Electronic Prescribing Will it make a difference to the average physician?

by David B. Porter Consultant, Six Degrees Health Care Consulting

Last year, there was a lot of talk in Washington, DC, about electronic prescribing (eRx). The original draft of the Medicare Act mandated electronic prescribing. That mandate was changed to “voluntary adoption” in the final version of the Act. So, can a physician just opt out and decide to ignore eRx? The answer is NO. Electronic prescribing is happening right now. Most health plans are interested in eRx, many are encouraging its use, and most plan to require physicians participating in their plans to switch to eRx sooner rather than later.

In addition to the health plan interest, the Medicare Act retained some very important provisions that will significantly influence how eRx is used in the United States. The process for developing standards for eRx was outlined and enabled in the Act, and the development of standards is already underway.

What is eRx and what do we need to know?
eRx replaces the traditional handwritten prescription that the physician writes and issues a patient with a paperless process through which the physician enters a prescription electronically and transmits it to the pharmacy, where it is filled and picked-up by the patient. eRx systems allow the use of either hand-held tools such as PDAs (electronic personal organizers) or desktop computers for the physician to enter the prescription, while most large pharmacy chains (retail and mail-order) have systems in place to accept electronic prescriptions.

Historically, the interest in electronic prescribing grew significantly in parallel with the release of statistics on medical errors. Many of these errors were attributed to bad handwriting on prescriptions, which contributed to the wrong drug or the wrong dosage being dispensed. Before the Internet era, few systems were available to address the errors that occur when handwriting on a prescription is almost illegible or when drug names are too similar.

About 10 years ago, hospital systems started to put electronic prescribing systems into place. They capitalized on the fact that they had closed, in-house systems (prescribers and dispensers within the hospital system and connected through an intranet) to institute computer prescription order entry to send prescriptions electronically and build in tools that would check for errors. Some hospital systems such as, Brigham & Women’s, found that they could significantly reduce medical errors by using these systems. They reported a 55% reduction in serious medical errors using CPOE. Others, such as Cedars Sinai in New York, found that despite benefits in the system, other problems arose in the system that detracted from the safety enhancements.

As these systems enter the outpatient setting, will physicians applaud eRx or look upon it as yet another bureaucratic imposition to affect their practices and their relationships with patients? This article will review the pros and cons of eRx and some potential pitfalls. But in the end, physicians will choose what systems they will use and will decide how strong a voice they want to have in contributing to the standards process. Therefore, it’s essential that physicians understand the issues and decide how to respond to eRx.

There’s no doubt that a good eRx tool will enhance patient safety. System designers can build in automatic checks to remind physicians of drug interactions, contraindications, potential allergies, and safety alerts. The elimination of handwriting also should cut down on errors that occur in the transfer from prescriber to dispenser, and that should result in fewer call backs from pharmacists to clarify information. However, eRx will not solve all of the safety issues. Even electronic tools have room for human error and “machine error.” Some physicians working with eRx tools have reported errors because of dosage listings that are too close together on a screen and, as a result, it’s been easy to hit the wrong one. Another common problem is the need for very specific patient identifiers to ensure that the patient profile showing on the screen is the same patient in the office because many patients have similar names.

It’s hoped that many of those problems can be addressed as tools become more sophisticated and user-friendly. What about problems that are more “systemic” and cannot just be fixed by screen design? Six key areas will require specific attention as eRx emerges as the predominant prescribing method.

1. Efficiency and Relevancy: eRx tools should provide enough information on each patient to assist the physician in prescribing appropriately. Information would include relevant medical history such as concomitant medications and allergies to medications. In the interest of efficiency and patient privacy, lengthy and discontinued medications need not appear each time a prescription is written for the patient. The display of every possible adverse event reported on a particular drug is not necessary; instead, provide relevant safety alerts appropriate to the prescription and the patient. Furthermore, the system should allow for prior authorizations and appeals because any efficiency gains will be lost if the physician has to abandon the tool and complete paperwork to process PAs and appeals.

