Electronic PrescribingElectronic Prescribing

Jill MulderigJill Mulderig

Objectives:Objectives:

Describe Electronic PrescribingDescribe Electronic Prescribing Discuss tools and information system Discuss tools and information system

neededneeded Evaluate the Nurse Informaticist role in Evaluate the Nurse Informaticist role in

EMR/Electronic PrescribingEMR/Electronic Prescribing Discuss safety, ethical and confidentiality Discuss safety, ethical and confidentiality

issuesissues Discuss Advantages/Disadvantages with Discuss Advantages/Disadvantages with

Electronic PrescribingElectronic Prescribing

Electronic Prescribing or E-Electronic Prescribing or E-Prescribing is:Prescribing is:

Computer based mode of communicationComputer based mode of communication Electronic mode of generating prescriptionsElectronic mode of generating prescriptions Part of the growing Electronic Medical Record Part of the growing Electronic Medical Record

(EMR)(EMR) Designed for improved communication with Designed for improved communication with

pharmacies and to reduce errors.pharmacies and to reduce errors. Commercially available software- can be used Commercially available software- can be used

with or without EMR.with or without EMR.

(Finkelstein, 2006) (Finkelstein, 2006)

Main Goals of E-Prescribing:Main Goals of E-Prescribing:

Reduce medication errorsReduce medication errors

Improve patient safetyImprove patient safety

Increased access to medical informationIncreased access to medical information

Improved reporting abilityImproved reporting ability

Cost and time effectivenessCost and time effectiveness

( Barber, Cornford, Klecun 2007)( Barber, Cornford, Klecun 2007)

Hardware for E- PrescribingHardware for E- PrescribingCan be used with :Can be used with :

LaptopsLaptops

Desktop PC’sDesktop PC’s

Pocket PC’s Pocket PC’s

Tablet PC’s Tablet PC’s

PDA’s utilizing a wireless network PDA’s utilizing a wireless network

Personal Digital Assistant (PDA)Personal Digital Assistant (PDA)

Handheld computer with many similar functionsHandheld computer with many similar functions Works with an operating systemWorks with an operating system Personal computer needed for syncing data and Personal computer needed for syncing data and

updating.updating. Organizing while mobileOrganizing while mobile Compatible with innumerous programs and Compatible with innumerous programs and

software titles.software titles.

(Carmack, Freudenrich, 2003) (Carmack, Freudenrich, 2003)

PDA’s in E-PrescribingPDA’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

Software for E-PrescribingSoftware for E-Prescribing

Commercially available softwareCommercially available software Physician or provider chooses based on Physician or provider chooses based on

preferencepreference Many assist with patient tracking, ICD-9 Many assist with patient tracking, ICD-9

codes, interactions, pricing, and warnings.codes, interactions, pricing, and warnings. Work with desktop computers, laptops, Work with desktop computers, laptops,

PDA’s, and tablet pc’s. PDA’s, and tablet pc’s. Accurate drug databases in tune with Accurate drug databases in tune with

health insuranceshealth insurances (nationalerx, nd)(nationalerx, nd)

Commercial Software VendorsCommercial Software Vendors

SureScriptsSureScripts RxHub RxHub ProxyMed ProxyMed MedicWareMedicWare National E RxNational E Rx

eRX Software:eRX Software:

National ePrescribing Patient Safety Initiative (NEPSI) National ePrescribing Patient Safety Initiative (NEPSI) was enacted due to the large number of medical was enacted due to the large number of medical errors in the healthcare system.errors in the healthcare system.

Free program to all physicians and medication Free program to all physicians and medication prescribersprescribers

Created through an advocacy initiative – with Created through an advocacy initiative – with Claims to be simple, safe, and secureClaims to be simple, safe, and secure Designed to increase patient safety and reduce Designed to increase patient safety and reduce

errors.errors. Designed from funding to assist physicians in the Designed from funding to assist physicians in the

advanced technology without the high costs to them. advanced technology without the high costs to them.

