December 21, 2009

E-Prescribing at the Tipping Point
By Elizabeth S. Roop
For The Record
Vol. 21 No. 24 P. 20

Progress has been steady, but there are still barriers to overcome if the technology’s full powers are to be realized.

There is no question that David Gorelick, MD, is an early adopter of health information technology. His first taste came as the medical officer on the USS Tripoli during Operation Desert Storm in 1990 when he utilized computer systems to track the crew’s immunization status.

Later, while completing his residency at the Naval Medical Center San Diego, Gorelick built a patient history database. He then constructed a more elaborate version upon entering private practice.

Gorelick and his partners at Aquidneck Medical Associates in Newport, R.I., were the first practice in the state to adopt the eClinicalWorks EMR and served as beta testers for its e-prescribing functionality. He also served on the Rhode Island Quality Institute (RIQI) IT Leadership Committee.

With that HIT pedigree, it’s no surprise that he was also among the first to embrace e-prescribing.

“When we first implemented the EMR, we intended from the start to e-prescribe. We knew it would be more efficient, so we did it all at once,” says Gorelick, who sees approximately 500 patients per month for whom he prescribes and manages thousands of medications. “One reason is the time it saves … but it’s also about access to information. It is of huge importance to my practice to have complete knowledge about my patients and what is going on with them by having access to a full record.”

In terms of efficiency, Gorelick notes that it used to take up to 10 minutes to refill one prescription by the time the paper chart was pulled and reviewed and the script written. Now, it takes just seconds. Refill requests are received electronically, allowing him to review a patient’s chart, make a decision, and transmit the approved prescription simply by pressing a few buttons.

That time savings translates into financial benefits as well. It frees physicians to see more patients and allows for better use of staff resources. But Gorelick says the most important benefit of e-prescribing is the increased safety that comes from the automated screenings for allergies and interactions.

“Every aspect of my patients’ care is now organized and efficient. That is key,” says Gorelick. “There is a lot of art to medicine but also a lot of science. There is simply too much data with medical histories, medications, allergies, and test reports; too many clinical guidelines to incorporate into patient care; and too many drug interactions to be busy and [practice] confidently without e-prescribing and EMRs.”

A Slow Climb
The benefits of e-prescribing are well documented. The Institute of Medicine projects that e-prescribing will prevent more than 60% of medication errors caused by illegible handwriting, interactions, allergic reactions, and duplicate prescriptions by multiple providers. A Brown University study also estimated that it reduces the amount of time physicians and their office staff spend on prescriptions by 50% per day. This was attributed to a reduction in pharmacy and patient callbacks and fewer renewal requests from pharmacy benefit managers and mail order pharmacies.

Yet despite the litany of benefits cited by early adopters, provider adoption has been an uphill battle. According to figures from Surescripts, 24% of all office-based physicians, nurse practitioners, and physician assistants in the United States were actively e-prescribing at the end of October.

At more than 149,000, that figure represents double the number of prescribers who were doing so at the end of 2008. Nevertheless, there remains a long way to go before the volume of prescriptions transmitted electronically achieves the tipping point necessary to impact the healthcare system as a whole.

In its “2008 National Progress Report on E-Prescribing,” Surescripts reports that the number of prescriptions routed electronically grew from 29 million in 2007 to 68 million in 2008. Through October of this year, more than 150 million prescriptions had been routed electronically, more than double last year’s total.

Though significant, that number represents less than 10% of the 1.57 billion new prescriptions and renewals eligible for electronic routing in 2008.

“We have moved [from early adopters] to the early majority phase, but I would remind everyone that it really is about the high prescribers, the 30% of physicians who write 80% of the prescriptions,” says Kevin Hutchinson, president and CEO of Prematics and vice chair of the National eHealth Collaborative (NeHC) board of directors. “If you’re going to automate the process … it’s not about getting every doctor in the country to e-prescribe. It’s about getting the volume of prescriptions to be transmitted electronically.”

