Want to avoid drug errors? New software can help

Vendors are introducing low-cost programs for handheld computers that prevent common errors

From the April 2001 ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.

By Patricia Braus

By the time Charles F. Schaefer Jr., FACP, arrived on the scene, the patient was losing consciousness and his breathing was depressed. “The neurologist was flailing around thinking of a stroke,” he recalled. “The cardiologist was flailing around thinking of the effects of atrial fibrillation.”

Dr. Schaefer pulled out his handheld computer to check if the patient was experiencing a drug interaction. Sure enough, the Augusta, Ga., internist quickly discovered that the haloperidol the patient had taken an hour earlier can suppress nervous system function when taken with baclofen, a muscle relaxer he had just received. “Problem solved,” Dr. Schaefer recalled, “and it took about three minutes flat.”

As Dr. Schaefer’s experience demonstrates, the combination of drug interaction software and handheld computers can be a powerful tool in the battle to prevent drug errors. “Very few people want to dig through the Physicians’ Desk Reference for 15 minutes when they can find the same information in 15 seconds,” he said.

Medicine has always worried about mistakes, but the 1999 release of a scathing report on medical errors from the Institute of Medicine (IOM) has given new urgency to fixing a problem that was often kept quiet. The IOM report found that at least 44,000 Americans die every year as a result of preventable medical errors, making medical mistakes the eighth leading cause of death in the United States. The report called for health care to slash the number of errors by 50% by 2004.

Medical errors range from giving patients the wrong medicine to faulty diagnosis and incompetent pharmaceutical practices. While drug errors are only one part of the total picture (the IOM estimates that approximately 7,000 people a year die from medication errors), preventing medication snafus is one area that holds great potential for improvement, particularly in physician practices.

Several new products are being marketed to help physicians do exactly that. Some can help you avoid dangerous drug interactions and handwriting errors, while others help streamline the overall ordering process. And perhaps best of all, the tools are inexpensive—or free.

Celebrex vs. Cerebyx

While the public often believes that a single incompetent doctor or nurse is responsible for errors, the IOM report clearly stated that most problems can instead be traced to the nation’s complex health care system. When it comes to drug errors, for example, the sheer number of prescription drugs on the market makes errors almost inevitable.

There are currently more than 17,000 trade and generic names for drugs in the United States, according to the Institute for Safe Medication Practices in Huntingdon Valley, Pa. The organization also estimates that the number of drugs on the U.S. market has grown 500% in the last decade.

Making matters worse, analysts say, the names of many drugs sound alike. Celebrex, for example, is prescribed for arthritis, while Cerebyx is indicated for epilepsy.

And if confusion over names doesn’t make prescribing hard enough, physicians also face an exploding list of indications, contraindications and potential interactions for the growing number of drugs available on the market.

That’s where technology comes in. Instead of writing out a prescription and hoping that the pharmacist will get it right, physicians can tap into software on their handheld computers to write, check and fill prescriptions.

The market for this type of application has taken off since the IOM report, suggesting that the problem—and potential solutions—has hit a nerve. While many vendors are busy selling million-dollar computer systems to help hospitals and large health systems fix and prevent errors, several companies produce software that office-based physicians can use to streamline the prescribing process and help eliminate errors.

Dr. Schaefer, for example, uses qRX software from a company called ePocrates. The software helps him look for drug interactions without searching through huge textbooks. It can be downloaded free of charge from the ePocrates Web site (www.epocrates.com), but you need a handheld computer to use it.

Company officials say that they regularly update their drug database. When a drug is pulled from the market and a physician tries to prescribe that drug, for example, the computer alerts the physician. (Database updates are automatically downloaded into the handheld computer from the ePocrates Web site when you connect your handheld computer to a desktop computer.)

The company claims that to date, 90,000 physicians have downloaded a free copy of the software. “Physicians love this product because they can carry it anywhere,” said Tom Lee, ACP–ASIM Member, editor-in-chief for the company.

