E-Prescription

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E-Prescrition by Doctor

E-Prescription

Asim Priyendu, Anantha Naik Nagappa and Uday Venkat Mateti

Dept. of Pharmacy Management, Manipal College of Pharmaceutical Sciences, Manipal University -576104.

E - Prescriptions are prescriptions filled in computers by the physicians or physician assistants under the supervision of the physicians and transferred to a pharmacy electronically with all details of patient, prescription medicines, special instructions along with doses.

Read about

  1. What is a prescription?

The prescription is a written order by the doctor to the pharmacist to make and dispense the medicines for a patient. Prescriptions are personal and unique for a patient which should not be shared with other patients with similar conditions. The prescription has details of prescriber, patient and signature of the prescriber. The superscription symbol Rx in a prescription is a Latin abbreviation of the word Recipe meaning "you take". The body of the prescription contains abbreviated diagnostic details of patient's condition, name of medication and dosage instructions. Prescriptions are given the status of legal document and are to be preserved by the dispenser and also stamp the dispensed prescription as dispensed in order to avoid re-dispensing. The repeat dispensing is illegal and hence each prescription can be dispensed only once and after that it becomes invalid. The specimen of a prescription is reproduced below in figure-1.

Figure1 Standard Prescription specimen

Figure-1: Standard Prescription specimen

  1. What are the drawbacks of a conventional prescription?

Hand written Prescriptions

The hard copies of prescriptions are criticized for being poorly legible and error prone while dispensing. The doctors in olden days were writing prescriptions in a sign language so that the patients should not get familiar with medicines name and treatment details just to avoid self medication. The communication between doctor and pharmacist was a guarded secret whereas pharmacist was able to understand what doctor had written in the prescription. The doctors were using self created abbreviations and sign language as per their style and wish which used to cause chaos if the patient took the prescription to a new place or different pharmacy. There are serious implications arising due to illegible prescriptions which are listed in the table-1 given below.

Table 1: Issues in Handwritten prescriptions2, 3

Issues in Handwritten prescriptions

Inaccuracy in writing

Poor legibility of writing

Incomplete writing or insufficient information

Use of non-standard abbreviation

Unintended omissions

Failure to stop a drug timely

Dose errors

Dosage form errors

  1. What are the legal aspects of prescription?

Medicines are classified as prescription-only medicines (POM) and non-prescription drugs. Non-prescription drugs are over the counter medicines which are usually for symptomatic relief and can be used by informed self medication given by registered pharmacist. The POMs are further classified into medicines to be dispensed on a prescription of a registered medical practitioner (Schedule H) and drugs which are highly regulated (Schedule X) e.g. narcotics and psychotropic substances as per the Drugs and Cosmetics Act 1940 in India. The Schedule X drugs regulation is supplemented by The Narcotics and Psychotropic substance Act 1985.

Schedule H is further classified as Schedule H and Schedule H1. Schedule H is the list of POM whereas Schedule H1 is an appendix to the D&C rules amended in 1945. Manufacture, marketing and distribution are regulated as per the law and retail dispensing of Schedule H should be done against a prescription of RMP. Violation of this clause attracts the punishment.

The purpose of regulation is to avoid unnecessary health hazards by unscientific use of medicines in the society. It is also necessary to protect people from addiction of psychotropic and narcotic drugs. Regulation requirements for prescriptions in a few countries is listed in the table-2 below.

Table-2: Prescription requirements as amended in the federal laws of British Columbia,Canada1

CLASSIFICATION

DESCRIPTION

PRESCRIPTION REQUIREMENTS

Narcotic Drug

Examples: Codeine, Codeine Syrup, Ketamine, Lomotil,, Morphine,

All narcotic compounds containing more than one narcotic drug.

All narcotic compounds containing less than two other non-narcotic ingredients in a therapeutic dose.

All products containing hydrocodone, methadone, oxycodone or pentazocine.

Written or faxed prescription signed and dated by physician, dentist or veterinarian.

Prescription must include components detailed immediately below.

Note: Schedule 1A drugs cannot be faxed. (exception: licensed facilities)

Verbal Prescription Narcotic Drug *

Examples: Coactifed, Cotridin, Dimetapp C, 282 and 292, Fiorinal C 1/2, Fiorinal C 1/4, ratio-Lenoltec-30, Tylenol No.2 and No.3.

