TY - JOUR
AU1 - Chang, Sophia W.
AB - Health care has moved into the computer era at a pace that might be described as “glacial.” The federal government hopes to accelerate the process by making large investments in electronic systems today, on the bet that they will reduce costs for the overall health care system in the long run. The article by Weingart et al supports this premise. The federal stimulus package (HR 1-353, American Recovery and Reinvestment Act of 20091) includes funding to promote the “meaningful use” of electronic health record systems, a term which, at the time of this writing, is still being defined. However, it will likely include several components beyond paperless medical records, namely, e-prescribing, quality reporting, and health information exchange. The intended goals are to simultaneously achieve more effective care and slow the growth in health care spending. The findings reported in the article clearly point to the need for smarter systems in health care and, in particular, ones that truly make the right thing to do the easier thing to do rather than overload the clinician with alerts and reminders. Using conservative estimates, Weingart and colleagues demonstrated the potential benefit of e-prescribing in averting patient morbidity and saving the health care system from the expense of treating avoidable sequelae. The fact that the scientific methods for determining the relative severity of an adverse drug event (ADE) still rely on expert panel opinion (as opposed to real patient outcome data) strongly underlines the need to align electronic health record systems with comparative effectiveness research and surveillance. In other words, through the use of electronic records, we have an opportunity to develop robust mechanisms that can support both patient safety and data-driven health care improvement. Electronic prescribing remains woefully nascent in the United States. This is particularly true in ambulatory care, where the volume of retail prescriptions now runs at 12.6 per capita.2 The greater the number of prescriptions, the greater the chance for error and ADEs. Even within hospitals, which have adopted information technology at a higher rate, the technology cannot address the issue of medication reconciliation or alleviate the confusion of patients and families as they navigate through admission and discharge. Indeed, unless the full function of e-prescribing is in use (including the ability to see a patient's medication history from all sources), important drug interactions and duplications will continue to be missed. Equally important is the capability to share prescription information across different systems and settings, a feature crucial for patients who receive care from multiple physicians, as well as a necessary element for ensuring that the federal technology investments reap their intended benefit. Because it is generally required for reimbursement, prescription information is more consistently stored in an electronic format than are other types of health records. Prescription information is also more likely to comply with existing standards and nomenclature. Even though the data exist, the “business case” for mining it to improve care has not been made. The information has been used more effectively by pharmaceutical companies in their marketing than by providers seeking to identify patterns of prescribing and how they could be improved. What does all this mean for the practicing clinician? For both small and large physician practices, the incentives to e-prescribe may become more compelling. Following the passage of the e-prescribing incentive included in the Medicare Improvement for Providers and Patients Act of 2008 (MIPPA),3 the number of clinicians sending e-prescriptions doubled, growing from 36 000 in 2007 to 74 000 in 2008 and generating more than 240 million prescriptions.4 Although this reflects just 12% of ambulatory prescribers, the fact that the first incentive payments did not begin until 2009 means that the relative advantage to patients has yet to be fully demonstrated. Adoption of e-prescribing is not just for innovators. Medicare has certified acceptable systems, and programs to support wider use have been launched by several states.5 Much work is still needed to better integrate e-prescribing with the full electronic medical record (ie, to prompt renal dosing of drugs), as well as to make the process more efficient. The Centers for Medicare and Medicaid Services program even designates codes to document current clinician limitations in e-prescribing, namely, a controlled substance prescription, a state or federal requirement (or patient request) for a faxed or paper prescription, or a pharmacy that does not use an electronic system.6 Without a seamless system—one that transmits a medication order from the electronic system in a doctor's office to a pharmacy computer and generates the prescription (and bill) without the information dropping to a paper transaction—the necessary efficiencies cannot be gained. That is, in a given community, a critical mass of (and ideally all) prescriptions would be communicated consistently so that more efficient work flows for prescribing, dispensing, and refilling/reordering can take hold. In addition, the more providers there are using the system, the more comprehensive the patient information contained within it and the greater the chance for identifying and avoiding potential errors. Pharmacies, commercial health plans, and pharmacy benefits management companies have come together to develop a centralized mechanism for prescription data exchange (the Surescripts network [Surescripts, Alexandria, Virginia]). Medicare Part D plans have now added their data to meet MIPPA requirements, but many Medicaid systems have yet to fully participate.7 It is this very “tipping point” of e-prescribing adoption that the federal incentives hope to achieve, believing that clinician use will be the decisive factor. Perhaps one of the more important messages from the work of Weingart et al is that automated decision support systems should follow Sutton's adage8,9 that we put our effort “where the money is”—not for the purpose of drug sales but to improve patient care and safety. By automating and ensuring that the most common issues are addressed consistently, we provide clinicians with the ability to spend time tailoring care to the patient rather than dealing with rote tasks. Unlike sophisticated automation to control complex machinery, the intent of health information systems is to support better human interactions. If we allow the electronic systems to become the goal, as opposed to being a tool tailored to meet clinician and patient needs, then a significant opportunity—and billions of dollars—will be wasted. Correspondence: Dr Chang, Better Chronic Disease Care, California HealthCare Foundation, 1438 Webster St, Ste 400, Oakland, CA 94612. Financial Disclosure: None reported. Additional Contributions: Tom Schmitz, MA, provided editing assistance. References 1. HR 1-353; American Recovery and Reinvestment Act of 2009. Division B—Tax, Unemployment, Health, State Fiscal Relief, and Other Provisions. Title IV–Medicare and Medicaid Health Information Technology; Miscellaneous Medicare Provisions. §4101. Incentives for eligible professionals. January 6, 2009 2. Lundy J Prescription drug trends. Kaiser Family Foundation Web site. http://www.kff.org/rxdrugs/upload/3057_07.pdf. Published September 2008. Accessed June 5, 2009Google Scholar 3. Medicare Improvements for Patients and Providers Act of 2008, Pub L No. 110-275 (July 15, 2008) 4. National progress report on e-prescribing. Surescripts Web site. http://www.surescripts.net/downloads/NPR/national-progress-report.pdf. Published 2008. Accessed June 5, 2009 5. Getting connected: the outlook for electronic prescribing in California. California HealthCare Foundation Web site. http://www.chcf.org/documents/chronicdisease/E-PrescribingOutlookCalifornia.pdf. Published November 2008. Accessed June 5, 2009Google Scholar 6. US Department of Health and Human Services, Medicare's practical guide to the e-prescribing incentive program. http://www.cms.hhs.gov/partnerships/downloads/11399.pdf. Published November 2008. Accessed June 5, 2009 7. Mertz K E-prescribing: missives from the front. State Health Notes. February4 2008;29 ((508)) National Conference of State Legislatures Web site. http://www.ncsl.org/programs/health/shn/2008/sn508c.htm. Accessed June 5, 2009Google Scholar 8. Altman L A law named for Willie Sutton assists physicians. New York Times. January3 1970;§13Google Scholar 9. Rytand DA Sutton's or Dock's Law? N Engl J Med 1980;302 (17) 972Google Scholar
TI - Health Information Technology as a Tool, Not an End: Comment on An Empirical Model to Estimate the Potential Impact of Medication Safety Alerts on Patient Safety, Health Care Utilization, and Cost in Ambulatory Care
JF - Archives of Internal Medicine
DO - 10.1001/archinternmed.2009.264
DA - 2009-09-12
UR - https://www.deepdyve.com/lp/american-medical-association/health-information-technology-as-a-tool-not-an-end-comment-on-an-jrav0KzhmI
SP - 1474
EP - 1475
VL - 169
IS - 16
DP - DeepDyve
ER -