Other handheld software goes even further to help physicians combat errors. EPhysician (www.ephysician.com), for example, is one of several companies that lets physicians use a handheld computer to electronically create prescriptions and transmit them directly to patients’ pharmacies. (Not all states allow physicians to e-mail prescriptions directly to pharmacies. In some states, physicians must print the prescription and fax it to the pharmacy.)

Internist Linda Oberstein, ACP–ASIM Member, said she likes the company’s ePad software because she feels it helps reduce prescription errors. To order a given medication, she must choose the medication from her handheld computer’s screen. “There’s no possibility of error due to handwriting or the dose,” she said, acknowledging that, “Sometimes my handwriting’s not that great.”

The ePad software costs $20 per month and includes a database of prescription drugs. Other vendors that offer similar products include Allscripts (www.allscripts.com), Pocketscript (www.pocketscript.com) and iScribe (www.iscribe.com). Their services range from free to about $250 per month per physician.

Because handheld programs like ePad ask physicians to choose from standard doses, the potential for a dosing error is reduced, said Stuart Weisman, ACP–ASIM Member, a gastroenterologist who is ePhysician’s founder and CEO. He explained that while physicians can easily override standard doses, they must do so deliberately, reducing the chances that they will make a mistake.

Results

Just how effective are handheld computers in the fight against medical errors? No one can say for sure, in large part because so many of these products are relatively new. Dr. Weisman, for example, acknowledged that researchers have not had enough time to study whether handheld computers can actually prevent errors.

There is proof, however, that large computer systems can reduce medication errors. Hospitals and other health systems use order entry software connected to patient records to warn physicians when a medicine may hurt a patient or when a medicine they have ordered costs more than another equally effective drug.

Studies have shown that these systems reduce “significant medical adverse events,” or major mistakes, by half, explained Jonathan Teich, MD, an internist and emergency medicine physician at Brigham and Women’s Hospital and assistant professor of medicine at Harvard University. (Dr. Teich is currently on leave from the hospital and working with an Internet start-up.)

A study in the Jan. 22, 1998, issue of the New England Journal of Medicine found that a physician order entry system at LDS Hospital in Salt Lake City helped drastically reduce drug-ordering problems. In the two years before the system was installed, the hospital recorded 405 excess drug dosages among 1,136 patients, or 36% of patients. After the system was installed, the hospital recorded 87 excess dosages among 545 patients, or 16% of patients.

Similarly, the system helped reduce the number of orders for drugs to which the patients had allergies from 146 to 35. The study also found that drug costs per patient dropped, because patients stayed in the hospital for a shorter period of time.

Brigham and Women’s has also used physician order entry since 1993. The hospital installed computer stations throughout its facility, and doctors must sign on to prescribe medicine. Approximately 3% of all physician orders written are changed because of computer intervention, said Dr. Teich.

Dr. Teich said he believes the computerized system improves the caliber of medicine practiced. “These computer systems are not smarter than you, but they remember better and present information properly.”

Physicians can’t expect to see the same level of benefits from handheld systems, in part because their computers aren’t typically set up to access information like patient history. But there is plenty of anecdotal evidence from physicians like Dr. Schaefer showing that these little devices can improve patient care and help reduce drug errors.

Besides, supporters say, drug software for palmtops offers other important benefits. Dr. Schaefer, for example, said that his ePocrates software gives his patients much-wanted information about the costs of prescription medicine. “Cost information is very useful to patients,” he said, explaining that some patients ask if there is a less expensive medication available when they see the cost estimate.

And Dr. Oberstein said that her patients like the fact that the prescription she writes in her San Mateo, Calif., office is sent directly to their pharmacy. “People like the fact that I can write a prescription and send it in,” she said. “They don’t have to wait in line.”

While these benefits may spur more internists to consider handheld drug software, internists like Derek C. Angus, MD, point to big-picture benefits. “The human brain is just not organized to be a good database retrieval system,” said Dr. Angus, an associate professor at the University of Pittsburgh School of Medicine. “It remembers anecdotes more than information that might seem to be unimportant.”

Patricia Braus is a freelance writer based in Rochester, N.Y.

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