Hand-Held Electronic Prescribing

Do any of the following situations sound familiar?

1. You want to prescribe 25 mg of a drug but are uncertain whether the drug is supplied as a 25-mg or 50-mg tablet.
2. An elderly patient comes in for an update on her multiple problems. At the end of a long visit, she asks to have all 17 of her prescriptions refilled.
3. You need to determine whether there is a possible drug interaction between existing medications and an upcoming medicine.
4. You would like to be able to generate a list of all your patients taking a recently recalled drug.

Now imagine a hand-held prescribing device the size of a prescription pad that turns on instantly, knows the date, and through a connection to your computer, knows your patient list for the day. Using this device you could quickly select the patient’s name from a drop-down list and see his or her insurance plan, age, and other demographic information. You could select medications from an alphabetic scrolling list that includes information specific to the patient’s insurance plan. You could check allergies and drug interactions against the patient’s list of previously prescribed drugs and known medication allergies, alerting you only if a clinically significant problem is detected. After selecting the medication, you could choose from a list of available dosages and specify the quantity to be dispensed Figure 1, and the prescription could be digitally signed and sent electronically to the patient’s pharmacy or to your printer. Chart documentation could be produced concurrently on a sticky-backed label that can be affixed to the patient’s medical record. The prescription would be saved for generating rapid renewals in the future. Drug information and insurance formularies would be updated regularly from central computers, and new drugs and dosage forms could appear on the hand-held devices before they show up on the pharmacists’ shelves.

Does all this sound far-fetched? It’s not. This type of technology is currently available. Systems range from simple prescription writers—a hand-held device with initial manual entry of patient data and prescription printing from an infrared-equipped printer—to full electronic medical records systems. Prospective users have to decide which features provide sufficient benefit to merit the investment of time necessary to learn them. In this article, 3 systems (PocketScript, ePhysician ePad, and AllScripts;)Table 1, Table 1a are reviewed by physicians who have successfully incorporated electronic prescribing into their practices.

A system that does nothing other than produce legible prescriptions in the same time it would take to write one by hand can benefit many physicians. One that provides an accurate record of previous prescriptions that allows the rapid renewal of multiple prescriptions is even more valuable. Another important potential benefit of an electronic prescribing system is fewer errors, including those caused by illegible handwriting, incorrect dosage selections, drug-drug or drug-disease interactions, and drug allergies.

These systems still have some limitations, however. Most do not automatically suggest a dosage adjustment for age, renal function, hepatic function, and alcohol and tobacco use (although drug monographs may be available on the hand-held device itself). Similarly, weight-based pediatric prescription information may be available in monographs on the hand-held device but is not built into the prescribing process. Some states allow electronic transmission of prescriptions, some do not, and some have made no ruling; specific rules vary. Fortunately, each of the vendors reviewed in this article made certain that their system is installed in a way that conforms to state laws.

Most primary care physicians have not made the leap to electronic medical records; package delivery services and supermarket checkouts use more technology at the point of service than the average physician does. These devices may change that by providing a relatively low-cost low-risk improvement with less impact on work processes than a full electronic medical record.

Common Features

Each of the systems we reviewed is “wired” somewhat differently Figure 2. PocketScript and AllScripts use a wireless local area network in the physician’s office to move information from the hand-held device to a desktop computer server in the physician’s office. This server is in turn connected to the vendor’s computer through a modem or other high-speed access device to get drug information updates. The office computer also sends prescriptions directly to pharmacies either as an electronic message or by fax.

A system using ePhysician includes a personal computer in the physician’s office to load patient demographic information onto the hand-held using a docking cradle. Prescriptions can be sent directly from the hand-held device to a central computer server at the vendor’s offices using a wireless modem. Alternately, they physician can dock the hand-held device in a cradle attached to the computer, which is connected by a modem to the vendor’s central computer. The vendor’s computer server then sends prescriptions to the selected pharmacy, either electronically or by fax. All systems use sophisticated encryption to protect the confidentiality of data as it is sent between computers.