updated in real time. Possible financial benefit through improved formulary compliance. Organizations Reduced medication cost by influencing a greater use of generics and preferred brand name drugs. Fewer communication time and cost (physicians-pharmacies). Less paperwork for staff (faxes, letters, etc). Table 1. Benefits of the e-prescribing systems implementation Less than 5% of all prescriptions are currently processed entirely electronically; however, physician order entry system in hospitals and e-prescribing in community pharmacies are becoming more common. In many cases external forces are pressuring health systems and individual providers to use e-prescribing systems. Physician s handwriting is frequently cited as a common cause of 5

medication errors. For this reason, specialized groups such as the Institute for Safe Medication Practices (ISMP) support strongly electronic prescribing. ISMP has called for the elimination of handwritten prescriptions by 2004. In parallel, principles have been developed for health plans to assure the safety of procedures and the resulted benefits. One of these principles is the implementation of the Computerized Physician Order Entry (CPOE) systems in hospitals [11,9,29,28]. E-prescribing has the potential to increase efficiency and reduce the probability of medication errors. The physician has immediate access to online prompts for dosing, drug interaction, and formulary information. Bates, et al. [9] demonstrated that CPOE systems are able to cut transcription errors by 84% and save more than $2.5 million in adverse drug reactions. obstacles to the use of e-prescribing include the following. Sending electronic prescriptions depends on electronic data interchange. It is necessary for e- pharmacy systems to communicate in the same language to e-prescribing systems, necessitating a standard code. In the table 2 are included all potential areas for e- prescribing standards. AREAS Message format Drug Terminologies Formulary Reference Information: Drugdrug interactions Indications Contra Indications STANDARDS NCPDP, SCRIPT FDA, RX Norm, NDF-RT 3.3 E-prescribing Technology The increased use of PDAs is making it easier to adopt e-prescribing. Palm-sized PDAs are relatively inexpensive, easy to carry and convenient for the mobile physician or pharmacist to use. Software from companies such as epocrates provides a convenient source of information (e.g. drug interactions, dosing information, pharmacokinetic dosing programs) and aids in decision making [13]. The trends indicate that e- prescribing is increasing worldwide, yet the rapid adoption of new technologies faces several obstacles. One limitation to using PDAs is the difficulty of maintaining continuous communication with the central database server. Other Adverse Drug Reactions Eligibility Harmonization of standards required for seamless decision support Contra Indications with HL7 Lab Results Contra Indications with allergies, medication lists, problem list Coordination of benefit standards NCPDP and HL7 Pharmacy 6

Table 2. Potential Areas for e-prescribing standards The National Council for Prescription Drug Programs has developed SCRIPT as a standard for electronic commu-nication that allow pharmacy computers to read electronic prescriptions regardless of the e-prescribing system [7]. 3.4 Other Issues Although, getting physicians to order prescriptions electronically is a challenge, developing new habits is very difficult. Mandated technical standards drug reference file, messaging standards, EHR standards, electronic data interchange standards, in parallel to development of IT infrastructure and user friendly systems, decision support systems, like as drug knowledge base for alerts and reminders, guidelines on use of new drugs, linked IT initiatives and financial incentives as also technical integration and cultural changes are the basic needs to face the development of new solutions. Deciding who is going to pay for e- prescriptions is another obstacle. Ensuring security and patient privacy is also a very important issue. The digital certificate will facilitate pharmacist s use of the Internet by placing legally valid electronic signatures on their professional communications with other providers. As e-prescribing technologies become easier to use and less expensive, it is likely that the number of physicians adopting it will continue to increase. The ability to improve the cost and quality of health care is greatly enhanced by adopting new technologies and obstacles to their use can be overcome by collaboration among stakeholders. 4. TELEPHARMACY One of the most exciting and innovative approaches to providing pharmacy services during a time of pharmacist shortage or 24 hours base time is the concept of telepharmacy. Telepharmacy involves integrating telecommunications, information system pharmacy software, and remote controlled dispensing technology to support a pharmacy model in which a central pharmacy is electronically linked to single or multiple physician offices, local and remote clinics, emergency rooms, health and surgical centers, long term care facilities, correctional and rehabilitative facilities or other difficult to serve points of outpatient health care. Telepharmacy means electronic transmission of a prescription order from the remote location to the central pharmacy. There, the order is reviewed and verified by the pharmacist who then authorizes and oversees automated dispensing of the needed medication from the pre-filled drug cabinet at a distance. If necessary, web camera or real time videoconference can enable face-to-face consultation between the pharmacist, the physician and the patient [5]. Telepharmacy offers numerous advantages for the patient, including increased convenience, reduced waiting time, and increased access to medications and experts in locations where a full-time pharmacist may not be available. The development of a telepharmacy-enabled model of pharmacy practices is imperative for the pharmacists. From this 7

