Earlier this month the Center for Studying Health System Change, based in Washington, D.C., released its issue brief, “Even When Physicians Adopt E-Prescribing, Use of Advanced Features Lags” that showed that about 1 in 3 office-based physicians routinely e-prescribed in 2008 and even fewer used advanced features like transmitting prescriptions electronically, identifying potential drug interactions, and checking formulary information. HSC senior researcher Joy Grossman, Ph.D. spoke with HCI associate editor Jennifer Prestigiacomo about these interesting findings.
Healthcare Informatics: In your opinion, what were some of the big takeaways from this study?
Joy Grossman, Ph.D.: Even when physicians adopt e-prescribing, it doesn’t mean they use the system routinely. The use of advanced features certainly lags, and that’s [because] of a number of factors. They might not have that functionality, and even if they do, it doesn’t mean that it’s used routinely by physicians. Those are the two key takeaways. The last point is there’s some variation, when you look into the different subgroups of physicians, whether that’s users of electronic medical records or physicians in larger groups, you see that some types of physicians are more likely to be routine users of the system, with respect to the basic functionality and the more advanced features.
HCI: What are your thoughts about the findings showing higher electronic prescribing rates among physician using EMRs exclusively than those with stand-alone systems?
Grossman: For one, physicians with EMRs are more likely to use the [e-prescribing] feature routinely. It is more integrated into their workflow. The computer’s open, they’re inputting the data, their staff is using the system and e-prescribing is often the first module that is implemented in an EMR because it’s one of the things that give physicians pretty quick payback. For practices where it’s easier to integrate into workflow, physicians are likely to get up to speed more quickly and use it more routinely.
Standalone products have the same issues around uptake and part of that is because it’s not integrated into the workflow. They might have a computer in their office, but not in the exam room, or they might be sharing computers with other people, or they might be using a handheld and there are problems with the wireless. The barriers to integrate these standalone systems into workflow are higher, and because of that, there’s potential for physicians to get frustrated and not use it.
In some practices you might have physicians with various specialties. Some physicians tend to write standard prescriptions, like in an ophthalmology practice, often their prescription pad has all of the medications they typically order, typed into the prescription pad, and they just check off what it is [they need to prescribe] because 90 percent of the time they prescribe 10 medications. Or surgeons who prescribe generic painkillers—they may find their threshold for using this technology is higher to connect it into their workflow because the payback is lower for them, relative to an internist or a rheumatologist.
HCI: Why do you think the physicians who do have e-prescribing in their practices aren’t using advanced e-prescribing features?
Grossman: The reason why doctors might not use advanced features is that, first of all, the systems may not have the functionality. The functionality even if it is available, might not be apparent to the doctor, so they may have not had adequate training, or they might not have absorbed that training. Second thing is that the practice may have decided the functionality does not work well and for that reason, they’ve actually turned it off. Even for the physicians who know it’s there and it’s on, they may find it hard to use, and it takes five clicks to get the information, or they may find the information is not particularly helpful.
For example, with the drug interaction alerts, there’s what’s called alert fatigue, and this is a well-written-about phenomenon. Alerts may trigger often for things physicians do any way or for patients they’ve treated for a long time, so they ignore the alerts, and then at some point there’s potential for an alert to come by that would be important for them to see, and they might not notice it.
HCI: Can these alerts be customizable?
Grossman: The more sophisticated the system, the more customizable it is. Sometimes it can be customizable at the practice-level, and sometimes individual physicians have control over that, but most times physicians express dissatisfaction with that. No one has really figured out the optimal design for your average physician and practice to take out of the box and go with.
HCI: Why do you think formulary checks were used less often than the other two advanced features [transmitting prescriptions electronically and identifying potential drug interactions] cited?
Grossman: There are other examples for the formulary information. Even when the information is provided, there are barriers to matching the patient to the formulary data. The formulary data may be missing for their health plan. Their health plan may be out of date.
HCI: The study showed a higher adoption rate in physicians in larger practices than smaller ones. Can you talk a little about why that is?