every physician is required to use. Mandating a uniform prescription pad across all states would require legislation. Congress has been considering legislation that would require all Medicaid prescriptions be tamper proof, but it is currently on hold because of numerous problems.

Widespread use of electronic medical records may lead to prescription format changes. However, only 10 percent of physicians currently have electronic medical records. They are very costly—about $30,000 to $50,000 per physician per setup, with a $1,000 monthly maintenance fee. Furthermore, because there are between 100 and 300 providers of the software for electronic medical records, interoperability is a problem.

Improving patient understanding requires better physician counseling. The AMA has a large literacy program with workbooks for clinicians and others, as well as patient handouts. There are also movies about health literacy available on the AMA website.

The AMA supports efforts aimed at improving patient understanding and will work with others to accomplish this. In response to a question from the audience, Dolan agreed that there should be a convening organization—perhaps the National Patient Safety Foundation, the IOM, or the AMA—to bring together interested stakeholders. There should also be broad collaboration of all stakeholders in the effort.

Bloomberg School of Public Health, Johns Hopkins University

There is enough evidence available to show that something must be done to address problems with patient understanding and use of medications. The question is, What should be done? To answer this question, evidence tables are needed that delineate the level of evidence available for each of the recommendations made in the white paper and for the specific proposal for standardization. A research agenda to evaluate the effectiveness of different strategies is needed as well.

There are several challenges that will be encountered as one moves forward with standardizing medication container labels. One of the challenges of standardization is that there must be room for exceptions. All guidelines are applicable in 80 percent or 90 percent of the cases, but they must be written to allow room for improvisation because there are always nonstandard orders that need to be written. Another challenge is the writing of prescriptions. Handwriting as a method for getting prescriptions into the medication system is one of the root causes of variability and should be eliminated. It is important to take action before ePrescribing is in widespread use so that the systems will be interoperable. A third challenge is that the business case for standardization has not been made. What will