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Full Text with Search Facility Online at Editorial VOLUME 34 NUMBER 1 AN INDEPENDENT REVIEW FEBRUARY 2011 CONTENTS 2 Setting a standard for electronic prescribing systems (editorial) J Reeve & M Sweidan 4 Letters 6 Non-surgical treatments for skin cancer SP Shumack 8 Analgesics and pain relief in pregnancy and breastfeeding D Kennedy 10 Dental notes Analgesics and pain relief in pregnancy and breastfeeding 11 Book reviews Pregnancy and breastfeeding: medicines guide Therapeutic Guidelines: Palliative care 12 Abnormal laboratory results: Thyroid function tests RH Mortimer 16 Managing delirium in older patients G Caplan 19 Caution with complementaries for cognitive impairment K Harvey & C Stough 21 Valediction: John Tiller 22 Medicines Safety Update No. 1; 2011 26 New drugs: T-score for transparency 28 Your questions to the PBAC Enoxaparin 29 New drugs corifollitropin alfa, meningococcal vaccine Full text with search facility online at www.australianprescriber.com Editorial Setting a standard for electronic prescribing systems James Reeve, Program manager, and Michelle Sweidan, Deputy program manager, Pharmaceutical Decision Support, National Prescribing Service, Melbourne Key words: general practice. complete and legible prescription orders, improving the (Aust Prescr 2011;34:2–4) detection of drug allergies and by reducing medication errors and adverse reactions.2–5 However, these systems can also have In Australia, electronic prescribing (e-prescribing) systems in general practice were first developed in the early 1990s by a few unfavourable effects on workflow and communications, and can innovative general practitioners who wrote software for their have unintended effects on prescribing. For example, they may 6–8 own use. The uptake of e-prescribing systems was accelerated introduce new types of errors and high levels of unhelpful 9 in 1999 because of Commonwealth government incentive alerts, and impact on repeat prescribing. General practitioners payments of $10 000 to practices that acquired an email address have also expressed concern about the comprehensiveness and and used e-prescribing software to write the majority of their accuracy of some of the information provided in their software.10 prescriptions. Currently over 90% of general practitioners use In a comparative study of nine electronic prescribing and one of the 20 or so commercial systems that are available to dispensing systems used in primary care in Australia in 2006, an write prescriptions, order pathology and other tests, record expert panel found that most systems do not offer consistently medical progress notes or communicate with other healthcare useful and relevant information for general practitioners and providers.1 Despite the widespread use of e-prescribing pharmacists to make decisions about drug interactions.11 systems, there are no clear standards or guidelines for their Recently, a number of organisations and researchers have development. This has led to a variety of systems with markedly identified desirable functionality and safety features for different capabilities, particularly in terms of assisting general e-prescribing systems in various healthcare settings.12–16 In practitioners to prescribe safely and effectively. Australia, the National Prescribing Service (NPS) has worked Overseas studies have shown that e-prescribing systems can with general practitioners, professional organisations and enhance the safety and quality of prescribing by ensuring the Medical Software Industry Association to identify the key features of e-prescribing systems which support patient safety 17 In this issue… and quality care. Many of the safety and quality features identified for general practice apply equally to other settings Electronic systems can help health professionals find such as hospitals or aged care. information quickly. Examples could be looking up For safety and quality, an ideal system needs suitable the safety of analgesics for use during pregnancy, as information resources, interoperability with other systems and discussed by Debra Kennedy, or the efficacy of non- clinical decision support. The goal of clinical decision support surgical treatments for skin cancer, as reviewed by Stephen is 'to provide clinicians or patients with clinical knowledge and Shumack. However, James Reeve and Michelle Sweidan patient-related information, intelligently filtered and presented at inform us that there are no standards for electronic appropriate times, to enhance patient care'.18 prescribing systems. The ideal system should record clinical data such as diagnoses, Delirium is a common problem in older patients, but medicines and allergies in a standard coded format. This helps Gideon Caplan says that the diagnosis is often missed. to facilitate one system being