When the focus is narrowed to the state level, the picture is much brighter. Massachusetts, recently ranked by Surescripts as the top e-prescribing state in the nation, saw more than 6.7 million prescriptions transmitted electronically in 2008. That represents 20.5% of all eligible prescriptions in the state, up from 13.43% in 2007 and 8.8% in 2006.

Rhode Island ranked second with just more than 1 million (17.27%) prescriptions transmitted electronically in 2008. That is up from 9% in 2007 and 5.6% in 2006. The state also recently achieved 100% adoption by retail pharmacies.

According to Laura Adams, president and CEO of the RIQI and a member of the NeHC board of directors, 62% of Rhode Island’s physicians practice at least some level of e-prescribing. Nearly one half of all the state’s e-prescriptions are transmitted through EMRs, which have been adopted by roughly 36% of the state’s physician practices.

“It’s been a slow climb. … It was a chicken-and-egg [situation] in the beginning. The physicians struggled mightily and so did the pharmacies,” says Adams. “I just admire and respect those physicians and pharmacies that began this process because the fewer people you have on a network, the less valuable it is. But now we’re about to cross the tipping point.”

Like most other HIT initiatives, achieving that tipping point is expected to accelerate thanks to the promise of incentive funds under the HITECH Act. Also helping is the rate of adoption by the nation’s pharmacies, 85% of which were connected to the Surescripts network for prescription routing as of October. Six of the largest mail order pharmacies were also connected.

“All that groundwork had to be laid and … at the same time, we needed to begin certifying applications to enable connectivity,” says Kate Berry, senior vice president of business development at Surescripts.

Berry, who also serves as executive director of the Center for Improving Medication Management, notes that in the early days of e-prescribing, physicians had only a handful of standalone applications from which to choose. That in itself was a significant barrier because it was difficult to sell providers on the return on investment (ROI) for an application that served just one purpose, particularly when the network across which it was to communicate was relatively small.

Now, however, there are more than 200 applications that enable e-prescribing, including EMR applications. Further, as EMR adoption has increased, so, too, has the rate of e-prescribing.

“Adoption has been growing fast for six years, but in the past 18 months, things have really started to accelerate,” says Berry. “But there is still a gap in some cases between adoption and use. We need to continue to get all the leaders in the industry to help provide the tools necessary to close that gap.”

Mind the Gap
To close the gap and push e-prescribing past the magic tipping point, most agree that the single most powerful tool the industry can provide is information. In addition to better physician education about e-prescribing, the technology behind it, and its impact on practice workflows, broader campaigns are needed to counter the misinformation that impedes progress.

“There is a lot of misinformation out there. Maybe vendors have set the wrong expectations; maybe news articles have been wrong. But there needs to be a reality check of what’s available today,” Hutchinson says. “This is as real as an ATM network and ATM machines. There is still this belief that we are still early stage, but we’re not.”
He notes that a common misconception among providers is that the majority of pharmacies frequented by their patients are not wired for e-prescribing. As evidenced by the latest Surescripts reports, that is not the case.

However, that misperception may be driven in part by the difficulties physicians encounter when trying to locate pharmacies within e-prescribing systems. It is not that they aren’t included in the master list, but rather it is difficult to identify a specific pharmacy because they are listed by store number and exact street address.

“Physicians and patients don’t necessarily think of their pharmacy like that. So what physicians will traditionally do when they’re having trouble picking a pharmacy is just print [the prescription],” says Hutchinson, noting that 25% of the prescriptions entered into an e-prescribing system for noncontrolled substances are printed rather than transmitted.

“What we’re doing at the network level is changing descriptions to put in cross streets and nicknames. We’re working with pharmacies to find out how they are referred to … and changing the directories to be more user friendly and to use more local language to describe where the [pharmacies] are located,” says Hutchinson.

