Safe prescribing

[Dr. Shojania responds:]

Even the most plausible, well-intentioned interventions to improve care can be undermined in unexpected ways.1 Thus, I fully support subjecting proposed safety interventions to the type of critique offered by Nadeem Bhanji. Nonetheless, I think the recommendations I made remain reasonable.

Bhanji worries that pharmacists will interpret prescriptions that include both the generic and the brand names of a medication as requiring dispensation of the brand name drug. If “Do not substitute” is not written on the prescription, I think most pharmacists would proceed with whatever generic substitution they would usually make. In fact, many provinces mandate such substitutions.2^,3

I agree that the alternative solution of stating the indication for the medication requires discretion. For potentially sensitive conditions I would suggest that physicians use the generic name plus brand name approach and ask their patients for permission to include specific diagnoses on their prescriptions. Another possibility is to use preprinted prescriptions with categories of conditions (or symbols for organ systems) that the physician simply ticks off4 (e.g., “cardiovascular” or “neurology or mental health”). The vast majority of prescriptions are for conditions that are unlikely to generate privacy concerns for patients, such as hypertension, diabetes and gastroesophageal reflux. Stating the indication for the prescription will also provide important information for patients, many of whom have difficulty keeping track of which prescription is for which medical condition.

Bhanji's concerns about the legal and ethical protections for electronically stored medical information and about the possibility that commercial interests will hijack electronic prescribing for mass marketing have received widespread attention. They should not stop us from proceeding with important advances in managing health information; similar concerns in other sectors have not prevented us from now routinely making electronic transactions involving important personal information.