Special Health IT Report: Electronic Prescribing Increasing Despite Glitches

 Dr. Marek Durakiewicz initially welcomed the opportunity to send prescriptions to drugstores electronically, using free computer equipment provided by a state pilot program.

The chief of staff at Hickman Community Hospital in Centerville, Tenn., Durakiewicz recognized the potential benefits of “e-prescribing.” Special software allows doctors to see instantly if the drug they are ordering is covered by a patient’s health insurance plan; if there’s a less expensive, generic alternative, or if the patient is already taking medication that may interact dangerously with the new one. For patients, there’s no piece of paper to misplace.

Advocates say e-prescribing is a key advance toward health care’s digital future because of its potential to reduce medical errors, cut drug costs and save doctors and patients time and money. E-prescribing is growing – the number of doctors doing it is now more than 120,000, 20 percent of all office-based prescribers, according to an industry source. But kinks need to be worked out to spur more rapid acceptance.

Doctors and patients in a number of states have complaints, including Durakiewicz. Malfunctioning hardware and cumbersome security features — such as software that logged him out automatically every 30 minutes — left him frustrated. Patient prescription histories provided by the system weren’t as current as he had expected. In addition, federal restrictions prevented him from e-prescribing certain pain medications.

Now, a year later, he doesn’t use the pilot system at all. Instead, he types prescriptions into another computer and prints them out. “It’s faster,” said Durakiewicz, one of 50 doctors participating in the pilot offered by the state’s Medicaid program and the technology company Shared Health.

Emily Bagley, product development consultant with Shared Health, says electronic prescription histories should be immediately available; paper prescriptions take longer to retrieve. Log-offs, she says, result from federal regulations requiring e-prescribing software to log out doctors at regular intervals to prevent unauthorized use of systems.

There are other obstacles to e-prescribing, which helps explain why currently only about 10 percent of eligible prescriptions nationally are sent electronically. (Prescriptions for controlled substances, such as certain pain medications, aren’t eligible.) E-prescribing requires special computer equipment, which can be costly, and seamless coordination of an immense amount of data from doctors, health plans and pharmacies.

But federal money for health technology in the stimulus package and other incentives are expected to drive greater adoption of e-prescribing in coming years. Another key step occurred in 2008, when two prescription processing networks combined to form Surescripts. The e-prescribing company maintains the largest secure network through which doctors send prescriptions to patients’ pharmacies.

For the system to work, the doctor’s office must have e-prescribing software and an Internet connection; the patient’s health plan must participate, so the doctor can electronically check the patient’s drug benefit, and the patient’s pharmacy must be connected to Surescripts.

Currently, about three-quarters of U.S. retail pharmacies participate in Surescripts and support the network by paying transaction fees. Doctors generally don’t pay to send prescriptions, but they bear the costs of maintaining their computer system with periodic upgrades.

Rick Ratliff, president of the Virginia division of Surescripts, says the network, which processes 15 million prescriptions a month, is extremely reliable. However, with more than 130 different software programs certified to link with the network and many medical practices relatively new to e-prescribing, it’s inevitable that there will be problems, whether with the technology itself or with the people learning to use it, according to the company.

To encourage greater participation, Medicare, the federal health plan for the elderly, in January began giving e-prescribing doctors a bonus of 2 percent of their overall Medicare reimbursement. That incentive may be helping: Surescripts reports in the first three months of 2009 a 49 percent increase in e-prescriptions compared to the last quarter of 2008.

Tennessee — where only 3 percent of prescriptions are sent electronically – is giving grants to more than 1,800 rural doctors to help them buy or upgrade electronic prescribing and medical records systems. The state also is offering training sessions.

Other states are encouraging doctors, too, hoping to contain prescribing costs and improve care. Arkansas is one of seven states that fully link their Medicaid programs for the poor to Surescripts. After the state began heavily promoting e-prescribing in December, the number of doctors using it shot up from 225 to 665 in March.