able to 'talk to' another system The investigation of delirium may include tests of thyroid and easily exchange patient data, for example with hospital function and these are reviewed by Robin Mortimer. systems or personal electronic health records when they A risk factor for delirium is dementia. As there are few become available. Information about recommended therapeutic drugs for dementia, people may try complementary options for the current diagnosis should be offered. The system medicines for cognitive impairment. While these products ought to ensure that medicine selection processes are safe. In addition to drug interaction alerts, the system should provide may not be very effective, Ken Harvey and Con Stough warnings if a drug is contraindicated, the dosage regimen is remind us that complementary medicines can have adverse potentially harmful, or if the drug is the subject of new safety effects and interactions. advice from the Therapeutic Goods Administration. Warnings 2 | VOLUME 34 | NUMBER 1 | FEBRUARY 2011 www.australianprescriber.com need to be prioritised by clinical importance otherwise they may References be ignored. Users should be able to see the reason for the alert. 1. Britt H, Miller GC, editors. General practice in Australia, Decision support and therapeutic information offered by the health priorities and policies 1998 to 2008. Canberra: prescribing system must be underpinned by high quality, Australian Institute of Health and Welfare; 2009. up-to-date evidence and guidelines. Independent, evidence- www.aihw.gov.au/publications/gep/gep-24-10721/gep-24- 10721.pdf [cited 2011 Jan 5] based drug information and clinical practice guidelines should 2. Ammenwerth E, Schnell-Inderst P, Machan C, Siebert U. be accessible from within the software. High quality patient The effect of electronic prescribing on medication errors and resources, such as printable information leaflets and a suitably adverse drug events: a systematic review. formatted current medicines list, are also important. The ideal J Am Med Inform Assoc 2008;15:585-600. system should have sophisticated reporting capabilities to 3. Mahoney CD, Berard-Collins CM, Coleman R, Amaral JF, enable clinicians to monitor clinical care and audit individual or Cotter CM. Effects of an integrated clinical information practice performance. The system needs to be intuitive and easy system on medication safety in a multi-hospital setting. to use in clinical practice. Am J Health Syst Pharm 2007;64:1969-77. How do current systems used by general practitioners in 4. Shamliyan TA, Duval S, Du J, Kane RL. Just what the Australia rate? The NPS has evaluated seven commonly used doctor ordered. Review of the evidence of the impact of computerized physician order entry system on medication systems against a predefined set of criteria (J Reeve, M Sweidan, errors. Health Serv Res 2008;43:32-53. unpublished, 2011). It found that features to support safety 5. Wolfstadt JI, Gurwitz JH, Field TS, Lee M, Kalkar S, Wu W, and quality were highly variable between systems and there et al. The effect of computerized physician order entry with were some significant gaps. Clinical decision support features clinical decision support on the rates of adverse drug events: were ranked the most important for safety and quality, but in a systematic review. J Gen Intern Med 2008;23:451-8. five of the systems fewer than 50% of these features were fully 6. Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. implemented (for example, there were no alerts for harmful Types of unintended consequences related to computerized doses or new safety warnings). One of the main reasons for provider order entry. J Am Med Inform Assoc 2006;13:547-56. this is the lack of clinical information resources in a format 7. Donyai P, O'Grady K, Jacklin A, Barber N, Franklin BD. The which is suitable for decision support. When systems included effects of electronic prescribing on the quality of prescribing. decision support, it was often unclear where the information Br J Clin Pharmacol 2008;65:230-7. was derived from and whether it was up to date. Features 8. Eslami S, Abu-Hanna A, de Keizer NF. Evaluation of outpatient computerized physician medication order entry relating to the medicine selection process and the recording and systems: a systematic review. J Am Med Inform Assoc display of patient data were also rated as important. Another 2007;14:400-6. important safety issue identified was that most systems did not 9. Newby DA, Fryer JL, Henry DA. Effect of computerised clearly differentiate between similar-named medicines during prescribing on use of antibiotics. Med J Aust 2003;178:210-3. prescribing, increasing the risk of selecting the wrong drug from 10. Ahearn MD, Kerr SJ. General practitioners' perceptions a list of
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