Doctors' handwriting jokes, RIP?

Quebec gears up for electronic prescribing,
but is Canada ready to leave the paper trail behind?

BY SUSAN USHER

We hear more and more about medication error, says Dr Robyn Tamblyn, associate professor in the Department of Medicine and the Department of Epidemiology and Biostatistics at McGill University. "The media attitude has been 'Surely these people should know better. Didn't they go to medical school?' The blame is laid on the person caught in the middle of a very complicated system."

She hopes to change this situation by introducing communication and support tools aimed at reducing the risk of misunderstanding at the prescribing stage. The MOXXI project (Medical Office of the 21st Century) targets community-based family physicians in private or group practice. "This group writes 70% of all prescriptions and it's time we started paying attention to them," says Dr Tamblyn. She believes that these situations are caused by an increasingly complex healthcare system with serious communication problems.

Results from a first phase of the MOXXI were published in the Canadian Medical Association Journal last September. The research team selected 107 primary care physicians with at least 100 older patients and randomized half to a computerized decision-making support system. The system gave them access to information on patients' prescriptions through a link to the provincial seniors' drug program database. The computer system also alerted physicians to 159 clinically relevant prescribing problems at the moment they were writing the prescription.

In the 13 months of the study, the percentage of patients with at least one potentially inappropriate prescription fell from 32% to 18% in the group using computer support. Dr Tamblyn concluded that computer-based access to complete drug profiles and alerts about potential problems reduces the incidence of inappropriate prescribing.

But the study also supported Dr Tamblyn's conviction that much more needed to be done. "The first thing we need to do is get rid of the handwritten prescription," she says. Some 13% of handwritten prescriptions (dispensed by pharmacists) contain an error, 1.6% of which could produce serious adverse events. As well, Dr Tamblyn reports that "about 15% of prescriptions dispensed are not what was prescribed: they are either the wrong drug or the wrong dosage." A $650,000 suit filed against Jean Coutu Pharmacy in December 2003 for the death of a woman who was dispensed twice the prescribed dosage of her chemotherapy medication is a wakeup call for doctors and pharmacists alike.

"As of July 2004," says Dr Tamblyn, "it will be illegal to issue a handwritten prescription in Florida, and the Medicare reform bill in the US includes provisions to have electronic prescriptions in place by 2006." European countries have moved more rapidly and electronic prescribing is now the norm.

MOXXI Phase III is linking up pharmacists in the community and physicians in private practice to try and close the information loop between prescriber and dispenser. Pharmacists in Quebec are already hooked into the online electronic adjudication system run by the provincial drug plan. MOXXI III brings community-based physicians into the loop, equipping them with handheld computers called iPacs that give them access to patient drug profiles and an electronic prescribing pad that helps them build a prescription by telling them exactly what dosage forms are available. The prescription is printed for the patient, added to their chart and transmitted electronically to the pharmacist. Alerts for inappropriate prescriptions are flagged and there are a number of other features, most notably a compliance record.

"When a patient is not really achieving the expected therapeutic response at a follow-up visit, doctors don't know to what extent the person has really been taking their medication," says Dr Tamblyn. "They ask but get vague responses." As a result physicians are often unsure whether to increase the dosage or add another medication or change the medication. The iPac system calculates and graphs the supply of drugs dispensed over a given time period and allows doctors to see where the gaps are.

Both doctors and pharmacists have been positive about the system. "The pharmacists involved in the study are utterly overjoyed to have a typed prescription," says Dr Tamblyn, "both because of the liability issues attached to filling the wrong prescription, and because of the hours on the telephone they used to spend trying to get doctors to clarify prescriptions." Doctors find features like the drug profile helpful because when a printout is given to the patient he or she doesn't have to remember the names of all their drugs.

However, Dr Tamblyn anticipates ongoing struggles in convincing doctors to invest in the equipment, maintain and use it, unless government provides some incentive. "Some form of subsidization is going to make the difference between rolling out the project very quickly like Australia did or waiting for physicians at the front line to make their own decision," she says. In Canada the only province with an organized subsidization program is Alberta.

The intention is now to see the physician-pharmacist loop rolled out across Quebec. Dr Tamblyn is already working at integrating hospital systems and hopes to see them interconnected into hubs that community-based physicians can link into for labs and radiologic tests. McGill has spun off a company, MOXXI Medical, that will actually undertake the rollout in conjunction with the province. "The incentive to use the network will really depend on what's on the network," says Dr Tamblyn. It just remains to be seen who will get with the program.