E-prescribing and access to prescription medicines during lockdown: experience of patients in Aotearoa/New Zealand.

BACKGROUND: Health services internationally have been compelled to change their methods of service delivery in response to the global COVID-19 pandemic, to mitigate the spread of infection amongst health professionals and patients. In Aotearoa/New Zealand, widespread electronic delivery of prescriptions (e-prescribing) was enabled. The aim of the research was to explore patients' experiences of how lockdown, changes to prescribing and the interface between general practices and community pharmacy affected access to prescription medications. METHOD: The research employed a mixed-method approach. This included an online survey (n = 1,010) and in-depth interviews with a subset of survey respondents (n = 38) during the first COVID-19 lockdown (March-May 2020). Respondents were recruited through a snowballing approach, starting with social media and email list contacts of the research team. In keeping with the approach, descriptive statistics of survey data and thematic analysis of qualitative interview and open-ended questions in survey data were combined. RESULTS: For most respondents who received a prescription during lockdown, this was sent directly to the pharmacy. Most people picked up their medication from the pharmacy; home delivery of medication was rare (4%). Survey and interview respondents wanted e-prescribing to continue post-lockdown and described where things worked well and where they encountered delays in the process of acquiring prescription medication. CONCLUSIONS: E-prescribing has the potential to improve access to prescription medication and is convenient for patients. The increase in e-prescribing during lockdown highlighted how the system could be improved, through better feedback about errors, more consistency across practices and pharmacies, more proactive communication with patients, and equitable prescribing costs.

Integrating E-Prescribing and Pharmacy Claims Data for Predictive Modeling: Comparing Costs and Utilization of Health Plan Members Who Fill Their Initial Medications with Those Who Do Not.

BACKGROUND: Nonfilling of prescribed medications is a worldwide problem of serious concern. Studies of health care costs and utilization associated with medication nonadherence frequently rely on claims data and usually focus on patients with specific conditions. Past studies also have little agreement on whether higher medication costs associated with higher adherence can reduce downstream health care consumption. OBJECTIVES: To (a) compare the characteristics between people with and without complete medication initiations from a general population and (b) quantify the effect of medication initiation on health care utilization and expenditures with propensity score weighting. METHODS: We conducted a retrospective cohort study using 2012 and 2013 electronic health records (EHR) and insurance claims data from an integrated health care delivery network. We included 43,097 eligible primary care patients in the study. Annual medication fill rates of initial prescriptions in 2012 were defined as the number of filled prescriptions from claims divided by the number of e-prescriptions from EHRs, while excluding all refills. A claim was considered filled if (a) EHR and claims records were from the same drug class; (b) claims occurred between the date of a current EHR order and that of the next EHR order of the same class; and (c) the maximum fill rate was 100%. The 6 annual outcomes included total costs, medical costs, pharmacy costs, being a high-cost "outlier" (in top 5%), having 1 or more hospitalizations, and having 1 or more emergency department (ED) visits. Individuals were classified as either having completed all medication initiations (100% annual filling rate for initiations) or not. We used propensity score weighting to control for baseline differences between complete and incomplete initial fillers. We adopted linear and logistic regressions to model costs and binary utilization indicators for the same year (concurrently) and next year (prospectively). RESULTS: Approximately 42% of the study sample had complete medication initiations (100% filling rate), while the remaining 58% had incomplete initiations. Individuals who fully filled initial prescriptions had lower comorbidity burden and consumed fewer health care resources. After applying propensity score weighting and controlling for variables such as the number of prescription orders, patients with complete medication initiations had lower overall and medical costs, concurrently and prospectively (e.g., $751 and $252 less for annual total costs). Complete medication initiation fillers were also less likely to have concurrent health care utilization (OR = 0.78, 95% CI = 0.68-0.90 for hospitalization; OR = 0.77, 95% CI = 0.72-0.82 for ED admissions) but no difference in prospective utilization other than for ED visits (OR = 0.93, 95% CI = 0.87-0.99). CONCLUSIONS: Identifying the subpopulation of patients with incomplete medication initiations (i.e., filling less than 100% of initial prescriptions) is a pragmatic approach for population health management programs to align resources and potentially contain cost and utilization. DISCLOSURES: No outside funding supported this study. This study applied the Adjusted Clinical Group (ACG) case-mix/risk adjustment methodology, developed at Johns Hopkins Bloomberg School of Public Health. Although ACGs are an important aspect of this study, the goal of the study was not to directly assess or evaluate the methodology. The Johns Hopkins University receives royalties for nonacademic use of software based on the ACG methodology. Chang, Kharrazi, and Weiner receive a portion of their salary support from this revenue. Chang is also a part-time consultant for Monument Analytics, a health care consultancy whose clients include the life sciences industry, as well as plaintiffs in opioid litigation. Alexander is past Chair of FDA's Peripheral and Central Nervous System Advisory Committee; has served as a paid advisor to IQVIA; is a co-founding Principal and equity holder in Monument Analytics; and is a member of OptumRx's National P&T Committee. These arrangements have been reviewed and approved by Johns Hopkins University in accordance with its conflict of interest policies. The other authors have nothing to disclose.

