One of the most useful functions of an EMR is the ability to manage medications more effectively. Currently, all EMRs in Canada can generate a prescription and record that prescription in the patient’s cumulative profile. Depending on the sophistication of the EMR software and, whether automatic drug interaction checking is integrated within the EMR, these clinical decision support tools can place more control in the hands of the prescriber — but only if they are correctly configured.
Consider a best practice for medication management via the following use case scenario. This takes place in a completely interoperable healthcare system where data is securely shared between multiple systems and providers:
Mrs. Smith, a 65-year-old patient with diabetes and atrial fibrillation, attends her family doctor for a check-up and renewal of her medications. She is taking oral Metformin and Glyburide for her Type II diabetes, Warfarin for her atrial fibrillation, as well as a beta blocker for her hypertension. After completing her check-up, Dr. Brown renews her medication using the EMR. Within Mrs. Smith’s summary record, Dr. Brown is able to click on a button and in one step enter an authentication code in order to access Mrs. Smith’s provincial drug information record. He notices that her cardiologist in the last few days has added a new anti-hypertensive drug, Enalapril, to her treatment regime. He confirms the new drug and is able to add Enalapril to Mrs. Smith’s medication list in the EMR by importing it directly from the provincial drug information system. During the prescribing process, because a new medication has been added to her treatment regime, the EMR conducts checks for drug-drug, drug-disease, drug-allergy, and drug-dose interactions. Dr. Brown has configured the EMR to display only severe interaction warnings, although a list of moderate and minor interactions are listed for review if felt clinically appropriate. Interaction warnings are quickly checked and noted by Dr. Brown via a single screen and he is able to acknowledge this medication combination so that the alerts are not presented at the next renewal unless a new medication is added, a new allergy alert is present, or a dosage has been changed. The EMR also calculates exactly how many pills Mrs. Smith should have left from her prior prescriptions (including the newly added Enalapril). He is able to select medications for renewal and enters three months for duration of renewal. The correct medication amounts are calculated and he confirms the pharmacy to which Mrs. Smith would like the prescription to be sent. (She has two pharmacies on her file as her son sometimes picks up her medication.) Dr. Brown is given the option of faxing the prescription directly through the EMR if the pharmacy is not yet able to receive E-Prescriptions; however, the pharmacy is fully E-Prescribing enabled and the prescription is submitted electronically. He immediately receives a notification that the prescription has been received and advises Mrs. Smith to pick up her medications. Dr. Brown is also provided with drug cost information at the time of prescribing and is alerted to the fact that generic drugs will be dispensed that will save Mrs. Smith 70% of the cost of brand-name products.
Although this appears to be a complicated process, it is fast and efficient. Screens only present relevant information, the user interface is optimized for rapid and safe prescribing, and the supportive data provided through the EMR’s drug interaction software, provincial drug information system, and drug cost information provides Dr. Brown with a comprehensive view of his patient’s medication profile and current status.
Much of what has been described in the above scenario will be available in Canadian EMRs (depending on the status of various provincial drug information systems) in the future. In the U.S., which has a sophisticated E-Prescribing network predominantly managed through Surescripts, much of this functionality is already being used. The system is not perfect and requires optimization, but all of the elements are in place. Similarly, both Sweden and Denmark have sophisticated E-Prescribing capability.
Medication management is going to be the next big area of focus across Canada for provincial programs. Because safe management of medications is complex and involves multiple parties, it will require significant effort and the involvement of pharmacists as much as physicians. The benefits are significant; it will just take time to get it right.
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