Electronic transmission of outpatient prescriptions still requires significant pharmacist oversight

The Covid-19 pandemic has led to increasing numbers of patients moving to the use of electronic prescriptions and internet pharmacies in many healthcare systems. For example, there has been a dramatic increase in use of the English electronic prescription service since March 2020, with internet pharmacies in the UK also experiencing large increases in the numbers of patients signing up. Rather than requiring a patient to physically take a printed prescription to a pharmacy in person, electronic prescriptions are transmitted directly from the prescriber to an institutional, community-based, or mail-order pharmacy.

As well as providing greater patient convenience and providing fewer opportunities for a prescription to be lost or forgotten, it might be easy to assume that electronic prescriptions also make life easier for the pharmacist. In theory, pharmacy staff receiving electronic prescriptions don’t have to re-enter information from a paper prescription. And they won’t have to re-type the prescriber’s original directions specifying how the patient is to take the medication.

But, in practice, it’s not that simple. Zheng and colleagues’ article in the journal reports that, in a study of nearly 530,000 prescriptions dispensed by a US mail-order pharmacy, prescribers’ directions are often poor in terms of readability. As an example, the direction “1 po q day”, meaning “take one tablet by mouth every day”, is unlikely to make sense to the typical patient or carer.  Additionally, almost half have other quality problems, such as missing at least one key item of information. The result is that the vast majority of prescription directions end up being edited manually by pharmacy staff to make them more understandable to patients. This is even more important when medications are provided by post, as there is less opportunity for pharmacy staff to check patients’ understanding of how to take their medication, or for the patient to ask questions.

Making such edits has considerable workload implications for pharmacy staff.  Zheng and colleagues estimate this to be 6.6 seconds per prescription; this may not sound like much, but when multiplied by the 6,000 prescriptions processed per week in the pharmacy studied, it amounts to 11 hours of pharmacist time. And this doesn’t include any additional time spent contacting prescribers for clarifications. Even then, pharmacists’ amendments don’t address every quality problem – pharmacy staff corrected around 80% of the quality problems identified, leaving the other fifth uncorrected. All of these issues may be even more challenging in mail-order pharmacies experiencing a rapid surge in workload due to the current Covid-19 pandemic.

So, what’s the solution?  Zheng and colleagues suggest implementing standardised data fields in the electronic prescribing software used by medical staff and other prescribers, rather than relying on free-text fields to enter patient directions. This would be more akin to the structured data used in most inpatient electronic prescribing systems, although a free-text option is always likely to be needed for some cases. Errors can also occur in the selection of options from a standardised menu. This key role for pharmacy staff is therefore likely to be needed for the foreseeable future – and is arguably even more important during the current pandemic.

-Bryony Dean Franklin

Professor Bryony Dean Franklin is Executive Lead Pharmacist (Research) and Director of the Centre for Medication Safety and Service Quality at Imperial College Healthcare NHS Trust, Professor of Medication Safety at UCL School of Pharmacy, and a Senior Editor for BMJ Quality & Safety.

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