E-prescribing has the potential to provide a bridge that will have a remarkable impact on quality and safety in the healthcare system.
By George Sawabini, DO, FACOFP and stephen M. Swetech, DO, FACOFP
Computers, viewed by many professionals as a blessing and by few as a curse, have many applications in the complex medical profession. Compact portable computers, PDA’s (Personal Digital Assistants), and other hand-held devices helped fuel the information explosion including medical informatics.
Despite dramatic advances in healthcare related technology, the prescriptive road map from writing a prescription to the fulfillment by a patient/recipient remains primarily manual. The historical paper based recording system exists unchanged for over half a century even though applicable advanced computer technology is available.
Construction of an electronic link via the World-Wide-Web (i.e. www) connects a prescribing physician to the pharmacy supply site and is called e-prescribing.
The Process
The process of e-prescribing automates the scribing, electronic transmission, verification, and interpretation of a prescription order. Fulfillment of a clean order request holds promise to eliminate legibility errors, encourages formulary adherence, can predict unexpected drug allergies or interactions, and significantly reduces a practitioner’s pharmacy or patient call backs.
Transmission and exchange of data from the exam room to a pharmacy requires a portable web-connected electronic device, usually a palm pilot. Electronic hand-held devices are similar to desktop computers, but allow greater portability. Although PDA’s are relatively inexpensive, extremely mobile, and simple to use, they have drawbacks.
For instance, only two portable systems are accessible to Americans, namely the Palm, and the Windows Operating Systems. Although several differences exist between the two systems, their end products are the same. Newer improvements to the portable devices are the Tablets and the Mobile PC’s. One latest high-tech innovation is a PDA combined with a cell phone providing wireless Web based access.
PDA usage
Many physicians currently use PDA’s for a multitude of operational tasks, sadly only a few are being used in electronic prescription transmission.
Improvement needed
The rise in healthcare costs since the 1970’s is unparalleled by any other segment of the economy with the fastest and steepest rise in price being in the prescription component. Accompanying this rise in medication prices and the development of many new medications has been an exponential increase in adverse drug reactions, frequently requiring costly treatments and even hospital admissions.
Appropriate electronic prescribing bestows a potential to combat errors, a current issue of concern. Patients, payers, providers, and policy makers are all in agreement that the existing system demands improvement. The main
impetus for change is patient safety and quality care.
Organizations such as the Institute of Medicine (i.e. IOM), and the Institute for Safe Medications Practices (i.e. ISMP), are vigorously promoting and extolling the virtues of electronic prescribing. Leap Frog, a consumer and employer consortium has made computer prescribing in the hospital setting a prime recommendation for the year 2004 to prevent medical errors.
Distinction between in-patient and out-patient care is slowly fading and the time is right for the development of a complete and efficient patient-centered healthcare system. This new system will be known as the electronic health record, and will contain shared medical information about the patient.
Electronic Health Record
The shared information present in the electronic health file will be available to all, in-network providers. The electronic health record will contain the complete patient medical records, laboratory results, radiology reports and images, allergies, patient demographics, and all the other information needed for a patient’s complete medical care.
Funding
Funding for this momentous undertaking is available from certain pharmaceutical companies. Larger pharmaceutical companies anticipate promotion of their new, generally more costly or innovative therapeutic agents. Although formulary adherence, especially using generic substitution, is a positive benefit, unexpected resistance, as evidenced by lack of funding, is encountered by third party payers, insurance companies, and managed care organizations.
Sadly, these entities could realize considerable cost savings, error reduction, and increased efficiency, utilizing a complete working system. Many cost conscious organizations are reluctant to contribute for research and development.
Lackluster Response
Currently, relatively few physician practices have embraced e-commerce’s full potential. Reasons for this short fall are varied. For instance many systems exist, but there is no one single complete system. Intercommunication between the existing systems is not always possible due to incompatibility issues, and certain physician offices possess older, obsolete systems.
The closest integrated system has been constructed for the United States Armed Forces and the Veteran’s Administration hospitals and outpatient clinics.
Unfortunately, this system is not readily available to the private sector. Implementation to a fully digital system in the public sector is estimated to be less than 15 percent in American hospitals. Even gratis systems, such as e-Procrates and i-Scribe, are widely available, but infrequently embraced by the physician community.
Similarly, a portable computer version of the Physician Desk Reference (i.e. PDR) is easily accessible, but not as popular as the hand-held copy. Additional restrictions to wide acceptance
of e-medicine were further affected by the demise of a few companies that formed the infrastructure of the information technology portion.
Due to low reimbursement from payers and other financial concerns, as well as the absence of new investments in healthcare technology, physicians and physician organizations have been placed in a difficult position. Since medical care and economic rewards have the potential to be gained from a seamless, complete working electronic system all parties stand to benefit.
Benefits
Aside from operational and maintenance costs, benefits from e-prescribing can be observed by reducing a practice’s cost from improved efficiency and improved quality of care with fewer errors.
Additional benefits include convenience to patients, instant record access for clinicians, allowance of interface between various management programs, improved sales and marketing utilizing e-detailing, and product and formulary design for better medical management. Interestingly, despite reluctance to fund this initiative, insurance companies would be able to accumulate statistics on drug usage, institute disease management programs, and ultimately help control costs and return on investment.