A combination for other than parenteral use containing only one narcotic drug plus two (or more) non-narcotic drugs in a therapeutic dose, except products containing hydrocodone, methadone, oxycodone or pentazocine.

Written, verbal or faxed prescription by physician, dentist or veterinarian.

All prescriptions must include:

Patient's name, initials, address

? Prescriber's name, initials, address

? Name, quantity, strength and form of drug(s)

? Complete directions for use

? Date of prescription

? Date of dispensing

? The prescription record of verbal prescriptions must include the identification of both receiving and dispensing pharmacists, if different.

A pharmacist may receive verbal prescription authorizations either directly from a practitioner or from a practitioner's recorded voice message.

Controlled Drug Part 1 *

Examples: Adderall XR, Dexedrine, Ritalin, Concerta, Vyvanse.

Amphetamines and their salts and derivatives, methylphenidate,, phenmetrazine, pentobarbital, secobarbital.

Controlled Drug Preparation Part 1

Combination containing only one controlled drug listed immediately above plus one (or more) active non-controlled non-narcotic drug(s).

Controlled Drug Part 2 *

Examples: Nubain, Phenobarbital, Apo-Butorphanol NS

Barbiturates and their salts and derivatives (except pentobarbital and secobarbital), butorphanol, chlorphentermine, diethylpropion, nalbuphine, phentermine, thiobarbituric acid.

Controlled Drug Preparation Part 2 *

Examples: Fiorinal, Tecnal, Bellergal Spacetabs.

Combination containing only one controlled drug listed immediately above plus one (or more) active non-controlled non-narcotic drug(s).

Controlled Drug Part 3

Examples: Andriol, Androderm, Androgel, Delatestryl Injection, Depotestosterone.

Anabolic steroids and zeranol.

Targeted Drug Substances

(Part 1)

All benzodiazepines, their salts and derivatives (but not including the thienobenzodiazepines: clozapine, flunitrazepam, olanzapine), clotriazepam, ethchlorvynol, ethinamate, fencamfamin, fenproporex, mazindol, mefenorex, meprobamate, methyprylon, pipradol.

Written, verbal or faxed prescription by physician, dentist or veterinarian.

Podiatrists may prescribe benzodiazepines.

Requirements of a prescription as on page one.

Other Prescription Drugs

(Schedule F)

All other drugs listed as Schedule I in the Drug Schedules Regulation to the Pharmacy Operations and Drug Scheduling Act (which contains all drugs in Schedule F to the Regulations to the Food and Drugs Act of Canada, plus a number of others).

Written, verbal or faxed prescription by physician, dentist, veterinarian, podiatrist , nurse practitioner (within scope) optometrist, naturopathic physician or midwife (limited schedule for midwives)

All prescriptions must include:

? Patient's name, initials, address

? Prescriber's name, initials, address

? Name, quantity, strength and form of drug(s)

? Complete directions for use

? Date of prescription

? Date of dispensing

? The prescription record of verbal prescriptions must include the identification of both receiving and dispensing pharmacists, if different.

A pharmacist may receive verbal prescription authorizations either directly from a practitioner or from a practitioner's recorded voice message

Controlled Prescription Program (CPP) Drugs

All drugs listed as Schedule 1A in the Drug Schedules Regulation to the Pharmacy Operations and Drug Scheduling Act.

Written prescription on an approved two-part form.

Fax transmission is not allowed in community pharmacies (exception: licensed facilities)

More than one medication or strength of medication can be included on one Controlled Prescription Program form, provided the orders are legible.

The prescription expires after midnight of the fifth day following the date of issuance by the prescriber, unless the prescription is for methadone.

  1. Why and how the conventional prescription is not able to meet the current clinical practice?

The current clinical practice depends on electronic systems and documentation. The conventional prescriptions are difficult to manage above objectives. As a result of it, the conventional paper based prescriptions are not able to integrate into modern healthcare system.

  1. What is an e-prescription?

E-prescription or electronic prescription is a system based multiple stakeholder secured information exchange system. For example, the RMP writes an e-prescription which automatically gets transferred to the pharmacy and the prescription is read and understood before making a dispensing package. The patient when arrives at the pharmacy, he/she can get his/her medicines with counseling as pharmacist had time to think before the patient arrives to pick the medicines.