model will emerge the practice standards, policies, guidelines, needs and all other elements defining pharmacy practice in the twenty-first century. Pharmaceutical care models have mainly focused on faceto-face care, while relying on computers for health care records and clinical decision support systems. There has been no systematic evaluation of telepharmacy services through multiple communications and data transfer methods till this writing time [1]. Recently, online pharmacies have been redirecting their efforts toward new partnerships and business models. 5. TRENDS AND CHALLENGES The past years have witnessed the explosion of the mobile computing platform like personal digital assistants (PDAs), wireless networks and satellite networks, which provide coverage of large geographic areas. Wireless Internet may favour for e-prescribing systems in the future. The development of better standards for electronic data interchange may be accelerated by the RxHub Initiative. There are many possible reasons for the sluggish progress of use of e-prescribing. Several aspects of the structure of the health care are likely contributing [2]. Beyond the market issues and the difficulty of new technologies acceptance from physicians, they may also be sceptical about the value delivered by e-prescribing systems. In most cases safety benefits are limited to production of legible prescriptions, checked against a list of current medications and perhaps allergies. These contributions are significant, but may not live up to expectations of physicians considering the switch to e-prescribing. Several issues currently in play are likely to have profound influence on the future of e-prescribing. The Health Insurance Portability Accountability Act (HIPAA) regulations on security and pry carry important and specific implications for the use of e-prescribing technology [8,19]. HIPAA privacy rules will have to guarantee and verify that patient information is adequately protected. Another dynamic issue is the interoperability of different systems. A great advantage will be determined by the degree to which mobile computing be able to be integrated with health care legacy systems, including practice management systems and the use of open standards for application development and communications. It seems likely that e-prescribing will play an increasing role in patient care in the future. Three major companies like as Advance PCS, Merck Medco and Express Scripts have formed the RxHub Consortium to facilitate the communication between physicians and pharmacies by the electronic transmission of prescriptions and medication data [15,19]. The RxHub members state that new standards will meet the HIPAA security requirements and other privacy standards. The standards will also incorporate encryption technology to ensure security of transmissions. In Denmark e-prescribing has been practised since the beginning of the 1990 s [11]. Over 600.000 electronic prescriptions have been sent to pharmacies every month. This number limits to 1.000.000 prescriptions per month in 2004. On average 70% prescriptions sent to pharmacies electronically in Denmark, in Sweden on 8

average 25% as other European countries support pilots or start considering the planning phases. On the other hand, Intel was conducting a venture to build up the security of internet-based communications between pharmacists, physicians and other health care professionals in US. European nations are moving forward from national Health strategies to the implementation of e-health services. Many new services are already or will soon become available for the European citizens. There is an overwhelming business case for improving the prescribing and medication management process with ICTs applications and there is an sentiment that e-prescribing will take a central role in reducing errors, increasing quality, reducing costs and delivering effective clinical care in many nations and regions in Europe. 6. CONCLUSIONS The health care delivery must meet a number of challenges before the new technologies can be widely adopted. Pharmacists and physicians daily functions are enhanced with the use of time-saving technologies, but electronic prescription processing in some only countries is yet routine. Despite the appearance of a sluggish rate of adoption, these new technologies will slowly pervade and revolutionize the health care system and the manner in which medication reach to end users. The pharmacy profession must stay abreast of current trends and changes in information technology to ensure that pharmacists are viewed as key health care providers in contemporary health care systems. The implementation of e-prescribing technology and telepharmacy applications in combination to the reengineering of healthcare processes and suitable management tools elevates the core value proposition beyond the digital conversion of prescription writing and positions e- prescribing as a more formidable technology solution. Business models provide the strategies that should integrate to e-health concept and assume its role in care delivery. E-prescribing has the potential to provide a bridge that will facilitate a transformation in health care delivery, which will have a remarkable impact on quality, safety, efficiency, and ultimately the value delivered by the health care system. REFERENCES [1]. ANGARAN, D.M. (1999). Telemedicine and telepharmacy : current status and future implications. American Journal of Health System Pharmacy, 56(14),1405-26. [2]. MELLIN, A. (2002).E-prescribing: an opportunity for process reengineering. Health Management Technology, 23(1), 42-7. [3]. MONANE, M., et al. (1999). Improving prescribing patterns for the elderly through an online drug utilization review intervention: a system linking the physician, the farmacist, and computer. Journal of American Medical Association (JAMA), 281(13), 1168-1169. [4]. KROHN, R. (2002). Making E- prescribing Work - A Fresh Approach. Journal of Healthcare Information Management, 17(2), 17-19. [5]. BASHUR, R.L., SANDERS, J.H., SHANNON, G.W. (1997). Telemedicine 9

