Electronic prescribing: implications for physicians’ workloads and liability risks At a special roundtable discussion at the Annual Conference of the Health Information and Management Systems Society (HIMSS) in 2007, Susan Corley, M.D., the Chief Medical Officer of Next Gen (part of Quality Systems, Inc., which makes electronic practice management and health records systems) posed the following dilemma:   As e-prescribing physicians gain the ability to find out when and whether patients pick up their medications, they’ll be able to provide better patient care, but they’ll also face new responsibilities. For one thing, they’ll have to decide whether to address (patient) compliance issues during or between visits. If doctors choose to pursue patients as soon as they know that they didn’t fill a prescription or get a refill, it will add to their workload. For the vast majority of patients, physicians aren’t going to be checking their fill/no fill and whether they’re missing meds. But when you have a patient with hypertension that’s poorly controlled despite six medications, certainly the opportunity is awesome to see whether they’re filling their medications and whether they’re missing doses. - Corley, S., Electronic Prescribing Roundtable; Annual Meeting of the Health Information and Management Systems Society (HIMSS); Chicago; February, 2007.   It doesn’t take much imagination to envision a plaintiff’s attorney making the case for a physician defendant’s neglect for not using electronic prescribing software to check on whether his patient filled a prescription if that patient then suffered a stroke as a result of not filling multiple prescriptions for antihypertensive agents. This is one of the major downsides from a liability risk perspective deriving from the use of any electronic information technology. It provides the facility for physicians to access pertinent information on patients and their behaviors much more easily, thus placing a greater burden on them to obtain and act upon this information.   There are also liability risks associated with ignoring or overriding alerts not to prescribe certain medications which are built into most e-prescribing software. These raise many of the same potential liability issues which need to be addressed and overcome discussed in the May 2008 issue of Risk Review on clinical decision support systems.   Addressing the risk dilemma: recommendations for physicians The vast majority of physicians in practice who still do not electronically prescribe may find themselves faced with this dilemma: Is it worth the short-term economic and increased workload pain as well as potential increased liability risk in order to continue to be assured of optimal reimbursement?   Physicians who, in good faith, are trying to improve care delivery for their patients through electronic prescribing should not have to be so concerned with new liability and workload risks. Most e-prescribing software programs - especially those that are components of electronic health record systems - should be able to keep easily accessible logs of patients who do not fill prescriptions which may be regularly reviewed by office personnel and reported to physicians on an ongoing basis. Just as there are built-in mechanisms in practice management systems to contact patients who miss critical appointments, so too should there be systems to notify patients between or during visits who do not fill prescriptions. These systems could even be calibrated to notify patients with certain clinical and medication history characteristics on a more urgent basis to make it less likely that potential catastrophic events could occur between visits due to medication noncompliance. The existence of such an alerting and follow up system and its use should suffice to address claims that physicians were not diligent in ensuring medication compliance in their patients, especially those for whom such compliance was most critical.   Embedding adverse drug reaction prevention alerts into e-prescribing software should be as simple as with any clinical decision support system. The physician must be able to adjust these alerts or tamp them down so that only the most serious adverse reactions were the subject of alerts. Further, there must be allowance in these programs for physicians to justify overriding an alert because of the compelling need for patients to have a particular medication despite even strong precautions or relative contraindications, even though that places more of a burden on the physician to ensure patients obtain and take these drugs accordingly.   It is at once an exciting and very challenging time to be a practicing physician. New technologies are not going to go away. The major payers of healthcare – both in the public and private sector – are going to continue to employ various measures and means to get physicians to use them, especially in light of their potentially great quality improvement and cost saving benefits.