The E-prescription system
E-prescription system is a replacement of handwritten medical prescriptions. In this system, prescriptions are generated with the help of computer technologies. The first system was implemented in the early 2000. This system has proved to be very effective tool in improving the current Health Care System, by limiting the errors in medical prescription and reducing operational cost. Also, the patient's information is easy to access by the doctors or by the people involved in medical health care system.
In past, medical records of patients were kept in the paper files and the medicines were prescribed on paper. This manual system was error prone. These errors could be drug-drug interactions and wrong dosage plan. There are several reasons behind these errors in the manual system. E.g. sometimes doctors do not bother to go through the paper files to check the history of the patients. On the other hand many times hand writing of the doctor is hard to read. Furthermore, most of the time doctors are not aware of the ingredients of the medicine and its compatibility with other medicines (pharmacists are aware of this compatibility they can advice the doctors to correct the prescription). As a result, these errors in prescription lead to other diseases or death of the patient (Adler 2009).
E-prescription system is faster and convenient way to generate prescriptions with less number of errors. However, the success of this system depends upon its stakeholders such as physician and the patient. This report tries to discuss all these factors. On the other hand, there are some barriers and issues related with this new system such as financial, social, personal and technical issues.
This report tries to explain the implementation and working of the e-prescription system. Furthermore the report emphasises the barriers, benefits and issues associated with E-prescription. Apart from that report also enlists the ethical dilemma among physicians and patients related to E-prescription. From the study of relevant literature we found some promoting organisations and solutions to overcome the difficulties of e-prescribing system.
2. An Ideal E-prescription System
A system is expected to provide care workers and nurses a fully operational drug information system to help care workers in administrating and double checking medication, drug interaction, drug allergies and intravenous drug compatibility. An Ideal E-prescription system should be implemented in four different phases:
- Drug Administration Information: The first part should give the clear drug administration information. It means that at what time the drug should be taken, should it be before meal or after meal, dosage time gap should be 8 hours or just before or after meal. This small but effective information can help efficiency of the drug and is also important to control some diseases.
- Concise and useful drug Information: In the administration level, nurses and care workers don't have enough information about the drug. This phase would provide detailed information about the drug. To recognize, it can also show the images of the drugs. Moreover if it is implemented in non-English countries, it can also provide information translated in local language for the better understanding.
- Drug interaction alerts: This phase is the key phase to provide drug interaction alerts. This includes drug-drug interaction, meaning how one drug will interact with another. Secondly it can also tell a drug-health interaction alert, which means that, how the drug would react according to the patient's health. Not only this, but also any allergy alerts and duplication alerts are prompted by the system. In this phase, care workers can ask physicians, if there is any need to revaluate patient's medication.
- Intravenous drug compatibility: Phase four plays a vital role in the system. If a new drug is in the market and does not have enough detail of interactions with other drugs, it can automatically calculate the interactions between drugs according to the salts used in the drugs. This can avoid many medical disasters by evaluating drug-drug and drug-health interactions.
Database: The implementation of the system requires different database sources to fetch the useful information about the patients, drugs and the interaction between them. The database source should be a local database which is connected to centralized database. The major database sources could be:
- Medicine licence database: It provides information about government approved medicines to public and physicians or nurses.
- Medicine bag: It provides the detailed information about the drugs and the drug-drug, drug-health interactions.
- Drug appearance: This database is used to provide the images to recognize the drug.
System Software: Software is implemented in the hospital/clinic Information system. It has its own database to store and fetch/add patient information. It can fetch/add information from/to central database or local database. It can interact with all the databases and can work according to the need. It should be a user-friendly system to use for the non-expert users. Here is the basic overview of the system in the following diagram:
On the left hand side "Information of Inpatients with prescription", "Drug information Plus Drug image", "Query of Drug-Drug Interactions", these are 3 centralized databases which are using XML to interact with each other. On the Right hand side of the diagram "Remote HIS Host" is Hospital Information system, "Local Drug info. DB" is the local database, "Local Injectable Drug info. DB" is used to inject information into the local and centralized database. MySQL is used to maintain the databases.
