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While many practices adopt e-prescribing as a way of trying out the technological waters before jumping into an EMR, it's more common for practices that already have electronic medical records to initiate prescribing electronically as well.

Implementing e-prescribing within an EMR presents challenges that differ from those of implementing a stand-alone system, experts say.

A recent study by the Center for Improving Medication Management looked at characteristics of both high- and low-performing practices. CIMM was able to identify drivers of success, as well as common problems many practices struggle with during the process of implementing e-prescribing within an EMR.

"It's interesting to see how it is challenging to automate the prescribing process, and even more challenging to do so within an EMR," said Kate Berry, senior vice president of SureScripts-RxHub and the executive director of CIMM.

The center was founded by SureScripts-RxHub, the American Academy of Family Physicians, BlueCross BlueShield Assn., Humana, and the Medical Group Management Assn., all of whom have seats on the organization's board.

Berry said e-prescribing often gets shortchanged when it comes to automating an entire practice at one time. Either the vendor has spent less time developing the e-prescribing component, or less time is spent training physicians and their staffs to use it.

Among the problems that low-performing practices have in common, CIMM found, are inadequate training, an inability to address technical problems, and awkward workflow created by the prescribing applications.

Physicians "want to be successful with e-prescribing, and are committed and believe in the technology and its ability to deliver higher-quality and more efficient care to their patients, and they definitely want to make it work," Berry said. "The biggest challenge is they don't know where to run to for help when they run into technical or workflow issues.

"In particular, support is referred to universally as the 'black hole,' " Berry said. "It's a gap that needs to be filled, especially for the implementation phase. That's where medical organizations and groups can help."

Steven Waldren, MD, director of the AAFP's Center for Health Information Technology and a CIMM board member, said physician organizations have been providing as much information as possible on the processes involved with technology deployment. "But we have struggled with how to provide that last mile of support."

The difficulty has been figuring out how to offer meaningful support to physicians, Dr. Waldren said, given the diversity of available software and hardware.

While many adoption challenges could be eliminated by choosing the right vendor or system, that's not always the case. The report found examples of similar-size practices that had used the same vendor with varying levels of success.

The CIMM study suggests one indicator of success could be timing.

Sandy Cave, practice administrator of Herndon (Va.) Family Practice, which participated in the study, said implementing e-prescribing a year prior to an EMR gave the physicians an opportunity to realize the benefits of the technology and figure out how it would change their workflow.

Mark Wallace, MD, an internist in a four-physician internal medicine practice in Phoenix, adopted an e-prescribing system as a first step into full-fledged EMR adoption.

"I think having a narrow scope of this process has been good. It's been able to give the staff more experience with the electronic aspect of taking care of patients, without it being so encompassing that the learning curve is too steep," said Dr. Wallace.

While Berry said she doesn't think the decision should be either e-prescribing or full EMR, she does believe e-prescribing can be a beneficial first step, especially for small primary care offices.

The CIMM study found that high-performing practices communicate the benefits of e-prescribing not only to physician colleagues, but also to patients and local pharmacies. And as more new prescriptions are sent electronically, more electronic refills follow.

James Morrow, MD, one of 13 doctors at North Fulton Family Medicine in Cumming, Ga., said communicating e-prescribing benefits to his patients has not only led to more patients requesting e-prescriptions, but also has put competitive pressure on pharmacies that aren't yet accepting them.

Dr. Morrow said when he offers a patient the option of taking a paper prescription to the pharmacy and waiting for it to be filled, or having him send an e-prescription so the medication will be waiting when the patient arrives, the patient generally chooses the latter. So his practice writes fewer paper prescriptions every month, and pharmacies that don't accept e-prescriptions are losing business.

The CIMM study suggests practices should gather and analyze cost and utilization data associated with paper versus e-prescribing in order to make a case to physicians who are on the fence. In addition, creating sensible workflows that save physicians' time also will prompt higher use.

Much of this effort comes down to leadership and commitment.

"Every practice needs a champion, but also someone in each department to talk about the beneficial aspects of each technology," Dr. Morrow said. "They are gung ho and are able to talk to people about, 'I did this and [I] did that.' "

With Medicare incentives for e-prescribing set to take effect Jan. 1, 2009, there has been a larger push to get physicians to adopt the practice. Organized medicine has been involved in that effort.

The AMA, along with other medical organizations, published "A Clinician's Guide to Electronic Prescribing," which offers tips on adopting and using e-prescribing systems http:/www.ama-assn.org/ama1/pub/upload/mm/472/electronic-e-prescribing.pdf.

Twelve medical societies, including the American Academy of Family Physicians, offer physicians advice and tips on e-prescribing through GetRxConnected (www.getrxconnected.org).

Dolan is a business reporter. She can be reached at 312-464-5412 or by email (pamela.dolan@ama-assn.org).

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