Implementing E-prescribing

Meaningful use is a term that has drawn harsh emotions from many physicians. To get federal incentive money for using an electronic health record system, practices have to meet a laundry list of criteria - some of which are not very meaningful to the physician in the exam room. Our practice, despite the fact that we have been using an EHR since 1996, has had to dedicate a lot of time and effort to make sure we qualify for incentive money. However, one area that we haven't found onerous is e-prescribing. E-prescribing, the electronic transmission of a prescription from the provider to the pharmacy, has not only improved the efficiency of our practice, it has improved quality at the same time. This is a rare combination that makes adoption much easier than other parts of EHR.

The benefits

Why do I paint such a positive picture? Here are the benefits we have seen:

1. Immediate transmission -The prescription sent by the provider is immediately received by the pharmacy. This means we can tell patients "the prescription is at the pharmacy already." This eliminates the possibility of patients losing prescriptions or simply not filling them.

2. Accurate transmission - The prescription sent to the pharmacy is exactly what appears in the provider's record. There is no question of illegible prescriptions or transcription errors that can occur with written (or even faxed) prescriptions.

3. Refill requests - These come directly to the provider's desktop from the pharmacy, allowing immediate assessment and response. This greatly streamlines the process, eliminating phone calls from the patient and time spent by the nursing staff on follow up.

4. Formularies - When working properly, e-prescribing taps into the patient's insurance plan and pulls up the proper formulary, informing the prescriber if the medication is covered and suggesting formulary alternatives if it is not. This greatly reduces aggravation for physicians, nurses, and patients.

5. Access to filling history - Patients often come from a specialist or a hospitalization with new prescriptions, and often don't remember the changes that were made to their medications. E-prescribing systems tap into pharmacy databases - showing recent prescriptions filled by the patient, the provider's name who prescribed them, and the pharmacy they were filled at. This is a very useful tool when dealing with "drug-seeking patients," who will ask multiple doctors to prescribe controlled drugs, and then use different pharmacies to fill the prescriptions so they can hide their usage. I have personally used this information to expose this illegal behavior in several of my patients.

The negatives

Despite the rosy picture I paint, there are some negatives:

1. No "take back" feature - If the prescription is sent to the wrong pharmacy, there is no way to electronically cancel that prescription. The pharmacy must be notified by phone that the prescription was sent in error.

2. Duplicate refill requests - Pharmacies don't always make note of refill responses from physicians, resulting in duplicate (or more) requests for the same medication. At my practice, this improved after a few irate phone calls to the pharmacy, but still remains a problem.

3. Lack of formularies - The promise of full formulary integration is sadly not yet fulfilled. The accuracy of the formulary is not near 100 percent, and even when correct, our system will reject prescriptions written in the brand name instead of the generic. Both doctors and patients often refer to the medication by its brand name, so this causes some confusion.

4. Controlled drugs - Despite the fact that e-prescription of controlled drugs eliminates the chance of forgery, losing prescriptions, or having them stolen, this practice hasn't been approved in most states. Those that have approved it, require extra authentication that adds extra work on the part of the prescriber.

Implementing e-prescribing

Implementation depends on what system is being used. There are stand-alone e-prescription products, but since this doesn't count toward meaningful use incentives, I'll focus on those products integrated into the EHR. Here are some tips on having a smooth implementation.

1. Set reasonable expectations - The first step in implementation is to know the benefits and the negatives. Users will put up with a new system if they see enough benefit, and will deal with negatives better if they know about them in advance. Visiting another practice that is well versed in using your chosen e-prescribing system is key; assuring a smooth adoption process. Don't depend on vendor demos!

2. Stack the deck - Don't introduce e-prescribing to reluctant physicians before you have first tried it with those who are more enthusiastic. Let the enthusiasts work through the bugs before releasing it to all providers.

3. Don't forget about nurses - In our office nurses write as many, if not more, prescriptions than physicians. Depending on the office, nurses may be more or less accepting of this change. Be sure to involve nurses deeply in the implementation process.

4. Revisit after implementation - Always give users a chance to look back and list pros and cons for the implementation process. This will not only improve future implementations, but will make users feel listened-to.

Robert Lamberts, MD, who is board-certified in internal medicine and pediatrics, practices in Augusta, Ga. His practice won the 2003 Davies Award for outstanding application of IT in a primary-care setting. Dr. Lamberts can be reached at rob.lamberts@gmail.com.