Saturday, April 04, 2009

The Wonders of Electronics


The envy of Washington.

The envy of IT departments.

But occassionly, the scourge of doctors and patients.


No paper trail. No proof. Just lost electrons when a prescription fails to go through.

When it works, it's great: a script flies at the speed of light (literally) to a local pharmacy near you. One set up to receive the little electrons and it pops up on Mr. Pharmacist's work cue. Presto!

But when it fails, doctors become the impotent bad guys:
"Hey doc, you never sent my script."

"Uh, yes, Mr. Jones, I did. I sent it to YourLocalPharmacy in YourTown yesterday. I even have the order number."

"Doc, I was at YourLocalPharmacy and he said you never sent it. He didn't have any scripts with my name. Nothing. Nada. You sure you sent it off?"

"Yes, Mr. Jones, I'm looking at the order right now. I never received an e-mail that it failed to deliver, like it's supposed to if that happens, but I'll call the Pharmacist at YourLocalPharmacy in YourTown and find out what's up."

"Thanks, Doc."

* brrriinnnnggggg bbbbrrrriinngggg *

* Click *

"Hello. Welcome to YourLocalPharmacy where you can get all your meds at a moments notice! If you're a calling about a new prescription, press 1. If you're a doctor or a doctor's office calling, press 2..."


"Just a moment please..." ("Tie a yellow ribbon 'round the old oak tree" plays in the background...)

"This is Sally the pharmacy assistant, may I help you?"

"Yes Sally, this is Doctor Fisher and I'm inquiring about a prescription on Mr. SomeDude that I wrote as an e-prescription yesterday for 10 mg tablets of Wonderdrug, and he says you never received it..."

"Just a moment, doctor..."

(... it's been two long years, will you still want me...)

"This is Joe the Pharmacist..."

"Yes, Joe, this is Doctor Fisher and I'm calling about my prescription on Mr. SomeDude that I sent yesterday as an e-prescription for 10 mg tablets of Wonderdrug and he was told you never received it..."

"What was the last name?"


"One second..."

(...stay on the bus, forget about us, put the blame on meeeee...)

"I'm sorry, we don't have anything for a Mr. SomeDude here at our pharmacy..."

"Would you like the order confirmation number that I have on my handy dandy EMR screen that says it was sent to you yesterday about 12:45 PM - yep, sent to YourLocalPharmacy in YourTown on 3 April."

"We don't use order numbers here... Wait, let me check one other place. One second..."

"Now the whole damn bus is cheering, and I can't believe I seeeee, a hundred yellow ribbons round the ole oak tree..."

"Hello, Dr. Fisher?"


"We don't have any scripts here for Mr. SomeDude. I checked both our systems and don't see anything for him here.... Maybe our staff hit a delete key or something. Sometimes that happens you know. I just don't see it... What did you want to give him again? I'll just take the verbal and have it ready for him..."

"Its for sixty 10-milligram pills of WonderDrug with two refills. The sig is one to two tablets every six hours as needed for what he really needs it for."

"Okay, I'll have it ready for him..."

I sat and looked at the order verification screen before me. Wonderdrug. 10mg tablets. YourLocalPharmacy in YourTown. E-Script. Order confirmation number. All correct. Seemingly sent.

And yet, nothing. Vapor. Into the electronic ether. I felt like the the young apprentice sitting before the zen master:

Apprentice: "Master, if a tree falls in the forest and no one hears it, does it make a sound?"

Zen Master: "No, Grasshopper... but the squirrel it lands on does."


Anonymous said...

That sounds like me on the pharmacy end of e-prescribing. Yep, lots of instances just like this - it goes into some electronic ether. Or - my day from hell is when there is a software update & all the e-rxs ever sent get downloaded - again! But, I don't know they're duplicates until I process them. So, now I've got duplicate rxs for Wonder Drug & don't know if you really wanted that or not. I'll get 60 of these in a day - too many to call on.

Then, this beautiful e-prescribing system will send the rx my way & the drug name says "Long Drug Name" - I kid you not! Do you know how many long drug names I stock in my pharmacy???? Hundreds. I have no idea if you ordered benazepril/hct, sulfamethoxazole/trimethoprim or triamcinolone 0.1% cream - these are all long drug names. I can guess, but I have to put something in there for the hard copy to print out. Then after I process it, I have to go back & fix the "Long Drug Name" to the correct drug you prescribed which is written in tiny letters in one place only at the bottom of the printed copy. Now - is this a receipe for disaster or what? We've finally decided to put in "Dummy Drug" as a choice to use so no one will accidentally dispense something which isn't what you prescribed.

When e-rxs come to me, they go into a fill queue of rxs waiting to be processed. We try to get them out as soon as we can, but they often need my override as a pharmacist - particularly for those ridiculous Long Drug Name problems. So, I might have 3 or 4 waiting to be processed. On my worst day, there were 57 waiting to be processed. I cannot search for one particular patient by name or reference number that you know. They come out - first in, first out. So, when someone from the Dr says I've sent it to the pharmacy & they'll have it waiting - uh - no. They'll get it, but any rx will take me 20 minutes. If I'm particularly busy - especially with those folks who've had the foresight to order their rxs ahead of time or who've brought an rx in hand, then it will be longer. So - don't make promises to your patient you can't keep & you have no idea what my wait time is.

The current e-prescribing is a nightmare & contributes to more errors than anything I've seen in a long time & I've been a pharmacist for 32 years.

I could go on and on - but, the bottom line is if you want to get the rx to me fast & accurately - call it in just like you always have done. If the patient needs it right away - tell me that & I'll respect it & do it as soon as I can. If thats not the case, tell the patient you've called it in and they can pick it up in an hour or two or even the next day.

After all - people come to me all the time with problems they perceive related to heart issues. I listen, think of what it could be & let them know if I think they should be seen right away (ER), call their own Dr for advice (unusual side effect of med) or wait & call the next day (known side effect of med that needs your assurance in addition to mine).

So - do me a favor - not all rxs are urgent. That rash thats been there for 3 weeks won't need to have the cream in 15 minutes. That increased dose of benazepril can wait for a day or so if they have enough lower strength tablets to double up. But, I'll always do my best to get right on a new rx for any heart or lung related issue.

Oh - and don't say the medication will be covered by their insurance. You have no idea! When they come to me & I say its not a covered drug, you look like an idiot because your patient was assured by you it was covered. Tell them you don't know & I'll let them know. If its not covered - I'll fax that info to you & you can change the drug or start the PA process.

Sorry for the rant. E-prescribing was designed by morons & the rest of us have to deal with it!

Keith Sarpolis said...

Hey Wes,

Another great example how our politicians have been sold on the value of untested technology. It sounds good in theory, but I have the same experience using aan Allscripts program. I send a script and two days later I get a call from the patient asking either why it has not been taken care of, or asking why I refused to refill the script. So I guess these aren't considered medical errors whe patients can't get their medication due to the unpredictability of the software? I continue to maintain that what EMR systems have done is certainly improved access to information, but errors still seem to abound; they just take a different form!

Anonymous said...

I experienced this a patient. Not fun on that end, either. The Rx was for prednisone, and from the attitude of the pharmacy staff, you would have thought I was try to get free morphine. I'd rather drive to the doctor's office and pick up a written hard copy.

Anonymous said...

They aren't "errors" if you're measuring from the system, and the system deleted the event... :) All joking aside these systems sound terrible, is there no good tech support for them? I would think there should at least be some logs... :(