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E-Prescribing: Good or Bad?

Pauline Dowe, Doctor of Pharmacy Candidate, Florida A&M University, looks at the latest trend in medicine, E-Prescribing. Medicare has mandated it and medical professionals seem to either love it or hate it. Read her review of the pluses and minuses and you can decide if it is good or bad.

E-Prescribing: Good or Bad?

Pauline Dowe, Doctor of Pharmacy Candidate, Florida A&M University – College of Pharmacy & Pharmaceutical Sciences

Today there are many loopholes within our nation’s current prescribing and dispensing system. The use of E-prescribing can help reduce the incidents of drug interactions, monitor patient compliance, and also help with workflow. But electronic data interchange isn’t 100% effective just yet. From the popularity ratings among healthcare providers, to system incompatibilities, there are many downfalls of electronic data interchange as well.

Congress has mandated the fabrication of standards for electronic transmission of prescriptions and information concerning prescribed Part D drugs for eligible Part D members in the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. Medicare promises a 2% bonus to physicians that are compliant with e-prescribing prescriptions from point-of-care computers to a pharmacy’s computer by April 1, 2009. The new regulation is supposed to help with improving the quality of patient care and also the work flow for healthcare providers. E-prescribing is optional for pharmacies and physicians, but Part D prescription drug plans that are involved in the new prescription benefit are required by Medicare to enroll in E-prescribing. If healthcare providers use faxed Part D prescriptions, they will have to deal with penalties, and will not qualify for bonuses.

So why won’t everyone just jump on the bandwagon? There’s much concern regarding electronic data interchange (EDI). There are positive points, but on the other hand there are some negative issues as well.

One benefit that E-prescribing offers is the formulary and benefits information standard. With this, providers can instantly compare and contrast drugs listed on patients’ health insurance formulary and decide what can be clinically effective and cost efficient for a patient. Another standard that can be used is exchange of medication history. Providers can look at a patient’s medication history without having to ask the patient if they can remember what medications they’ve taken. The patient, status, provider, coordination of benefit, request, and response segments of SCRIPT are all included with this standard. The fill status notification standard can give providers an idea if the patient is being compliant with taking their medications or not. This standard can inform providers when a prescription is filled, not filled, or partially filled. It also includes the patient, provider, and drug segments of SCRIPT message. The structured and codified SIG standard provides information such as indication, dose, dose calculation, dose restriction, route, frequency, interval, site, administration time and duration, and stop order instructions. Another standard, clinical drug terminology provides administered dose forms and standard names for clinical drugs. It also provides links from clinical drugs to their active ingredients, most related brand names, and drug mechanism. The prior authorization standard requires a subscriber, requester, header information, utilization management, and other relevant information for prior authorization requests.

Although there are some benefits to E-prescribing, physicians are reluctant to use it. The cost burden is of one concern for physicians. Physicians should consider that in time they will reap the rewards of implementing such technology within their facility. Using the E-Prescription system, the workload for healthcare providers would be diminished outstandingly. Calling in a prescription or calling to verify a prescription can be time consuming and bothersome to both the prescriber and the dispenser, especially when there are so many other things that need to be taken care of. E-prescribing will take the hassle out of calling in and verifying prescriptions. Also, insurers will be reassured that medication errors will be less of a concern, and decreases in liability would also occur.

Some providers are confused about how the technology of E-prescribing works and are also skeptical about E-prescribing ease of use and technical issues that they may not be able to combat alone. Furthermore, some healthcare providers have EDI, but their systems aren’t up to date or not of use because it’s not compatible with CMS standards. On top of that, no list of CMS-approved vendors exist. A lot of healthcare providers don’t even know if their software program can be used as an EDI! Healthcare providers can use SureScripts-RxHub and GetRxConnected.com to find out if their software supports EDI.
Another issue with EDI is incomplete structured and codified SIG, prior authorization of certain drugs, and medical terminology. All of these entities must be uniformly similar throughout the electronic data interchange to provide a universal system in which all providers can interpret information in the same fashion. If there’s no uniformity, then the system will be of no use. Too much variation of codified SIG can lead to disaster and increase medication errors. Pharmacists would have a very hard time interpreting SIG codes if there’s not any uniformity within the system that everyone abides by. Not only will there be frustrated healthcare providers, but there would also be patients that are put in harm’s way due to error of interpretation. For instance, a patient is supposed to take a medication once daily (QD), but instead is taking the medication four times daily (QID) because the prescriber mistakenly wrote the prescription for QID instead of QD. One sure thing with E-prescribing is that there are no legibility issues to deal with, although errors can possibly still occur like in the previous example due to a typing error. Also, there are the look-alike/sound-alike drugs that can be transcribed incorrectly, which can lead to medication errors and potentially harm a patient.

Although E-prescribing can reduce a lot of errors, it can also produce some. Healthcare providers may find a sense of reliability and become a little too comfortable with the automatic drug interaction checker available on the system. A very severe drug interaction would be flagged, but because the system continuously flags drug interactions, the physician may not notice it, so the severity of the interaction will go unnoticed. In turn, this can pose as a liability issue to the physician and/or pharmacist. A drug interaction checker would be beneficial, but it can be detrimental to healthcare providers that let warnings fall between the cracks, costing someone to be harmed.

There’s also another loop-hole with E-prescribing – controlled substances. Is it possible to prove that E-prescribing is safer than using tamper-proof paper specifically for controlled substances? The DEA isn’t ready to decide if E-prescribing is the best way to go just yet, so for now the classic method prevails.

As a future pharmacist, I totally understand the concern that veteran pharmacists have about E-prescribing. Although there is some apprehension, I also recognize the benefits that E-prescribing offer as well. Currently, I believe that the benefits of E-prescribing outweigh the risks. Once the electronic data interchange system is 100% systematically organized, E-prescribing will be one of the best moves for the healthcare industry. E-prescribing will open doors in which there will be more time to effectively carry out other important tasks such as counseling patients. Knowing ahead of time any potential issues that may occur (drug interactions, un-affordable prescribed drugs, prior authorizations, etc.) is crucial in the healthcare setting, not only saving time and money, but also keeping everyone satisfied in the end.

References:
1. http://www.cms.hhs.gov/EPrescribing/Downloads/E-RxReporttoCongress.pdf
2. http://www.cms.hhs.gov/PrescriptionDrugCovContra/Downloads/MemoERx_09.19.08.pdf
3. http://mamedicallaw.com/blog/2008/06/11/the-legal-pros-and-cons-of-e-prescribing/
4. http://mamedicallaw.com/blog/2008/06/11/holding-on-to-your-prescription-pad-barriers-to-e-prescribing/
5. http://mamedicallaw.com/blog/2008/06/11/new-e-prescribing-regulations-applauded-by-doctors-lawyers/