: Theory and Practice.Springfield, IL: Thomas, C., pp:5-35. [6]. WEST, D., SZEINBACH, S. (2002). Prescription Technologies: Keeping Pace. Journal of the American Pharmaceutical Association, 42(1), 21-25. [7]. MADLE, K.D., SZOLOVITS, P., KOHANE, I.S. (2001). Public standards and patients s control: how to keep electronic medical records accessible but private. British Medical Journal, 322, 283-6. [8]. HAMBY, P., McLAUGHLIN, M. (2001). HIPAA Standards offer more accuracy and eventual cost savings. Healthcare Management and Finance, 55, 58-62. [9]. BATES, D.W., LEAPE, L.L., CULLEN, D.J., et al. (1998). Effect of computerized physician order entry and team intervention on prevention of serious medication errors. Journal of American Medical Association (JAMA). 280, 1311-6. [10]. LOADER, J., SEWELL, G.J. (1999). The role of the pharmacist in the provision of hi-tech health care at home. Pharmaceutical Journal, 264, R 70-1. [11]. DEMKJAER, K., JOHANSEN, I.B., BERNSTEIN, K. (1999). Third generation electronic pharmacy communications. Studies in Health Technology and Informatics, 68, 278-82. [12]. PHILLIPS, K.A., VEENSTRA, D.L., OREN, E., LEE, J.K., SADEE, W. (2001). Potential role of pharmacogenomics in reducing adverse drug reactions : a systematic review. Journal of American Medical Association (JAMA), 286(18), 2270-9. [13]. FOX, G.N., WEIDMANN, E., DIAMOND, D.E., et al. (2001). Hand- Held Electronic Prescribing. Journal of Family Practice, 50(5), 449-54. [14]. BISHOP, M.A., SEYMOUR, R.J. (2001). Delivery of pharmaceutical care via the Internet. Tenessee Medicine, 94(8), 277-9. [15]. WHITAKER, S. (2000). The members, the medium and the message: an evaluation of Private-Rx, the information network for UK pharmacists. The Pharmaceutical Journal, 265, R74. [16]. WEST, D. (2000). On-line pharmacies: implications for the future. Drug Topics, May 1, 83-92. [17]. POSEY, L.M. (2001). Electronic physician order entry: segue to a fully automated medication system. Pharmacy Today, 9, 1-10. [18]. ELSON, B. (2001). Electronic prescribing in ambulatory care: a market primer and implications for managed care pharmacy. Journal of Manag Care Pharm, 7, 115-120. [19]. HOWELL, S. (2001). E-Rx systems seek to improve care. Quality Indicator Newsletter, June, 1-7. [20]. TRIBBLE, D.A. (2001). The Health Insurance Portability and Accountability Act.: security and privacy requirements. American Journal of Health Systems Pharmacy, 58, 763-70. [21]. FOCUS GROUP ON TELEPHARMACY. (2001). American Journal of Health Systems Pharmacy, 58, 167-9. [22]. WEST, D.S., SZEINBACH, S. (1997). Information technology and pharmaceutical care. Journal of the American Pharmaceutical Association, S37, 1-5. [23]. CAREVIC, K. (2003). Telepharmacy: A new application for telemedicine. http://www.amia.org. 10

[24]. MANDEL, R., BOULTER, P. (2004). E-Rx Collaborative, E- prescribing: A bridge to the 21 st Century. http://www.ncvhs.hhs.gov. [25]. INSTITUTE FOR SAFE MEDICATION PRACTICES WEB SITE. (2001). A Call to Action : Eliminating Handwritten Precriptions within 3 years (White Paper). http://www.ismp.org/. [26]. RxHub Web Site. (2004). Introducing the next level of electronic prescribing technology. http:// www.rxhub.net. [27]. BELL, D.S., CRETIN, S., MARKEN, R.S., et. al. (2004). A conceptual framework for evaluating outpatient electronic prescribing systems based on their functional capabilities. J Am Med Inform Assoc, 11(1), 60-70. [28]. TEICH, J.M., MERCHIA, P.R., SCHMIZZ, J.L., et. al. (2000). Effects of computerized physician order entry on prescribing practices. Arch Intern Med. 160(18), 2741-7. [29]. BATES, D.W., TEICH, J.M., et. al. (1999). The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc, 6(4), 313-21. [30]. SCHIFF, G.D., RUCKER, T.D. (1998). Computerized prescribing: building the electronic infrastructure for better medication usage. JAMA, 279(13), 1024-9. [31]. EDER, N.C., DOVEY, S.M. (2002). Classification of medical errors and preventable adverse events in primary care: a synthesis of the literature. J Fam Pract, 51(11), 927-32. 11