Implications of parenteral chemotherapy dose standardisation in a tertiary oncology centre.

BACKGROUND: Dose banding parenteral chemotherapy has the potential to optimise aseptic unit capacity and reduce drug expenditure without compromising the service provided. METHODS: Dose banding tables from NHS England were implemented into the electronic chemotherapy prescribing system. Compliance to the dose bands was analysed and submitted quarterly. Analysis of drug expenditure, drug use and cost per milligram data was also collected. RESULTS: Expenditure on the 17 drugs identified in the 2016/17 dose standardisation CQUIN reduced by approximately £100,000 per month over the CQUIN despite an increase in the number of prescribed doses of these drugs. At the beginning of the year, the percentage of work compounded in house was 60%, which was reduced to 51% of total workload at the end of the year due to outsourcing commonly prescribed doses from commercial pharmaceutical aseptic manufacturers. CONCLUSION: Dose banding parenteral chemotherapy is an efficient cost-saving strategy which also can help to increase the capacity of the aseptic unit.

Factors Influencing the Total Inpatient Pharmacy Cost at a Tertiary Hospital in Malaysia: A Retrospective Study.

The steady growth of pharmaceutical expenditures is a major concern for health policy makers and health care managers in Malaysia. Our study examined the factors affecting the total inpatient pharmacy cost (TINPC) at the Universiti Kebangsaan Malaysia Medical Centre (UKMMC). In this retrospective study, we used 2011 administration electronic prescriptions records and casemix databases at UKMMC to examine the impact of sociodemographic, diagnostic, and drug variables on the TINPC. Bivariate and multivariate analyses of the factors associated with TINPC were conducted. The mean inpatient pharmacy cost per patient was USD 102.07 (SD = 24.76). In the multivariate analysis, length of stay (LOS; B = 0.349, P < .0005) and severity level III ( B = 0.253, P < .0005) were the primary factors affecting the TINPC. For each day increase in the LOS and each increase of a case of severity level III, there was an increase of approximately USD 11.97 and USD 171.53 in the TINPC per year, respectively. Moreover, the number of prescribed items of drugs and supplies was positively associated with the TINPC ( B = 0.081, P < .0005). Gender appears to have affected the TINPC; male patients seem to be associated with a higher TINPC than females (mean = 139.55, 95% confidence interval [CI]: 112.97-166.13, P < .001). Surgical procedures were associated with higher cost than medical cases (mean = 87.93, 95% CI: 61.00-114.85, P < .001). Malay (MYR 242.02, SD = 65.37) and Chinese (MYR 214.66, SD = 27.99) ethnicities contributed to a lower TINPC compared with Indian (MYR 613.93, SD = 98.41) and other ethnicities (MYR 578.47, SD = 144.51). A longer hospitalization period accompanied by major complications and comorbidities had the greatest influence on the TINPC.

