What happens when medications are cancelled, but no one ever tells the pharmacist? As I mentioned in my last post, this issue hit home recently. A relative who has multiple physicians started to exhibit worsening symptoms of muscle weakness, hypotension, fatigue, reflux, and shortness of breath that progressed over a roughly 15-month period. Quite by accident, it was discovered that medications that had long been cancelled, were still being sent by the mail order pharmacy! The meds sent included three anti-hypertensives (two different meds of the same drug class and a third med in two different dose sizes) that had been discontinued by the provider more than a year before.
None of the discontinued meds were in the patient’s electronic medical record as active meds, yet somehow all were being refilled! Even worse, where was the drug review that should have been done by the online pharmacist? Both amlodipine and nifedipine were being refilled without any questions being asked. Happily now, three months after having stopped all improperly continued medications, most symptoms have substantially resolved.
There are three problems here:
- The pharmacy review failed to prevent both amlodipine and nifedipine from being given, nor did it catch two dose sizes for the third anti-hypertensive medication.
- Drugs that were not in the patient’s chart were somehow being approved for refills.
- Few EHR systems support a “Cancel” command for e-prescribing.
When trying to get at the root cause, one thing became obvious; much of this could have been prevented if e-prescribing done via EHR systems supported Cancel commands. Not one of the patient’s clinicians was aware of the fact that canceling a medicine in the EHR does not cancel that medication with the pharmacy. This is a classic example of a failure to close a loop. It is possible to order a medication electronically, but not to cancel one. Why are EHR vendors dragging their feet on this?
It is not as if no one is aware of the problem. An article in the ACP Internist newsletter warned about this in 2013. Reviews of records found that 1.5% of discontinued meds were still being dispensed. Fischer and Rose raise this point in a recent article from JAMA. The authors note that most EHR systems outside the VA system have no support for cancelling medications electronically. A standard already exists and has existed for the last 20 years or so, for a cancel command as part of the SCRIPT standard.
All three problems listed above are examples of failed processes. It is difficult to imagine how a pharmacist could make the mistakes listed. Certainly, any pharmacy software would have offered warnings. Right? Which brings me to the next case. In this instance, two NSAIDs were prescribed to a relative for back pain, both at maximum strength. When I was asked if it would be safe to take both, I advised to take to only one, and then called the pharmacist to ask about the two meds having been dispensed together. To my the surprise, the pharmacist admitted that taking two maximum strength NSAIDs could cause renal damage, but stated that the meds were dispensed anyway. When asked why, I was told it was unusual but not unheard of. I asked if the doctor had been called to clarify. Nope. So, next I called the doctor’s office, spoke to a nurse and voiced my concerns. About 20 minutes later, the doctor called my relative and said only one medicine should be taken. Apparently, unusual medication regimens no longer invite suspicion and, in the age of e-prescribing, calling a provider to ask about medication concerns is passé. I wonder if the doctor called the pharmacy to cancel the second NSAID?
It is hard to know how to attack these problems. Certainly, adding a Cancel command to EHRs would help. But what about the seeming lack of pharmacist review? I wonder if the increased reliance on technology, which is far from perfect, has not supplanted the more interactive relationships that pharmacists once had with clinicians. Are pharmacists spending more time with computer screens, just as most providers are? Is the time that would have once been used to call a provider about a prescription now used for “computer work”?
Plenty has been published extolling the virtues of e-prescribing; I certainly like its convenience. But, now, having seen close up what can go wrong, I wonder if too little time has been spent looking at what harm might result? To what extent, and in what ways, has e-prescribing altered the provider-pharmacist relationship? I have seen one life-threatening outcome and one potentially serious outcome, and I doubt my relatives are isolated cases. Every new technology brings with it unintended consequences, and e-prescribing is not exempt. It is certainly not all goodness and light…