The Evolution of Drug Ordering
For centuries, the process of ordering medications was a manual, paper-based, and often handwritten task. A physician would write an order or prescription, which would then be physically delivered to a pharmacy or dispensed by a nurse. While this system served its purpose, it was prone to errors stemming from illegible handwriting, transcription mistakes, and lost paperwork. The advent of digital technology has dramatically reshaped this process, introducing electronic and automated methods that prioritize accuracy, efficiency, and patient safety. Understanding this evolution is crucial for any modern healthcare professional, as a mix of new and old methods may still be encountered depending on the practice setting.
Modern Electronic Drug Ordering Methods
Computerized Provider Order Entry (CPOE)
CPOE systems are a cornerstone of modern inpatient care. These systems allow healthcare providers to directly enter all types of orders, including medications, lab tests, and procedures, into a computer application. The integration with Electronic Health Records (EHR) provides a powerful safety net by instantly checking for potential issues.
Key features and benefits of CPOE include:
- Improved Legibility: Eliminates errors caused by ambiguous or poorly written orders.
- Enhanced Safety: Clinical decision support systems (CDSS) within CPOE automatically check for drug-drug interactions, allergies, and appropriate dosing based on patient-specific factors like weight and renal function.
- Increased Efficiency: Orders are immediately transmitted to the pharmacy, accelerating the dispensing process.
- Comprehensive Tracking: The system creates a clear, timestamped electronic trail of every order, improving accountability and record-keeping.
- Standardization: Promotes compliance with institutional guidelines and standardization of care.
E-Prescribing (e-Rx)
E-prescribing is the digital transmission of prescription orders to pharmacies, primarily used in outpatient and ambulatory settings. A provider uses a software application, often integrated into their EHR, to generate a prescription and send it electronically to the patient's preferred pharmacy.
Benefits of e-prescribing include:
- Reduced Errors: Ensures clear communication and reduces the risk of errors associated with phone calls or faxes.
- Workflow Efficiency: Saves time for both the provider and the patient. Prescriptions can be ready for pickup by the time the patient arrives at the pharmacy.
- Convenience: Offers a seamless process for patients and providers, eliminating paper slips.
- Automated Services: Many systems can perform real-time pharmacy benefit checks and send automated refill requests.
Automated Dispensing Systems (ADS)
In institutional settings, automated dispensing systems like Pyxis or Omnicell store medications on nursing units. These systems electronically track the dispensing of unit doses. Nurses can retrieve patient-specific medications after the pharmacy has verified the CPOE order.
Traditional and Legacy Methods
While electronic systems are becoming the norm, certain traditional methods still exist, though their use is generally discouraged due to higher risks.
Manual Paper-Based Orders
For decades, handwritten prescriptions and order sheets were the standard. In some settings, especially during system downtime, paper-based forms are still used as a fallback. These forms are then often scanned or faxed to the pharmacy.
Challenges include:
- Poor legibility, which can lead to medication errors.
- Transcription errors when orders are manually entered into a system later.
- Slower processing and greater risk of loss.
Verbal and Telephone Orders
Verbal or telephone orders are used when a prescriber cannot enter the order electronically, such as during an emergency. A nurse or pharmacist writes down the order and 'reads it back' to the provider for confirmation. The provider must then countersign the order within a set timeframe.
Risks include:
- Higher potential for communication errors or misunderstandings.
- Dependence on clear communication and mandatory 'read-back' protocols.
Faxed Orders
Faxing is another legacy method, which has diminished in relevance with the rise of e-prescribing. A handwritten or printed order is faxed from the prescriber's office to the pharmacy. This method can introduce quality issues due to poor fax resolution and requires the pharmacy to manually enter the information into their system.
Special Considerations for Controlled Substances
Ordering controlled substances requires heightened security and compliance with federal regulations. For Schedule I and II substances, the Drug Enforcement Agency (DEA) traditionally mandated the use of a triplicate paper form (DEA Form 222). Today, the DEA's Controlled Substance Ordering System (CSOS) allows for secure electronic ordering using digital certificates, which has become a more efficient method. For Schedule III-V substances, ordering is often electronic, but still requires robust tracking and secure handling.
The Pharmacy Procurement Process
Beyond the patient-specific order, pharmacies must also order drugs to maintain their inventory. This involves procurement methods to purchase drugs from manufacturers or wholesalers.
- Prime Vendor Purchasing: Most pharmacies use wholesalers as their primary source, as it is efficient to purchase a wide range of products from a single vendor.
- Direct Purchasing: For specific, specialty, or hard-to-find drugs, pharmacies may purchase directly from the manufacturer.
- Group Purchasing Organizations (GPOs): Pharmacies can join a GPO to leverage collective buying power and negotiate better pricing.
- E-Procurement Platforms: Digital systems streamline the ordering, invoicing, and tracking of inventory, replacing manual purchase orders.
Comparison of Drug Ordering Methods
| Feature | Electronic (CPOE/e-Rx) | Traditional (Paper/Verbal) |
|---|---|---|
| Safety | High. Automated checks for drug interactions, allergies, and dosage errors significantly reduce medication risks. | Lower. Prone to errors from illegible handwriting, transcription, and miscommunication, especially with verbal orders. |
| Efficiency | High. Instantaneous transmission of orders improves workflow for providers and pharmacists, and speeds up patient care. | Lower. Time-consuming due to manual processes like handwriting, physical delivery, and transcription. |
| Cost | High initial investment for software and implementation, but lower long-term costs due to reduced errors and increased efficiency. | Lower initial cost (paper, phones), but higher hidden costs from potential errors, wasted time, and administrative overhead. |
| Tracking | Robust. Provides a clear, time-stamped digital trail of all orders, improving accountability and record-keeping. | Poor. Manual tracking is less reliable and can be incomplete or lost. Audits are more difficult. |
| Controlled Substances | Uses secure, regulated electronic systems (CSOS) that are safer and more efficient than paper forms. | Requires strictly regulated paper forms (DEA Form 222), which are slower and more susceptible to loss or misuse. |
Conclusion
The landscape of drug ordering has undergone a profound transformation, driven by technology and the paramount goal of patient safety. While traditional methods like paper and verbal orders played crucial historical roles, modern electronic systems such as CPOE and e-prescribing represent the gold standard for accuracy, efficiency, and error reduction. These systems, combined with sophisticated automated dispensing and procurement platforms, create a multi-layered approach to medication management. The ongoing shift toward digital methods, including electronic ordering for controlled substances, streamlines workflows and minimizes risk. By embracing these modern methods while understanding the occasional need for legacy processes, healthcare professionals can ensure the highest standard of pharmaceutical care.
For more information on the safety aspects of computerized order entry, you can visit the Agency for Healthcare Research and Quality's primer on CPOE.
