Showing Your Work: Impact of annotating electronic prescriptions with decision support results

Abstract

e-Prescribing systems with decision support do not routinely communicate an adequate amount of information regarding the prescribers' decision to pharmacists. To address this communication gap in the e-prescribing process, we implemented a system called Show Your Work (SYW) that appends alerts and override comments to e-prescriptions generated by an e-prescribing system. To assess the quantitative impact of this system, we conducted a randomized, double-blinded, controlled study to assess pharmacy callback rates and types, and to uncover any unintended consequences of the annotations. Each day, SYW output across the enterprise was turned "on" or "off" randomly for all e-prescriptions. A convenience sample of three pharmacies, blinded to SYW status, submitted callback logs each day. These logs were used to calculate the rate of and reason for callbacks. At the conclusion of the study, we surveyed the 50 most frequently used pharmacies in our area to assess the impact of SYW on satisfaction and communication. A total of 202 callbacks had occurred yielding a callback rate of 45 callbacks/1000 prescriptions for SYW "on" days and 40 callbacks/1000 prescriptions for "off" days (p=0.4). We received 38 surveys (76% response rate) with 33 respondents commenting about SYW. Most respondents agreed (69%) that SYW favorably impacted callbacks--especially with pediatric prescriptions (82%). Comments suggested that SYW increased callbacks where necessary and decreased them in other situations, but did not contribute to unnecessary callbacks. These findings support the continued and potentially expanded use of SYW by e-prescribing systems to enhance communication with pharmacists.

E-prescribing: A focused review and new approach to addressing safety in pharmacies and primary care

“…24 Over time, the potential of e-prescribing to improve safety, quality, and efficiency in primary care settings during patient care was recognized and recommended by policy makers. 1,25 It was assumed that this technology would lead to a significant improvement in safety in the process of prescribing and dispensing medications 24 even though improvement in patient safety and cost benefits are not well established or understood in ambulatory practice. 26,27 …”

Ensuring effective computerised clinical decision support

“…If you have decided after careful evaluation that the benefits of prescribing a medicine singly or in combination with other medicines outweigh the risks and elect to override an alert, then this should be clearly documented in the patient record and highlighted on the prescription. 5 • Give specific instructions when prescribing. For example, instructions such as "as directed", "as required" or "prn"…”

Electronic Prescribing in Pediatrics: Toward Safer and More Effective Medication Management

“…34 Finally, a recent article demonstrated the power of annotating electronic prescriptions with the actual calculation leading up to the dose. 35 …”

“…44,45 In pediatrics, e-prescribing can improve communication through both improving clarity of prescriptions and providing standardized information about indications for therapy, rationales for overriding allergy alerts, and the weight-based calculations leading to a specific dose. 35 For all patients, e-prescribing systems can improve communication about provider willingness to allow generic substitution, [46][47][48] which, by avoiding higher copayments, can improve medication adherence. 49 A study on prescriptions 35 demonstrated the value of including body weight and the process associated with calculating a dose.…”

“…35 For all patients, e-prescribing systems can improve communication about provider willingness to allow generic substitution, [46][47][48] which, by avoiding higher copayments, can improve medication adherence. 49 A study on prescriptions 35 demonstrated the value of including body weight and the process associated with calculating a dose. In this study, pharmacies stated that prescribing safety was improved by "showing your work" related to the cognitive processes associated with prescribing and found it especially beneficial in pediatric prescribing.…”