2. Freedom of Clinical Judgment: Exercise of clinical judgment is fundamental to the physician’s ability to treat patients appropriately. While most physicians believe it’s helpful to have some information on cost available in discussing treatment options with patients, the best interests of the patient always should prevail in making prescribing decisions. Tools for eRx should not be configured to inappropriately influence prescribing decisions toward least costly choices or to covertly obstruct prescribing decisions. Examples of this include:
a. Forcing the entry of a diagnosis before the physician can choose what drug to prescribe;
b. Building in multiple pop-up messages that interrupt the prescription process and ask the physician to “think again” if the choice of drug is off formulary, and;
c. Restricting the choice of drugs available on the pull-down menu.

3. Commercial Messaging: Because the legislation allows eRx tools to be used for commercial messaging, it’s important that this type of use be distinguished from the prescribing process, especially prescribing at the point of care. Commercial messaging, whether from pharmaceutical companies, other vendors or healthcare payors, should be easily identifiable as such and should not interfere with the prescribing process. The easiest way to address this would be to allow the physician an “opt out” option that turns off commercial messaging when a prescription is about to be written.

4. Connectivity and Interoperability: The backbone of any electronic transmission system is its ability to transfer the information from one place to another. In addition, the use of electronic tools in the physician’s office requires multiple types of information to be easily and securely shared. A good eRx system will be backed by solid infrastructure that ensures connectivity (to pharmacies and to payor databases for example) and will also be able to share information with other office systems such as the electronic medical record and patient database.

5. Preservation of the Patient’s Role: The tools that improve efficiency should not obviate the role of the patient in healthcare decision-making. Instant and “behind the scenes” transmission of prescriptions should not detract from the importance of including patients in the treatment decision. Patients should be allowed to retain their choice of pharmacy to dispense the prescription without eRx systems forcing them into a pre-selected pharmacy. Most important, tools that interrupt the prescribing process or provide too many hoops for physicians to jump through in order to issue a prescription inevitably will take time away from the patient visit and reduce opportunities to build a physician/patient relationship.

6. Use of eRx to Monitor Physician Behavior: It is common for data on our prescribing habits to be sold to interested parties. The emergence of eRx, however, makes capturing and sharing this information easy and instantaneous. In addition, as trends toward “physician rating” and “pay for performance” by health plan administrators grow, such information could be used to profile physicians who are considered non-compliant in terms of prescribing patterns, with potential punitive ramifications. At a time when physicians are already squeezed financially, be cautious of a trend toward “black-balling” physicians based on prescribing profiling.

The bottom line is that all these potential problems could be addressed through stringent standards that acknowledge the needs of patients and practicing physicians. For this reason, it’s important that physicians add their voice to the standards debate. You can add your support to this position on the development of eRx standards by contacting the National Committee on Vital Health Statistics (federal advisory board currently developing national standards for electronic prescription services). Comments should be directed to the attention of:
James Scanlon
Acting Deputy Assistant Secretary,
Office of Science & Data Policy
Office of the Assistant Secretary
for Planning and Evaluation
DHHS, Humphrey Building,
200 Independence Avenue, SW
Room 440-D
Washington, DC 20201
Phone: 202-690-7100 Fax: 202-690-5882
E-Mail: jim.scanlon@hhs.gov

About The Author:
David Porter’s 17-year career includes government service, nonprofit association management, and for-profit pharmaceutical marketing. Mr Porter directed the American Medical Association’s Specialty Society Relations, overseeing the AMA’s interaction with 90 major medical specialty societies, and accelerating the AMA’s integration of national specialty societies into their policy-making body. His political and government service includes positions in state and local political development, strategic fund-raising, and a political appointment in the previous Bush Administration. He was the youngest Senior Executive Service appointee at the US Department of Health and Human Services, overseeing the policy vetting process in the Office of the Secretary.