While the use of information technology to make prescribing safer has been a topic in the IT and safety worlds for as long as these domains existed, the key drivers that led to the rapid acceleration of what we now know as ePrescribing were: the dot.com boom; the launch of affordable mobile solutions; competition for prescriber “eyeballs;” and some pivotal work done by the eHealth Initiative.
In brief, with the dot.com boom came a gold-rush of opportunities, including a desire to infuse the Internet into all things healthcare. As we all remember, that didn’t work out as smoothly as hoped for (for a variety of reasons), and many thought leaders and innovators felt that the targeting was too broad (“we will fix medicine” – one refrain from one large IT company). However, one area stood out as ready for transformation – ePrescribing. It was simpler than attempting to tackle “all of medicine”; new and relatively inexpensive devices had been released so that prescribers didn’t have to buy and network PCs; and there were two competing businesses that wanted to make this work and were able to fund its build (SureScripts and RxHub). A pivotal meeting was held in a hospital conference room (outside of Boston), where many stakeholders were brought together under a “flag of truce” – and key ground rules were established. Soon thereafter, under the auspices of the eHealth Initiative and the leadership of physician informatics leaders (such as Jonathan Teich), a set of guiding principles were established for bringing ePrescribing into the 21st century.
Aside from the technical, these rules were as follows: ePrescribing shall be a neutral transmission space, where no messaging or meta-messaging could occur to influence the choice of medication (except for interaction decision support, formulary, and other cost data), and no messaging could influence where the prescription was sent to (independent drugstore, chain drugstore, mail-order pharmacy). In summary, though born of many parents and fed by competing interests, ePrescribing developed and thrived under the banner of vendor and business neutrality, where patient-provider choice was to be held as immutable.
And even though ePrescribing was ready for primetime before most EHRs, and could be used very elegantly as a standalone solution, its adoption was still slow – in my view because standalone use of ePrescribing was not a great fit for the workflow of many physicians (but certainly acceptable as a migration path). What drove its integration into EHRs? I would say the Medicare Improvement Act of 2008 and Meaningful Use. Use it more than a certain number of times for Medicare patients, and you can receive incentive bonuses (and now, avoid negative payment adjustments); and use it more than a certain percentageof times and you can successfully attest for Meaningful Use; fail to use it more than that percentage of times, and you fail Meaningful Use.
Thinking About ePrescribing – What Meaningful Use Accomplished; What Increasing the Threshold Percent for Stage 2 is Likely to Accomplish
Let me start by saying for the record; I like ePrescribing. I think it offers safety and convenience advantages. And as I mentioned in Part 1 of this post – I didn’t think ePrescribing was mature enough such that most prescribers could reach the 40% ePrescribing threshold for Stage 1 Meaningful Use – and I was proven wrong.
But’s let’s move to the overarching reason that ePrescribing is embraced by thought leaders who believe it will make prescribing and medication management better and safer. Have those goals been accomplished? I am not so sure. Clearly, some things are better. Prescriptions that are ePrescribed are legible, although in truth, illegibility led to far more instances of delay and inconvenience (calls to the doc – “what does @#$% mean?”) than to dispensing the wrong drug. And with full ePrescribing, all prescriptions must be for coded medications, with formulation, strength, instructions, dispense, and refill number ALWAYS included. And a requirement of certification for ePrescribing is the ability to provide prescription coverage, formulary, and medication history – so this information has to be available – and that is a good thing. And at least within the Baltimore-Washington corridor, we were able to convince the small number of independent pharmacies frequently used by our providers that did not accept ePrescriptions to do so, or risk our providers feeling obligated to send their prescriptions elsewhere.
So what hasn’t happened; and why will just increasing the threshold for eligible prescriptions (likely for Stage 2) not necessarily lead ePrescribing to move from being a good application to a great application?