(nationalerx, nd)(nationalerx, nd)

E RX software is designed E RX software is designed to:to:

Eliminates handwriting issues and errorEliminates handwriting issues and error Creates electronic records to ensure prescription Creates electronic records to ensure prescription

information is saved.information is saved. Reduces healthcare costs by improving efficiency and Reduces healthcare costs by improving efficiency and

identifying generic drug optionsidentifying generic drug options Checks for allergies, drug interactions, dosing errors, and Checks for allergies, drug interactions, dosing errors, and

many other patient specific factorsmany other patient specific factors Maintains an comprehensive drug databaseMaintains an comprehensive drug database Expedites prescription refill requests and saves staff timeExpedites prescription refill requests and saves staff time Provides up-to-date formulary and insurance informationProvides up-to-date formulary and insurance information Improves data exchange between pharmacists and Improves data exchange between pharmacists and

prescribersprescribers

(nationalerx, nd)(nationalerx, nd)

Included in the free Included in the free program: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)

Usability of Software:Usability of Software:

The system appears to be user friendly for both beginners The system appears to be user friendly for both beginners and experts with minimal training.and experts with minimal training.

Pilot program in 2001 for physicians to evaluatePilot program in 2001 for physicians to evaluate Two pilot projects confirmed better ease of use and usability Two pilot projects confirmed better ease of use and usability

for physicians.for physicians. There is an iterative design – which can cause less There is an iterative design – which can cause less

anxieties.anxieties. There are icons and visual aids There are icons and visual aids forfor the users to see. the users to see. Workarounds possible but less likelyWorkarounds possible but less likely Cognitive work analysis- program was developed under Cognitive work analysis- program was developed under

influence of physician’s concerns.influence of physician’s concerns.

(Mandel, Boulter, nd)

Evaluations on UsabilityEvaluations 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)

Information SystemInformation System

E-prescribing is an information system E-prescribing is an information system that is available as a stand alone that is available as a stand alone configuration.configuration.

It is also part of a larger information It is also part of a larger information system- Electronic Medical Record (EHR)system- Electronic Medical Record (EHR)

Many use e-prescribing as a starter or Many use e-prescribing as a starter or part of the electronic transition into the part of the electronic transition into the EMR.EMR.

Clinical Information System: Clinical Information System: EMREMR

EMR is an electronic record with EMR is an electronic record with ability to generate a complete record ability to generate a complete record of a clinical patient & supporting care of a clinical patient & supporting care related activities through an related activities through an computerized interface.computerized interface.

Use specific software to personalize Use specific software to personalize specific needs.specific needs.

Electronic Medical Records:Electronic Medical Records:MedicwareMedicware

Clinical information systemClinical information system EMR and components are used by EMR and components are used by

physicians, nurses, hospitals, support staff, physicians, nurses, hospitals, support staff, billing departments, and other personnelbilling departments, and other personnel

Available in many configurations such as Available in many configurations such as workstations, Tablet PC’s, and servers. workstations, Tablet PC’s, and servers.

Networking capabilitiesNetworking capabilities Some information available on PDASome information available on PDA

Electronic Medical RecordsElectronic Medical Records

Computer-based Computer-based Systematic documentation of a clients health Systematic documentation of a clients health

status and health care in a secure format status and health care in a secure format Can be processed, stored, transmitted, and Can be processed, stored, transmitted, and

accessed by authorized professionals for the accessed by authorized professionals for the purpose of supporting efficient, high quality purpose of supporting efficient, high quality health care and accurate sharing of health care and accurate sharing of information across the continuum information across the continuum

(McGonigle, Mastrain, 2009)(McGonigle, Mastrain, 2009)

MedicWare EMR Software MedicWare EMR Software System System

Clinical Information SystemClinical Information System Centralized computerized patient medical Centralized computerized patient medical

record softwarerecord software Streamlined diagnostic and treatment Streamlined diagnostic and treatment

processes processes Available online or via software purchaseAvailable online or via software purchase Houses data and information regarding the Houses data and information regarding the

health status of a clienthealth status of a client (Medicware, 2008)(Medicware, 2008)

Components to Medicware Components to Medicware include:include:

Clinical Data Repository (CDR) Clinical Data Repository (CDR) Clinical Decision Support System (CDSS) Clinical Decision Support System (CDSS) Electronic Prescribing with Alert messagesElectronic Prescribing with Alert messages Medical VocabularyMedical Vocabulary Evidence-based decision support with outcome reportingEvidence-based decision support with outcome reporting Billing and schedulingBilling and scheduling HIPAA compliantHIPAA compliant Automated task management Automated task management Nurses notesNurses notes Patient Education materialsPatient Education materials Quality management and control Quality management and control HL7 interface HL7 interface

(Medicware, 2008)(Medicware, 2008)

Data Standards for Data Standards for Medicware:Medicware:

American National Standards American National Standards Institute (ANSI)Institute (ANSI)

Healthlevel 7 (HL7)Healthlevel 7 (HL7) Continuity of Care Record (CCR)Continuity of Care Record (CCR)

(Medicware, 2008)(Medicware, 2008)

Classifications compatible with Classifications compatible with Medicware:Medicware:

ICD-9, ICD-10 - ICD-9, ICD-10 - International Statistical International Statistical Classification of Diseases Classification of Diseases

CPT – Current Procedure TerminologyCPT – Current Procedure Terminology SNOMED – Systemized Nomenclature of SNOMED – Systemized Nomenclature of

MedicineMedicine HCPCS - Healthcare Common Procedure HCPCS - Healthcare Common Procedure

Coding System Coding System NANDA – used only for nursing SOAP notesNANDA – used only for nursing SOAP notes

(Medicware, 2008)(Medicware, 2008)

EMR advantages to Nursing:EMR advantages to Nursing:

Promoting standardized nursing Promoting standardized nursing language and terminologylanguage and terminology

Error reductionError reduction Improve medication safetyImprove medication safety Fast, clear access to patient Fast, clear access to patient

informationinformation Time savingTime saving

E-Prescribing AdvantagesE-Prescribing Advantages

Cost saving (over time)Cost saving (over time) Time savingTime saving Error reductionError reduction Medication TrackingMedication Tracking Easy accessEasy access Better formulary complianceBetter formulary compliance Provider/Nurse mobilityProvider/Nurse mobility Improved quality of care Improved quality of care

E-prescribing Advantages:E-prescribing Advantages:

Possible Medicare bonuses for e-Possible Medicare bonuses for e-prescribingprescribing

Disadvantages/Barriers to e- Disadvantages/Barriers to e- prescribingprescribing

Staff resistanceStaff resistance CostCost Security concernsSecurity concerns Lack of IT staffLack of IT staff Technology MistrustTechnology Mistrust Possible reduction in staffPossible reduction in staff

(Anderson, 2007)(Anderson, 2007)

Ethical & Legal Issues:Ethical & Legal Issues:

SecuritySecurity Privacy Concerns – HIPAAPrivacy Concerns – HIPAA Legal barriersLegal barriers

(Anderson, 2007)(Anderson, 2007)

Informatics Competencies Informatics Competencies Required for Eprescribing and Required for Eprescribing and

EMR:EMR: Health information literacyHealth information literacy Privacy and confidentiality knowledgePrivacy and confidentiality knowledge Technical security knowledge Technical security knowledge Basic computer literacy skillsBasic computer literacy skills Informatics skills – acquiring, processing, Informatics skills – acquiring, processing,

and sharing knowledgeand sharing knowledge * Above required by the Professional Nurse* Above required by the Professional Nurse

(McGonigle, Mastrain, 2009)(McGonigle, Mastrain, 2009) (Miller et al, 2005). (Miller et al, 2005).

Informatics Nurse Role:Informatics Nurse Role:Eprescribing and EMREprescribing and EMR

EducationEducation Lead projectsLead projects Assist in implementation, access and support of Assist in implementation, access and support of

eprescribing leading to the expansion to the EMR.eprescribing leading to the expansion to the EMR. Ensure security processes are correct and in placeEnsure security processes are correct and in place Clinical resource personClinical resource person Facilitates the integration of data, information, and Facilitates the integration of data, information, and

knowledge to support patients, nurses, physicians, and knowledge to support patients, nurses, physicians, and staff.staff.