A more significant issue related to misinformation about e-prescribing relates to writing prescriptions for controlled substances. Currently, the Drug Enforcement Administration (DEA) prohibits the electronic transmission of prescriptions for controlled substances such as opiates.

However, many prescribers misinterpret or define the regulation more narrowly than intended, believing that it prohibits even the act of entering the prescription into the system and then printing and signing it so it can be carried to the pharmacy. In fact, only the act of transmitting the prescription is prohibited.

“It’s not only a barrier to adoption—we’ve had many physicians say that they’ll adopt as soon as the DEA approves [e-prescribing]—but we’ve also found that it’s a barrier to utilization. Those that have adopted e-prescribing aren’t using it for all their medications; they’re doing a mix just to be safe,” Hutchinson says. “It’s amazing how much confusion we have to clear up in our own install base. That was a shock to me, although I can understand it.”

When fear of noncompliance results in physicians bypassing their e-prescribing systems entirely, the safety benefits of making decisions based on a comprehensive patient history and automatic interaction and allergy screening are lost.

That is why, in addition to physician education, organizations such as the NeHC are working with other industry groups at the national level to change the DEA’s stance on e-prescribing. Most recently, Adams testified before a judiciary committee charged with examining the issue. According to the NeHC and Adams, part of the strategy is to refocus the DEA’s attention onto the very real safety issues involved when prescriptions are processed manually—everything from illegible handwriting to adverse events that could have been avoided with an interaction screening.

“They seem to be softening, but it is painfully slow,” says Adams. “That is where a voice coming from something like NeHC can have an impact and get them thinking of the real effect their holdout is having. These [prescription errors] can truly cause ‘death by decimal point.’

“For those who have converted [to e-prescribing], the safety issue is a foregone conclusion,” she adds. “That might be a stronger argument at the federal level, that these people are being forced into a lower standard of care. This is a population of patients that needs more protection, and we ought to be expressing it that way vs. [from] the standpoint of fraud and abuse.”

Workflow Challenges
The belief that compliance with DEA restrictions requires physicians to function in a dual prescribing environment relates directly to the workflow concerns that also serve as adoption barriers. As is the case with any process-altering technology, the introduction of e-prescribing into a practice will result in chaos if not properly managed.

“That little e-prescribing [function] can change the workflow in an office and take up a lot of time and resources,” says Jennifer Covich Bordenick, acting CEO and chief operations officer of the eHealth Initiative. “You cannot underestimate the workflow issues for clinicians, but unfortunately they are so often an afterthought.”

The problem is that there are few affordable resources available to the typical practice to help manage workflow issues before, during, or after implementation. Further complicating the problem is that much of today’s attention and resources are focused on EMR adoption, which can leave those seeking e-prescribing support out in the cold.

“Eighty percent of care is delivered by small practices, and it’s hard for these guys. It is expensive, and they need to see ROI. They might feel [e-prescribing] is a valuable thing, but it might be something they can’t afford,” says Bordenick. “Providers need implementation support. … They don’t want to waste their money or stick their necks out; they need some confidence in the products they are purchasing and guidance in implementation.”

The good news is that the same source of the incentive funds that are expected to accelerate EMR implementations may also be the answer to the lack of resources to support and guide physicians through the adoption and workflow challenges of e-prescribing. The HITECH Act mandates the establishment of HIT regional extension centers, which will offer technical assistance, guidance, and information on “best practices to support and accelerate healthcare providers’ efforts to become meaningful users” of HIT, including e-prescribing.

The resources available through these regional centers are expected to go a long way toward breaking down the few barriers that keep e-prescribing from becoming standard procedure.

“It’s an exciting time, and there are so many opportunities out there. The fact that we’re even talking about these issues at a federal and state level is an incredible stride from five years ago,” says Bordenick. “One in four [physicians] are currently e-prescribing. It’s picking up, but it needs to go further [because] we don’t want to just have e-prescribing. We need to have a healthcare system that is fully electronic and connected. So this is all good news.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.