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Electronic prescribing holds both promises and problems
The Institute of Medicine has recommended that all prescriptions be written electronically by the year 2010.
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The average physician in primary care practice writes 30 time-consuming new prescriptions per day and nearly the same number of refills.
Handwriting interpretation errors are estimated to cause 9% of all medication errors. Although electronic prescribing (e-Rx) is finally well underway in the United States, it has for several years been the norm in many European countries. As recommended by the federal government and other national health care improvement organizations, the use of electronic prescribing applications in pediatric practice should be encouraged. The Institute of Medicine has recommended that all prescriptions be written electronically by the year 2010. It is estimated that 20% of U.S. physicians in practice currently prescribe electronically. Currently, there are at least 18 stand-alone e-prescribing vendors, and 29 electronic medical record vendors that feature e-prescribing in their software, often as an optional add-on package with increased cost.
Many large medical multispecialty or single specialty medical practices have successfully implemented e-prescribing. AAP officials believe that there is sufficient evidence to support the ability of e-prescribing systems to prevent medical errors and enhance patient care. AAP officials support legislation that would require all pharmacies to accept digitally transmitted and signed prescriptions. Of course, for e-prescribing to live up to its promise, physicians must use the system regularly and the system in turn must deliver on its promises.
E-prescribing is defined as entering a prescription for a medication into an automated data entry system and thereby generating a prescription electronically instead of handwriting the prescription on paper. It promises to reduce medical errors, improve patient safety, decrease pharmacy costs, and increase efficiency, record keeping and collation of prescribing data. E-prescribing also reduces the chance of alterations in the prescription by drug seekers, the prescription has much less tendency to get lost, and there is the promise, as yet unfulfilled, of receiving a no-fill e-mail from the pharmacy that received the e-Rx.
There are several benefits to e-prescribing, including improved patient safety because of improved legibility of prescriptions, improved adherence with health plan formularies and reduced pharmacy costs by increasing use of generic medications, reduction of telephone call-backs to physician’s offices, reduction in time to process requests for refill of prescriptions, and a reduction in time to fax prescriptions to the pharmacy (Table 1). In selected states, state law mandates substitution of less expensive generic drugs, unless overridden by the physician provider. These perceived advantages are very attractive to managed care organizations (MCO).
In addition, e-Rx promises to facilitate the usually painful transition toward the implementation of a paperless medical record system, which has been a difficult goal to achieve, particularly for smaller private pediatric practices (Table 1). AAP officials anticipate that a stand-alone e-prescribing software program should be a stepping stone to ultimate adaptation of an electronic health record.
A communication bridge must be established between the e-Rx software and the individual pediatric practice with the e-Rx software and this process can be costly. The database includes all demographic information about the patient.
The cost of e-prescribing will not be offset by increased pediatric practice revenue; therefore, the AAP believes that the cost would be paid by pay-for-performance incentives.
Physician adoption of e-prescribing rests on three principles: perceived value to the practice and to the individual physician, fit with the practice workflow and affordability.
At present, e-prescribing in the ambulatory setting occurs in two principle forms: handheld devices loaded with e-prescribing software, or using ambulatory electronic medical record systems software on a computer or handheld device. It will dramatically alter the manner that a prescription is transferred from provider to the pharmacy transmission of legible prescriptions as they are routed from the physician’s office through SureScripts, RxHub or by electronic fax. There are differences between SureScripts and RxHub, and both are shifting targets in terms of their offerings. RxHub routes or switches electronic prescriptions from the provider to major mail order pharmacies, and SureScripts instantly routes prescriptions to retail pharmacies. RxHub is the collaborative product of three pharmaceutical benefits management companies: Advance PCS, Express Scripts and Merck-Medico. E-prescribing networks allow providers to verify patient and pharmacy eligibility, drug plan benefits and current medication and allergy history for patients, at the medical provider’s office, at the same time that they incorporate encryption technology to secure the Health Insurance Portability and Accountability Act (HIPAA) requirements to protect privacy. The AAP recommends that prescriptions should be cross-checked for correct dosage against a child’s current weight and age, checked for drug-drug interactions and checked against the patient’s history of drug allergies. This ideal may not be achieved in medical offices using paper prescriptions.
