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Tuesday, April 5, 2011

Electronic Prescribing-Savior?

E-Rx's, or as I  prefer to call them- The new scourge of healthcare.
Let's introduce the newest tool used by prescribers to shirk some of their human responsibilities when it comes to writing prescriptions for their patients.  Pharmacists are already used to deciphering the hieroglyphics doctors use hand writing scripts in felt-tip or other ink.  It has become like a second language to us and our staffs.  Our technicians already come to us to ask for a second or third opinion on what the Rx actually says, or who even wrote it.  Add poor penmanship to the ghastly custom of doctors using cell phones to leave us voice mails where they leave the office number, but not their cell number and we should be paid as detectives as well.  Mix this with nurses who spend a large part of their time calling Rx's in to pharmacies but can never quite manage to get all of the details covered in one call and we now have to call them back to research all of this for us.  When we call to get this info, why can they not remember each subsequent time, that this is important and if they do not leave it, we will have to call them back thereby wasting everyone's time?  It's simple, formulaic even: "HI! This is Barb (there's one at every office) from Dr. Zoffis calling in a script for Sandy Cheeks, DOB 5/5/75.  She needs Prozac 20mg, once a day.  Give her 30 with no refills.  Our phone # is..."  If you're really spot on, you'll remember the DEA on the controls too.  Since I am an equal opportunity cynic, I must say it does go both ways.  When we call for refills, we need to slow down and enunciate our info.  I don't like people calling us back saying they didn't know what the patient needed, who the patient was, or even who we were.  
Another thing I can't understand is the office person calling and telling us to "just refill what they had last time.  You have it on file".  Yes, I do have it on file.  So do you.  In that thing in your office called a chart. That you keep on every patient.  Go get it.  Read it to me.  I'm not paid to be your file clerk.  Just because the girl who answers your phones took the message from the patient as "hydradyzine" or some other combination of what they think they are taking doesn't necessarily mean it is correct.  Here's your opportunity to do your job and fix it.  There's a good chance the doctor may have changed something; or the patient requested 90-day supplies on everything now; or he just switched pharmacies because he has a coupon and we've never filled that for him; or he has a new allergy; or someone misfilled it last time and this is your chance to catch it.  This goes with the patient who calls for a refill and the office calls us and says "well, he hasn't been seen for over a year.  Go ahead and give him a month with 11 refills and tell him to make an appointment."  Fine.  I understand I'll see him before you will but what kind of incentive is there for him to make and keep an appointment if you don't bother making him visit you but every couple years?  You even put these notes on your E-Rx's.
On top of everything else you ignored so far and you have us doing for you, I have to schedule your appointments and, in the electronic prescribing realm, this is the part you care to take the time to get right?  I was skeptically hopeful this would help our profession provide better service to our patients when I saw this software is so easy, even a caveman (or elder statesman physician) can do it.  It appears a lot of these offices have employed this caveman as their IT guy too.  Instead of a doctor making a mistake by writing illegibly or attaching the wrong strength to the wrong drug (Nexium 30mg), I believe the mistakes made on E-Rx's can be even more egregious.  It's a lot like the auto-correction function on your texting keyboard.  What often appears may seem similar to what you intended, but makes no sense on the whole.  I'm not talking about selecting Amoxil CAPS vs. TABS, but scripts that read like a giant non sequitur.  For example: KCL 20 mEq SOLN, #30 1 tab qd; or Lorazepam 1mg soln (as either injection or intensol soln) qty #30 and to give 1 mg sublingually.  On these examples, after some research the doctors actually wanted KCL PACKETS and Lorazepam 1mg TABS to be administered SL.  How many different ways could a pharmacy have filled this?  This ultimately comes from not checking what was selected from the drop-down menu.The next line on many of these is the quantity.  While often omitted on handwritten scripts, it is more common to see "N/A" in the quantity field than an actual number.  This should never be skipped, ever.  How about those directions?  How many times have I seen "1 tab(s) 3 qhs"?  This would obviously not happen on a handwritten script and I can read this version, but what does it mean?  I mean, it's like the doctor is trying to speak to me, as if his lips are moving and words are coming out, but I'm missing the key to the mystery.  
I have no confidence in an office that will let these scripts leave in their patients' hands without being double-checked.  If they are being sent to my computer or fax, that is a different story, but isn't there a hard-stop that asks "are you sure?" before it is sent?  The worst is when I call the office, just doing my job by clarifying, and the nurse says "oh yeah. they told us that could happen all the time.  We can't figure it out.  It just happens."  Seriously?  Your answer is "WTF"?  I can tell you exactly why it happens: YOU are NOT paying attention.  No one is.  Except for me.  It's just click-and-tap-and-print-and-send.  What's happening is the same person is doing the same thing and not fixing the problem.  If you always do what you've always done, you'll always get what you always got.  Just wait until it gets to a pharmacy that's too busy, that carries that odd drug you prescribed that makes sense to them, and they don't call but fill it as-is.  
Alas, as I originally feared, this has not become our savior, but yet another issue for me to have to overcome in my daily routine of "everyone else's problems I need to fix".

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