Choosing the Right E-prescribing Application

Terry Hashey, a family physician in Jacksonville, Fla., remembers how the e-prescribing application in his electronic health record helped him when a new patient presented at his office with an acute problem. She had just flown in from out of state to visit her daughter, and he knew nothing about her medical history. But by the time she'd filled out her registration form, he'd pulled up her complete prescription drug list by using the medication history feature of Surescripts, a company that connects his e-prescribing application online with pharmacies and pharmaceutical benefit management firms.

A patient's medication history, which shows which prescriptions were filled at area pharmacies as well, helps Hashey in a number of ways. He can use it to check on patient compliance, to see what prescriptions other physicians have written for his patients, and to detect "shoppers" who are after controlled substances. And when he writes an electronic prescription, the medication history operates in the background to alert him to potential drug interactions.

Hashey also likes his ability to do rapid refills and to obtain formulary information through his e-prescribing software. Overall, Hashey says, electronic prescribing is "the best part of the EHR for efficiency, work flow, and error prevention."

Al Juocys, who practices family medicine in Rochester, Mich., also loves his e-prescribing application, which is separate from his EHR. Juocys's e-prescribing application can be used with a patient portal that allows patients to view their medications and request refills online. The program also notifies patients when prescriptions are sent to pharmacies so that they can go pick them up.

Neither of these features is available within his current EHR, Juocys points out. Also, he was reluctant to use the EHR's e-prescribing module because his EHR vendor would have charged him a hefty fee for connecting with pharmacies through Surescripts. That link is included in his e-prescribing application's cost.

The downside of not using an e-prescriber integrated with his EHR is that every time Juocys writes a new prescription or a refill, he has to re-enter the information into his EHR's medication list. (He doesn't consider that a bother, however.) If you're considering getting into e-prescribing, a standalone application or one that's part of a bundle of connectivity services might be a good choice. The cost is substantially less than that of an EHR; it can help your office gain efficiency; and it can prepare you for the work flow changes that a full EHR will entail.

On the other hand, if you're going to get an EHR eventually, there are numerous advantages to using e-prescribing as part of an integrated system, including the automatic transfer of patient demographic data from your practice management system and the ability to view lab results when you're prescribing. The key is to make sure that the EHR you buy has a robust e-prescribing application. Here's a brief sketch of the landscape and some factors to consider in your decision.

Rapid adoption of e-prescribing

By the end of this year, according to Surescripts, about 200,000 physicians, physician assistants, and nurse practitioners will be prescribing electronically. That number represents nearly a 25 percent increase from the 156,000 clinicians who were e-prescribing at the end of 2009. The number of electronic prescriptions written this year is expected to hit 300 million, compared to 190 million in 2009.

Of the clinicians who prescribe electronically, 77 percent do so within EHRs, up from 70 percent in 2009. The high percentage of EHR use for e-prescribing can be ascribed partly to vendors' upgrades of existing customers so that they can send their prescriptions online to pharmacies, says Kevin Hutchinson, the former president of Surescripts. Hutchinson, who is currently CEO of Prematics, a vendor of standalone e-prescribing software, also notes that many standalone products that connect with Surescripts have either been broadened into "lite" EHRs or incorporated into some of the leading full-featured EHRs.

On the other hand, 80,000 prescribers, including 50,000 doctors, have downloaded a free standalone e-prescribing product, sponsored by the National ePrescribing Safety Initiative (NEPSI). That's according to Lee Shapiro, president of Allscripts, which makes the software. In addition, he notes, many hospitals and integrated delivery systems are sponsoring a slightly different Allscripts e-prescriber for their staff doctors. Some health plans are sponsoring other e-prescribing solutions, including Prematics. So there are inexpensive choices out there that don't require you to get an EHR.

Another advantage of a standalone product is that Medicare is now offering an incentive for e-prescribing. Nevertheless, fewer physicians are now considering standalone e-prescribing applications, practice management consultants say. Most doctors are more interested in the government incentives for showing meaningful use of qualified EHRs, which begin next year. With $44,000 to $64,000 per physician on the table for achieving meaningful use, Medicare's 2 percent bonus for physicians who prescribe electronically - which turns into a penalty in 2012 if you don't e-prescribe - looks like chump change.

"It's good if doctors are thinking about getting an EHR, because it will prevent that penalty for not e-prescribing," says Rosemarie Nelson, an MGMA consultant. "But they're focused on the $44,000."

Meaningful use counting

To show meaningful use, physicians will have to attest that they're sending at least 40 percent of their "permissible" (non-controlled substance) prescriptions electronically. Nelson suggests that doctors look for EHRs or standalone applications that will automatically count qualified prescriptions for them and create a report. Referring to the 90-day period in 2011 in which physicians must demonstrate meaningful use, she says, "You don't want to wait the 90 days and find out that you didn't qualify for the incentive."

Shapiro says it's no big deal if your EHR doesn't count electronic prescriptions. If doctors e-prescribe routinely, he says, they'll easily surpass the minimum. "Providers aren't going to count patients and decide that since they already met that level today, they are not going to e-prescribe for the rest of the day."

Controlled-substance app coming

Physicians have long groused about the legal ban on prescribing controlled substances electronically, which creates a dual work flow for them. In June, the federal Drug Enforcement Administration (DEA) adopted new rules that permit the process, but pharmacy groups have requested clarifications.