How Stakeholder Assessment of E-Prescribing Can Help Determine Incentives to Facilitate Management of Care: A Delphi Study.

BACKGROUND: Little research has been conducted on the quality, benefits, costs, and financial considerations associated with health information technology (HIT), particularly informatics technologies such as e-prescribing, from the perspective of all of its stakeholders. OBJECTIVES: To (a) identify the stakeholders involved in e-prescribing and (b) identify and rank order the positives and negatives of e-prescribing from the perspective of stakeholders in order to create a framework for payers, integrated delivery systems, policymakers and legislators, and those who influence public policy to assist them in the development of incentives and payment mechanisms that result in the better management of care. METHODS: The Delphi method was used to enlist a panel of experts in e-prescribing, informatics, and/or HIT who have published in the field. This panel was presented with the results of initial research and an online survey of questions that sought to prioritize the quality, benefit, cost, and financial effects of e-prescribing from the perspective of each stakeholder. Eleven experts completed the first survey, which contained a list of stakeholders and positives and negatives associated with e-prescribing. Nine of the 11 experts completed the second survey, and 7 experts completed the final survey. From the results of these 3 surveys, a framework was presented to 5 framework experts, who were representatives from payers, integrated delivery systems, policymakers and legislators, and those who influence public policy. These framework experts were interviewed regarding the usefulness of the framework from their perspectives. RESULTS: The experts added stakeholders and many positives and negatives to the initial list and rank ordered the positives and negatives of e-prescribing from the perspective of each stakeholder. The aggregate results were summarized by stakeholder category. The positives and negatives were categorized as health, finance, effort, time, management, or data concerns. The framework experts evaluated the framework and found it useful. CONCLUSIONS: Positives and negatives associated with e-prescribing in the areas of quality, benefits, costs, and financial considerations can be rank ordered from the perspective of each stakeholder. The experts agreed on some points but disagreed on others. For example, they agreed that the main negative of e-prescribing from the perspective of pharmacists and pharmacies was its implementation costs but differed on the importance of providing faster information transfer. A framework was created that could be successfully used by payers, integrated delivery systems, policymakers and legislators, and those who influence public policy for the development of incentives and payment mechanisms. DISCLOSURES: This research was supported by the National Library of Medicine of the National Institutes of Health under Award Number T15LM007088. The authors declare no conflicts of interest in the research. Study concept and design were contributed by DeMuro, Ash, Middleton, and Fletcher. DeMuro took the lead in data collection, along with Ash, and data interpretation was performed by DeMuro, Ash, Madison, Middleton, and Fletcher. The manuscript was written primarily by DeMuro, along with Ash and Middleton, and revised by DeMuro, Madison, and Ash, along with Middleton and Fletcher.

Impact of Internally Developed Electronic Prescription on Prescribing Errors at Discharge from the Emergency Department.

INTRODUCTION: Medication errors are common, with studies reporting at least one error per patient encounter. At hospital discharge, medication errors vary from 15%-38%. However, studies assessing the effect of an internally developed electronic (E)-prescription system at discharge from an emergency department (ED) are comparatively minimal. Additionally, commercially available electronic solutions are cost-prohibitive in many resource-limited settings. We assessed the impact of introducing an internally developed, low-cost E-prescription system, with a list of commonly prescribed medications, on prescription error rates at discharge from the ED, compared to handwritten prescriptions. METHODS: We conducted a pre- and post-intervention study comparing error rates in a randomly selected sample of discharge prescriptions (handwritten versus electronic) five months pre and four months post the introduction of the E-prescription. The internally developed, E-prescription system included a list of 166 commonly prescribed medications with the generic name, strength, dose, frequency and duration. We included a total of 2,883 prescriptions in this study: 1,475 in the pre-intervention phase were handwritten (HW) and 1,408 in the post-intervention phase were electronic. We calculated rates of 14 different errors and compared them between the pre- and post-intervention period. RESULTS: Overall, E-prescriptions included fewer prescription errors as compared to HW-prescriptions. Specifically, E-prescriptions reduced missing dose (11.3% to 4.3%, p <0.0001), missing frequency (3.5% to 2.2%, p=0.04), missing strength errors (32.4% to 10.2%, p <0.0001) and legibility (0.7% to 0.2%, p=0.005). E-prescriptions, however, were associated with a significant increase in duplication errors, specifically with home medication (1.7% to 3%, p=0.02). CONCLUSION: A basic, internally developed E-prescription system, featuring commonly used medications, effectively reduced medication errors in a low-resource setting where the costs of sophisticated commercial electronic solutions are prohibitive.

