E-prescribing stumbling blocks

The fits and starts of electronic prescribing systems show why their use and development should be encouraged but not mandated.

Posted March 5, 2007.

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Medical information technology offers great promise to improve the efficiency and quality of health care. But it takes some time for promise to equal reality.

A much-touted technology that has been slow to live up to its potential is electronic prescribing.

E-prescribing has been around for years, and it is often promoted as a relatively inexpensive way -- at least compared with electronic medical records -- to use information technology to provide better care. State-of-the art systems allow a physician to send a prescription wirelessly from a handheld computer to a pharmacy computer. It also can alert a physician during the prescription-writing process of any drug interaction problems.

In short, e-prescribing is looked upon as the more efficient, safer and -- given the spotty reputation of physician handwriting -- neater replacement for pen and pad. Even in 2003, the U.S. House of Representatives was so confident in e-prescribing's potential and progress that it passed a measure (which got rejected by the Senate) requiring its use as a condition of participating in Medicare.

But in 2007, it seems that little progress has been made in creating workable systems that will do what their proponents say they can do. As such, e-prescribing provides a good case study illustrating why the AMA has warned against costly physician mandates to adopt not-ready-for-prime-time technology.

As it turns out, e-prescribing in practice is much more complicated than e-prescribing in theory. Right now, e-prescribing does not have established technology standards. There's no ensuring that a system can talk to any EMR or pharmacy computer, or that patient information is protected. Meanwhile, physicians face what one AMA leader rightly called a "dizzying array" of vendor choices, many of them small, unknown companies.

Anti-kickback regulations and Stark laws were loosened to allow hospitals to provide physicians with e-prescribing systems. But such donations have been held up, because the Internal Revenue Service has warned nonprofit hospitals that giving physicians technology could violate their tax-exempt status. Health plans are issuing systems to physicians, though results are mixed, as some physicians question whether it is wise to take technology from what they consider an unfriendly foe.

Also, workflow issues have not yet been streamlined. A paper prescription gets to the pharmacy more slowly than an e-prescription. But a patient can take a paper prescription to the pharmacy of his or her choice, rather than a designated, specific location. In some cases, an e-prescription can't even get from computer to computer. Instead, a pharmacy gets a fax, which is less efficient.

Some of the systems have other inefficiencies. For example, some have long drop-down lists containing every medication imaginable, rather than only the most-prescribed medications, with less-prescribed drugs on a separate list. Also, some systems check for drug interactions all too well. For example, if a patient is taking aspirin, some systems always pop up warning screens, even though in the vast majority of cases the interactions are noncritical.

These problems with e-prescribing are not insurmountable. A big boost could come by April 1, the Centers for Medicare & Medicaid Services' deadline to report on the result of an e-prescribing pilot that ended at the start of this year. If CMS endorses technology standards set by the National Council for Prescription Drug Programs, that at least could help ensure that all systems will be made with the same backbone.

Also, more vendors are becoming more established, and they are responding more to physicians' requests to make systems smarter so that doctors don't have to plow through a large list of medications to get to the one they want, or that they get only the drug interaction warnings that are truly important.

Practices that have adopted e-prescribing on their own often report reducing prescribing errors and practice costs. Even so, the e-prescribing decision is one that a physician must make based on the situation at his or her individual practice. Many wisely have chosen to hold off on a well-promoted promise that has yet to pass the reality test.

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