Rural physicians may face pharmacy hurdle in e-prescribing

A number of rural physician practices that decided to start e-prescribing share one common problem -- the local pharmacy's inability to accept the electronic transmission.

But practices should know they have options that will keep them paperless, experts say. Also, they just might have enough bargaining power to convince local mom-and-pop pharmacies to get connected.

The number of independent pharmacies, usually located in rural communities, accepting electronic prescriptions has doubled from a year ago, but they still lag far behind the big-name chains that virtually all accept e-prescriptions.

"I don't think you'll find small, independent pharmacies are fighting it and don't want to participate. I just think your big chains have large corporate offices and IT departments who are figuring all this out for them, and they say, 'Hey, we are putting these terminals in your pharmacy, and this is what you'll do,' " said Tony Purkey, executive director of American Health Network's Greenfield, Ind., multispecialty practice. "They have the support, where your small, independent pharmacies don't have that support and have to figure it out on their own."

But according to Rick Ratliff, president of the Virginia division of Surescripts, the e-prescribing health information exchange, even though those independent pharmacies are not yet connected, more than 97% already have the software. It's only a matter of flipping on the switch, he said. They are simply waiting for physicians to demand it, he said.

Marcie Bough, director of federal regulatory affairs for the American Pharmacists Assn., said many of the pharmacies haven't flipped that switch because there hasn't been a compelling business case made to do so.

That has been the problem physicians at Marshfield Clinic in Marshfield, Wis., have encountered with some local pharmacies.

John Melski, MD, a dermatologist at Marshfield Clinic and medical director of informatics, said the pharmacies are charged a transaction fee for every prescription received electronically. Many aren't willing to take on the extra costs if only a small percentage of their total prescription requests are received electronically.

Dr. Melski said Marshfield is new to e-prescribing and has not yet started a dialogue with the local pharmacies, but it intends to.

Bough said the pharmacies likely will want some assurance that a certain percentage of prescriptions will be coming in electronically to ensure that the upfront costs associated with e-prescribing are met.

Ratliff said demand from physicians is expected to increase thanks to the e-prescribing incentives now offered by the Centers for Medicare & Medicaid Services. The incentives, which kicked in Jan. 1, have resulted in a 39% jump in the number of physicians e-prescribing in the first quarter of 2009.

Dr. Melski believes that mom-and-pop shops eventually will have to comply now that they are competing with Wal-Mart, which tends to locate in rural communities and is connected.

One pharmacist in Purkey's practice area is using its connectedness as a marketing tool. Once those incentives kicked in, Purkey said, a small pharmacy in Greenfield sent a letter to the practice saying it was equipped to accept electronic prescriptions and encouraged the practice to choose it over its competition that was not yet connected. It worked.

Purkey said if patients don't have a preference in pharmacy, the physicians will send prescriptions to that pharmacy to avoid the hassle of sending a fax or writing a paper order.

Through the Surescripts network, physicians also can search for pharmacies that are connected or, if the patient agrees, the physicians can send an electronic prescription to one of the many mail-order pharmacies that now accept e-prescribing.

Dr. Melski said physicians at Marshfield have been taking advantage of another Surescripts service, which converts electronic prescriptions to faxes that can be sent to the unconnected pharmacies. He said the practice has to pay a transaction fee, but it's worth it, because sending the prescription this way counts toward qualifying for CMS incentive money.

Anne Burns, vice president of professional affairs for the APhA, said while faxing the prescriptions isn't ideal, it still allows some benefits of e-prescribing to be realized. Even though the end result is a fax, physicians are still creating an electronic medication history, and the faxed prescriptions help prevent errors caused by handwriting misinterpretations.

Surescripts offers downloadable letters that physicians can personalize to send to local pharmacies letting them know that they are now e-prescribing and how they can become connected to accept the prescriptions. It has information on its Web site for both physicians and pharmacists interested in becoming connected (link).