E-Prescribing: Mainstream, but Not Yet the Norm

December 05, 2011

December 5, 2011 — Electronic prescribing recently passed an important milestone, but it is still far away from its final destination.

Surescripts, a pharmacy-industry group that promotes the use of this technology, announced last month that 52% of office-based physicians were electronically transmitting their scripts to pharmacies as of September. That figure compares to roughly 32% of office-based physicians in September 2010. So e-prescribing has crossed a halfway mark, by one measure.

That accomplishment, however, does not tell the entire story about e-prescribing, which is marked by inconsistency as well as progress. Although the technology has won over a majority of office-based physicians, only about 33% of scripts travel directly from a physician's computer to a pharmacy's computer via a nationwide network operated by Surescripts. This tally does not include prescriptions for controlled substances, which face restrictions. It also does not include computer-generated scripts that are faxed to the pharmacy or printed out for a patient.

To be sure, 33% represents dramatic growth since September 2010, when roughly 20% of scripts were electronically transmitted. However, prescribers who have learned to click "Send" are not necessarily clicking for every Rx.

Furthermore, the latest state-by-state e-prescribing rates from Surescripts show that adoption is geographically uneven. At the end of 2010, 69% of office-based physicians in Massachusetts were e-prescribing compared with 23% in California and 20% in Utah. And although the rate of scripts transmitted electronically was 42% in Massachusetts and 36% in Rhode Island, it was only 8% in North Dakota and Washington, DC.

Still, e-prescribing has come a long way since 2008, when less than 10% of office-based physicians were zapping scripts to the pharmacy. Rob Cronin, senior director of communications at Surescripts, says the great leap forward has been powered by 2 federal programs that financially reward physicians who use prescribing software.

The oldest program was created by the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008. In 2011, eligible physicians using approved e-prescribing software received a 1% Medicare bonus, which also applies in 2012. The bonus decreases to 0.5% in 2013 and disappears in 2014. Medicare penalties kick in next year for physicians who cling to their prescribing pads as opposed to their iPads.

The other incentive program sprang from the American Recovery and Reinvestment Act (ARRA) of 2009. It promises up to $44,000 under Medicare over 5 years, and almost $64,000 under Medicaid over 6 years, to physicians who demonstrate "meaningful use" of an electronic health record (EHR) system. The government's definition of meaningful use includes e-prescribing.

"The growth in e-prescribing that we have seen this year is due mostly due to the (ARRA) incentives," Cronin told Medscape Medical News.

What Holds Physicians Back

The penalty side of the MIPPA program figures into the lag between the percentage of office-based physician who e-prescribe and the percentage of all scripts e-prescribed, according to Rosemarie Nelson, a healthcare IT consultant in Jamestown, New York, who is affiliated with the Medical Group Management Association.

"I'm not at all surprised by the discrepancy," Nelson said in an interview with Medscape Medical News.

Medicare will dock physicians 1% of their reimbursement next year if they failed to transmit at least 10 e-prescriptions in the first 6 months of 2011 or else qualified for a hardship exemption. Nelson explains that many physicians adopted the technology this year and shot off their 10 e-prescriptions to avoid the penalty, but did not become everyday e-prescribers.

What holds back physicians from a full conversion? Nelson said 1 reason may be that some e-prescribers — estimated at 15% by Surescripts' Rob Cronin — use stand-alone prescribing software as opposed to an EHR that includes that function. Such physicians may be deterred from going back and forth between their paper charts and their prescription program, Nelson said. "The process may be a disruption to their workflow."

The disruption gets even worse when e-prescribers do not operate in a wireless environment, said Nelson. "They may have to go out of the exam room to write the script on a PC."

In addition, writing scripts with stand-alone software can take up to 12 times longer than using pen and paper, added Mark Anderson, a healthcare IT consultant and president of the AC Group in Montgomery, Texas. What makes the job so laborious is entering a patient's demographic and insurance information for the first electronic script, he said. When e-prescribing is an integrated part of an EHR, those data are already in the system.

"I think a lot of physicians tried e-prescribing, but then stopped because of the time constraints," said Anderson.

Cronin notes that for new e-prescribers, inconsistency reflects a learning curve. "Many are still being trained on how to make full use of (the software," he said.

The Hassle Factor for Controlled Substances

Yet another barrier to consistent e-prescribing is the complication surrounding controlled substances. Until March 2010, the US Drug Enforcement Administration had prohibited the electronic transmission of scripts for controlled substances. The DEA now makes that an option, but a complicated one, deterring physicians from going that route.

This hassle factor, explains Rob Cronin, has a detrimental effect on e-prescribing of noncontrolled substances. Physicians frequently prescribe a patient a bouquet of controlled and noncontrolled medications in one sitting. Instead of switching back and forth between prescription pad and computer screen, some physicians resort to paper for all the drugs.

One impediment to e-prescribing — the inability or unwillingness of some pharmacies to accept electronic prescriptions — is decidedly waning. Surescripts reports that 94% of retail pharmacies nationwide are now receiving these scripts, up from 76% at the end of 2008. The acceptance rate is higher in some states and lower than others, which appears to partly explain the e-prescribing gap between different states.

Other possible, but unproven, explanations for state-to-state variations include:

  • Rates of EHR adoption;

  • Participation by insurers and pharmacy benefit management companies in the Surescripts network (their involvement allows physicians with e-prescribing software to access information on a patient's drug benefits and drug history, which could make e-prescribing more attractive); and

  • The EHR vendors that dominate the market in a particular state, and where they are in the rollout of their e-prescribing technology.

Inexorably, both the percentage of physicians who e-prescribe and the scripts that are transmitted that way will continue to rise, said Cronin.

"Physicians always start off at a relatively low level of e-prescribing," he said. "It always increases over time."

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