Let’s start with the threshold definition, “eligible prescriptions.” While ePrescribing can now be legally done for controlled substances, aside from the work of a few leading edge vendors in a few pilot areas, it is still not widely available. I hear from doctors that their prescribing workflow is clunky, as they currently queue up multiple prescriptions for the same patient, and are ready to ePrescribe, but the process interrupts with a warning about ePrescribing a controlled med – and they now have two choices. Back out of the process and unselect the controlled substance; ePrescribe everything else and then print the controlled substance prescription. Or the easier process, change the prescribing method to “print” – and just print them all. ePrescribing of controlled substances must move rapidly to a generally available application; and it is not clear that ONC and CMS’ “threshold setting” will create sufficient market pressure.
Next, while we have fixed legibility, ePrescribing has enabled a whole new category of prescribing errors related tohaving a legible prescription for the wrong medication: drop-down list and type-ahead errors. There are informatics fixes for both error types, but these fixes typically add complexity and possibly another step in the prescribing process. So the development and insertion of these features by vendors who are still trying to sell software or software services to the majority of providers who are not yet onboard with Meaningful Use is unlikely to happen. What will increasing a Stage 2 threshold likely lead to? Perhaps the opposite – let’s keep it simple and easy so that more docs use ePrescribing more of the time.
Third, aside from a great paper a few months ago by Joy Grossman (Center for the Study of Health System Change) on missing or immature features of ePrescribing (that serve as barriers to its expanded use) – there has been no push to understand why ePrescribing does not work for all eligible prescriptions. Here is a short list of features that need work:
- Move towards insertion of safety features when choosing a prescription, a formulation, a dose, and instructions. It is clear that as prescribers try to balance use of EHRs and ePrescribing software and maintaining eye contact with patients – drop-down list and type-ahead errors are made.
- While in some geographic areas with few pharmacies, pharmacy list management is a non-issue, in urban areas it can be a big issue. Patients sometimes have trouble identifying their preferred pharmacy, or have multiple preferred pharmacies. ePrescribing applications should work with mapping programs to make it easier for patients to identify pharmacies located in shopping centers, at intersections, etc.
- While it is helpful to have formularies electronically available when new prescriptions or renewals are created, some formularies are highly usable (drugs that are not preferred readily point to formulary alternatives), and others are not. As I have heard from industry experts – formulary presentation is up to each pharmacy benefit plan – there is no standard. We know that most providers do not consistently use formularies – and that some of that non-use can be explained by having several bad experiences (“I tried and it was a waste of time; what I prescribed was labeled as tier 2, and there was never a tier 1 listed, so why bother”).
- One of the most common reasons I hear from colleagues as to why they don’t ePrescribe more is that for patients who are on chronic meds, there is no reliable way now to “future date” prescriptions. “I asked, but the patient said she needed them in 6 weeks, so don’t send them electronically or the pharmacy will fill them now.” And unknown to the patients, when these prescriptions are not picked up, these patients may be labeled in the system as “medication non-compliant,” which could have downstream implications for insurance rates.
- I have heard from pharmacist colleagues that they are never sure how to act when they receive an ePrescription and their dispensing software indicates a possible drug-drug interaction. Do they assume that the physician saw the interaction and deemed the interaction trivial, or do they hold on dispensing the prescription until they address the issue with the prescriber? What would help in this circumstance are two enhancements:
- An ability to message back and forth with between prescribers and pharmacists
- Another messaging field with a prescription that could indicate a drug-drug, drug-allergy, drug-condition, drug-dosing reaction – that the interaction was viewed and overridden, and the reason for the override.
- My last issue is at least one that is being worked on now – but in the view of most providers, not quickly enough – embedding prior authorization requirements and electronic fulfillment with the prescription and medication renewal process. For example, if a particular medication is covered ONLY when several other formulary choices have been used first, and that information is already available within the EHR (with start and stop dates, and reason why the drug was stopped, such as “not effective”) – one would hope that the application and process could make use of what is already known to save time and resources for everyone. Unfortunately, this is not now the case.
While these six suggestions are not meant to be a complete, at least in my view, they are all issues serve as barriers to the near universal use of ePrescribing, and also as barriers to ePrescribing used as more than a transmission vehicle.