Medical history information, while planned for some future time, is only in the pilot phase at present. Physician providers are able to access the patient’s complete drug history no matter where the prescription was filled. Access to the e-Rx software from the home computer permits access to patient’s office records when it is important to reach them from home or anywhere there is a computer hooked up to the internet. A “favorites” list of medications, most frequently ordered by each physician, speeds the selection of common medications. RxHub, but not SureScripts, provides patient eligibility information as well as formulary information. With SureScripts, one would get an electronic message about non-formulary status after they received the prescription, not at the time of prescribing.
Benefits to MCOs
MCOs benefit from e-prescribing by accumulating information about provider prescribing habits, encouraging the use of less expensive generic medications and having a default on the computer program that gives preference for the medications included in their company MCO formulary.
Health plans and pharmacy benefit managers (mail order pharmacies) have a financial interest in reducing expenditures through adherence to MCO drug formularies and from efficiencies associated with clean, accurate prescriptions. Pharmaceutical companies require data about physician prescribing habits and pay for the information accrued by e-Rx software vendors. Sale of data to various pharmaceutical companies and pharmacy benefit management companies furnishes the sash for software development.
Benefits to patients, physicians
Patients benefit from e-prescribing by having the pharmacy receive the legible prescription before they even leave the physician’s office. E-prescribing facilitates checking for drug-drug interactions, drug-allergy and drug-disease interaction.
Among the stand-alone providers are Allscripts TouchWorks, ZIX, Chart Rx, eScript, ScriptSure, Medical Manager e-Rx and DrFirst Rcopia. These are only a sample of the 18 or more stand-alone e-prescribing programs. Prescriptions can be electronically faxed or transmitted to pharmacies and a hardcopy can be printed and given to the patient, included in the printed chart, or both. Payers, provider organizations and even some states such as Massachusetts sponsor e-prescribing. A coalition of technology companies and health care organizations, the National ePrescribing Patient Safety Initiative, announced in January 2007, that it would be offering free electronic prescribing software (e-Rx NOW, provided by Allscripts) to physicians in an effort to reduce medication errors associated with writing prescriptions. Licensed physicians with computers or hand held devices can register for the free e-prescribing at www.nationale-Rx.com. All patients are given a private identifier that ties their medication record to their physician. Only that unique physician, using a PIN number or password, can access the record. Allscripts is legally required never to divulge to third parties the information identified as personal health information. Allscripts e-Rx NOW is connected to the Pharmacy Health Information Exchange (PHIE), which is operated by SureScripts, and is dedicated to facilitating the transmission of prescription orders and refills between physician providers and retail pharmacists. More than 95% of retail pharmacies are currently certified for a connection to the PHIE. Some of the smaller pharmacies that are not part of a large pharmacy chain such as CVS, RiteAid, Target, Walmart and others may not able to accept e-Rx. However, the SureScripts or RxHub routing networks automatically convert e-Rx to e-FAX when it detects a pharmacy that is not capable of receiving Rx sent by e-prescribing. Parents of patients who use small individually-owned retail pharmacies can be given a hard copy of the e-Rx that must be signed by the physician provider. This is faster and more legible and accurate than a traditional handwritten prescription.
Problems with e-Rx
There are potential problems with e-prescribing, not the least of which is cost. Pediatricians can be expected to pay from $600 to $2,000 per full-time equivalent physician for the software, downloading of the patient demographic information, set up fees and instruction fees. There is also an annual fee for service and upgrades. Hardware expenses include dollars for hand-held, laptop, tabletop or personal desktop computers for each physician, each pod of exam rooms or every exam room. There is a hidden cost for the time involved in mastering the technique and for the extra time it takes to overcome the expected glitches in transmission of the prescription. After the learning curve has been overcome, it is expected that the physician provider would return to the baseline of patient encounters per morning or afternoon shift.
