By Gilly Munavalli, MD, MHS, April 01, 2014
Writing prescriptions and dispensing medications is arguably the lifeblood of modern medicine. It is something we are all taught in medical school and something we are encouraged to do for our patients every single day, multiple times a day. There are two related events that I will always remember about my medical training: writing my first prescription and the “coolness factor” the first time I used mobile pharmacology reference software in the ER (when I couldn’t quite remember the proper medication dosage). Unfortunately, my first Rx was so illegible and improperly formatted that I got the dreaded call from the pharmacist, casually mentioning something about an irate patient waiting, existing allergy to sulfa, and asking for clarification on “TIB.”
Times have changed and now, within our own office-based EHR software, we can send electronic prescriptions (eRx) with the click of a mouse, and never again fear poor handwriting or the incorrect sig. Indeed, utilization of eRx is on the rise nationwide. In my state of North Carolina alone, the percentage of eligible prescriptions routed electronically has gone from 23 percent in 2010 to 49 percent in 2012. The percentage of community pharmacies in my state that utilize eRx had increased to 96 percent by 2012, according to Surescripts.
E-prescribing modules will cross-check for allergies, and in some cases formulary eligibility, and alert us if we made a mistake, saving us time and safeguarding our patients. All is kosher, right? Oh, if life were only that simple. We have all experienced the modern day version of the irate patient whose pharmacy never got the eRx, because it went to a different store. Has the process of eRx made life easier for us or is that just a fallacy? Even with some of the electronic checks in place, we can still make mistakes in dosage and amounts dispensed. What if we want to cancel or amend that eRx that has just gone out into cyberspace? There is a way to do this ... or isn’t there? [pagebreak]
Nuances of eRx
As a dermatologist who is more procedurally and surgically based, I don’t often get into the eRx nuances or deal with the same volume of eRx as most pure general dermatologists. So for this issue, I wanted to supplement my own thoughts with the opinion of an eRx veteran. I found it very helpful to get real-world feedback. I interviewed my colleague and co-worker, Dr. Justin Haught, about his experience. He uses eRx exclusively, and has done so for the past two years. I asked for his unbiased opinion as a young dermatologist about six years removed from training. His answers are excerpted below.
Dr. Munavalli: What do you think about eRx?
Dr. Haught: Over the past two years I have written all of my prescriptions using e-prescribing through a major vendor. I must say that although I will continue to use the system, I find that it is only marginally, if at all, more efficient than paper prescriptions.
Dr. Munavalli: Does it save you time to do this electronically?
Dr. Haught: Although the time to hand-write the prescription has been reduced, it has been replaced by searching for the drug in the database or on a doctor’s list, and searching (sometimes exhaustively) for a patient’s pharmacy. “Is that the 6000 block CVS or the 9000 block CVS? What intersection is that at?” Although we are encouraged to be “paperless,” our office seems to receive more paper than ever, in the form of faxes. I receive between two and five pages for every prior authorization, alerts “warning” me of the side effects of medications, and paper requests for prescription refills.
Dr. Munavalli: What happens if you have to alter or cancel an eRx? [pagebreak]
Dr. Haught: The connection between the pharmacy and an EHR system is not truly two-way, and prescriptions cannot be changed or cancelled without a phone call. Currently, we cannot do this from within the software.
In addition, we are now frequently receiving calls from patients requesting that we “change pharmacies” as they decide that they would like their medicine filled somewhere else. We are also receiving calls stating that the prescription was “never sent” although our system shows that the medication was indeed sent.
Medication coupons are also problematic. If we are changing a patient’s medication and they are not in the office, the only way to give the patient a coupon for a brand-name prescription is to fax it to the pharmacy or mail it directly to the patient.
Compounds are difficult with our e-prescribing system as we must select “miscellaneous medication” and place the compound instructions in the sig, which has limited space to write in.
Dr. Munavalli: Do you feel safer writing an eRx?
Dr. Haught: Interaction checking, although useful, is incomplete. Terbinafine interactions with medications such as beta-blockers do not show up in our particular system, for example. Prescriptions written in the system but printed out at the request of the patient are not exempted from meaningful use but are not counted toward the numerator — which, in my opinion, is unfair as it should be the patient’s decision whether or not the prescription is sent to the pharmacy.
I have not seen a decrease in medication errors as these prescriptions are still subject to human input error.
Dr. Munavalli: So how do you really feel about the whole thing?
Dr. Haught: It would seem that we went from one imperfect system to another, with a marginal increase, if any, in efficiency. I do, however, enjoy not needing to write prescriptions by hand or needing to carry a prescription pad. That’s an expensive convenience. [pagebreak]
In reality, the capabilities of eRx modules (within our individual EHRs) are not just a function of one’s individual EHR software, but of the interoperability between the software vendor and a prescription clearinghouse service. The largest such service in the United States is Surescripts, which is the result of a 2008 merger between the country’s two leading health information networks: RxHub and Surescripts. RxHub was founded in 2001 by the nation’s three largest pharmacy benefits managers — CVS Caremark Corporation, Express Scripts, Inc., and Medco Health Solutions, Inc. Today, Surescripts operates the nation’s largest e-prescription network and connects prescribers in all 50 states through their choice of e-prescribing software to the nation’s leading payers, chain pharmacies, and independent pharmacies.
With regard to office-based EHR and eRx, Surescripts independently certifies EHR vendors’ software packages for specific prescription-routing services. According to its website, Surescripts can certify EHR software for the following types of electronic routing messages:
- New Rx: the ability to electronically route new prescriptions to community pharmacies and mail-order pharmacies.
- Rx Renewal: the ability to electronically route prescription renewal requests and responses between prescribers and pharmacies (retail and mail-order).
- Cancel Rx: the ability to electronically cancel prescriptions that have been sent to community pharmacies.
- Electronic Prescribing of Controlled Substances (EPCS): gives providers the ability to electronically prescribe controlled substances for a streamlined workflow.
Electronic Prior Authorization, or ePA, is “coming soon,” according to Surescripts.
Looking through the list of vendors on the Surescripts site, I found quite a few dermatology EHR vendors who had adopted various levels of support. The software we use in our own office is indeed Surescripts certified. But I learned from the posted list that our vendor isn’t a “Gold Solution” certified provider, so we don’t have all of the routing services completely operational. That was news to me. That may explain why, as Dr. Haught described, we must physically get on the phone to officially cancel an eRx.
When we first adopted EHR, the potential of eRx really excited all of us. The promise of time savings and patient convenience/safety had us convinced this would be good for our professional lives. The reality is that there are still some lumps in the batter. I look forward to the day when our software can support the entire range of routing and really help to fulfill that promise.