Using pharmacy management systems for research: survival outcomes for lenalidomide in multiple myeloma in the clinical setting.

Background Health records can be used to measure medicine use and health outcomes. The public subsidy of lenalidomide in Australia was based on two phase III trials showing improved survival. Objective To use hospital pharmacy information management systems to determine survival outcomes for lenalidomide as a second line treatment in relapsed or refractory multiple myeloma (RRMM) patients. Setting Five public hospitals in Queensland, Australia. Method We extracted data on medicine use and survival for RRMM patients planned to start lenalidomide from pharmacy management and pathology databases. Descriptive statistical analyses (Kaplan-Meier curves) were used to calculate overall survival. Main outcome measure Overall survival. Results There were 136 patients who received at least one lenalidomide dose and 2234 cycles were ordered. The median age was 69 years and 54% were male. Two lenalidomide containing protocols were considered: 90% of patients had lenalidomide plus dexamethasone; 18% had lenalidomide plus dexamethasone with cyclophosphamide. The median starting lenalidomide dose was 20 mg (range 4.3-25 mg) on days 1-21 of a 28-day cycle. Median time on treatment 9.4 months (range 0.5-71.7 months). Median overall survival was 45.4 months (range 12.0-70.5 months). Conclusion The median survival in our study compared favourably to clinical trials. Patients and clinicians can be reassured that outcomes in this clinical setting are as good as those observed in trials.

ePrescribing: Reducing Costs through In-Class Therapeutic Interchange.

INTRODUCTION: Spending on pharmaceuticals in the US reached $373.9 billion in 2014. Therapeutic interchange offers potential medication cost savings by replacing a prescribed drug for an equally efficacious therapeutic alternative. METHODS: Hard-stop therapeutic interchange recommendation alerts were developed for four medication classes (HMG-CoA reductase inhibitors, serotonin receptor agonists, intranasal steroid sprays, and proton-pump inhibitors) in an electronic prescription-writing tool for outpatient prescriptions. Using prescription data from January 2012 to June 2015, the Compliance Ratio (CR) was calculated by dividing the number of prescriptions with recommended therapeutic interchange medications by the number of prescriptions with non-recommended medications to measure effectiveness. To explore potential cost savings, prescription data and medication costs were analyzed for the 45,000 Vanderbilt Employee Health Plan members. RESULTS: For all medication classes, significant improvements were demonstrated - the CR improved (proton-pump inhibitors 2.8 to 5.32, nasal steroids 2.44 to 8.16, statins 2.06 to 5.51, and serotonin receptor agonists 0.8 to 1.52). Quarterly savings through the four therapeutic interchange interventions combined exceeded $200,000 with an estimated annual savings for the health plan of $800,000, or more than $17 per member. CONCLUSION: A therapeutic interchange clinical decision support tool at the point of prescribing resulted in increased compliance with recommendations for outpatient prescriptions while producing substantial cost savings to the Vanderbilt Employee Health Plan - $17.77 per member per year. Therapeutic interchange rules require rational targeting, appropriate governance, and vigilant content updates.

Qualitative analysis of multi-disciplinary round-table discussions on the acceleration of benefits and data analytics through hospital electronic prescribing (ePrescribing) systems.