4. Benefits and Barriers
E-prescription technology solves number of problems in effective ways.
- It reduces the medication errors in many ways. For instance, it provides clear drug administrating information of patients such as drug should be taken before meal or after meal. These small details could affect a drug's efficiency and sometimes might be important to disease control.
- The system provides drug pictures as drug information explained in language demanded by medical staff, so that medical personnel could easily recognize.
- The system provides drug interaction alerts which help medical personnel to revaluate the drug information. By gathering such information medical staffs, doctors and pharmacists can reduce the medication errors.
- The e-prescription system gives status of patient's prescription, which means system keeps the patient's past medical history and their personal information. Using such information is helpful to provide the list of different diseases of patients which helps in prescribing medicines.
- Health authority's preapproval for certain medications helps to accelerate the e-prescription system in adoption.
- E-prescription offers higher health quality and lower cost.
- Finally, the system offers faster services for patients, doctors and pharmacists. Previously manual prescribing system was consuming lot of time. Using electronic prescribing system doctors, pharmacists, medical personnel and patients can save lot amount of time.
4.2 Technology Barriers:
As the e-prescribing system is on adopting and implementing stage so it has some certain barriers in terms of the system makers and its users.
- The first barrier is the e-prescribing system demands high implementation costs. Apart from implementation cost system also requires, huge infrastructure and technology literate staff for maintenance.
- Secondly, the consumers are much concerned about the patient's private information as this information is transferred between various sharing databases through internet. It could be stolen by the third part and might misuses.
- In addition, people find it difficult to adopt the new system. E-prescribing system is related to information technology and technology might cause certain problems with the current working environment. If this happens then patient's life will be endanger.
- Moreover, people who are older in age would not prefer to adopt any new technology as they are rigid by nature. So sometimes human nature is also performs major roles in technology adoptions.
5. Promotion difficulties and Rectification
One of the drawbacks of the E-prescription system is that it requires considerable amount of money. Moreover it also requires highly detailed standards, widely involved areas, and absolutely reliable technical support. So what the investors are most considering is the way of promotion.
Lack of promotion may directly lead to a failed system which costs dramatically but results in disproportionately low effectiveness. A pilot e-prescription system, which runs under Medicare Modernization Act (MMA), resulted in non-approval of system due to high implementation cost and non-development of technical standards, although it cut the average time spent per day on prescribing, in half. One of the reasons of the failure is that people involved in the system are ride-the-fence-users who are happy to use the trail version but not encouraged enough to pay for it.
The USA government adopted a carrot and stick policy to promote e-prescribing system.
The carrot means for the people, who pays for the e-prescribing use fee, may get 2% extra charge for their services. However, the bonus will reduce to 0.5% in 2013. Whilst the stick means for the people, who refuse to pay for the e-prescribing system, cannot use e-prescribing and their service fee should reduce by 2% in the end of 2014. (Kenneth G. Adler 2009)
This strategy significantly encourages physicians to use and pay for the e-prescribing system as they will retrieve the cost of e-prescribing in some extent.
Cost sharing is another effective promotion strategy. If e-prescribing system is successfully marketed, the cost will not be a main issue. However, the fee of installation and use for e-prescribing system is still unacceptable for an individual physician, thus it becomes an obstacle in promoting e-prescribing. A concession between investors and users is that the users should pay a certain percentage of total installation and use fee, the investors pay the left.
Despite the fact that investors and government spend numerous times and money on promoting e-prescribing system, the users is the decision maker. They should know how important and ethical it is to pay attention to the patients' health and lives.
6. Ethical Issues
E-prescription and drug interaction system is a modern technology to solve the medication problems. To solve this problem technology uses the several storage data centres and build the atmosphere which allows the users to access these centres remotely. In most of the cases this is helpful in conducting productive means of medications. But due to huge involvement of electronic data storage and accessibility, recently some ethical issues are also raised against the technology. These ethical issues can be divided into several sections, which are one by one stated and describe below:
6.1 Privacy issues
What is privacy??
