TECH/PHYSICIANS: What’s wrong with eRx?

Health Affairs has a study from HSC about ePrescribing. here’s the press release. The team interviewed a bunch of practices using eRx and some not. About 2/3 were using it as part of an EMR, the rest were using a standalone eRx system. It’s not an encouraging study. The main problems identified:

1) Challenges to maintaining complete patient medication lists. Most physicians were able to use e-prescribing systems to access prescriptions written by other physicians in their practice. But none were able to access comprehensive lists of patients’ medications prescribed outside their practices. As a result, physicians continued to rely on patients as the main source of information to complete medication lists.2) Difficulty obtaining accurate patient-specific formulary information. Physicians in slightly more than half of the practices did not have access to formulary data electronically, because either the systems did not have the feature or the practice had chosen not to enable it. In the practices where physicians had access to formulary information, respondents pointed out information was available for only a subset of patients, with estimates ranging from 25 percent to 90 percent. Even when information was available, practices often questioned the data’s reliability. Physicians’ views varied on the value of the formulary information, and in many practices, physicians routinely ignored it.

If the RxHUB vision is working the information about both current medications and formulary information should be available for a substantial share of patients in the eRx application. 90% sounds a little optimistic, but 25% doesn’t sound at all good, considering that the 3 big PBMs who own RxHub allegedly account for more than 90% of commercial lives. It appears tha accurate patient identification is a problem within RxHUB. Given that we’re not getting a patient identifier anytime soon, that’s also not good news..

3) Limited connectivity with pharmacies and mail-order PBMs. Only the practices with stand-alone e-prescribing systems were using electronic data interchange (EDI) that allows electronic transmission between computers in the physician practice and those in the pharmacy or PBM. Local pharmacies’ lack of readiness was cited as a barrier to full electronic transmission. Most practices using electronic fax or EDI reported spending substantial time educating local pharmacies about e-prescribing. It took a couple of months of daily communications about individual patients for pharmacies to be able to treat electronic transmissions as routine.

That tells me that neither of the Surescripts and RxHub visions are yet working in practice. By this stage most pharmacies should be getting the eRx direct into their pharmacy system. If it’s a Surescripts certified vendor (which mot standalones and many EMRs are), then there shouldn’t be a need to rekey in the information at the pharmacy. In fact this line from the actual report For example, a physician in Syracuse reported that despite the presence of national chains reportedly capable of electronic transmissions, pharmacies in the area were not yet even "fax-friendly." is pretty frightening and suggests that Surescripts has much more work to do amongst its owners!

4) Challenges continue after initial implementation. Practices were not prepared for the amount of interaction needed with outside parties, such as vendors, state regulators, and local pharmacies, to implement and maintain the system. Practices continued to devote staff resources for maintenance well after e-prescribing products were in use.

Hmmm….also not good. The idea is that this is supposed to save staff time.

5) Limited use of clinical decision support. All but one of the practices’ e-prescribing systems offered some clinical decision support (CDS) in the form of drug-drug interaction alerts. However, access to more advanced CDS was limited; about half of practices reported being able to check for drug-allergy interactions, and only 20 percent for drug-condition contraindications. There was general agreement that pop-up alerts were triggered too easily. As a result, physicians typically overrode them.

Alert fatigue is commonly talked about by the vendors of these systems—it’s a problem that will take some intelligence to overcome. But I’m not so sure that this is a gamebreaker. The previous four may be.

There is though some hope:

Practice efficiency. Most physicians agreed that writing new prescriptions electronically took about the same amount of time as writing them on paper once they became familiar with the system and had created a "favorites" list. For those practices that sent new prescriptions electronically, e-prescribing systems eliminated much of the staff time spent printing, faxing, and calling in prescriptions.Legible prescriptions also meant many fewer callbacks for clarification. But respondents believed that the greatest time savings came from streamlining management of renewals, particularly for patients with multiple medications.

Only one practice could quantify savings from e-prescribing. Most of the others provided examples of how it had freed up support staff to do other tasks, although they could not point to staff cuts exclusively from e-prescribing. Several respondents felt that there were no substantial savings because any efficiency gains needed to be balanced against the up-front and ongoing costs of implementing the system and the additional effort invested in tasks that had not been done routinely–for example, collecting information on outside prescriptions. Their perspective was that e-prescribing produces better outcomes for a comparable effort.

Furthermore the data in the study is more than a year old now—so we have to hope that things are getting better. But clearly more work on the plumbing is needed.

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2 replies »

  1. I recently listen to a guy present at a large healthcare conference. He predicted that Rx-Hub would have significant chanllenges from the beginning and explained why SureScripts was in a better postion to succeed.
    He made a lot of since and it was refreshing to hear candor and industry knowledge from a software company.
    What was even more impressive was the adoption statistics for thier applications. The guys name is David Grant but I forget the name of the company…Med-somthing. At one time they apparently were also owned by PacifiCare.
    It was difficult to get any of his time following his presentation because he was bombarded by questions, but I bumped into him later at the conference and he was able to demostrate the application to me on his cell phone realtime. It was apparent to me that he had a great solution and did not have any of the problems mention in this article. Unfortunately, I work for Kaiser and we are stuck with Epic, which none of my peers like or even really use.
    I just thought you might like hear from a physician.

  2. I wonder how long before Pharma is paying for positioning in pre-populated “favorites” lists? Or is it already happening?
    BTW, great site.