Pilot programs in states such as Mississippi and Florida have reduced Medicaid costs, mainly by elimination of duplicate prescriptions and increased use of generic drugs.

When it works as intended, doctors and patients are enthusiastic. “I love it,” said Amber Blackwell, a working mother whose Clarksville, Tenn., pediatrician prescribes electronically. “I have an 18-month-old, so I don’t have to carry anything else to keep track of. And when I get to the pharmacy it’s ready.”

Challenges persist, especially at small practices that lack in-house technical support. Cumberland Family Care, a three-office doctor group in Sparta, Tenn., obtained a state grant for e-prescribing software. But the system hasn’t always worked well. “We send about 150 to 200 electronic prescriptions a day,” said Mischelle Ferrell, the practice manager. The failure rate is now about 20 percent.

When that happens, patients arriving at their drugstores may find no record of their prescriptions. “There’s a mother with a kid with a fever at the pharmacy who drove 15 miles and waited in line, and they have no record of the prescription,” Ferrell said. “You’ve got one mad mother on your hands.”

“There will be problems,” conceded Melissa Hargiss, director of Tennessee’s Office of E-Health Initiatives. “But I would say to doctors that this is the best time for providers to start using it, while there’s grant money available to offset the costs.”

Medicare to Pay Bonuses for 'E-Prescribing'

Starting next year, doctors can earn additional money from Medicare if they use electronic prescribing systems, U.S. health officials said Monday.

The bonus program, which will continue for four years, is designed to streamline the prescription process and cut down on errors. In 2009 and 2010, Medicare will give doctors an additional 2 percent bonus on top of their fee for “e-prescribing.” In 2011 and 2012, the bonus will drop to 1 percent, and in 2013, the bonus will drop again to 0.5 percent, officials said.

“There are terrific human and financial costs to illegible prescriptions,” Mike Leavitt, secretary of the U.S. Department of Health and Human Services, said during a Monday afternoon teleconference.

According to the Institute of Medicine, 1.5 million Americans are injured every year by drug errors, Leavitt said. Another study found that each year pharmacists make more than 150 million phone calls to doctors to clarify what was written on the prescription, he added.

“That’s a lot of people needlessly hurt and a lot of time spent trying to sort out bad handwriting,” Leavitt said.

“E-prescribing will help deliver safer or more efficient care to patients,” Leavitt said. He noted that the law that set up the Medicare prescription drug program in 2006 mandated that participating pharmacies be able to accept e-prescriptions.

After five years, bonuses for e-prescribing will be phased out; doctors who haven’t adopted e-prescribing will be reimbursed at lower rates, Leavitt said. There will, however, be exceptions for doctors who have legitimate reasons for not complying.

“We expect this will have a profound effect on the adoption and use of e-prescribing,” Leavitt said.

Medicare started paying bonuses to doctors last year for using the Physician Quality Reporting Initiative, which collects data on the quality of care delivered by doctors. Medicare recently paid the first bonuses to more than 56,000 doctors, totaling more than $36 million. Payments ranged from $600 for individual doctors to $4,700 for group practices.

The new bonuses for e-prescribing will be on top of those paid as part of the Physician Quality Reporting Initiative and other Medicare reimbursements. Medicare expects to save up to $156 million over the life of the e-prescribing program in fewer adverse drug events.

Despite the advantages of e-prescribing, barriers to implementing such systems remain. One of the largest barriers is the cost.

“It is fairly costly for a small practice to begin to change over to e-prescribing,” Dr. James King, a family physician in Tennessee and president of the American Academy of Family Physicians, said during the teleconference. “These incentives will help.”

It’s estimated that it will cost about $3,000 per doctor to initiate an e-prescribing system. It also takes between $80 and $400 a month to maintain and operate a system, Kerry Weems, acting administrator of the U.S. Centers for Medicare & Medicaid Services, said during the teleconference.

Other barriers include state laws that prohibit e-prescribing across state lines, King said. And, there are areas in the country where computer systems are slow and inefficient, he said.