Operations: Managing Prescriptions

Staff at Renaissance Pediatrics are spending way too much time on the phone. The four-physician, five-midlevel provider practice in Chesapeake, Va. gets between 1,300 to 2,000 calls a day from patients, says administrator Laurie Bradie, and some 30 percent of these are about prescriptions.

It’s a common problem for pediatric offices - and it’s getting worse.

“Parents no longer have the option to go over the counter,” explains pediatrician Shilpa Mehta, whose Bear, Del., practice has also seen an increase in prescription-related calls. Mehta was referring to the recent withdrawal of children’s cold and cough medicine from drugstore shelves. The alternative is a call to the practice for home remedies or an appointment and possible prescription.

Meanwhile, more children are on medications for chronic conditions, from asthma to attention deficit problems to depression.

What does all this mean for you? For one thing, money lost: Just answering the phone that many times is expensive. Tack on retrieving a chart for each call, routing charts to physicians, and contacting the pharmacy, and the work - and expense - really adds up. Physician and staff time spent on prescriptions adds up to more than $14,000 a year at most practices, according to the Medical Group Management Association.

What to do? There are some ways to streamline the prescribing process, from the mundane to the more sophisticated. Let’s consider the options.

Look for time savers

Elmwood Pediatric Group, in Rochester, N.Y., has a few tricks up its sleeve.

To reduce the time it takes physicians to write prescriptions for chronic conditions, nurses in that office complete as much of the prescriptions as possible before the doctor even enters the room, reports pediatrician Anne B. Francis. “The other shortcut we have taken is to have labels in each patient's chart with name and birthday so that these can be affixed to the prescription. That saves writing out this information multiple times.”

The practice also tries to simplify things when patients call in. Every patient has a medication list including “the date of the prescription, amount dispensed, whether generic or brand, refills if any, whether the prescriptions are to be called, mailed, or picked up, the prescriber’s … and nurse’s initials, as well as the last time the patient was evaluated for the medication,” Francis explains. If the patient needs to be re-evaluated, nursing staff can tell them right away, following set protocols and saving another phone call. And physicians reviewing requests don’t have to flip through chart notes to see the patient’s condition, dosage, or last evaluation.

Other practices are trying to ease appointment backlog and prescription burdens by writing scripts during patient visits that parents may opt not to fill. A common example is for ear infections. Like many other pediatricians, if Douglas Masucci, of Hanover (Pa.) Pediatric Associates, sees a young patient who has had a cold for five days, notices a little fluid on the ear, but thinks the child doesn’t seem that sick, he’ll tell the parent it’s just a cold and the child should get better in two or three days.

However, he’ll also go ahead and give the parent a paper script for an antibiotic, telling her to fill it only if the child is getting worse - and then to let him know. That saves the practice a call in the middle of the night a few days later, asking for the script. “Seventy-five percent of the time, they don’t fill it,” says Masucci. He adds that he has a different policy for infants or children too young to communicate their level of discomfort.

Faxing can help

A final tip from Elmwood Pediatric Group: Faxing prescriptions into pharmacies means less staff time on hold and makes life easier for patients since pharmacists can start working on orders before the patient arrives. Using a fax reduces staff time spent on refills from six minutes per call to less than one minute per fax, according to a 2003 article in Health Management Technologies entitled “Scrip for Success.”

“This system is working out well with the exception that many liquid medications that require reconstituting are not completed until the patient arrives at the pharmacy. Also, we cannot fax Medicaid or controlled-substance prescriptions,” says Francis.

If you decide to try faxing, check in with some of your local pharmacies on how they handle faxes. It won’t do to fax to machines that usually aren’t turned on, run out of paper, or get ignored by pharmacy staff.

Go electronic

Faxing and other work flow interventions can help, but the best recommendation from pediatricians is to use e-prescribing technology. Efficiencies come in several ways.

First, most programs have an “iterative learning ability,” says Lee Shapiro, president of Allscripts, an e-prescribing vendor. That means the program learns, for example, which antibiotic you usually choose first, so it appears at the top of the list on your computer or PDA screen. Then all you have to do is modify the choice based on variables, such as the patient’s weight, which are also in the system.

Shapiro compares it to using a tool like Quicken for keeping home accounting up to date. “If every month I know my cable bill is $58.90, every time I click on Comcast, it says it’s $58.90 and I just click. It’s one click. I could type in $58.90, but this is one click… I don’t have to do anything else in the work flow.”

You can similarly pull up all the medications for a single patient, review them all at once, and refill with one click, instead of hand-writing out several separate pieces of paper. “Before EMR and e-prescribing, it took a lot of time to handwrite out all prescriptions, flip through to see all meds, dosage, when did I change the dosage. Now it’s a lot less handwriting,” explains Michael Scaccia, MD, from Renaissance Pediatrics.

E-prescribing tools can also speed up communication. If a patient calls in a request, staff can simply enter the request into the system, and it will pop into the physician inbox. The same thing applies if the practice integrates a patient Web site - patient requests will flow right into the inbox for easy review from home or the office, ideally with access to the patient record in an EMR. Pharmacist has a question? Same deal.

Masucci especially values this facility. In the old days, he recalls, “people called in on a prescription refill line and then we had to have a staff member download it a couple times a day. They’d attach [the request to] the chart and give it to the doctor who usually sees that patient. You as the doctor go through the chart, check the dosage, then the staff calls it into the pharmacy. It’s a significant amount of time when at a six-doctor practice.”

E-prescribing streamlines all that; Masucci wouldn’t go back.

In addition to ease of use, Masucci likes the added safety of a tool that checks for drug interactions and dosage levels. Patient like it too, he says. It shows he is up-to-date, and parents enjoy the convenience. “You’d be shocked by how often a prescription is lost between the office and the pharmacy.”

Scaccia’s patients love that their prescription goes right to the pharmacy electronically, so they can simply stop to pick it up on their way home. For a parent with a sick child or coping with a couple of children in a drugstore with a candy and toy aisle, getting in and out fast is a huge benefit.

An added plus: Since he uses a free service from Epocrates to stay on top of the formularies for his patient’s plans, Scaccia rarely gets calls from the pharmacy asking to switch his prescriptions - or from patients wondering if there isn’t something cheaper. “It is less time my staff has to spend taking the calls, getting me, interrupting the flow,” he says, adding that he used to have a nurse dedicated to preauthorization duties.

It’s nice to see a physician finding ways to save time and money. As the burden of prescription management gets worse for pediatricians, more need to look for ways to do the same.

Pamela Moore is senior editor, practice management, for Physicians Practice. She can be reached at pmoore@physicianspractice.com.

This article originally appeared in the May 2008 issue of Your Best Practice: A Practice Management Supplement for Pediatricians.