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The paperless office: Taking the plunge

Patient safety is the driving factor behind federal mandates that require physicians to incorporate electronic prescribing into their practices.

Issue: February 2005

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(This is part four in a five-part series on the paperless, electronic practice environment.)
Part 1: [The paperless office: Taking the plunge]
Part 2: [Benefits of implementing an EMR outweigh barriers]
Part 3: [ More orthopedists using filmless technology]

Today’s prescription drug prescribing processes lead to 130,000 life-threatening events a year. And they create 8 million annual adverse drug events in ambulatory care overall, 2 million of them preventable, according to the National Committee for Vital and Health Statistics (NCVHS).

One potential solution to this problem: E-prescribing or eRx, which advocates claim could drastically cut such incidents and save $27 billion a year, too. One eHealth Initiative report defined eRx as using computers to enter, modify, review, and output or communicate drug prescriptions.

Orthopedists less aware

“I don’t think many orthopedists appreciate the value of e-prescribing because they are unaware of the magnitude of medication errors and their costs and implications,” said James Herndon, MD, William H. and Joanne A. Harris Professor of Orthopedic Surgery, Harvard Medical School. “Internists and family practitioners are more likely to use e-prescribing, as they prescribe a wider range of medications more frequently and are more aware of medication error rates than orthopedists.”

This may soon change. This summer, Medicare announced an initiative to accelerate the eRx timeline mandated by the Medicare Modernization Act (MMA) from 2009 to 2006. The MMA states that eRx, based on national standards, be mandatory for drug plans participating in the new Medicare Part D prescription drug benefit. Even though physician participation will be optional, the Centers for Medicare & Medicaid Services (CMS) hopes that physicians will adopt eRx as a stepping stone towards electronic medical records (EMR).

“Since HIPAA forced physicians to convert to electronic billing, this mandate may soon require them to do likewise with e-prescribing,” Herndon told Orthopedics Today.

Bumpy ride

“As with the HIPAA transition the process is likely to be somewhat chaotic, since the mandate requires physicians to utilize e-prescribing but doesn’t provide any standards,” said Jonathan Chang, MD, clinical assistant professor of orthopedics at the University of Southern California.

Recognizing this problem, a RAND Corporation expert panel developed a list of 60 recommendations for creating effective eRx standards; forty of these could be met in the next three years in the average physician’s practice. eHealth Initiative and NCVHS are also developing standards, but until all of this is resolved, “everyone will not be on the same page,” Chang said.

“Other barriers to e-prescribing exist, such as cost, physician resistance, poor integration between practice management and EMR systems, few incentives, complex, poorly designed systems, and industry competition,” Herndon said. Lack of reimbursement, information technology experience and/or interest, and broadband availability, as well as fear of decreased office efficiency add to obstacles.

The eHealth Initiative report notes that some state regulations inhibit the rollout of electronic communication and some areas of the country have little, if any, systems. Connectivity between pharmacies and physician offices remains minimal. Most pharmacy information systems are unable to receive electronic prescriptions, although one eRx vendor is working with pharmacies in 15 states to change this. “Right now, pharmacies are waiting to see how e-prescribing progresses before they accept the liability that goes with it,” said Chang. “Fear of fraud is adding to their reluctance.”

“For example, in California physicians must now use tamper-resistant prescription blanks for controlled substances instead of triplicate prescriptions,” said Chang. “These pads can only be purchased from printers that have been pre-approved by the state. Since the issue of how to handle these prescriptions hasn’t even been addressed for e-prescribing, pharmacists may not fill these orders if they don’t feel comfortable with the format.”

Herndon told Orthopedics Today, “I wish that we had overcome some of these barriers, but unfortunately, we are making slow progress. In the past, 3% to 5% of hospitals were using computerized physician order entry (CPOE) systems for their physicians; this has only increased to about 7% to 10 % today.” It is estimated that only 5% to 18% of physicians are using eRx in their practices, according to the eHealth Initiative report.

Jump start

Since eRx is not currently considered a standard practice, orthopedists must “learn how cost effective and valuable it can be,” said Herndon, so as to have an incentive to use it. “However, the American Academy of Orthopedic Surgeons is educating residents about patient safety through a series of programs on topics such as medication errors and rates, signing the surgical site and patient communication.”

ERx can improve patient safety and lower costs, says CMS, by doing the following:

1. reducing medication errors due to illegible handwriting or improper dosage;
2. automating the process of checking for drug interactions and allergies; and,
3. checking against formularies.

A study in the Annals of Family Medicine found that using computerized decision-support systems (CDSS) for the eRx process can assure that patients and providers have relevant, evidence-based medical information and help patients get the most benefits at lower prices. Many eRx systems retrieve this data and formularies from RxHub, a venture by three pharmacy-benefit managers to create a nationwide electronic information exchange for prescription and pharmacy information.

“The use of CDSS also improves communication between the ordering physician and any other physicians who see the patient,” Herndon said. “Duplication of orders is one of the biggest wastes of money and time.”

So are pharmacy call-backs. According to NCVHS, almost 30% of the 3 billion prescriptions written annually require dispenser call-backs. That leads to 900 million extra phone calls annually.

Other eRx advantages include the ability to immediately determine which patients take a recalled drug, such as Vioxx, and contact them, states Eric Fishman, MD, orthopedic surgeon. To encourage use, some health plans are offering their physicians free, wireless, handheld devices or PCs, along with subscriptions to an eRx service. WellPoint Health Networks invested $40 million into eRx; by October 2004, 19,000 of its physicians in four states were participating in the program. Similarly, Tufts Health Plan and Blue Cross/Blue Shield of Massachusetts have 3400 high-prescribing physicians using eRx. Now CMS has a proposal to provide a reimbursement incentive for eRx, and some Pay for Performance programs and state medical societies may offer incentives.

Slow and steady

Incentives make the transition easier and cheaper. But most physicians must still go it alone. “I believe there will be a slow adoption roll out of e-prescribing,” said Chang. Physicians will have to separate the wheat from the chaff when it comes to vendors and software and “they may need consultants to help them,” said Herndon.

There are many eRx vendors, so interoperability becomes very important, Chang said. “Too many e-prescribing companies had stand-alone systems; likewise, EMR vendors didn’t offer e-prescribing software, as it was more of an afterthought. Now, with the mandate, it is on the forefront. Some vendors will take the time and money to develop e-prescribing software from scratch that is compatible with their EMR software, whereas others will simply purchase existing software and try to make it fit — sometimes this works and sometimes the systems are poorly integrated.

“Vendors and their programmers must design e-prescribing systems that are intuitive, easy to use and acceptable by multiple users — hospitals, pharmacies, labs, physicians and payers,” Chang added. “These systems must fulfill all of the mandate requirements. You need to research an EMR company’s experience with e-prescribing software and find software that has a robust encryption system for security reasons — this will also help ensure HIPAA compliance.”

“Find one simple system to start with and plan how you will add on other technologies,” Herndon said. “Don’t bite off more than you can chew,” like Cedars-Sinai Medical Center in Los Angeles, which ended up turning off its CPOE system due to physician resistance and delays in processing orders. “Failures like this show that implementation can be tough,” but success is attainable as demonstrated by WellPoint.”

“Since there are multiple parties involved in e-prescribing, it’s likely there will be delays in getting this technology established on a national basis,” Chang said. “Even though e-prescribing still has a long way to go,” Herndon said, “it’s catching on. At least 30% of hospitals report that they are looking into CPOE. I expect more physicians will adopt e-prescribing as a result of the mandate.”

Dr. Fishman is the owner of EMRConsultant.com.