After purchasing an electronic prescribing software program, either stand-alone or as a feature of electronic medical record program, it is necessary to download all patient records that contain vital information. Pediatric offices using stand-alone e-Rx software also require a software interface so that new patient information is automatically added to the e-Rx database at the time of each new patient encounter. Obviously there is a cost for this time-consuming chore that must be born by someone, the pediatric practice or a sponsoring organization.
Some critical information required by e-prescribing software may be missing from the patient management system currently used by the pediatric practice. After installing an e-prescribing software program, missing information for an individual patient, particularly one who has not had an e-prescription sent at that office, must be typed in whenever an e-prescription is written. A prompt will appear on the computer screen for all missing details, notably patient sex, current weight and specific drug allergies. There is also an additional cost to automatically include new patients as they enter the practice from the downloaded daily from patient management system.
HIPAA regulations on security and privacy carries important implications when e-prescribing is used. There are several rules which must be followed: secure point-to-point electronic transmission of the prescription at each node in the chain, entity authentication, audit trails and data authentication to ensure that data have not been changed or altered during transmission. Every participating physician who is cleared to use the e-Rx software is given a name and unique password that must be protected and remembered. For many physicians, it is annoying to have to remember yet another password. Re-entry of passwords to sign in to the system are important security practices that physicians need to learn to live with. In the future, entry recognition may be facilitated by using biometrics (iris pattern or fingerprints) or proximity badges.
After downloading the software program and patient information from the patient management system, all physicians in the practice must choose to carry a handheld PC or use a laptop or tabletop computer or a traditional PC. The tiny key size, small print and small screen of a handheld computer are a disadvantage for physicians who are maladroit with technology. From personal experience, it may require several different trials to find the best hardware fit for an individual pediatrician to use consistently.
Another decision that must be made is whether to use wireless or wired technology for tabletop or personal computers. Should the tabletop or PC remain in the examination room? Should it be located where little fingers can play with the keyboard or located on a swing-out arm above the reach of small children? Some buildings or even suite locations within a commercial building do not permit wireless transmission so alternative methods must be considered. Some suites have encountered interference in some exam rooms but not others. If the computer is located outside the exam rooms in a common area and multiple physicians use the same computer, it is annoying and time-consuming to enter the unique password every time a physician who has a different password from the previous person uses the computer.
At present, many controlled drugs, including stimulant drugs for attention-deficit/hyperactivity disorder cannot be transmitted by e-Rx. Because prescription refills would be so much easier with a simple press of a few keys with e-Rx, we hope that it would be not too far in the future that we can use e-Rx for that purpose.
There is also a retail pharmacy learning curve. One common problem occurs when one enters the name and pharmacy number of the preferred pharmacy given originally by the parent of the patient. On the way home from the pediatric office, the patient may stop off to do some shopping and decide to use a different pharmacy. When the expected prescription is not ready, the pharmacist insists that it has not been sent. This causes frustration and confusion at many levels. To prevent this from occurring, it is necessary to ask every parent whose child requires a prescription if their pediatrician are still using the previously preferred pharmacy for this prescription. If the parent is indecisive, it is best to print the electronic prescription and hand it to the parent. Another problem occurs when the e-Rx is entered and successfully sent to the pharmacy but the busy pharmacist can only download the e-Rx prescriptions every hour. The parent arrives about 10 minutes after leaving the pediatric office and still has to wait more than one hour to actually receive the medication. A gentle reminder from the physician provider to the chief pharmacist or notifying the e-Rx software vendor or SureScripts usually corrects that problem. Some pharmacies will refuse to actually fill phoned or e-Rx prescriptions for antibiotic suspensions because the parent may not show up to claim the medication for a variety of reasons. The pharmacy must then incur a loss on the wasted antibiotic in such cases. Drug allergies are often not included in the information provided by the physician’s office, although this is an important goal for e-Rx. These problems are generally solved as the individual retail pharmacists master the learning curve for e-Rx.
