By 2012, physicians who do not electronically prescribe medications — instead of hand-writing them — will be penalized financially by the federal government.
The Centers for Medicare and Medicaid Services, or CMS, has employed this carrot and stick approach to encourage complete adoption of e-prescribing to improve healthcare quality and cut costs.
While e-prescribing has grown dramatically in recent years, local doctors said there continue to be barriers to widespread acceptance of a technology that could save thousands of lives.
In a study released last week the Washington-based health policy think tank the Center for Studying Health System Change found that fewer than one-third of the nation’s office-based physicians were e-prescribing.
The study also revealed that even fewer doctors who were e-prescribing used important components of the program, such as checking for harmful drug interactions and cross-referencing patient insurance formularies to verify health plans will pay for the drug prescribed.
Few doctors using the service actually transmit the prescription electronically, choosing to fax it instead to pharmacies.
According to the Institute of Medicine, about 7,000 Americans die annually due to preventable medication errors, which injure another 1.5 million Americans.
The process has been fraught with glitches, said Munster physician Alex Stemer, M.D., who heads the practice Medical Specialists Inc.
Stemer said his large group practice is e-prescribing now “because the federal government wants us to. But all those theoretical improvements in health care that have been predicted are not yet occurring, though they’ll probably be realized in the future.”
He said e-prescribing eliminates some errors.
“Physicians are notorious for their bad handwriting,” he conceded. “But if a doctor’s prescription cannot be read, the pharmacist will usually call. E-prescribing opens a new type of mistake even more common: the wrong-click error.”
He said when a physician e-prescribes and begins typing in the name of the drug being prescribed, a series of drug names appear on the screen. He’s seen cases of the wrong drug being prescribed for a patient because the physician inadvertently clicked on a similarly spelled drug. But he suspects dosing errors are even more common.
“One click above or below many mean a 50 percent dosage difference in the drug,” he said. “How does a pharmacist catch that?”
He said while future generations of e-prescribing software may be more thorough, many of the current versions don’t offer black box warnings. In addition, many pharmacies only check their e-mail a few times each day, meaning patients sometimes come to the pharmacies hours after they thought their prescriptions had been filled only to discover they have not.
“When President Obama decided everyone should switch to e-prescribing, it was like giving everyone a 500 horsepower car, but no highway to drive it on,” he explained. “Much more needs to be done.”
Rob Jensen, executive director of support services for the Munster-based Hammond Clinic, said most e-prescribing at the 72-physician practice is done voluntarily.
“But we’re in the process of converting to a newer and more complex electronic medical record and we’re going on line Oct. 1,” Jensen said. “We’re trying to stay ahead and meet the government criteria to be eligible for government funding to purchase these robust systems.”
Jensen said searching a patient’s formulary to determine whether insurance will pay for a drug “is now a cumbersome process. “We’re hoping … that by electronically sending prescriptions, it will reduce handwriting misinterpretations. We need to do a whole education process. But once all the local pharmacies are plugged in, it will be a big benefit to them as well.”
Trudy Tieman, practice administrator for Merrillville orthopedic physician John Diveris, M.D., said the solo practitioner switched to e-prescribing 18 months ago.
“We switched when we converted to electronic health records,” said Tieman. “We love it and the patients love it,” she said.
“It’s more convenient for them. Instead of waiting for it to be filled, or dropping it off and driving back, they just go pick it up, although we advise them to call first to make sure it’s ready. The minute Dr. Diveris writes it, it is automatically released.”
Dick Roskam, M.D., the chief medical information officer for the Sisters of St. Francis Health Services in Indianapolis, parent to five Northwest Indiana hospitals, said they believe e-prescribing is an important technological tool to improve patient care.
“And as a result of that belief we have invested in a state-of-the-art electronic health record now featuring e-prescribing that is now employed by 400 physicians across our network,” Roskam said.
He said e-prescribing has been around a while, but is not as widely adopted as people think.
“There are some very reasonable explanations for that,” he said. “The cost of acquiring a system for e-prescribing, while not excessively high, is yet another additional cost of operating practice. It’s a technology that works well when fully embedded in an electronic health record. But many doctors either have standalone e-prescribing program or programs poorly embedded in older electronic health records.”
He said a fairly high percentage of Indiana pharmacies were not ready until recently to do e-prescribing and were unable to accept e-scripts.
Indiana slow to adopt
Indiana has lagged behind other states, ranking 33rd in 2009 in e-prescribing adoption. But parts of Indiana are moving more rapidly than others. Todd Rowland, M.D., director of medical infomatics for Bloomington Hospital, said in 2003 only 3 percent of Bloomington physicians were e-prescribing, a figure that leaped to 60 percent by 2010.
Rowland said while most electronic health records systems offer e-prescribing as a feature, they charge doctors to make electronic transmissions.
“The physicians say they can fax the scripts for free or pay electronically and receive no benefit. They don’t want to subsidize those services for insurance companies, so many don’t electronically transmit their prescriptions.”
He said physicians are very time sensitive in their practices and new systems requiring more time or additional steps are often ignored.
Rowland said the drug interaction component of many current e-prescribing programs spurs a series of “annoying pop-up alerts, many of which are unnecessary,” he said. “We want doctors to receive the best possible information that is really meaningful to them at the point of use and doesn’t slow them down.”
Gloria Sachdev, PharmD, a clinical assistant professor at Purdue University’s School of Pharmacy and Pharmaceutical Sciences, said the cost of purchasing electronic health records and e-prescribing systems has posed a significant barrier to e-prescribing adoption.
“But with the federal subsidy incentive, cost is no longer the perceived issue. They have to change the way they’re doing things and most doctors don’t know which product to use. There is a fear of change. There are too many systems and too many products and some vendors don’t offer any training or support. If the doctors knew they’d have that support up front, they would be more accepting of change.”
Sachdev said ultimately the solution boils down to process reengineering and education. “We need to make it fit into their work flow.”