There are many ways by which privacy was defined in the past. Out of them one of the definitions is
"Privacyis the ability of an individual or group to seclude themselves or information about themselves and thereby reveal themselves selectively."
This is a very general definition of privacy, but the implication of this is different for every individual. The limitations regarding the contents of what is considered as a private thing are also different for every individual. Cultural and religious thinking plays a very big role in deciding these boundaries. Sometimes privacy also means that an individual doesn't want to reveal certain facts in front of public. If these facts are exposed in front of public without the wish of that individual person, then that is called as a privacy theft or privacy issue.
How critical privacy is??
The privacy issues are one of the most critical issues raised by many information technologies recently. The reason why privacy considered as the most critical issues is that, privacy occupies the highest priority in any individual's life. According to the wiki when a thing is private to a person, it is also a very special or personal sensitive thing for him.
Privacy issues related with E-prescription??
In the previous section of this report, it has been mentioned how this technology is implemented in different countries. At the first stage, inpatient information is stored in a database. This inpatient information contains, identity, hospitalized date, past history, diseases, weaknesses etc (Sung at el p.743). This information is available in the centralized database, by which it is extracted to the hospitals and pharmacies local servers. Though this information is general about the patient, but as the medical history is also involved it is very risky to put that in a centralized place. Most of the patients find it difficult to digest that there weakness are stored somewhere and anyone can watch it, anytime they want. This really has raised the privacy issue, with the implementation of E-prescription. People apposing this technology in many countries, due to such privacy issues involve in that. Patient arguing the fact that, through this technology they have lost control upon sharing their private information by their wish. It's all in the hands of the machines. This problem of privacy has also generated the alarming situation for other ethical issues, such as security, law and many undetected.
6.2 Security issues
After privacy, the second most critical issue is security. Though security is narrower then the privacy issue, but the loss of privacy actually gives birth to the security issues. The concept of security is very much related to the individual's safety. When privacy of an individual is exposed in public domain, then personal safety problem rises. Due to this, security issues are raised.
In case of E-prescription, huge amount of information, of an individual is stored in a centralized database. Information about person's private life such as Identification, contact details and postal address are stored. If this private information gets sacrifices, then with the help of modern technology, it is very easy for a third party to spy on patients. Though such kinds of cases are not yet detected with E-prescription technology, but there are plenty of safety issues, registered with the other technologies implemented in the same manner as E-prescription. So there are high chances that, this technology also suffer those security issues in near future. Moreover drawback of E-prescription is that, with the private data, patient's medical condition is also available in the data-centres. There are chances that, any physical or biological weakness of a patient is used against his safety.
6.3 Legal problems
Is there any law for such security issues???
It is very important that before implementing this technology at a large scale, current legislation system needs new amendments. In most of the countries legislation system is lacking of such amendments. People argue that, before implementing E-prescription technology, it is very important to create new laws, which can be used to decide the physical and capital punishments against such acts.
6.4 Ego problems of the professionals
In the E-prescription technology, system gives medical staff certain suggestions, regarding the drugs to be prescribed to the patient's, accordingly their current medication. In most of the cases doctors are in agreement with the suggestions of the system. However in many of the other cases it has been found that, doctors don't agree with the system suggestion and they want to prescribe the drugs according to their knowledge. If such situations arrive frequently, then human ego plays its role. In the past, some interviews of medical staff have been recorded upon their views on E-prescription system. The outcome suggests that, medical staff sometimes finds it difficult to cope with this system. They think that, modern technology has been imposed upon them through such medication system.
As one can see, there are plenty of ethical issues related to E-prescription technology. Before implementing this system, it is important that these issues should be rectified. In the next section report tries to suggest some rectifications for these issues.
7. Rectification of Issues
Issues are needed to be rectified and solved in order to make e-prescription system more widely available, affordable and inclusive of services as possible. Different policies and encryption techniques are implemented to address issues in e-prescription system. In order to overcome privacy issues, cryptographic tool are used to maintain patient's confidentiality. Implementation of cryptographic tool enables the data to be encoded so privacy is not hindered. Legislation based rule are also implemented in order to protect privacy. HIPAA (health Information Portability and Accountability Act) established privacy policies at federal level to maintain confidentiality regarding data-storage (Ateniese G., Mederios B., p. 19). A privacy note can also be signed from physician in order to maintain high level of confidentiality.