Assist and lead researchAssist and lead research Tech supportTech support

(McGonigle, Mastrain, 2009)(McGonigle, Mastrain, 2009) (Miller et al, 2005).(Miller et al, 2005).

SUMMARYSUMMARY

With proper implementation eprescribing can:With proper implementation eprescribing can:

Reduce medication errorsReduce medication errors Increase access to medical informationIncrease access to medical information Reduce cost and increase time effectivenessReduce cost and increase time effectiveness Ease into the transition to Electronic Medical Ease into the transition to Electronic Medical

RecordsRecords Improve patient safetyImprove patient safety Increase direct care time to patient Increase direct care time to patient Space Savings Space Savings Legibility of Notes – reduce errors cause byLegibility of Notes – reduce errors cause by

Summary Cont:Summary Cont:

Accessibility of Charts Accessibility of Charts Transcription Costs Savings Transcription Costs Savings Space Savings Space Savings Eliminate StaffEliminate Staff Eligibility for Pay-for-performanceEligibility for Pay-for-performance Multiple Users Use a Chart Simultaneously Multiple Users Use a Chart Simultaneously Automatic laboratory and radiological reportsAutomatic laboratory and radiological reports Electronic PrescriptionsElectronic Prescriptions System Recovery System Recovery Drug to Drug Interaction and allergy interaction Drug to Drug Interaction and allergy interaction

checkingchecking

REFERENCESREFERENCES Finkelstein, J (2006).E-Prescribing first step to improved safety. Finkelstein, J (2006).E-Prescribing first step to improved safety. Journal of Journal of

the National Cancer Institutethe National Cancer Institute. . 9898, 1763-1765, 1763-1765 Barber, N, Cornford, T, & Klecun, E (2007). Qualitative evaluation of an Barber, N, Cornford, T, & Klecun, E (2007). Qualitative evaluation of an

electronic prescribing and administration system. electronic prescribing and administration system. Quality and Safety in Quality and Safety in Health CareHealth Care. . 1616, 271-78. , 271-78.

Anderson, J (2007).Social, ethical and legal barriers to e-health. Anderson, J (2007).Social, ethical and legal barriers to e-health. International Journal of Medical InformaticsInternational Journal of Medical Informatics. . 7676, 480-83. , 480-83.

Miller, MD, R, Gardner, PhD, R, Johnson, MD, MS, K, & Hripcsak, MD, MS, G Miller, MD, R, Gardner, PhD, R, Johnson, MD, MS, K, & Hripcsak, MD, MS, G (2005). Clinical decision support and electronic prescribing systems: A time (2005). Clinical decision support and electronic prescribing systems: A time for responsible thought and action. for responsible thought and action. Journal of the American Medical Journal of the American Medical Informatics AssociationInformatics Association, , 1212, 403-09 , 403-09

Carmack, C, Freudenrich (2003, 06, 12). How PDAs work. Retrieved Carmack, C, Freudenrich (2003, 06, 12). How PDAs work. Retrieved September 30, 2008, from HowStuffWorks.com. Web site: September 30, 2008, from HowStuffWorks.com. Web site: http://communication.howstuffworks.com/pda.htmhttp://communication.howstuffworks.com/pda.htm

Retrieved September 30, 2008, Web site: Retrieved September 30, 2008, Web site: http://www.nationalerx.com/http://www.nationalerx.com/ Anderson, J (2007).Social, ethical, and legal barriers to E-health. Anderson, J (2007).Social, ethical, and legal barriers to E-health.

International Journal of Medical InformaticsInternational Journal of Medical Informatics. . 7676, 480-83. , 480-83.

REFERENCESREFERENCES

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What is HN7?. Retrieved October 26, 2008, from What is Web site: What is HN7?. Retrieved October 26, 2008, from What is Web site: http://www.hl7.org/ http://www.hl7.org/

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von Krogh, G, Dale, C, & Naden, D (2005). A framework for integrating von Krogh, G, Dale, C, & Naden, D (2005). A framework for integrating NANDA, NIC, and NOC terminology in electronic patient records. NANDA, NIC, and NOC terminology in electronic patient records. Journal of Journal of Nursing ScholarshipNursing Scholarship. . 3737, 275-81 , 275-81

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