  1. How e-prescriptions are better than the conventional prescriptions?

The e-prescription is safe, secure and system based where there is little chance for human based errors of dispensing. As the prescription is transferred electronically, it can reach pharmacy much early which gives enough margin time for the pharmacist to plan dispensing. There are no issues of illegible prescriptions and the errors associated with conventional prescriptions. The e-prescriptions can be adopted for electronic inventory control and documentation of sales in multiple pharmacies on day to day basis.

  1. What type of software and hardware is required to establish the e-prescription system?

There are many software packages available in the market; however a certified, cloud-based platform by Haymarket Media, Inc is available as Monthly Prescription reference based in New York. The e- prescription system comprises of Prescriber, Transaction hub, Pharmacy and Pharmacy Benefit Manager (PBM).

  1. In which part of the world e-prescriptions are utilized and what is their experience?

USA leads in e-prescription implementation and regulation. The HITECH Act of electronic medical records makes mandatory of e-prescriptions. According to SureScripts, a champion company in e-prescriptions in USA has declared that there are one-third million physicians who are using e-prescriptions.

In Canada, the e-prescriptions are having a legal status as a part of Personal Information Protection and Electronic Documents Act. The Europe and other developed countries, e-prescription is under pilot study.

  1. What are the barriers in implementing e-prescription?

The generation of the physicians who have practiced medicine using the conventional paper prescriptions feels threatened and insecure are bottlenecks in adaption of e-prescriptions. The ignorance of all stakeholders like government, regulators, pharmacists and patients may resist the change over from conventional to e-prescriptions.

  1. How e-prescriptions are stakeholder and patient friendly?

The primary stakeholders involved are doctors, nurses, pharmacist and patients. The secondary stakeholders involved are regulators, manufacturers and insurance companies. The primary stakeholders are at ease and can function without confusion but with confidence in healthcare settings. For patients they are happy to receive medicines without much waiting time in the pharmacy. The medication errors, drug utilization reports, irrational prescriptions can be routinely checked and corrected.

  1. What are the limitations of e-prescriptions?

E-prescriptions is a new technology with a huge expectations from the stakeholders, however except for the initial investment, the operational cost is very low and cost-effective. There is a need of a software engineer to keep the system running. The confidentiality of large number of patients will be at stake if proper security systems are not implemented in the platform.

  1. What are the issues in relation to the medication errors in e-prescriptions?

There is a need of efficient communication sent back to the prescriber from the pharmacist in case a medication error comes to his notice. The two-way communication in case of medication error poses a challenge in front of the healthcare team which can be resolved with efficient follow up by the initiation of pharmacist. Possibility of electronic failure leading to miscommunication can lead to errors. The present e-prescription softwares lack a provision for feedback and back-communication for clarification as an in-built system.

A Conventional specimen prescription is shown in figure 2.

Figure 2 Conventional specimen Prescription

Figure-2: Conventional specimen Prescription

References

  1. Prescription regulations, 5014 Prescription Regulation Tablev2012.2 ; Available online at URL: http://library.bcpharmacists.org/D-Legislation_Standards/D-4_Drug_Distri... [Accessed Mar 2014]
  2. Giampaolo PV, Pietro M. Medication errors: prescribing faults and prescription errors, Br J Clin Pharmacol. Jun 2009; 67(6): 624-628
  3. Medication Errors. The Academy of Managed Care Pharmacy'sConcepts in Managed Care Pharmacy; Available online at URL: http://www.amcp.org/WorkArea/DownloadAsset.aspx?id=9300[Accessed Mar 2014]

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About the Author

Anantha Naik Nagappa's picture

I am professor, intrested in developing the community pharmacy services in India, We have an association called ASSOCIATION OF COMMUNITY PHARMACISITS OF iNDIA. CHECK AT www.acpi.in for further detials

Comments

Albert Ana-Maria's picture

How is best to do when electronic recipe is wrong from the doctor?

Anantha Naik Nagappa's picture

E-prescriptions are managed in a software package. The software shall be having an option to alert the prescriber regarding drawing the attention to the error. The doctor also can be alerted by other communication modes like telephone, by messaging etc. One should take care that the professional harmony does not get jeopardized due to improper or inadequate communications. The communication should be one to one and there is no need to alert the patient regarding the mistake in the prescription.

Prof Anantha Naik Nagappa

My Page : http://www.pharmainfo.net/ananthanaik

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