BACKGROUND: Electronic systems that facilitate prescribing, administration and dispensing of medicines (ePrescribing systems) are at the heart of international efforts to improve the safety, quality and efficiency of medicine management. Considering the initial costs of procuring and maintaining ePrescribing systems, there is a need to better understand how to accelerate and maximise the financial benefits associated with these systems. OBJECTIVES: We sought to investigate how different sectors are approaching the realisation of returns on investment from ePrescribing systems in U.K. hospitals and what lessons can be learned for future developments and implementation strategies within healthcare settings. METHOD: We conducted international, multi-disciplinary, round-table discussions with 21 participants from different backgrounds including policy makers, healthcare organisations, academic researchers, vendors and patient representatives. The discussions were audio-recorded, transcribed and then thematically analysed with the qualitative analysis software NVivo10. RESULTS: There was an over-riding concern that realising financial returns from ePrescribing systems was challenging. The underlying reasons included substantial fixed costs of care provision, the difficulties in radically changing the medicines management process and the lack of capacity within NHS hospitals to analyse and exploit the digital data being generated. Any future data strategy should take into account the need to collect and analyse local and national data (i.e. within and across hospitals), setting comparators to measure progress (i.e. baseline measurements) and clear standards guiding data management so that data are comparable across settings. CONCLUSIONS: A more coherent national approach to realising financial benefits from ePrescribing systems is needed as implementations progress and the range of tools to collect information will lead to exponential data growth. The move towards more sophisticated closed-loop systems that integrate prescribing, administration and dispensing, as well as increasingly empowered patients accessing their data through portals and portable devices, will accelerate these developments. Meaningful analysis of data will be the key to realise benefits associated with systems.

Model of Current Practice Regarding Prescriptions of Controlled Substances and the Perceived Benefits of E-Prescribing in an Academic Medical Center.

To review current practices regarding prescribing controlled substances at an academic medical center and describe possible advantages of electronic prescribing of controlled substances (EPCS). A 10-question multiple choice survey was sent electronically to all house staff at an academic medical center. Aggregated data was analyzed for trends. 193 surveys (18.8 %) were completed. Of all respondents, 46.6 % were not able to write their own prescriptions. 70.0 % have used another provider's prescription pad to write prescriptions. 53.4 % have had prescriptions rejected or not filled by a pharmacy for being written incorrectly. 59.6 % kept a patient as an inpatient for a longer period of time due to the inability to obtain a prescription, costing an estimated $3.28 million per year. 58.0 % needed to have a patient return to the hospital to pick up prescriptions for an estimated 1583 return trips to the hospital yearly. 35.1 % had a patient return to the emergency department due to uncontrolled pain, estimated at $139,000 in yearly emergency department patient charges. The authors' survey highlights some of the financial, legal, efficiency, and satisfaction disadvantages due to the inability to use EPCS. Implementing EPCS and making it ubiquitous may limit some inefficiencies in academic hospital systems.

Initial Medication Adherence in the Elderly Using PACE Claim Reversals: A Pilot Study.

