Safe E-Prescribing: A Primer for Practices

When allergist/immunologist Melinda Rathkopf's paper-based Anchorage practice began e-prescribing three years ago as a first step toward adopting an EHR, the switch was stressful enough that it contributed to one of her physician colleagues retiring.

There were other headaches, from changing work flows, to debating such decisions as how many computers to purchase for every exam room.

"Work flow was really a challenge," says Rathkopf, who has been practicing medicine at Allergy, Asthma and Immunology Center of Alaska for six years. "Another big one was we had to get a variety of physicians at a variety of ages comfortable."

Another big challenge: getting pharmacies and patients on board. "Three years ago, a lot of pharmacies did not have e-prescribing," Rathkopf recalls. "We still have two or three that I can name off the top of my head that don't have e-prescribing. We still fax to them."

But although the benefits of e-prescribing far outweigh those of using paper prescriptions, most practices will find there are a few important adjustments and safety precautions that must be considered when making the transition.

The case for e-prescribing

Today, an estimated 317,000 office-based physicians (58 percent) actively e-prescribe, according to data released in May 2012 by Surescripts, which runs one of the largest certified e-prescribing networks in the country.

"It's been just tremendous, tremendous growth," says David Yakimischak, chief quality officer and senior vice president, and general manager of e-prescribing at Surescripts. "Physicians are digitizing. With it, the use of computers and technology and information systems is growing extremely rapidly."

It's easy to see why adoption has mushroomed. E-prescribing offers multiple advantages, most notably the elimination of handwriting errors. In a 2010 study of outpatient providers in New York conducted by researchers at the Weill Cornell Medical College, researchers found 37 errors for every 100 paper prescriptions, versus seven per 100 e-prescriptions.

"Physicians are often concerned, but the reality is e-prescribing is more secure than paper prescribing, and even faxing, because the transmission is done through a secure channel," says Tony Schueth, CEO and managing partner for health IT consultancy Point-of-Care Partners. "Hesitations about e-prescribing often stem from unfamiliarity. Common concerns include such things as stealing a password and hacking into a system, and really they're less of an issue than someone stealing a prescription pad."

There are other advantages, too.

"Physicians and pharmacists and their support staff spend considerably less time with the e-prescribing process once they get up to speed," says Schueth. "It also provides significant quality value by enabling the prescriber to have more information at the point of prescribing. There are [features] like drug-interaction alerts, formulary alternatives, suggested alternatives, clinical-decision support. Those are some of the features that you can add on to e-prescribing."

However, even with problems like bad handwriting out of the picture, errors still occur, and there are still certain safety precautions that need to be taken by your practice.

Safely switching

Even with all the advantages of electronic prescriptions, some physicians are still hesitant to make the switch.

"The reasons physicians don't e-prescribe [are] they don't want to use a computer, they don't want to have to pay for a program, or they've used a free program and they found it was horrible for their work flow … and they're afraid their staff isn't going to use the system," says Peter Kaufman, chief medical officer for DrFirst, Inc., a developer of e-prescribing software that can integrate with EHRs. "We have found that once people start electronic prescribing, they are hooked on it."

If your practice is ready to get started, the first thing you need to do is make sure you select a system that is certified to work with most e-prescribing networks.

"You want to use a program that is, in the very least, certified under meaningful use for the e-prescribing criteria. That will make sure that it does the drug-drug and drug-allergy checks," says Kaufman.

Next, physicians should test out potential e-prescribing systems.

"You want to try the program and make sure it's something you can use quickly and not slow you down too much," says Kaufman. "If it's too slow, the doctor is not going to use it, which defeats the purpose."

Watch your clicks

While e-prescribing eliminates most errors caused by manual prescribing, depending on the EHR or practice management system you are using, you could find yourself at risk for errors. One example mentioned again and again is errors related to drop-down menus, for example, when a physician is asked to put in the numeric value of a dosage.

"Some systems don't have a summary screen that says 'is this what you meant to write?'" says Schueth.

"With [older] systems, a prescriber could have written in '60 ml,' but the physician meant to write '600 ml.'"

With the newer systems, sometimes physicians might pull down a drop-down list and pick the value above or below the appropriate one by mistake.

Better e-prescribing systems now avoid this by having another line that displays the name of the prescription, so a physician can double check it, and then click the "use" button.

Another problem with legacy systems, as well as some newer ones, is alert fatigue, when so many "alert" messages pop up during prescribing that the physician begins ignoring them. The result could be catastrophic if a physician, by ignoring annoying alerts, doesn't check the alert displayed when a new prescription is incompatible with an existing drug the patient is taking.

Be prepared to regress

Ready to sign up for e-prescribing? Don't toss your prescription pad just yet.

There are going to be situations where making callbacks, using fax machines, and even writing or typing prescriptions on trusty, traditional pads is necessary.

For example, if a physician has a patient on a current course of a statin for their cholesterol and the physician wants to change or cancel the medication, the physician will need to use the change or cancel transaction feature in their automated system if they want to communicate electronically (if their system supports the change/cancel transactions).

"If however, the pharmacy they need to communicate with cannot accept a change or cancel transaction, or their EHR system is unable to send this transaction, it will have to be done manually by phone or fax," says Yakimischak. "In this case, the physician will have to manually add to the notes of a patient's chart after making any prescription changes."

At Rathkopf's practice, many of her patients' payers don't yet accept electronic prescribing, so she has to be ready to either prescribe by hand or call in prescriptions a few times per week.

"We cannot e-prescribe to the [Department of Veterans Affairs], to the native health system, or to the military, and up here that is a huge population … and we still can't do controlled substances up here," says Rathkopf. "Luckily in our practice we don't prescribe many controlled substances, but I have to hand-prescribe them. …I'm more concerned about security of my prescription pad than I am with electronic prescribing."

Marisa Torrieri is an associate editor of Physicians Practice. She can be reached at marisa.torrieri@ubm.com.

This article originally appeared in the October 2012 issue of Physicians Practice.