Electronic Prescribing in Pediatrics: Toward Safer and More Effective Medication Management

The American Academy of Pediatrics (AAP) is committed to providing the best and safest health care system possible for children.

Medication prescribing or ordering in pediatrics is an error-prone process that can lead to adverse medication events and patient harm.^1,2 Electronic prescribing (e-prescribing) is widely recognized as a component of the care process that improves quality and reduces costs by facilitating handoffs, improving clinical decision-making, and potentially improving medication adherence.

Prescribing error rates in children were estimated to be between 5% and 27% in a recent systematic review.³ Prescribing errors are most prevalent with antibiotic agents but may occur even with medications that do not require weight-based dosing.⁴ Medication errors in children may lead to more severe complications because of narrow therapeutic profiles and the inability of some children to communicate adverse effects. Many existing e-prescribing systems are not well designed for use in pediatric patients and lack the required features outlined in this statement. Parental health and English literacy have been shown to play important roles in the correct medication administration in children.^5,6 

From a legislative viewpoint, the past decade has been an active one for the national medication-prescribing landscape. In particular, 2 major statutes specifically addressed the goal of 100% adoption of e-prescribing through both time-dependent incentives and penalties. The Medicare Improvements for Patients and Providers Act (Pub L No. 110-275 [2008]) provided for incentive payments to Medicare-participating providers that use e-prescribing software to generate prescriptions. The Health Information Technology for Economic and Clinical Health Act (Pub L No. 111-5 [2009]) established a program of incentive payments for Medicare and Medicaid providers who adopt, implement, and demonstrate meaningful use of health information technology. One of the key requirements of meaningful use is to generate and transmit prescriptions electronically to the pharmacy. The meaningful use requirements also encourage the routine use of medication lists, medication allergy lists, drug–drug interaction and drug-allergy checking, and drug formulary checking.

E-prescribing systems can improve the quality and safety of medication administration by reducing preventable adverse drug events,^7,–9 reducing dosing errors,¹⁰ improving communication,^11,12 avoiding adverse effects,^13,14 and improving efficiency.¹⁵ The benefits of e-prescribing systems in pediatrics can only be achieved by systems with appropriate functionality and may be hampered by poorly developed systems¹⁶ or implementation strategies.¹⁷ At present, many e-prescribing systems fall short of providing expert-recommended functional characteristics.¹⁸ Specific challenges in pediatric e-prescribing include age- and indication-specific, weight-based dosing requirements, rounding based on formulary (liquid or solid), the conversion of doses from an ingredient amount to a volume for liquids, the desire to provide easily administered home doses, and, when necessary, extemporaneously compounded dosage forms. Although these systems already confer numerous advantages over the paper-based alternative, they will need to evolve to be an ideal platform for safe and effective pediatric medication prescribing. The features listed in Table 1, derived in part from previous work by the AAP,¹⁹ will help address these challenges to safe and effective pediatric prescribing.

1. Because safety for children is paramount, e-prescribing systems used for the care of children should include, at a minimum, pediatric-specific medication catalogs; pediatric-specific decision support, such as weight-based dose calculations and individual and daily dose alerts; rounding; ingredient amount-to-volume conversions for liquid medications; metric-only labeling instructions; and pediatric drug information and formulation options. This recommendation may be implemented by sharing reports, such as the accompanying technical report,²⁰ with standards development organizations and the Office of the National Coordinator for Health Information Technology–Authorized Testing and Certification Bodies to encourage the inclusion of minimum requirements into the development of standards and certification criteria.

2. When possible, e-prescribing systems should be implemented as part of a robust electronic health record and include drug–drug interaction and allergy checking. When implementing a stand-alone e-prescribing system, consideration should be given to a solid design (including correct field length and standard vocabulary) and the potential future need to generate reports with, transfer data to, or interface the e-prescribing system with an electronic health record. E-prescribing systems must be efficient for use in pediatric offices and must integrate well with existing office workflow. Recommendation 2 may be implemented by educating providers on the required elements of pediatric-appropriate e-prescribing systems through published reports, such as the accompanying technical report.²⁰ 

3. E-prescribing systems should be able to provide patients and their parents with administration instructions based on their level of health literacy and their preferred language. Recommendation 3 may be implemented by educating e-prescribing vendors and providers of the need for this feature.

4. Pharmacies should work to enhance their technology infrastructure and workflows to enable efficient acceptance and processing of electronic prescriptions generated and transmitted by certified health information technology. Furthermore, pharmacies should be capable of performing the dose-range checks to provide independent redundancy.

5. Private and public insurers and other third-party payers should offer financial incentives to health care providers and pharmacies to use e-prescribing systems with appropriate decision support.

6. States should work to harmonize their respective legislation to the US Drug Enforcement Agency’s interim final rule on e-prescribing of controlled substances. Recommendations 4, 5, and 6 may be implemented by continued advocacy activities at the local, state, and national levels.

Christoph U. Lehmann, MD

Kevin B. Johnson, MD, MS

Mark A. Del Beccaro, MD, Chairperson

Gregg Alexander, DO

Willa H. Drummond, MD, MS

Anne B. Francis, MD

Eric G. Handler, MD, MPH

Timothy D. Johnson, DO, MMM

George R. Kim, MD

Michael Leu, MD, MS, MHS

Eric Tham, MD, MS

Stuart T. Weinberg, MD

Alan E. Zuckerman, MD

Christoph U. Lehmann, MD

Kevin B. Johnson, MD, MS

Jennifer Mansour

Ielnaz Kashefipour, MPP