BACKGROUND: The Medicare Modernization Act, with its requirements for Medicare Part D to comply with electronic prescribing (e-prescribing), bolstered the adoption of e-prescribing, which increased to 73% in 2013. Therefore, understanding whether electronic prescriptions are less likely to be picked up is important as e-prescribing continues to be emphasized. OBJECTIVE: To assess whether prescription origin is among the factors associated with initial medication adherence, using claim reversals as a proxy measure. METHODS: A cross-sectional study was completed using a sample of reversed claims from the Pharmaceutical Assistance Contract for the Elderly (PACE) program for September 2014. The total number of reversed claims for new prescriptions (15,966) was categorized by prescription origin (written, telephone, electronic, fax, and pharmacy). Using a chi-square analysis, the reversed claims were compared among prescription origin to determine if there is a difference in the proportion of electronic prescriptions reversed compared with those from other origins. RESULTS: When compared with all other prescription origins, electronic prescriptions (E) were more likely to be reversed at day 0 (E = 50%, any other [AO] = 49%, P < 0.05) and after day 0 (E = 58%, AO = 42%, P < 0.05). CONCLUSIONS: Electronic prescriptions are associated with a higher rate of claim reversals and may reflect poorer initial adherence. Electronic prescriptions may more likely be forgotten or not picked up because they were not presented to the pharmacy by the patient. The growing adoption of electronic prescriptions merits particular attention, since it may be a factor in initial medication adherence in the elderly. DISCLOSURES: This study was not supported by any funding. Peterson reports advisory board and consultancy fees from IMS Health and Pfizer and employment by Genentech. Klaiman is currently employed by AccessMatters. No other financial or other conflicts of interests were reported. Study concept and design were primarily contributed by Forestal, along with Klaiman and Peterson. Heller took the lead in data collection, along with Forestal, and data interpretation was performed by Forestal, Klaiman, and Peterson. Forestal, Klaiman, and Heller were responsible for manuscript preparation.

Initial Medication Adherence in the Elderly Using PACE Claim Reversals: A Pilot Study.

BACKGROUND: The Medicare Modernization Act, with its requirements for Medicare Part D to comply with electronic prescribing (e-prescribing), bolstered the adoption of e-prescribing, which increased to 73% in 2013. Therefore, understanding whether electronic prescriptions are less likely to be picked up is important as e-prescribing continues to be emphasized. OBJECTIVE: To assess whether prescription origin is among the factors associated with initial medication adherence, using claim reversals as a proxy measure. METHODS: A cross-sectional study was completed using a sample of reversed claims from the Pharmaceutical Assistance Contract for the Elderly (PACE) program for September 2014. The total number of reversed claims for new prescriptions (15,966) was categorized by prescription origin (written, telephone, electronic, fax, and pharmacy). Using a chi-square analysis, the reversed claims were compared among prescription origin to determine if there is a difference in the proportion of electronic prescriptions reversed compared with those from other origins. RESULTS: When compared with all other prescription origins, electronic prescriptions (E) were more likely to be reversed at day 0 (E = 50%, any other [AO] = 49%, P < 0.05) and after day 0 (E = 58%, AO = 42%, P < 0.05). CONCLUSIONS: Electronic prescriptions are associated with a higher rate of claim reversals and may reflect poorer initial adherence. Electronic prescriptions may more likely be forgotten or not picked up because they were not presented to the pharmacy by the patient. The growing adoption of electronic prescriptions merits particular attention, since it may be a factor in initial medication adherence in the elderly. DISCLOSURES: This study was not supported by any funding. Peterson reports advisory board and consultancy fees from IMS Health and Pfizer and employment by Genentech. Klaiman is currently employed by AccessMatters. No other financial or other conflicts of interests were reported. Study concept and design were primarily contributed by Forestal, along with Klaiman and Peterson. Heller took the lead in data collection, along with Forestal, and data interpretation was performed by Forestal, Klaiman, and Peterson. Forestal, Klaiman, and Heller were responsible for manuscript preparation.

Defining and Measuring Primary Medication Nonadherence: Development of a Quality Measure.

Poor medication adherence has been increasingly recognized as a major public health issue and a priority for health care reform. Primary medication nonadherence (PMN) is a subset of this broader subject and occurs when a new medication is prescribed for a patient, but the patient does not obtain the medication, or an appropriate alternative, within an acceptable period of time after it was prescribed. It is increasingly evident that the public health problem of PMN is widespread. However, the lack of standardized definitions and measures inhibits the ability to establish the true incidence of this problem or to track changes in PMN rates over time. Given the limitations of current measures, the Pharmacy Quality Alliance (PQA) convened an expert working group to set parameters for a new industry measure. That new measure, which links electronic prescribing and pharmacy dispensing databases and was developed and approved by the PQA, is described here. PMN literature from 1990 to June 2015 is also reviewed, and existing PMN measures are summarized. DISCLOSURES: No funding was received for this article, and the authors declare no conflicts of interest. The views expressed in this article are those of the authors alone and do not necessarily reflect those of their respective employers. Adams has received grant support from Pfizer for adherence research. Adams and Stolpe were equally involved in all aspects of study design, data collection and interpretation, and manuscript preparation.

