How an EMR can be shockingly inconvenient for prescription refills

Let me start by confessing I’m something of a gadget freak.  I was an early Palm Pilot adoptor, loved the iPod from the get-go, and need to avoid CNET, Engadget, Gizmodo, and David Pogue’s columns for the New York Times when deadlines loom.

Not surprisingly, I embraced the shift to electronic medical records (EMRs) enthusiastically. While I acknowledge that sometimes EMRs slow clinicians down a bit, and have terrible — horrible — interoperability (how’s that for a tech writer term?), I believe the net benefits from EMRs outweigh the problems.  And our EMR has many time-saving and just plain nifty features.

However …

Every so often something happens with an EMR that is so shockingly inconvenient that it makes me wonder whether we’re on a road to EMR purgatory.

Example:  prescription refills.

This is how we used to authorize a prescription refill in our practice:

E-mail from RN or LPN:  “Hi Paul, ok to refill Joe Smith’s Bextrim 10 mg?”
Response:  “Yep, one a day, 11 refills.  Thanks.”
[RN or LPN then refills via our EMR by clicking "renew" and sending electronically to pharmacy.]

Simple.  Time required for MD?  Around 3 seconds.  Plus, easy to manage on a hand-held device — you don’t need a computer.

So here’s how we’re supposed to do it now (physician clicks or keystrokes in brackets):

  1. RN or LPN enters request for refill into queue.
  2. Email is automatically generated that gets sent to MD stating that he/she has a refill request.  E-mail does not include patient name, medical record number, medication, or pharmacy info.  It’s just a notification.  In other words, it’s completely useless on a hand-held device — except as a form of taunting. “You have a task, but you can’t do it until you log into a computer, log into the EMR, and follow multiple steps — nah-nah, nah-nah.”
  3. At computer, MD clicks on email, then deletes it [clicks 1 and 2].
  4. MD switches to EMR [click 3].
  5. MD clicks on refill request [click 4].
  6. Refill screen appears.  Screen looks like it was developed by a web designer who collects mouse clicks the way that some people collect pennies or odd bits of string — the more the better!  It literally has four separate panels, each panel containing various radio buttons, check boxes, drop-down menus, scrolling lists, comment fields — a veritable panoply of web interactive tools.
  7. In second panel, MD clicks on “Renew” [click 5].
  8. At bottom of page, MD clicks on “Mark as complete” [click 6].
  9. At bottom of page, MD clicks on “OK” [click 7].  Yes, there are two separate clicks for “Mark as complete” and “OK.”
  10. “Sign” is now highlighted red in the menu.  MD clicks on “Sign” [click 8].
  11. Sign page appears, with request to enter key.  MD enters key [5 keystrokes] and clicks “OK” [click 9].
  12. Prescription page appears.  MD clicks “Send” [click 10].
  13. Prescription is sent to pharmacy electronically.

Mind you, this is for one patient, and one medication.  More meds and/or patients?  More clicks.

I understand that there are medicolegal reasons for documenting that MDs review and approve renewals.  But there has to be a better way — and of course, there are many, two of them implemented in the commonly-used electronic medical records EPIC and the terrific one at the VA.

But until electronic medical record designers start reviewing “best-of” strategies from their competitors, I’m afraid there will be lots of these one-step-forward, two-steps-back experiences for us clinicians, just like this one.

Paul Sax is the Clinical Director of Infectious Diseases at Brigham and Women’s Hospital. His blog HIV and ID Observations, is part of Journal Watch, where he is Editor of Journal Watch AIDS Clinical Care.

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