Setting a standard for electronic prescribing systems

In Australia, electronic prescribing (e-prescribing) systems in general practice were first developed in the early 1990s by a few innovative general practitioners who wrote software for their own use. The uptake of e-prescribing systems was accelerated in 1999 because of Commonwealth government incentive payments of $10 000 to practices that acquired an email address and used e-prescribing software to write the majority of their prescriptions. Currently over 90% of general practitioners use one of the 20 or so commercial systems that are available to write prescriptions, order pathology and other tests, record medical progress notes or communicate with other healthcare providers.¹ Despite the widespread use of e-prescribing systems, there are no clear standards or guidelines for their development. This has led to a variety of systems with markedly different capabilities, particularly in terms of assisting general practitioners to prescribe safely and effectively.

Overseas studies have shown that e-prescribing systems can enhance the safety and quality of prescribing by ensuring complete and legible prescription orders, improving the detection of drug allergies and by reducing medication errors and adverse reactions.^2-5 However, these systems can also have unfavourable effects on workflow and communications, and can have unintended effects on prescribing. For example, they may introduce new types of errors^6-8 and high levels of unhelpful alerts, and impact on repeat prescribing.⁹ General practitioners have also expressed concern about the comprehensiveness and accuracy of some of the information provided in their software.¹⁰ In a comparative study of nine electronic prescribing and dispensing systems used in primary care in Australia in 2006, an expert panel found that most systems do not offer consistently useful and relevant information for general practitioners and pharmacists to make decisions about drug interactions.¹¹

Recently, a number of organisations and researchers have identified desirable functionality and safety features for e-prescribing systems in various healthcare settings.^12-16 In Australia, the National Prescribing Service (NPS) has worked with general practitioners, professional organisations and the Medical Software Industry Association to identify the key features of e-prescribing systems which support patient safety and quality care.¹⁷ Many of the safety and quality features identified for general practice apply equally to other settings such as hospitals or aged care.

For safety and quality, an ideal system needs suitable information resources, interoperability with other systems and clinical decision support. The goal of clinical decision support is 'to provide clinicians or patients with clinical knowledge and patient-related information, intelligently filtered and presented at appropriate times, to enhance patient care'.¹⁸

The ideal system should record clinical data such as diagnoses, medicines and allergies in a standard coded format. This helps to facilitate one system being able to 'talk to' another system and easily exchange patient data, for example with hospital systems or personal electronic health records when they become available. Information about recommended therapeutic options for the current diagnosis should be offered. The system ought to ensure that medicine selection processes are safe. In addition to drug interaction alerts, the system should provide warnings if a drug is contraindicated, the dosage regimen is potentially harmful, or if the drug is the subject of new safety advice from the Therapeutic Goods Administration. Warnings need to be prioritised by clinical importance otherwise they may be ignored. Users should be able to see the reason for the alert.

Decision support and therapeutic information offered by the prescribing system must be underpinned by high quality, up-to-date evidence and guidelines. Independent, evidence-based drug information and clinical practice guidelines should be accessible from within the software. High quality patient resources, such as printable information leaflets and a suitably formatted current medicines list, are also important. The ideal system should have sophisticated reporting capabilities to enable clinicians to monitor clinical care and audit individual or practice performance. The system needs to be intuitive and easy to use in clinical practice.

How do current systems used by general practitioners in Australia rate? The NPS has evaluated seven commonly used systems against a predefined set of criteria (J Reeve, M Sweidan, unpublished, 2011). It found that features to support safety and quality were highly variable between systems and there were some significant gaps. Clinical decision support features were ranked the most important for safety and quality, but in five of the systems fewer than 50% of these features were fully implemented (for example, there were no alerts for harmful doses or new safety warnings). One of the main reasons for this is the lack of clinical information resources in a format which is suitable for decision support. When systems included decision support, it was often unclear where the information was derived from and whether it was up to date. Features relating to the medicine selection process and the recording and display of patient data were also rated as important. Another important safety issue identified was that most systems did not clearly differentiate between similar-named medicines during prescribing, increasing the risk of selecting the wrong drug from a list of products.

The findings of this evaluation highlight the need for guidance or standards to ensure that essential functionality and safety features are included in all e-prescribing systems. There is some related work currently in progress in Australia. The National e-Health Transition Authority (NEHTA) is developing standards in relation to drug and disease terminologies, messaging and unique identifiers - these are important foundations. The Australian Commission on Safety and Quality in Health Care, in conjunction with NEHTA, has developed guidelines for the safe implementation of Electronic Medication Management in hospitals. Recent progress has been made in the UK^14-16,¹⁹ and USA¹⁸ on desirable functionality and design of systems to optimise usability and patient safety - much of this guidance will be applicable to the Australian setting.

Given the widespread use of electronic prescribing systems in day-to-day practice, coordinated activity to ensure these systems meet key quality and safety criteria is overdue. Clear guidance and standards are a prerequisite. Government, professional bodies and the software industry have a shared responsibility to develop and support processes to improve quality and safety in e-prescribing systems in Australia.