5 obstacles to e-prescribing: 5 approaches to overcoming them

While they've been around for years, online prescriptions are still a long way from replacing the written pad. Physicians and others tell how to change that.

By Tyler Chin, amednews staff. May 12, 2003.

Edward Zabrek, MD, is such a believer in electronic prescribing that he chose to pay for a new system after the company providing his old one for free went bankrupt. "I chose to pay because I had used an e-prescribing system before, liked it and didn't want to live without it," said Dr. Zabrek, a solo obstetrician-gynecologist in Houston.

But most physicians aren't as enthusiastic about e-prescribing, in which a medication order is transmitted from the physician's computer to a pharmacy computer, rather than written on a pad and handed to the patient. Although ambulatory e-prescribing technology has been around since the late 1990s, only a fraction of physicians are using it.

Underutilized
See related content

Several technology-savvy physicians interviewed by American Medical News identified five key reasons why it will be years before most doctors adopt e-prescribing:

Obstacle 1: Physicians can't afford the technology.
Potential solution: Someone else must pay for or subsidize the up-front cost.

Cost is the biggest turn-off for doctors. The e-prescribing companies that sprouted up in the mid- to late 1990s sold stand-alone information systems that did not work with physicians' practice management systems. That meant doctors had to pay thousands of dollars to integrate the different systems -- on top of the cost of the technology -- or manually enter data twice, said Kent E. Willyard, MD, a family physician with a 40-doctor multispecialty group in Newport News, Va.

E-prescribing systems can cost physicians thousands of dollars to set up and maintain.

Prescription pads don't cost doctors a cent, he said, but an e-prescribing system can cost thousands of dollars to set up and maintain.

"When you're looking at doctors who are in survival mode, struggling to pay employee salaries, covering their overhead and dealing with rising liability and employee insurance costs -- not to mention your own health insurance -- the last thing we want to do is take something we're currently able to do at essentially no cost and pay for it," Dr. Willyard said.

Obstacle 2: There is no direct benefit to doctors.
Potential solution: Those who do benefit could offer financial incentives to physicians.

E-prescribing is a tough sell to physicians because it requires them to absorb the full cost of a technology that benefits everyone but them. It saves time and money for insurers, pharmacies, pharmacy benefit managers and employers, but at physicians' expense, said J. Marc Overhage, MD, PhD, senior scientist with the Regenstrief Institute, a research organization active in medical informatics and affiliated with the Indiana University School of Medicine in Indianapolis.

Many physicians find it more time-consuming to enter new prescriptions on computers than to write them on paper.

D.C., Michigan, New Jersey and North Dakota ban e-prescribing, all other states allow it.

But eventually it becomes quicker, said Dr. Overhage, an emergency physician who prescribes electronically. Once a physician has entered new prescriptions for all patients into the computer system, the "refill cycle" can be handled quickly. But since it takes at least six months to reach that point, most doctors won't make the sacrifice, assuming they even agree that e-prescribing could help in the long run, he said.

"When you can see a quick level-3 patient in five minutes, depending on whether the patient has something fairly straightforward, spending five minutes doing something for which you get no reimbursement is a complete waste of time," Dr. Willyard said.

The e-Health Initiative, a nonprofit entity, recently assembled several industry players who are looking to recommend that those doctors who stand to benefit the most from e-prescribing efforts should offer incentives to encourage doctors to adopt e-prescribing in the outpatient environment.

These incentives could include paying doctors for writing electronic prescriptions and offering discounts on medical liability insurance premiums.

"Incentives must be realigned for adoption," said Peter Basch, MD, an internist and medical director of e-Health initiatives for MedStar Health, a Columbia, Md.-based health system that is planning to test electronic prescribing with 200 doctors. "Physicians are so time-strapped that adding time, even necessary time, to an already rushed encounter without some extra incentive will not be accepted by them."

But getting organizations to dole out incentives will also be difficult.