Economic impact of electronic prescribing in the hospital setting: A systematic review.

OBJECTIVE: To examine evidence on the economic impact of electronic prescribing (EP) systems in the hospital setting. METHOD: We conducted a systematic search of MEDLINE, EMBASE, PsycINFO, International Pharmaceutical Abstracts, the NHS Economic Evaluation Database, the European Network of Health Economic Evaluation Database and Web of Science from inception to October 2013. Full and partial economic evaluations of EP or computerized provider order entry were included. We excluded studies assessing prescribing packages for specific drugs, and monetary outcomes that were not related to medicines. A checklist was used to evaluate risk of bias and evidence quality. RESULTS: The search yielded 1160 articles of which three met the inclusion criteria. Two were full economic evaluations and one a partial economic evaluation. A meta-analysis was not appropriate as studies were heterogeneous in design, economic evaluation method, interventions and outcome measures. Two studies investigated the financial impact of reducing preventable adverse drug events. The third measured savings related to various aspects of the system including those related to medication. Two studies reported positive financial effects. However the overall quality of the economic evidence was low and key details often not reported. DISCUSSION: There seems to be some evidence of financial benefits of EP in the hospital setting. However, it is not clear if evidence is transferable to other settings. Research is scarce and limited in quality, and reported methods are not always transparent. Further robust, high quality research is required to establish if hospital EP is cost effective and thus inform policy makers' decisions.

Estimating the cost of unclaimed electronic prescriptions at an independent pharmacy.

OBJECTIVES: The increasing rate of e-prescribing is associated with a significant number of unclaimed prescriptions. The costs of unclaimed e-prescriptions could create an unwanted burden on community pharmacy practices. The objective of this study was to calculate the rate and costs of filled but unclaimed e-prescriptions at an independent pharmacy. METHODS: This study was performed at a rural independent pharmacy in a Midwestern state. The rate and costs of the unclaimed e-prescriptions were determined by collecting information about all unclaimed e-prescriptions for a 6-month period from August 2013 to January 2014. The costs of unclaimed prescriptions included those expenses incurred to prepare the prescription, contact the patient, and return the unclaimed prescription to inventory. Two sensitivity analyses were conducted. RESULTS: The total cost of 147 unclaimed e-prescriptions equaled $3,677.70 for the study period. Thus, the monthly cost of unclaimed e-prescriptions was $612.92 and the average cost of each unclaimed prescription was $25.02. The sensitivity analyses showed that using a technician to perform prescription return tasks reduced average costs to $19.33 and that using a state Medicaid cost of dispensing resulted in average costs of $18.54 per prescription. The rate of unclaimed e-prescriptions was 0.82%. CONCLUSION: The percentage of unclaimed e-prescriptions in this pharmacy was less than 1%. In addition to increased cost, unclaimed e-prescriptions add inefficiency to the work flow of the pharmacy staff, which can limit the time that they are available for performing revenue-generating activities. Adjustments to work flow and insurer policies could help to reduce the burden of unclaimed e-prescriptions.

A review of the literature and proposed classification on e-prescribing: Functions, assimilation stages, benefits, concerns, and risks.

