Panel weighs competing views on federal e-prescribing standards

Washington -- Patricia Hale, MD, an internist from Glen Falls, N.Y., wants the ability to prescribe electronically.

Several years ago, she test-drove several commercial e-prescribing systems in her rural practice in the Adirondack mountains. But none of them were viable.

They didn't operate well with her practice management software, forcing her to re-input patient information. Formulary information from insurance companies, if available at all, was quickly out of date. And though Dr. Hale knew local pharmacies wouldn't be able to accept electronic prescriptions, she thought she could at least fax the prescriptions. But the pharmacies that had fax machines were unwilling to commit to checking them on a regular basis.

"It turned out because of all those things, it wasn't worth using," she said. "It took longer to do it than it did writing them by hand with no real reward to it."

The federal government is now working to resolve many of the problems Dr. Hale faced in trying to bring electronic prescribing to a small-practice setting. But myriad competing interests and a high level of complexity has left government officials with a lot to accomplish in a short amount of time.

The Medicare Modernization Act of 2003 directed the Dept. of Health and Human Services to develop standards for electronic prescribing by Jan. 1, 2006, and then to pilot-test them and have them ready for voluntary adoption nationwide by 2009. That would allow systems developed by different companies to interact with each other.

To assist HHS, Congress charged the National Committee for Vital and Health Statistics, a government advisory panel, to seek input from physicians and other health practitioners to make recommendations on how to create the standards.

Meanwhile, health care information technology has become a priority for the Bush administration, which sees a potential to reduce medical errors and save the system money. Earlier this year, President Bush announced a 10-year goal of creating electronic health records -- which could provide the basis for e-prescribing -- for all Americans. Speaking at the Vanderbilt University Medical Center in Nashville, Tenn., in May, the president said that despite the technological advances in health care, prescribing remains an anachronism.

"One of the amazing discrepancies in American society today is we're literally changing how medicine is delivered in incredibly positive ways, and yet docs are still spending a lot of time writing things on paper," he said. "The ability to make sure we prescribe the right drug and the right dosage can be controlled by the proper use of medical records, which is really important and cost-effective."

Focus on doctors, patients needed

NCVHS began collecting input on e-prescribing standards during a three-day meeting last month that spelled out many challenges. The committee heard testimony that software developers, pharmacy benefit managers and insurance plans often have different expectations for e-prescribing systems than do physicians and patients.

The new law allows third parties to fund e-prescribing systems on behalf of doctors, but that funding could shape these systems in a way that distorts medication choices toward the third parties' interests, Douglas Bell, an associate natural scientist at Rand in Santa Monica, Calif., told the panel.

"Recommendations are therefore needed to ensure that electronic prescribing systems meet patients' needs for better health outcomes and a greater ability to manage their own costs," he said.

Bell recently convened a panel of health care experts that came up with 60 recommendations for creating effective e-prescribing standards. About two-thirds of the suggestions, published on the Web site of the policy journal Health Affairs, were deemed achievable in the average physician's office within three years.

That's a far cry from the current situation. Doctor groups, including the AMA, testified that today's e-prescribing products are geared toward larger organizations that can afford complex information technology.

"There seems to be a lack of focus on the necessity for vendors to incorporate the specific needs of the practicing physician in the ambulatory care setting," Jean Nacisi, AMA director of electronic medical systems, said at the hearing. "Development of a single set of standards appropriate for all health care delivery situations will be a significant undertaking."

Government standards must be flexible and adjustable to the scale of the user to encourage adoption in both small and large health care groups, and by physicians from both high- and low-volume prescribing specialties, she said.

Dr. Hale, who testified on behalf of the American College of Physicians, said it was critical that the e-prescribing system not include elements that would permit plans or pharmacy benefit managers to influence the choice of medications. E-prescribing should facilitate prior approvals, she said.

"There's no interest on the health plan side to do that because the more obstructions there are, the less likely physicians are to prescribe it," she said.

The physician groups also stressed that e-prescribing could be implemented successfully, but only if it doesn't become a burden for physicians. Doctors need adequate funding to implement the systems, and the systems should be able to convey special dosing instructions or other critical information within the electronic submission, the groups said.

"Physicians are not opposed to e-prescribing. We absolutely want these things," Dr. Hale said. "I would have this in my office tomorrow if I could. It's a concern about being able to do it right and not spend the time that we've been spending for things that don't work."