"So far, we haven't seen any improvement or that there's anything to be gained" from electronic prescribing and other forms of electronic medicine in terms of reducing malpractice awards, said Mark Gorney, MD, medical director of The Doctors Company, a medical liability carrier in Napa, Calif. "At a time when we're at a crisis, we don't see any advantage in offering discounts for e-medicine."

Obstacle 3: The technology is poorly designed and more inefficient than the paper-based system it's supposed to replace.
Potential solution: Companies should design technology that reflects how doctors work and offers them many benefits in a seamless package.

The issue of efficiency is more than a matter of how much time a physician may spend inputting a prescription. It's also a matter of what happens after that prescription is sent.

A doctor who gives a patient a paper prescription doesn't have to worry about dealing with equipment failures or other transmission glitches in the office or pharmacy. And they don't have to worry about re-sending prescriptions if a patient's preferred pharmacy can't fill the order or was closed when the prescription was sent, said Andre Chen, MD, a family physician in Austin, Texas.

"The main problem with e-prescribing is that it's a technology that seeks to replace a simple process with a much more complicated process," he said.

To complicate matters further, most pharmacies can't accept electronic prescriptions. So many e-prescribers end up typing, printing and faxing their prescriptions to the pharmacy.

Even when a pharmacy can accept the order electronically, patients may not pick up their medicines. Dr. Overhage and his colleagues ran into this problem a decade ago, when their attempt at electronically transmitting prescriptions to an Indianapolis-based pharmacy chain stopped after six months.

"Pharmacies had spent time processing, filling prescriptions and restocking, but the patients didn't show up to get them," Dr. Overhage said.

Even so, more than 20,000 pharmacies around the country have agreed to accept electronic prescriptions through SureScript Systems Inc., which aims to facilitate these transactions between physician offices and pharmacies

Since its launch in 2001, SureScript has been working to develop both software and a network, and to strike deals with technology companies that sell pharmacy, physician practice management and electronic medical records software. Most of the country's major pharmacy chains have agreed to use SureScript's network, but the company hasn't made much progress in signing up technology companies.

Obstacle 4: There is a lack of interoperability.
Potential solution: Companies should seek a wider adoption of clinical data standards so different information systems will work with each other.

Many technology firms don't embed the voluntary standards developed by health care standards organizations, or they use different versions of the standards.

In March, the federal departments that deliver health care services -- the Dept. of Health and Human Services, the Dept. of Defense and the Dept. of Veterans Affairs -- announced that they will adopt a set of standards that will make it easier to exchange data and thus improve patient care. Although the government isn't mandating that others adopt the same standards, the move "sends a strong signal to the rest of the industry," said Janet M. Marchibroda, e-Health Initiative's CEO.

She believes that the industry will follow along. "A lot of the private folks we work with -- vendors, hospitals alike -- say, 'Yeah, we all know that we need data standards because we spend a ton of money [integrating systems] due to the lack of interoperability, but we really need a signal about what is the right standard.' "

Obstacle 5: There are regulations that ban or can be interpreted to ban e-prescribing.
Potential solution: The federal government needs to develop laws facilitating both e-prescribing and a clearer understanding of the applicability of the Health Insurance Portability and Accountability Act.

When electronic prescribing companies surfaced in the late 1990s, it was illegal or unclear whether it was legal to transmit prescription to pharmacies via computer. But over the last three years, most states have amended or added regulations allowing e-prescribing.

Today, only the District of Columbia, Michigan, New Jersey and North Dakota do not allow prescriptions to be transmitted to pharmacies' computer systems, said Carmen Catizone, executive director of the National Assn. of Boards of Pharmacy.

But some physicians think the privacy provisions of HIPAA, which took effect April 14, may keep doctors from adopting the practice in the short term. Doctors already struggling with the rules don't want to make compliance harder by dealing with third parties, Dr. Chen said.

"I don't have to worry about HIPAA compliance when I write and give the patient a written prescription," he said. "There are enough HIPAA things to worry about. Why would I want to worry about doing something else if I don't have to?"