Deterrents
Physician associated barriers and disadvantages to e-prescribing include the costs, and physician resistance to change. Most significant deterrents are high costs, both direct and indirect, as well as the lack of economic incentives for adoption of an electronic health record.
Unanticipated costs and extended maintenance fees can be expected due to requirements of 24 hours-per-day, seven-days-a-week online technical support, obligated by the medical profession’s unusual working hours.
Physician resistance to accepting new technology, again revolves around cost, ease of use, and perceived obstacles to productivity. Many view this advancement as another unfunded mandate similar to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In fact, the new HIPAA regulations have impeded progression of e-prescribing even influencing several American states to legislate prohibitions on faxes and electronic prescribing.
The economic climate for the introduction of any new products is limited by availability of investment funds and an unpredictable and potentially unstable market. The Stark Law, which limits self interest referrals may also influence willing investment into the healthcare arena. The Future
Evidence is lacking that e-prescribing will decrease errors or improve formulary compliance, in fact preliminary reports are to the contrary. Furthermore, there are weak security safeguards in place for wireless data transmission or patient data stored on PDA’s. Incidents of
e-commerce fraud are frequently reported, another real fear interfering with wide acceptance. Overcoming these barriers and financial obstacles inherent in this industry must be a priority to policy makers and consumers alike.
The e-prescribing industry faces an uncertain future. In the short term it is resting on a delicate balance between the merits and the detractions. The question posed is not why this technology should be implemented immediately, but how and how soon?
Placing a detached PDA in a physician’s hands and expecting rapid adoption has proven to be a flawed model. Fact be known there is no myth that e-prescribing will likely be a reality in less than a decade. Presently we must strive to develop an error proof system exhibiting a smooth transition for our members.
As members of the American College of Osteopathic Family Physicians (ACOFP), we should consider endorsing the concept of e-medicine in principle. The college should be dedicated to educate the membership elucidating the benefits of this cutting edge technology, so that our members will be able to make informed and educated choices regarding system selection and hardware decisions. Our membership must influence the various legislators to formulate laws that are more physician-friendly and uniform within the United States, perhaps internationally.
Providers and patients should oppose the inclusion of provisions mandating that physicians begin electronic prescribing without adequate times for evaluation of technologies and costs associated with implementation. This mandate without proper funding, could pose significant financial burdens to physicians, and unintentionally impact patient care.
Our elected governmental officials need to compose national standards for utilizing this new technology. Having a proactive insight to supply financial support fostering interest in this essential system is critical. Talking Points on Electronic Prescribing from the AOA Department of Governmental Relations
Technological advances have been instrumental in improving the quality and safety of healthcare. With discussions to provide prescription drug coverage to Medicare beneficiaries continuing, conferees consider requiring the use of electronic prescribing systems to enhance the delivery of healthcare services and improve patient safety.
The American Osteopathic Association (AOA) supports initiatives to improve the quality and safety of care available to patients. To this end, the Senate provisions of “the Prescription Drug and Medicare Improvement Act of 2003” relating to electronic prescribing should be adopted.
While an electronic prescribing system might improve patient safety by eliminating illegible prescriptions and reducing the possibility of dangerous drug interactions, development, and implementation must be accomplished within a realistic framework. Talking Point 1
Implementation of electronic prescribing should be voluntary. Federally mandated electronic prescribing creates a new and costly unfunded mandate for physicians. Small practices that are unable to benefit from economies of scale would be hardest hit. Talking Point 2
Electronic prescribing systems should not impinge upon the patient-physician relationship. An effective electronic prescribing system should provide the physician with access to independent, up-to-date, evidence-based information on drugs. In addition, the system should provide an accurate patient history. Voluntary standards should be compatible with electronic health records currently under development. Talking Point 3
Rural providers would be disproportionately impacted. Physicians in rural communities have potentially fewer technological resources and face numerous difficulties complying with new and expensive mandates. Talking Point 4
The development of uniform standards without a legislative mandate to transmit or receive prescriptions electronically allows for the effective development and implementation of electronic prescribing standards and technology. Voluntary implementation would allow physicians the needed flexibility to determine how best to ensure patient care is not adversely impacted by unnecessary integration problems.
Talking Point 5
It is unclear how or whether an electronic prescribing system will be compatible with the Health Insurance Portability and Accountability Act (HIPPA) security standards. Specifically, there needs to be greater clarity with regard to how patient records containing a medical history and conditions would be linked to an electronic prescribing system to effectively accomplish the goal of integration.
George Sawabini, DO, FACOFP is a family physician practicing in Farmington, Michigan. He is a fellow in the ACOFP and serves on the Board of Governors for the ACOFP.
Stephen Swetech, DO, FACOFP is a family physician practicing in Clinton Township, Michigan and is a fellow in the ACOFP.
Caveat and Disclaimer: This is an informational article only, simplifying a complex topic, for the purpose of promoting development and promotion of an upcoming development. This article neither endorses nor criticizes any corporation or vendor. As expected, figures and specific details of actions by individuals or corporations are difficult to substantiate.
