How a better health record system could reduce medication overload
When the medical field switched over from paper records to electronic health records (EHRs) in the early 21st century, this new technology held a lot of promise. EHRs could identify important health trends early with nationwide data, provide life-saving point-of-care alerts and tips, eliminate the problem of unreadable handwritten notes, and generally improve health care quality and efficiency.
In reality, EHRs have made clinicians’ jobs harder without improving quality of care. From the start, EHR development was privatized, leading to a fragmented system of records that don’t connect automatically across institutions. EHRs were built primarily as a tool for billing rather than for clinical care, so performing seemingly simple tasks like bringing up a patient’s medication list can take dozens of clicks.
The structure of EHRs creates another serious problem, which Dr. Saira Shervani at the University of Chicago Medicine and colleagues discuss in a recent “Teachable Moment” article in JAMA Internal Medicine. Shervani et al share a story of a woman with a history of epilepsy who was admitted to the hospital due to recurrent falls and instability. They eventually discovered that she was experiencing adverse events from a duplicate epilepsy drug that was deprescribed by her neurologist, but had continued to be dispensed by the pharmacy.
Why would the pharmacy keep giving the patient a drug that her clinician had discontinued? Because when the neurologist discontinued the drug in the EHR, neither the patient nor the pharmacy were notified of this change.
While EHRs have the ability to send deprescribing requests to pharmacies, health networks don’t always turn on this functionality, because that “would entail additional costs for health care professionals and networks, including costs for software licensing and integration, as well as ongoing network fees and maintenance costs,” Shervani and colleagues write. The result is that deprescribing orders in the EHR are not transmitted to pharmacies in the same way as orders to prescribe.
In an accompanying editorial in JAMA Internal Medicine, Vanderbilt University Medical Center pharmacist Scott D. Nelson and professor Dr. Yaa Kumah-Crystal explain more about how clinicians have to work around the lack of deprescribing functionality:
Because most EHRs are not configured to notify pharmacies of prescription cancellations electronically, clinicians and staff are required to call the pharmacy to communicate that a prescription has been discontinued or actively submit a fax communication to the pharmacy about the prescription discontinuation…At times, prescribers attempt to prevent subsequent pharmacy dispenses by modifying the medication order in the EHR and sending a new prescription with “stop” or “cancel” in a free-text field, again hoping that the pharmacists will see and understand the message.
Think about that for a second. Doctors can notify pharmacies when they want to prescribe a new drug, with just a few clicks. But to get them to stop a drug, they might have to submit a fax to the pharmacy or write a note in the EHR and hope the pharmacist gets it. It’s hard to believe that this is the state of affairs in health technology in 2021.
We know that EHRs need a complete overhaul — they should be interoperable across systems, there should be secure and fast information exchange, and they should be much more usable for clinicians. However, part of the problem with deprescribing electronically is not technical but political. As Nelson and Kumah-Crystal write, there already exists a program that can cancel prescriptions through the EHR called CancelRx, which was developed in 2006. However, there are no minimum use requirements for this program, like there are for other EHR programs, so it often goes unused. Clinicians at Johns Hopkins Medical Center and the University of Wisconsin have had success using CancelRx, but adoption nationwide remains slow. Nelson and Kumah-Crystal recommend that institutions engage prescribers, pharmacists, IT specialists, and training teams to make sure that questions about workflow and troubleshooting can be worked out for a successful implementation.