The Illusion of Electronic Prescribing

The other day Bigtown Pharmacy sent an angry fax addressed to me. It was a printout of an electronic prescription I had sent the night before. Scribbled at the bottom were the words: “Unit field can’t say unspecified. Please correct”.

I looked at the printout, which was actually a fax they had received from the prescription clearinghouse that connects doctors and pharmacies. Even though I enter prescriptions in my Electronic Medical Record, that pharmacy receives it from the clearing house via fax.

My prescription was for lancets for a 72-year old diabetic to check her blood sugar once a day. But it didn’t say “lancet”. It said “lancer”. My first thought was that my two-fingered typing had offended the Bigtown pharmacist.

The way electronic prescribing works, at least in my EMR, is by having every medication available in this country already programmed into the prescription module, so there can’t be any misspellings or ambiguities of which drug I want my patient to have. But medical supplies like glucometer strips and lancets are not in the system, so they have to be entered manually, which means my computer program doesn’t know at all what I am prescribing; it’s just a bunch of letters to it. The same thing happens when I prescribe a Canadian medication, not available in this country, for patients who cross the river for their prescriptions; the computer can’t check for allergies or interactions because the drug had to be “manually entered” instead of picked from its list.

As I hastily had entered “lancer” instead of “lancet” in the box for “unit” in my EMR, I assumed at first that the angry pharmacist didn’t tolerate any typos, but as I looked closer at the fax, I realized that there was more to this.

The layout of the form didn’t look anything like the layout of my prescription screen. There was a field titled “unit”, and it said “unspecified”. The misspelled word appeared in a free-text window a little below, so the context seemed obvious, even if the spelling was off.

I called Bigtown. The pharmacist explained that Medicare will not pay for my patient’s strips if any of the boxes, particularly the “unit” box, is not specific enough. This is apparently a new requirement. That sounded similar to the “meaningful use” criteria medical practices have to meet in order to get paid under the new health law. One of those requirements is to reach a certain percentage of prescriptions done via the computer instead of on paper prescriptions or sent via fax.

As I was talking with the pharmacist, I pulled up my patient’s prescription log and there was my misspelled “lancer” just where it belonged in the “unit” box on my screen, even though it was missing on the pharmacy’s fax.

“Lost in translation at the middleman”, I mumbled to myself. I asked the pharmacist:

“It is entered correctly, except the spelling, at my end. What can I do?”

“You can free-text ’Unit: Lancet’ anywhere, and we can accept it.”

“Will do”, I said and typed it into the comment field. Then I moved the cursor up to my own “Unit” field and corrected “lancer” to “lancet”. I couldn’t just leave it blank, because if I did that, my EMR wouldn’t send it electronically; I, too, have to fill out all my boxes, even if the receiver can’t see them. After all, I still have to meet my own “meaningful use” requirements.

1 Response to “The Illusion of Electronic Prescribing”

  1. 1 Shoshana Simon April 17, 2014 at 5:55 pm

    Holy moly! No wonder doctors quit private practice. Is there anything a patient can do to facilitate this process?

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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