Holding on to your prescription pad? Barriers to e-prescribing

As valuable as the newly adopted e-prescribing standards may be, there are still a number of hurdles that could act as barriers to widespread adoption of e-prescribing, practitioners say.

They include:

• Absence of certain standards

The absence of a standard for structured and codified SIG, which refers to instructions for medication use, is a serious shortfall in the regulations at this point, clinicians say.

In the e-prescribing context, the prescriber typically enters the SIG into a free text box within the e-prescribing system. That text is then transmitted to the pharmacy system and generally put in a comments or notes field for the pharmacist to review.

However, the current lack of a standard for codified or structured SIG means that the physician is still able to use abbreviations or shorthand when writing the instructions. Those abbreviations may vary among prescribers and the lack of a SIG standard means that the pharmacist is left to interpret the intended instructions.

This poses a potential clinical risk, says Steven J. Stack, head of the emergency department at St. Joseph’s Hospital East in Lexington, Ky., and chair of the American Medical Association’s Health Information Technology Advisory Group.

For example, Stack explains, in a very simple but dangerous miscommunication, a prescriber intending to enter “QID,” which he intends to mean “four times daily,” might miss the “I” key and transmit “QD,” which means “once daily,” resulting in a four-fold dosing error.

“If we’re using e-prescribing, there’s no legibility problem anymore and no confusion due to lack of clarity,” says Stack, pointing out that with a standard in place, a dropdown menu containing universal codes can be employed, leaving no room for misinterpretation at either end. “We want to make sure there’s also no error by wrong information transmitted with perfect clarity.”

It’s also problematic that CMS hasn’t adopted standards for clinical drug terminology and prior authorization, Stack says.

As he explains, most e-prescribing systems use proprietary drug code tables, such as First Data Bank or Multum. If the e-prescribing system and pharmacy system use different drug terminology, the drug code entered into the e-prescribing system is translated to the equivalent drug code in the pharmacy system. However, there’s still a risk of error in the translation between systems that can result in the wrong drug being prescribed. With a standard for clinical drug terminology, uniform codes could be used in every prescriber or pharmacy database.

“A higher frequency problem is the system just saying ‘error’ and not working,” Stack adds.

Meanwhile, without a standard for prior authorization of prescriptions by insurance companies, doctors could still be stuck with a cumbersome, paper-heavy process of the sort that e-prescribing was designed to eliminate, he says.

• Ban on e-prescribing for controlled substances

Meanwhile, the government – specifically the Drug Enforcement Agency – is maintaining a considerable roadblock by barring e-prescribing of controlled substances such as pain medications, anti-anxiety medications and muscle relaxers. Moreover, such prescriptions have to be on special tamper-proof paper.

“For doctors who write a lot of prescriptions for controlled substances, you have to buy the paper and decide whether to use it for other prescriptions too,” says Stack. “And some would argue that a secure e-prescribing system should actually be safer for controlled substances than a paper system, but nobody has convinced the DEA that this is true.”

• Physicians’ confusion about systems

An additional hurdle is doctors’ confusion about e-prescribing systems because they typically focus on patient care, not information technology, observers say.

Physicians in smaller practices are less likely to have dedicated IT people to help them select the right system. Navigating these waters alone can be intimidating, particularly because there is no list of CMS-approved vendors.

“Many vendors who produce [these systems] are very small companies and may not have the wherewithal to continually update as the standards ramp up,” says Shrewsbury gynecologist Dale Magee, immediate past president of the Massachusetts Medical Society. “Some may even go out of business. If a doctor is left with software from a defunct company or one that has not upgraded, he’s not in a good place.”

• Cost concerns

Sources also say cost could be a major barrier to implementation.

However, David Harlow, an attorney and health care consultant in Newton, says doctors should overcome the sticker shock and realize that even for an individual practitioner, e-prescribing means less staff time devoted to calling in prescriptions and verifying information. These savings could pay for the system over time.

Insurers will save money too by not paying for care and liability associated with prescription errors. “So should the cost of implementing the change be borne entirely by the provider?” Harlow asks. “Providers would say insurers should kick something in as well.”

Providence, R.I., health care lawyer Linn Foster Freedman, a partner at Nixon Peabody, points out that avenues already exist to make e-prescribing more affordable for smaller practices. She notes that the federal Anti-Kickback Statute places tight restrictions on physicians receiving gifts from pharmaceutical companies and other entities. But in 2006, Congress carved out a safe harbor that enables providers to receive technology donations without running afoul of the act.

“The federal government wants the message out there and wants physicians to adopt electronic health records and e-prescribing,” she says. “It also understands physicians can’t just lay out $100,000 for a new system. So this is a wonderful opportunity for collaboration of different providers of services to lessen the financial burden on them.”

­ — Eric Berkman