Markian Hawryluk
The Bulletin

The digitalization of health records has made prescribing medication as simple as a few clicks of a physician’s mouse. Stopping prescriptions, however, is not nearly as easy.

According to a recent commentary in the Journal of the American Medical Association, few electronic health records have incorporated the process that allow physicians to discontinue previous prescriptions, which can allow for pharmacies to continue to refill medications the patient should no longer be taking.

“It’s a huge issue,” said Kyle Mills, a pharmacist with Mosaic Medical in Bend. “I see it daily.”

Electronic prescribing has taken off over the past decade, due in part to health plan demands and government incentives. In 2008, some 7 percent of physicians used e-prescribing; now nearly 3 out of 4 do.

Generally, physicians can send a prescription to a pharmacy electronically by adding it to a list of medications in the patient’s health record. That sends a message to the pharmacy, which then fills the prescription and keeps a record in its system allowing a certain number of refills.

But if physicians remove a medication from the list in the patient’s health record, the system does not necessarily send a message to the pharmacy to stop filling that prescription.

“They may not be aware that when they responsibly take it out of the EHR list, which they should be doing, it doesn’t stop it,” said Dr. Shira Fischer, a Boston-based physician researcher with the health policy think tank RAND Corporation, who co-authored the commentary.

The problem is compounded by pharmacy systems that automatically refill prescriptions or notify patients when a prescription can be refilled. Pharmacies have a financial incentive to ensure prescriptions are refilled as soon as possible, and patients may not always realize the notification is for a discontinued medicine.

Other times patients may find an old bottle and mistakenly refill a prescription their doctor no longer wants them to take.

In 2012, researchers from Brigham and Women’s Hospital and Harvard Vanguard Medical Associates found that 1.5 percent of discontinued medications continue to be filled by pharmacies, and in 12 percent of those cases, the refill had the potential to cause patient harm.

That could include cases where a new medication will have a potentially dangerous interaction with a discontinued medication, or the continuation of an older prescription when a change in dosage is made.

Mills often encounters the problem in reviewing what medications a patient is taking, often when some health problem is not improving and doctors aren’t sure why. Two-thirds of Mosaic’s patients are insured by PacificSource Health Plans, which can provide the clinic a list of what prescriptions that patient has filled.

Over his 14 years working as a pharmacist, he’s seen a major shift from paper to electronic prescriptions. And while the discontinuation issue existed with paper scripts as well, Mills said e-prescribing increased the volume of prescriptions, leaving pharmacists with less time for each one.

“The pace of the pharmacy was a little bit slower. They weren’t able to do as many prescriptions, because the paper made everything take longer,” he said. “So when they’re doing that, they may be able to review the medication list, ‘Oh, there’s a new prescription for a blood pressure pill that’s 20 mg, the other prescription was for 5 mg, so we’ll stop the five.’”

Now many of the functions pharmacists once did by hand — including checking for allergies or drug-to-drug interactions — are automated. Mosaic now employs pharmacy students to call pharmacies to notify them of discontinued prescriptions when they find them.

Fischer said what’s most surprising about the lack of e-discontinuation is how easily it could be fixed.

“This is such an easy solution,” she said. “There are a lot of other places for potential medication error that are much more complicated to deal with.”

Industry e-prescribing standards already include standards for e-discontinuation, and some 25,000 prescriptions are discontinued electronically each month. But most electronic health record systems are not set up to do so.

Health systems like Kaiser Permanente and the Veterans Health Administration have the e-discontinuation feature enabled. But Fischer learned from SureScripts, an intermediary that passes on electronic prescriptions from medical records to pharmacies, only a third of prescribers on the SureScripts network are using electronic health records that can send e-discontinuation notices, and only 40 percent of pharmacies on its network are capable for receiving them.

For patients with chronic conditions, prescriptions may allow for refills of up to a year, meaning patients could be taking medications well after they should have been discontinued.

Fischer said patients should make sure their medication list is updated every time they see their primary care physician.

“That’s what you should go off of,” she said. “The pharmacy doesn’t necessarily know what’s been discontinued and what you’re filling elsewhere.”

— Reporter: 541-633-2162, mhawryluk@bendbulletin.com

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