The Mindlessness of E-Prescribing

Is the ease of e-prescribing causing problems?

E-prescribing is an amazing innovation that saves me time with almost every patient.  Instead of having to write out a prescription and hand to the patient to take to the pharmacy, I am able to click a few buttons and have it electronically sent in.  This of course comes with its rare pitfalls such as defaults and errors not caught but overall has made my life much easier.  This ease was extended even further when I was introduced to e-prescribing of controlled substances.  

If you are not familiar with it, e-prescribing of controlled substances refers to the ability to send in a controlled substance over the internet directly to a pharmacy.  First a brief primer on controlled substances and writing for them.  Controlled medications include medications with the potential for abuse such as narcotics like Norco (hydrocodone) and benzodiazepines such as Xanax (alprazolam). Since controlled medications can be abused and are sought on the streets, it takes a specialized prescription pad to write for them called a triplicate prescription. This piece of paper contains a watermark and microprint for security reasons.  It used to be an actually three page “triplicate” with one copy filed in the chart, one sent with the patient and the last sent to the state controlling agency.  With the advent of two factor authentication on phones with a password, this was changed.  Controlled prescriptions became digital.  

Here is the process now: I order a controlled prescription on my computer and send it to the pharmacy.  A popup then appears asking for an authorization number.  I break out my phone where I use my fingerprint to open the device and open a secure app that has a 6 digit number that refreshes every 30 seconds. This number is tied to my online identity. After entering the number in the EMR (electronic medical record), I then enter my EMR password one more time and the prescription is sent. While this sounds very cumbersome, it is not and typically takes 10 seconds at most.

In my opinion the above process is much more secure as well. It is more difficult to go through the 2 layers of passwords (EMR login by using one of our computers and fingerprint on phone which is on my person all the time) than to get access to one of my prescription pads and forge my signature (even though I have a pretty sweet signature). Because of this, I was feeling very good about this process… until recently.

Last week we had a problem with our internet.  When you use a cloud based EMR like we do, this is a major issue and makes any computerized charting impossible. We couldn’t even get to the log on screen. With this we resigned to using paper to keep our charts for the day. Fortunately the internet issue was short lived and back up the next day, but in the time it was out I had a revelation: E-prescribing is not always a good thing.

While the computers were down I had to write a controlled prescription the old way.  I fished out an old triplicate prescription and hand wrote the medication.  I had to write the patient’s name, date of birth and the date.  I had to write the name of the medication, the dose, the directions and the dispense amount.  I had to check a box confirming the dispense amount.  I had to write an expiration date for the prescription. I had to confirm the number of medications prescribed. And lastly, I had to recheck everything to make sure there were no errors and sign my name. This process triggered something inside me.

I had become numb to the process of e-prescribing.  Hand writing the controlled prescription made me feel something down deep in my gut.  It made me do a double check to make sure the medication was appropriate and in the patient’s best interest.  E-prescribing didn’t do this.  Clicking a button was not the same as signing my signature in ink. It made me question: Does e-prescribing make us write more prescriptions?  Is it contributing to the narcotic problem instead of helping it?

I did some research to find if any studies had been done on this and came up dry.  Let me make a bold statement though.  I believe that e-prescribing can lead to overprescribing due to its ease.  Here’s why. I have read multiple studies that show people spend more when they use a credit card vs using cash.  Psychologists have concluded that this is because handing over cash creates a “pain of paying” due to the direct action of surrendering your hard earned money.  This is in contrast to using a credit card which is only plastic remotely connected to money.  

Let’s apply this to prescribing. When I e-prescribe I go through a couple clicks to send in a prescription.  When I hand write a prescription I have to go through a more lengthy process that requires my physical signature.  I feel a (to coin a new phrase) “pain of prescribing” that makes me make sure the medication is appropriate.  While this has implications on prescribing in general, it has more serious implications with e-prescribing of controlled substances.  

Despite all this, with the use of EMRs and abundance of e-prescribing, we will not be going back to hand writing prescriptions.  Technology is making it obsolete.  So I and other physicians need to create a process that brings the “pain of prescribing” back. I’m not sure there is a universal way this can be done.  I’m not sure it can even be done.  So, I will need to take care to make sure medications I prescribe are safe, necessary and correctly written.  Every time I hover over the “sign” button with the mouse I will ask myself “Is this the best option for this patient?”

4 thoughts on “The Mindlessness of E-Prescribing”

  1. While I agree with the fact that e-prescribing has multiple pitfalls even with regular prescriptions, the time saved from hand writing prescriptions can be used to do many other things that improve patient care. With controlled substances, an extra layer of caution is needed. What I do and recommend with narcotic e-prescribing is to use the time saved to pull up the CURES database on the patient to double check prescribing and patient filling patterns. This extra work brings back the pain of handwriting prescriptions while using the time saved to actually further benefit patient care without actually wasting time handwriting a script. Implementing procedures for certain electronic prescriptions can help advert some of the pitfalls. Thank you for the very thoughtful article.

    1. Yes, CURES is a great tool that can make sure controlled substances are not being abused. It can definitely bring back the “pain of prescribing.” It should be used every time we write a controlled prescription.

      1. Hello Dr. Gawayne
        You’ve been extremely helpful during my PA education and I have been attempting to find out how you treat an issue, ie patient has lesion, biopsy for pathology. I am 98% certain, visually, that the lesion will in fact present with atypical cells or abnormality. I understand that I cannot present a diagnosis without results. I get shakey and nervous. Any advice? I couldn’t find this through your search and was elated to see this topic touched upon.
        Thank you
        Erin Peters-Fortunato

        1. Treatment for any atypical/malignant lesion is excision. You need to get a diagnosis by biopsy. Depending on the site and character of the lesson this can be done through a punch or shave biopsy. If it is very concerning and amenable to excisional biopsy it should be completely excised. I will need to write a post on worrisome skin lesions in the future. Thanks for your input and question. Hope this helps.

          BTW I get the diagnosis wrong often when I guess before biopsy. It’s always good try to predict what the diagnosis prior to biopsy and state your reasons (ie this is a BCC because it has a domed appearance with neovascularization). It can build your confidence.

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