Despite the continued growth of ePrescribing thanks to federal incentive programs, the use of it still faces operational barriers, according to a recent study funded by the U.S. Department of Health and Human Services' (HHS) Agency for Healthcare Research and Quality (AHRQ).
Conducted by the Washington, D.C.-based Center for Studying Health System Change (HSC), the study focused primarily on transmission in ePrescribing, the electronic exchange of prescription data between physician practices and pharmacies. According to lead researcher Joy Grossman, there are multiple benefits from the use of ePrescribing to fulfill and renew prescription orders. Among those benefits are added efficiency to ePrescribing, a reduced risk of medication errors caused by poor handwriting, and ultimately, fewer safety risks.
Although the HSC researchers recognized all of the above benefits to ePrescribing, for the purpose of the study they interviewed approximately 114 pharmacies and physician practices focusing solely on the communication aspect of ePrescribing. Ultimately, the results were mixed, and spoke to why ePrescribing has yet to take off in greater numbers despite the growing federal incentives.
Both physician practices and pharmacies noted there were problems with the renewals process and connectivity between physician practices and mail-order pharmacies, as well as a need to manually enter some of the medication information on the pharmacy side. So despite the fact ePrescribing has come a long way in a short period of time, its users acknowledged a number of issues that remained to be worked out.
In general, both physician practices and pharmacies were satisfied with the electronic transmission of new orders. There were issues with timeliness, but those mainly had to do with either the pharmacy staff’s lack of training or the physician staff’s delay in sending the order, depending on who is being asked. Other than that, the problems with new orders were few and far between.
The renewals side told a different tale. According to Grossman, nearly one-quarter of the respondents didn’t fill renewals electronically, which was mainly due to a lack of capability or a desire to avoid transaction fees from ePrescribing network vendor SureScripts (Arlington, Va.). For those who had done renewals electronically, there was a breakdown in communication.
On one side, physicians said they would often get multiple requests from pharmacies using other means of communication such as faxes and phone calls. This would come, the physicians said, even after they processed the request electronically. On the other side, pharmacies said this was necessary if they hadn’t received a response from the physician within 24 hours. Other pharmacy respondents told Grossman their ePrescribing system sent re-requests automatically until there was a response from the physician side.
Making the process even more convoluted, there is the phenomenon of some physicians approving an order by phone or fax rather than electronically. This complication, Grossman says, is caused by a lack of underlying technical standards in the ePrescribing systems. There’s limited communication functionality between the two parties, causing each pharmacy and physician practice to have their own methods of response.
Mail-Order and Other Issues
Issues with renewals were only one aspect of connectivity problems between physician practices and pharmacies when it comes to ePrescribing. Approximately 75 percent of physician practices said they had experienced difficulties with mail-order pharmacies. According to Grossman, most practices weren’t sure which mail-order pharmacies accepted ePrescriptions in the first place, and didn’t rely on the process even if they did accept them.
Few vendors, she notes, that are certified through SureScripts to ePrescribe with community pharmacies, are also certified to do the same with mail-order pharmacies. Thus even if they tried to send the order to a mail-order pharmacy electronically, it often came in as a fax anyway. This connectivity problem came about because of the 2008 merger between SureScripts and RxHub and the continued use of legacy transmission networks.
The study also found there was an issue with some pharmacies having to manually enter parts of the prescription after transmission of the information. Three areas in particular of an order – medication name, quantity and patient instructions – required manual entry.
As for medication names, Grossman notes that most ePrescribing systems lack an up-to-date unique identifier from the Food and Drug Administration’s National Drug Code (NDC). The NDC is used as a standard of medication identification across systems. Without a unique identifier, if the NDC in the ePrescription system and the pharmacy system don’t match, the pharmacist has to go and manually select the medication from their own database.
Specificity and carefulness also came into play for many respondents, says Grossman. Physicians said they were forced to be more specific with dosage amounts and medication names in ePrescribing systems. Pharmacists also had to rewrite patient instructions from physicians to make them more user-friendly.
With more physicians likely to engage in ePrescribing as time goes on, Grossman says certain structural issues, such as the ones involving the mail-order pharmacies, will need to be addressed. She says a collaborative effort between stakeholders such as pharmaceutical and physician representatives, ePrescribing and network vendors, as well as government entities, to harmonize standards, is necessary. Most respondents, she says, are looking ahead on ePrescribing even with these issues at hand.
“Overall, the bottom line is physicians and pharmacies like ePrescribing and would like more opportunities to use electronic communication rather use fax or phone,” Grossman says. “They’re thinking about future ways to improve knowledge, management and patient safety. They’re thinking about the next steps that can include more advanced communication. There’s a real forward vision on what things can be done to enhance ePrescribing.”