BACKGROUND: Evidence from the literature indicates that besides its benefits, e-prescribing also generates new types of unintended medication errors that have the potential to harm patient safety. Analyzing both the benefits and risks of e-prescribing can give health care organizations a better understanding of the improvements gained and errors generated by this technology. OBJECTIVES: To review the primary functions of e-prescribing and its assimilation stages in the health care context. This review also aims to classify the potential benefits, risks and concerns associated with e-prescribing along with factors contributing to e-prescribing errors. METHODS: A literature review was conducted primarily in Web of Sciences electronic databases. The online databases were searched for both peer-reviewed quantitative and qualitative research papers written in English and published between January 2008 and December 2014 (i.e., the last seven years). Several additional studies were also accessed through Google Scholar and the citations of the selected articles. A total of 73 publications met the study's inclusion criteria. RESULTS: The key benefits of e-prescribing were identified as improving the quality of health care services, increasing the efficiency and effectiveness of prescribing and dispensing medications, reducing medication errors, and health care cost savings. Failure to properly implement e-prescribing systems can also result in new types of errors that reduce workflow efficiency, increase medication cost, and threaten patient safety. In this study, factors contributing to potential errors were categorized into four primary groups (human, technical, interaction and organizational errors). CONCLUSIONS: This review identified the primary benefits and risks of e-prescribing services. The study contributes to the body of knowledge related to the design, adoption and use of e-prescribing by providing a clear reflection on its potential gains and risks. Based on the findings of this review, conducting research in several areas is quite promising as future work. This review also has practical implications for health care providers, e-prescribing software vendors and policy makers.

An evaluation of e-prescribing at a national level.

OBJECTIVE: The aim of the article is to describe the process of implementing the Estonian national second generation electronic prescription service (e-prescription) and determine if the objectives set by the Estonian government were fulfilled. MATERIALS AND METHODS: The study presents an analysis of both retrospective and current data in the evaluation phase of a design research project. Sources include, among others, publicly available documents and previous evaluation studies. RESULTS: According to all of the major stakeholders, the Estonian e-prescription service has very high usability and user satisfaction scores have been high. There is only little empirical evidence available to confirm if the benefits aimed for in the creation of the service were achieved. From a public administration viewpoint, the implementation of e-prescription has led to potential efficiency gains. CONCLUSION: The Estonian second-generation e-prescription system is widely used by citizens, healthcare providers and administrators alike. However, there are gaps in measuring the impact of the service, especially with respect to time savings and enhanced healthcare quality. Additional functionalities will be key drivers in creating benefits for all stakeholders. Future nationwide e-health services should have a more rigorous evaluation process carried out during the design and implementation stages.

Incidence and cost of medications dispensed despite electronic medical record discontinuation.

OBJECTIVE: To determine the incidence and cost of medications dispensed despite discontinuation (MDDD) of the medications in the electronic medical record within an integrated health care organization. SETTING: Dean Health System, with medical clinics and pharmacies linked by an electronic medical record, and a shared health plan and pharmacy benefits management company. PRACTICE DESCRIPTION: Pharmacist-led quality improvement project using retrospective chart review. PRACTICE INNOVATION: Electronic medical records, pharmacy records, and prescription claims data from patients 18 years of age or older who had a prescription filled for a chronic condition from June 2012 to August 2013 and submitted a claim through the Dean Health Plan were aggregated and cross-referenced to identify MDDD. MAIN OUTCOME MEASURES: Descriptive statistics were used to characterize demographics and MDDD incidence. Fisher's exact test and independent samples t tests were used to compare MDDD and non-MDDD groups. Wholesale acquisition cost was applied to each MDDD event. RESULTS: 7,406 patients met inclusion criteria. For 223 (3%) patients with MDDD, 253 independent events were identified. In terms of frequency per category, antihypertensive agents topped the list, followed, in descending order, by anticonvulsants, antilipemics, antidiabetics, and anticoagulants. Nine medications accounted for 59% (150 of 253) of all MDDD events; these included (again in descending order): gabapentin, atorvastatin, simvastatin, hydrochlorothiazide, lisinopril, warfarin, furosemide, metformin, and metoprolol. Mail-service pharmacies accounted for the highest incidence (5.3%) of MDDD, followed by mass merchandisers (4.6%) and small chains (3.9%). The total cost attributable to MDDD was $9,397.74. CONCLUSION: Development of a technology-based intervention to decrease the incidence of MDDD may be warranted to improve patient safety and decrease health care costs.