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Joel Diamond 6/23/10

June 23, 2010 News 2 Comments

Random Thoughts on e-Prescribing

A few years ago, I admitted a 35-year-old man to the hospital with severe dehydration and electrolyte disturbance due uncontrolled diarrhea. The poor guy started out with fairly mild symptoms. After using his neighbor’s bathroom, he looked in the medicine cabinet and saw a drug labeled colchicine. The instructions read “Take every 1 hour– gout relief or diarrhea”.

For those of you unfamiliar with this old but effective treatment, you literally take it every hour until painful gout resolves, or stop taking it when you get the side effects of diarrhea. I will not comment on this gentleman’s intelligence or judgment, but somehow he misinterpreted the instructions as a treatment FOR diarrhea. Worse than that, as his symptoms got worse, he diligently followed the instructions and continued taking more, and more, and more… every one hour for the next 24 hours.

Sort of reminds me of the old lady who was prescribed a rectal suppository for symptoms of nausea. She called saying the medicine didn’t work. “And while I’m at it, how did you expect me to take that giant pill? And if you must know, it tasted awful!” I guess it’s not as bad as the elderly woman who didn’t enjoy the taste of the “Kentucky Jelly” on her toast in the morning. (K-Y Jelly is usually used for other purposes).

Clearly, the Sig (i.e. instructions) portion of a prescription is extremely important. Practitioners claim that the unstructured format in handwritten prescriptions offers more flexibility. For instance, writing complex dosing for a tapering course of medication can be difficult in an EMR.  This is commonly cited as an obstacle to widespread adoption of electronic prescribing. But in the end (pardon the pun), I suppose that the above suppository story could have been averted if the instructions had read “carefully place the huge waxy tablet firmly up your ass.”

Speaking of which, a colleague of mine told me of the time he once prescribed drops for a baby with an earache. The instructions were: “Put two drops in right ear every four hours” with right abbreviated as an R with a circle around it. The mother returned when the child did not get better. She showed the doctor the baby’s wet rectum as evidence of complying with the prescribed treatment. It turns out the pharmacy printed the instructions as “Put two drops in R ear every 4 hours”.

I’m a huge advocate of electronic prescribing. Elimination of handwriting errors, dose range checking, and monitoring drug-drug interactions are but a few of its virtues. My patients definitely appreciate having prescriptions waiting for them at the pharmacy.

As an aside, several years ago when I started e-prescribing, a pharmacist I knew told me that the drug store pharmacies were worried that this convenience would cause them to lose revenue. It seems that waiting around is precisely why they put the pharmacy there in the first place — to make you shop for other stuff during the 30 minutes it takes to put 30 tablets in a bottle.

Progress can oftentimes be thwarted by outdated legal issues. I still can’t figure out why I can call in prescriptions for Vicodin and Xanax over the phone (or worse, fax them), but I am not allowed to e-prescribe these controlled substances and significantly decrease illegal prescription diversion.

Speaking of old fashioned, one of my old mentors told me that he had an agreement with the local pharmacist back in the day. Whenever he had a hypochondriac in the office, he prescribed Obecalp for whatever ailed them. The pharmacist would fill the script with the biggest vitamin capsule he had in stock. (Obecalp is placebo spelled backwards). I often wish for that drug to appear in my EMR’s drop-down list. Talk about “Primum non nocere” –First do no harm (The Hippocratic Oath).

Frequently,  I just miss what might be the last bastion of the lost art of medicine … pulling a leather-bound prescription pad out of my pocket and writing Latin instructions with a fountain pen as closure to a satisfying doctor-patient encounter.

And then getting a call from the pharmacist telling me the drug isn’t on formulary!

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh, and a practicing physician at UPMC and of the Handelsman Family Practice in Pittsburgh, PA. He also blogs on interoperability.

Comments 2
  • Had a patient once who complained that her oral ingestion of the Clinitablet intended to measure glucose in the urine, was upsetting her stomach. Bless the patients who try so hard to comply with the many confusing messages they receive.

  • Interesting post. The NCPDP SCRIPT standard, which is used for ePrescribing, could benefit from consideration of these real-world cases. It sets unfortunate limits on the free-text instructions for meds (to 140 characters), doesn’t allow for instructions in > 1 language (1 for pharmacist, 1 for patient, which I often do with my Spanish-speaking patients so the phamacist can understand what the Rx is but can also just transcribe the Spanish onto the bottle for the patient), etc.

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