E-Prescribing – What’s the Problem?

The Center for Studying Health System Change (HSC) just published an Issue Brief entitled, “Even When Physicians Adopt E-Prescribing, Use of Advanced Features Lags.”  Since 2009, Medicare has offered financial incentives for successful e-prescribing physicians (see ACP’s summary of the E-Prescribing Incentive Program here and resources on AmericanEHR Partners here). The amount available for 2010 is 2% of allowable professional Part B Medicare charges under the Physician Fee Schedule.  The requirement is to use a certified system and document at least 25 prescriptions with that system during the reporting period.  Of course, as I documented in my July 16th post about Meaningful Use (MU), successful e-prescribing under the MU rule could be a critical component of satisfying several of the Core Set and a few of the Menu Set measures.  Reading the Issue Brief from HSC, however, I noted some statistics that are worth noting.

HSC’s data indicated that as of 2008, 41.9% of physicians in office-based ambulatory practice reported that technology was in place to generate electronic prescriptions – but 23.1% indicated that despite having the technology available, they only used it occasionally or not at all (i.e., only 76.9% of the physicians who had the technology used e-prescribing routinely).  As one might expect, larger practice were more likely to have the technology available versus small practices:  30.1% of solo practices up to 68% of practices with >100 physicians.  The utilization of available e-prescribing also varied by size of practice with only 68.8% of solo docs using it routinely to over 90% of docs in large groups.

However, HSC noted that only 64.5% of physicians routinely used the drug-drug interaction checking features; only 53.7% submitted prescriptions to pharmacies electronically, and 34.3% routinely used the formulary feature.  These are three “higher” features specifically addressed in the MU requirements for 2011.

HSC took their analysis a bit further and stratified the utilization of these three features (drug interactions, submission to pharmacies, and formulary checking) by whether the practices used a stand-alone e-prescribing product or an EHR with an e-prescribing capability.  The differences in utilization by the physicians were striking. Physicians in practices which used an electronic health record exclusively (i.e., not a hybrid paper/EHR system or paper alone) were almost twice as likely to use all three higher features than those physicians with stand-alone systems. In fact, 90.1% of physicians using EHRs used e-prescribing routinely versus 56.9% of paper-based practices – and remember that these are all practices with e-prescribing technology in their practice.

So, what is the problem with e-prescribing in practice? Is it the technology? Is it the variable uptake by mail order pharmacies and some retail pharmacies, the challenges with patient preferences (paper), or the new rules with electronic prescribing of Scheduled drugs?  Or do these data suggest that the integration of e-prescribing with EHRs is a critical factor implying a potential work flow issue with stand-alone e-prescribing systems? Or is it the commitment to the use of technology by practices that adopt EHRs  that accounts for the differences in e-prescribing versus those practices that have just invested in a stand-alone e-prescribing system?

What do these data mean with regard to the hope/expectation that practices will be able to successfully purchase/install/use certified EHR technology and qualify for the EHR incentives in 2011?

What is the problem with e-prescribing and how can we help physicians and other health care professionals to achieve the related meaningful use objectives?

This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.


2 responses to "E-Prescribing – What’s the Problem?"
  • July 27, 2010
    Arvind Cavale MD LLC

    Having been an electronic office for more than 8 years, I can safely say that the problems with e-Rx are:
    1) Significant delays at Surescripts, which unfortunately seems to be the only certifying body – clear bottleneck.
    2) Till recently, only those prescribers with a DEA # could access e-Rx via Surescripts – a non-starter for those of us that prefer not to use DEA # for scripts.
    3) Intrinsically, e-Rx is inflexible – both under the “Sig” area, and for generating variable scripts, such as when patients request a 30-day scripts to be sent to a local pharmacy and a 90-day script to a mail-order pharmacy. All these processes are simply too time-consuming to incorporate in a busy schedule.
    4) It is practically unrealistic to incorporate drug-drug check, formulary check, and transactions with more than one pharmacy into a busy schedule, especially when the average # of scripts for patients with chronic disorders is about 8.5!
    All those who tout e-Rx should actually demonstrate its utility in real-life situations before preaching to physicians in the trenches.

  • July 28, 2010
    Alan Brookstone, MD

    Arvind, it seems to me that what you have identified are a number of capabilities that need refinement once you hit the wall as a clinician and have to prescribe in a real practice setting. These types of issues should be openly debated, examining the pros and cons as well as the technical limitations and constraints that are currently in place.
    Do other physicians using e-Prescribing have the same problems? It will be interesting to hear from a range of users and determine if these are problems that all users are facing.

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