The write stuff

Have you ever been given a prescription from your physician that was completely illegible? Walking out of the examining room, you had sworn you were supposed to get a prescription for amoxicillin for your annoying sinusitis. Instead, the prescription looks to be for alprazolam, which you could probably use during this current economic turmoil but is unlikely to help with your upper respiratory symptoms.

Many patients and their pharmacists complain about the illegibility of prescriptions. Once you've been on both sides of the prescription pad, you begin to appreciate the difficulty of trying to somehow decipher "doctor handwriting." In cases where there is no electronic ordering system, it is not unheard of for the pharmacist to dispense the wrong dosage or medication to a patient. These incidents are not always benign—there can be life-threatening complications for illegible prescriptions. Lithobid is not a good substitution for Liquibid, although it might be beneficial if the coughing patient happens to be bipolar.

Why do so many physicians have bad handwriting? Are they so busy that they are unable to take the time to write legibly? Are their brains moving too fast for their hands? Do they have hand cramps from gripping golf clubs? Maybe it's some sort of prerequisite for medical school. Why has illegible handwriting been deemed appropriate for the medical field when so many prescriptions, clinical progress notes, and inpatient orders are written daily?

To help address the handwriting problem, The Joint Commission has established rules about which abbreviations are not allowed. The so-called "do not use" list was originally created in 2004 as part of the requirements for meeting National Patient Safety Goal Requirement 2B: Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. Abbreviations on the list were chosen in part because they can be easily—and sometimes fatally—confused with others. For example, the abbreviation "IU" can be confused with "IV" or the number 10. Bad handwriting makes such mistakes that much more likely. In May 2005, The Joint Commission affirmed its list, which includes these abbreviations.

In addition, The Joint Commission reviews the following annually for possible eventual inclusion

• the symbols ">" and "<",
• all abbreviations for drug names,
• apothecary units,
• the symbol "@",
• the abbreviation "cc", and
• the abbreviation "µg".

The Joint Commission's "do not use" list is a lower-tech solution to the handwriting problem, but there are also electronic medical records (EMRs), part of our technology-dominated society's trend toward computerized health care. Many believe EMRs have the potential to improve quality of care, decrease human errors, increase patient safety and lower costs of health care.

In a recent article in the Journal of General Internal Medicine, Shachak et al. reviewed the risks and benefits of using an EMR. They found that EMRs were beneficial because they allowed physicians to recall less information from memory and decreased the difficulty of reading illegible handwriting. EMRs reduced physicians' cognitive load and seemed to increase their efficiency. However, there were also some risks reported with the use of EMRs, including errors made by the user, such as selecting the incorrect medication or adding data to the record of the wrong patient. Also, EMRs disrupted patient-physician relations because physicians who used them ended up spending more time on the computer than they did with their patients.

So although EMRs may be able to help solve the problem of illegible handwriting, Shachak and colleagues' study has shown that they are not a cure-all. But there's no denying that in medicine, as in other fields, technology is leading the way. We can't get around it: EMRs are the future. Soon physicians won't have to handwrite clinical notes, prescriptions, or orders anymore, and the handwriting question may become moot. Perhaps typing speed will be the new hidden prerequisite for medical school. It may already be part of the application process.