As the privacy policies do not apply to pharmacy and vary from state to state, standardization was developed to protect privacy and prescriptions. Under this policy, each patient was given authority for property of his/her data. The patient was given rights to request disclosure of his/her data and can make any corrections in the records whenever needed. This feature helps the patients to select type of information to be stored in system, thus restricting third party involvement to access private data. Privacy issues mainly come when patient fear that their employs would know their past medical history (Ateniese G., Mederios B., p. 19) or patients would not like insurance company to check their medical history. Even identities of doctors are privatised under this policy excluding the data needed to research and analysis. Privacy of prescribed medicine is also significant in terms of confidentiality. Medical history can be known to certain limit if prescribed medicine is revealed.
A security model was developed for clinical information system to maintain confidentiality of medical data. In this system, multilateral forms of access control and information flow control are included. This technical feature supports access-lists, lattice-type hierarchical access structures, append only write access supporting audit trails and strong authentication. To support the implementation of policies by HIPAA, privacy officers are employed for establishing compliance laws concerning privacy of patients or doctors and with regulations on disclosure of medical information as well as translate pseudonyms into patient names in database. Implementation of policy by HIPAA has provided legal authority Government agencies to oversee medical prescription of patient when required. However, more issues with privacy and security are escalated with the development of new technology. But as coin has two sides, these issues can be rectified by providing technical as well as legislative solutions.
8. Future steps
The current e-prescribing systems are still immature. We have at least 4 steps in the future.
- Provide more awareness
- Do more user training
- Continuous update
- Widen and associate the coverage of e-prescribing
Make sure the patients, physicians and pharmacists are all aware of what e-prescribing system is and how effective it is to improve medical service.
For the investors, broadcast the introduction of e-prescribing system to all the physicians, also show the importance of correctly using drugs and the danger of drug interaction.
E-prescribing is a comprehensive and complex system; it covers most of the areas in medicine such as prescribing, treating, drug information searching. As a result, it causes confusion for a new user. In order to ensure that the system is really helping people to facilitate prescription, user training support should be provided by investors.
New drugs are created, current drug's dosage is probably changed, and some drugs may be reported as forbidden, all these leads to updates of e-prescribing database. The drug providers must login the system to update the drug information once a change happens. Therefore, the system's maintenance needs active helps from all the drug providers.
E-prescribing is a worldwide system as it transfers data from the internet. Nevertheless, countries or states have their own e-prescribing database; they cannot share information for patients and drugs between each other. When people move from one place to another place, they should create a new account and be treated as new persons. It loses the purpose of e-prescribing. For the sake of reducing data redundancy and users' convenience, all the e-prescribing system should be able to share data with each other.
To conclude, e-prescription systems are very effective tool to improve health care systems in effective and efficient way. As study shows electronic prescription reduces the number of errors in medication prescription but its utilization and effectiveness also depends on physicians as well as its implementation methods. People always resist the adoption of new technology but there is need to provide the awareness about the benefits of the technology.
In this report we discussed number of benefits as well as number of barriers to the implementation of e-prescribing system. Benefits such as reduce the number of errors in medication prescription, reduction in operational cost and fast access of patient information (only if the information is centralized) and barriers are financial, technical and social. Among all these barriers the financial barrier is most dominant barrier because the implementation cost is very high for e-prescription systems. In addition, the technical issue is also a serious issue because system needs to be up-to-date.
Apart from barriers and benefits there are plenty of ethical issues also. Among these ethical issues privacy, security, issues related to patients and physicians moral and legal issues are also stated by this report. Out of all these stated issues some are very critical. For successful implementation of this technology, these critical issues are still need to be rectified. This report has made an attempt to find out some solutions of these problems. If electronic prescription systems will overcome all these issues it can improve health care services to very high extent.
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