Electronic prescribing and Medicare: Let the doctor decide

Don't force physicians to buy and use unproven e-prescribing systems.

Editorial. Nov. 3, 2003.

When it comes to electronic prescribing, the federal government should not shoot off mandates first and ask questions later.

Yet that is what the House of Representatives is proposing as part of its Medicare reform bill. The bill contains a measure that would require Medicare officials, with help from an advisory panel, to establish electronic prescribing standards by Jan. 1, 2006. Then starting in 2007, physicians would be required to write electronic prescriptions for all Medicare patients, except in emergencies or certain other cases.

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Topic: HIPAA

The idea of setting technological standards is commendable. After all, it's much easier to adopt a technology if everyone is comfortable that information can transfer from point to point without glitches. But requiring use of a technology that may not be ready for prime time, even in four years, is not so laudable.

That's why the AMA and numerous medical societies are pushing for adoption of the Senate's version of the electronic prescribing measure as House and Senate conferees meet.

The Senate bill would require standards by the same date as the House bill, but it would allow physicians to choose whether to prescribe electronically.

There are many reasons that this is the wiser course. The first is that developing and implementing any technological standards is a difficult, time-consuming process.

In an Aug. 26 letter to House Ways and Means Committee Chair Bill Thomas (R, Calif.), the AMA and 46 specialty societies pointed out that Congress passed the Health Insurance Portability and Accountability Act in 1996, yet transaction standards had yet to be fully implemented. That's seven years.

Another example, which was not in the letter, is that since 1998, the Drug Enforcement Administration has met with the AMA and others to develop an encrypted electronic prescription system for schedule II and other controlled substances. The DEA has yet to issue a notice of proposed rule-making to begin any implementation. That's five years.

And yet the House expects standards implementation to take only a year?

The House bill doesn't explain, for example, how electronic prescribing will interact with the final HIPAA security standards, due to be implemented in 2005. Nor does the House bill explain how prescribing systems would be linked to a broader electronic medical record, a necessity given that the bill requires the ability to transmit information about the medical history or condition of the patient. And by the way, there is no standard for electronic medical records.

So under the House bill, physicians are put in a position of spending big money to buy unproven systems to meet the House's requirement.

The AMA has calculated that a typical five-physician practice would spend -- all out of its own pocket -- a staggering $140,000 over five years for even a modest e-prescribing system, figuring in hardware, software, training and maintenance. The burden could be greater on rural physicians, who may not have access to the high-speed data service providers and trained information technology experts available to their urban and suburban colleagues. Those small and rural practices don't have the economies of scale to make back that investment.

This is assuming a truly workable system. While the Senate has set a deadline for coming up with standards, at least its bill would not force physicians to adopt a technology that has not proven itself in the real world.

Development and pilot testing are essential to determining that the standards work, and in the technology world, that is done by interested groups of early adopters, and there are relatively few of them. According to SureScripts, a company developing standards between pharmacies and physicians, only 9% of physicians now prescribe electronically.

Electronic prescribing has the potential to reduce medication errors and minimize telephone tag with pharmacists, but it is a nascent technology. Physicians are right to question a House approach that is too quick on the trigger.