Linda M. Caldwell, DNSc, APRN, BC
American Association of Colleges of Nursing
Margaret McAllister, PhD, FNP-C, FAANP
American Academy of Nurse Practitioners
Ralph R. Velazquez, Jr., MD
American Association of Health Plans
Satya Verma, OD, FAAO
American Optometric Association
Belinda Vicioso, MD, FACP
American Geriatrics Society
Darrell P. Wheeler, PhD., MPH, ACSW
National Association of Social Workers
Background and Significance
The IOM (2000) report, To Err is Human, outlines serious breaches of patient safety including numerous studies of adverse drug events (ADE's) [1]. ADE's increase the cost of health care by causing more emergency room and primary care office visits, hospital admissions and deaths [2]. Medication errors lead to 7,000 deaths per year and the cost of drug-related morbidity and mortality is estimated at $177 billion annually [3]. Illegible handwriting is one of the most preventable sources of ADE's. The hazards associated with illegible handwriting include medication dosage decimal point errors, confusion over generic and brand name drugs, inaccurate patient instruction due to illegible abbreviations, and compromises in database integrity [4], [5],[6]. Pharmacists believe that improving provider's handwriting could be a major approach to preventing prescription errors [7]. The literature, however, points to the failure of education programs to impact provider prescription writing, and supports the efficacy of computerized prescribing in hospital settings [8].
The IOM recommended a plan to improve health care that included identifying factors to increase the quality of care [9]. This report cited numerous examples of automated hospital information systems shown to be effective in reducing medical error; however, as of today, only 5% of MD's currently write prescriptions electronically [x].
The Medicare Payment Advisory Commission (MedPAC) Report to Congress: Applying Quality Improvement Standards in Medicare recommends a policy framework that provides incentives to improve quality and foster accountability, and cites the need for leadership from Medicare in this arena [11].
Proposal
We recommend that CMS reward providers for safer performance at the point of care. Specifically, we propose that CMS provide a reimbursement incentive for electronic prescribing. This proposal is aligned with patient safety initiatives and is in keeping with the MedPAC report. Requiring the adoption of electronic prescribing to address illegible handwriting, one of the more common prescribing errors, is an attainable goal for all stakeholders.
This proposal is not intended to increase the cost to Medicare. It is anticipated that there will be a 4% decrease in provider reimbursement in 2004. In response, providers have requested a fee increase but did not suggest specific efforts for safer patient care or quality improvement. Rather than have CMS yield to requests that do not improve patient safety, we recommend that any negotiated increases be tied to electronic prescribing. The amount of the increase should not exceed any anticipated budgeted adjustments
The proposed incentive for electronic prescribing should be offered only to participating Medicare providers. CMS and the professional societies would determine the specifics of the tool. There exist draft guidelines, developed by the Institute for Safe Medication Practices, to guide electronic prescribing [12].
The proliferation and adoption of PDA tools, such as ePocrates Rx have demonstrated provider acceptance of technology. Over 200,000 physicians have downloaded ePocrates Rx; 50 per cent of physicians using this tool report averting 1-2 errors per week [13].
The e-prescribing tool can be used with multiple pharmacy plan formularies to improve formulary compliance. It will reduce member co-pays, decrease pharmacy waiting time, and reduce the potential for medication errors and fraud [14]. These features will become even more important if a Medicare prescription program is started.
There are several electronic-prescribing vendors. Estimated software costs range from $49-$150 per month per provider. Hardware costs for PDAs and printers continue to decline while gaining features. Increased use will stimulate software vendors to improve the tools for even greater patient safety.
Summary
This proposal focuses on one area of medication error reduction, those associated with illegibility of prescriptions, and would be the first of several steps in the process of increasing medication-related patient safety. Implementation of a simple and focused method to increase safety in prescribing is cost efficient, practical, and feasible. CMS, as the largest purchaser of health care, should be a leader in fostering strategies to decrease prescription error. It is also critical that CMS stimulate specific efforts to improve quality through the creation of incentives that foster quality and reward those who provide quality care.
The Secretary of the Department of Health and Human Services can provide directives that create an environment that rewards quality care. This proposal supports the agenda proposed by the IOM and the MedPAC report. Put simply, handwritten prescriptions ought to be a thing of the past
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