The sticking point in the addition of controlled substances to e-prescribing is the lack of a standardized protocol for authentication. DEA has specified the general requirements, but Surescripts is working out the details in conjunction with pharmacies and the leading EHR and e-prescribing vendors. Once that's done - assuming that certain states don't throw up additional roadblocks - the vendors should be able to quickly add the necessary fields to their applications, and physicians could prescribe controlled substances online. Shapiro thinks that this will happen sometime in 2011.

How to get started

Let's say you've decided you want to prescribe electronically, but you're not ready to make the leap to an EHR. Where do you begin?

The first step, according to Cindy Dunn, a senior MGMA consultant, is to understand what's involved. "Whether you buy the e-prescribing software or get it for free, you still have to put a computer network in your practice," she points out. "You have to get computers and you have to create a work flow to utilize this electronic piece. It's more than just purchasing the software. You're going to have to change what you do within your practice."

Installing a computer network and wiring offices can be costly, Dunn notes. Also, she says, outside IT support can run $150 to $200 an hour. Free e-prescribing software might entail extra charges for a Surescripts connection or upgrades. In a small practice, however, e-prescribing need not cost a fortune, Nelson says. The license fee for standalone e-prescribing software isn't expensive - for example, she points out, an average vendor charges roughly $600 per provider per year for its program and a Surescripts connection.

A small office can set up the required gear fairly easily, according to Nelson. If your nurse already uses a desktop PC, she says, you just need a portable device that you can carry from one exam room to another. A computer tablet or laptop will set you back about $1,000, and you can buy a business-grade wireless network and have it installed for under $1,000. If you have two nurses who share a computer, you might have to spend $600 on a second PC. An average vendor might charge about $500 for a one-time download of patient demographic data from a practice management system. So, if you don't mind entering the demographic and insurance data for new patients into the e-prescribing application, you can put together an e-prescribing system for around $3,000.

MGMA estimates manual prescribing costs are about $15,000 per provider per year, including the labor expense of office staff fielding calls from pharmacies. By shifting staff around or even reducing the number of FTEs, Nelson says, a practice can recoup the initial cost of e-prescribing within six months.

Brave new world of iPads

More and more doctors are using iPads and smart phones in their clinical work. These devices, which have plenty of computing power for e-prescribing, can connect with the Internet via either Wi-Fi or a cellular network. That means that a doctor could prescribe electronically without access to a wireless network.

But Nelson points out that there are security problems involved in working outside the practice's computer network. Not only does the browser need to have a secure connection, but patient data that remains in the iPad or smart phone memory must also be erased regularly. In addition, she points out, you can't download demographic data from a practice management system or share data with a partner unless your device is on the network.

Most doctors who prescribe through their EHRs are still using old-fashioned wired PCs or laptops or tablets that are wirelessly connected to a network. If you decide to use an iPad for e-prescribing, you can select the Wi-Fi option and stay in the network.

Other features to look for

A robust e-prescribing application, whether standalone or part of an EHR, should include good decision support features. These would include the ability to choose medications from a comprehensive therapeutic list and to check the drug you want to prescribe against the patient's other medications for potential adverse interactions. Hashey likes his EHR's e-prescribing drug-disease checker, which warns him, for example, not to prescribe NSAIDs to a patient with stomach ulcer.

Physicians tend to dislike overactive alerts in e-prescribing programs, notes Dunn. But Hashey says that in his EHR, he can adjust the level of alerts, and he's moved them to the highest level so they can't slow him down.

You should also make sure that your e-prescribing program can be connected with Surescripts so that you can send prescriptions online to pharmacies. This virtually eliminates the chance of error at the pharmacy, because the pharmacist doesn't have to manually enter your prescriptions into her system. Since pharmacists can also send refill requests online, it reduces the work for your staff and the burden on your phones.

Surescripts, which says that it links medical offices to 90 percent of the pharmacies in the country, provides medication histories and benefit and formulary information for about two-thirds of U.S. patients. But less than a quarter of e-prescribing applications that can send scripts online to pharmacies are capable of downloading both patient histories and formularies, according to Surescripts. Hutchinson says all of the major EHRs can do this, but this is an area where due diligence would serve you well.

Electronic prescribing can be one of the most rewarding and effective ways of moving your office toward paperless systems, and is one of the easiest applications to master. Whether you e-prescribe in an EHR or do it with standalone software, you'll reduce the chance of prescribing errors, make your office more efficient, and please your patients by having prescriptions ready to pick up at the pharmacy when they arrive. But remember that e-prescribing will require changes in your office processes. As Hutchinson says, "It's not just about the software, it's about the work flow."

In Summary

The big question around e-prescribing is not whether you should do it, but how your practice should do it. Should you choose a less-expensive, standalone e-prescribing application or an e-prescribing module that is integrated into your EHR? Here are some points to consider:

• If you are already considering purchasing an EHR to qualify for the government incentives, it might make sense to use an e-prescribing module within your new system.

• If you don't plan on moving to an EHR in the near future, adopting standalone e-prescribing software can help you get your practice inexpensively outfitted to help prepare you for later technology adoptions.

• With either choice, making sure you have the proper computer equipment, network connections, and new work flows in place is crucial to e-prescribing success.

Ken Terry is a New Jersey-based freelance writer and the author of the book "Rx for Health Care Reform." He can be reached at editor@physicianspractice.com.

This article originally appeared in the January 2011 issue of Physicians Practice.