At present, most large pharmacy chains and an increasing number of individually-owned pharmacies nationwide have the capability of receiving information sent by e-Rx. While most non-pharmacy benefit manager pharmacies are in the SureScripts network, most still receive them via fax rather than computer. Original problems with fax transmission such as pharmacies not checking their faxes and faxes running out of toner or paper, would often cause the pharmacist to tell the patient who arrived to learn that the prescription was not ready. For the most part, these issues have been resolved. It has been suggested that the words “DUPLICATE PRESCRIPTION” be written across the e-printed prescription to alert the retail pharmacist that the original Rx was sent electronically. Or, alternatively, a preprinted message that states: “My doctor has sent a prescription electronically through the SureScripts network. Please check the network for the prescription.” These can be printed on pads to rip off and handed to the parent as they leave the exam room. Prescriptions for pediatric medications that are FDA approved for children between 12 and 18 years may not be accepted by some e-Rx programs. Others require the physician to override the rejection default and acknowledge that they are prescribing a medication that has not received FDA approval for that age group.
It is estimated that call-backs cost physician practices $5 to $7 each. E-Rx is timesaving for refills that can be transmitted with a few keystrokes instead of the labor intensive effort for handling refills the traditional way. However, it is the physician provider’s responsibility (or designated telephone triage nurse) to periodically check the refill message alert for refill requests sent electronically by a retail pharmacy.
Privacy concerns surrounding the sale and use of patient data are causing real questions about acceptance of free e-prescribing software for fear of accepting a Trojan horse. At present, there is little oversight of the use of patient data and individual vendors must decide how to handle data sharing with third parties.
Overcoming glitches
In all fairness, most of the annoyances associated with e-Rx can be overcome with practice and time (Table 3). Once the system is in operation and practiced, savings in time for writing new and refillable prescriptions, the marked decrease in telephone calls to retail pharmacies for refills or to clarify illegible handwritten prescriptions or dosage errors more than outweighs the initial investment in e-Rx.
E-prescriptions are gaining in acceptance. They are here to stay. They promise to improve patient safety and save time at least for refills for the primary care pediatrician.
For more information:
- Alan A. Zuckerman, MD, is in the Department of Pediatrics at Georgetown University Hospital in Washington, and Michael Martin, MD, is in the Department of Pediatrics at Inova Fairfax Hospital for Children in Falls Church, Virginia.
- California HealthCare Foundation. E-Prescribing, 2001. www.ehealthinitiative.org/initiatives/e-Rx/document.aspx. Executive Summary: Electronic Prescribing: Toward maximum value and rapid adoption. Washington, April 14, 2004.
- Kohn LT, Corrigan JM, Donaldson Ms, eds. To Err is Human: Building a Safer Health System, Washington: National Academy Press; 1999.
- www.mahealthdata.org/ma-share/projects/e-prescribinged/20060627_eRxBenefitsFactSheet.pdf.
- Council on Clinical Information Technology, AAP: Policy Statement. Electronic prescribing systems in pediatrics: The rationale and functionality requirements. Pediatrics. 2007;119:1229-1231.
- Smith AD. Barriers to accepting e-prescribing in the U.S.A. Int J Health Care Qual Assur Inc. Leadersh Health Serv. 2006;19:158-80.
- Pennell U. What is E-prescribing and what are the benefits? www.himss.org/ASP/topics_eprescribing.asp.
- Tamblyn R. Improving patient safety through computerized drug management: The devil is in the details. Health Pap. 2004;5:52-68.
- Kaufmann MD. Focus on: Information technology. Electronic prescribing: An update. J Drugs Dermatol. 2005;4:106-07.
- Bell DS, Friedman MA. E-prescribing and the Medicare Modernization Act of 2003.
- Corley ST. Electronic prescribing: A review of costs and benefits. Health Inform Manage. 2003;24:29-38.
- Bates DW, Cohen M, Leape LL, et al. Reducing the frequency of errors in medicine using information technology. J Am Med Inform Assoc. 2001;8:299-308.