Murray MD et al. 1998 "Effects of computer-based prescribing on pharmacist work patterns."

Murray MD, Loos B, Tu W, et al. Effects of computer-based prescribing on pharmacist work patterns. J Am Med Inform Assoc 1998;5(6):546-553.
"OBJECTIVE: To measure the effect of computer-based outpatient prescription writing by internal medicine physicians on pharmacist work patterns. DESIGN: Work sampling at a hospital-based outpatient pharmacy. Data were collected from pharmacists wearing silent, random-signal generators before and after the implementation of computer-based prescribing. MEASUREMENTS: The type of work performed by pharmacists (activity), the reason for their work (function), and the people they contacted (contact) were measured. RESULTS: Total staff hours and prescriptions handled were similar before and after computer-based prescribing. Pharmacists recorded 4,687 observations before and 4,735 observations after implementation of computer-based outpatient prescription writing. After implementation, pharmacists spent 12.9 percent more time correcting prescription problems, had 3.9 percent less idle time, and spent 2.2 percent less time in discussions with others. Pharmacists also spent 34.0 percent less time filling prescriptions, 45.8 percent more time in problem-solving activities involving prescriptions, and 3.4 percent less time providing advice. Over 80 percent of pharmacist time was spent working alone both before and after computer-based outpatient prescription writing. CONCLUSION: Computer-based prescribing results in major changes in the type of work done by hospital-based outpatient pharmacists and in the reason for their work and small changes in the people contacted during their work."
"To measure the effect of computer-based outpatient prescription writing by internal medicine physicians on pharmacist work patterns."
Tools Used
Type Clinic
Primary care and specialty care
Other Information
At Regenstrief Health Center, the study site, "the outpatient pharmacy processes 1000 to 1500 prescriptions each day. More than 50,000 outpatients make over 400,000 visits annually to the clinics and emergency department."
Type of Health IT
Electronic prescribing (e-Rx)
Type of Health IT Functions
"The pharmacy module is the primary information system enabling the pharmacy to fill prescriptions...First, physicians entered their prescriptions directly into microcomputer workstations ... When the prescription order selection is chosen [by the physician], all active prescription medications for the patient are shown. The physician can renew or modify an existing medication that has been previously stored or order a new medication. Prescription renewal is as simple as highlighting the medication, reviewing the fields corresponding to the medication's dosage, [signature], and quantity to dispense. To prescribe a new medication, the physician can quickly summon a specific order by typing in a few letters of the medication's name or can peruse a specific formulary class of drugs to look for alternative treatments. This process can improve practice by removing some of the practical ambiguities physicians have in writing prescriptions (which drug, strength, dosage, how supplied, and costs) and by reminding physicians how to effectively monitor patients' drug therapy and avoid important drug interactions. After the physician enters all medications, an electronic copy of the patient's prescription is sent to the pharmacy and a paper copy is printed for the patient ... The paper copy brought to the pharmacy by the patient serves to notify the pharmacist that the patient is at the pharmacy and their prescriptions have already been written and stored. To display the patient's prescriptions, the pharmacist enters a prescription access code specific to the patient, physician, and date. All the patient's prescriptions are then displayed for the pharmacist to accept, modify, or reject."
Context or other IT in place
Electronic health records (EHR)
Workflow-Related Findings
"After computer-based outpatient prescription writing, pharmacists spent 45.8 percent more of their time problem-solving physician's orders.This undoubtedly had much to do with physicians' learning more about the various medications stored in the pharmacy inventory and the need for pharmacists to help them deal with a variety of prescribing issues that were new to them."
"Both before and after computer-based outpatient prescription writing by physicians, pharmacists spent more than 80 percent of their time working alone. There was a small increase (4 percent) in the amount of solo work by pharmacists after computer-based outpatient prescription writing and a complementary small decrease in the amount of time pharmacists spent in direct contact with other pharmacists."
"After computer-based outpatient prescription writing, pharmacists spent 12.9 percent more time checking prescriptions. These are activities that might be expected to increase as pharmacists became more vigilant with regard to physician's electronic orders."
"Before computer-based prescribing, pharmacists were required to conform to a firm syntax when entering the prescription sig such as '1 tab PO TID.' To make entry of prescriptions easy for the physicians, the system was designed to allow them to enter the sig as free-form text, which then had to be translated back by pharmacists into the appropriate syntax."
"Because physicians' lack familiarity with the strengths and dosage forms available in the pharmacy, pharmacists needed to edit [the free-text] entries. For example, a physician may enter a prescription as 'Take one 100-mg tablet TID' when the pharmacy has 50-mg capsules.... Physicians also have no way of telling when a drug or dosage has been depleted from the pharmacy inventory ... Moreover, physicians were not aware that some medications were available in ready-to-dispense packaging, which was encouraged to reduce counting of individual tablets and capsules for commonly used medications. Owing largely to this time spent problem solving, the time spent filling prescriptions decreased by 34 percent. The time pharmacists spent advising physicians about other aspects of patients' treatments and advising patients decreased by 3.3 percent, a considerably smaller effect than that seen with problem solving and prescription filling."
"We had some hopes that changes in prescription processing resulting from computer-based outpatient prescription writing would reduce the time pharmacists spent processing prescriptions and provide more time for communicating with patients and health professionals. That did not occur."
After CPOE inititation, "Pharmacists spent 3.9 percent less time waiting
for work to do and 2.2 percent less time meeting."
"Interestingly, pharmacists spent about the same amount of time entering information into the computer after computer-based outpatient prescription writing as they did before (P = 0.299), although this fraction of their activities is small. Before online entry pharmacists (or technicians) had to hand-enter all the prescription data from the paper copy. After computer prescribing began, most of the pharmacists' computer time involved the electronic review of previously entered prescription data, which involves moving through the fields (sig, dosage form, quantity to dispense) to accept or edit the data entered by physicians."
Study Design
Pre-postintervention (no control group)
Study Participants
Eleven full time and nine part time pharmacists participated.