Wide Gap Between Vision for E-Prescribing and Reality in Physician Practices

Physicians Report Major Barriers to Using Advanced E-Prescribing Features

News Release
April 3, 2007

FURTHER INFORMATION, CONTACT:
Alwyn Cassil (202) 264-3484 or acassil@hschange.org

WASHINGTON, DC—While physicians who have embraced e-prescribing wouldn’t go back to paper prescriptions, they report major barriers to using advanced e-prescribing features that many advocates believe offer the greatest potential to improve the safety and quality of health care, according to a study by Center for Studying Health System Change (HSC) researchers published today as a Web Exclusive in the journal Health Affairs.

"The gap between policy makers’ vision for e-prescribing to improve the safety, quality and efficiency of care and the reality in physician practices is pretty wide," said lead author Joy M. Grossman, Ph.D., a senior health researcher at HSC, a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation. The Health Affairs study was funded by the Agency for Healthcare Research and Quality.

While physicians were positive about the basic features of e-prescribing, products often lacked advanced features, or if they had them, physicians often did not use them because of implementation hurdles or their perceptions that the features did not add value, according to Grossman and coauthors Anneliese Gerland, an HSC health research analyst; Marie C. Reed, a former HSC health researcher; and Cheryl Fahlman, a former HSC health researcher now with Mathematica Policy Research.

Advanced e-prescribing features include the ability to maintain complete patient medication lists; clinical decision-support tools, including alerts and reminders; access to patient-specific formulary data; and capacity for two-way electronic communication between the medical practices and pharmacies and pharmacy benefit managers (PBMs) to send prescriptions, clarifications and renewal requests.

The Health Affairs article, titled "Physicians’ Experience Using Commercial E-Prescribing Systems," is based on 44 discussions conducted between November 2005 and March 2006 with representatives of 26 organizations, including 15 medical practices using e-prescribing, six medical practices without e-prescribing, health plans, e-prescribing vendors and pharmacies. Two-thirds of the practices used the e-prescribing module of an electronic medical record (EMR), while the remainder used stand-alone systems. Most practices had different technology vendors.

Key study findings include the following:

• Challenges to maintaining complete patient medication lists. Most physicians were able to use e-prescribing systems to access prescriptions written by other physicians in their practice. But none were able to access comprehensive lists of patients’ medications prescribed outside their practices. As a result, physicians continued to rely on patients as the main source of information to complete medication lists.
• Limited use of clinical decision support. All but one of the practices’ e-prescribing systems offered some clinical decision support (CDS) in the form of drug-drug interaction alerts. However, access to more advanced CDS was limited; about half of practices reported being able to check for drug-allergy interactions, and only 20 percent for drug-condition contraindications. There was general agreement that pop-up alerts were triggered too easily. As a result, physicians typically overrode them.
• Difficulty obtaining accurate patient-specific formulary information. Physicians in slightly more than half of the practices did not have access to formulary data electronically, because either the systems did not have the feature or the practice had chosen not to enable it. In the practices where physicians had access to formulary information, respondents pointed out information was available for only a subset of patients, with estimates ranging from 25 percent to 90 percent. Even when information was available, practices often questioned the data’s reliability. Physicians’ views varied on the value of the formulary information, and in many practices, physicians routinely ignored it.
• Limited connectivity with pharmacies and mail-order PBMs. Only the practices with stand-alone e-prescribing systems were using electronic data interchange (EDI) that allows electronic transmission between computers in the physician practice and those in the pharmacy or PBM. Local pharmacies’ lack of readiness was cited as a barrier to full electronic transmission. Most practices using electronic fax or EDI reported spending substantial time educating local pharmacies about e-prescribing. It took a couple of months of daily communications about individual patients for pharmacies to be able to treat electronic transmissions as routine.
• Challenges continue after initial implementation. Practices were not prepared for the amount of interaction needed with outside parties, such as vendors, state regulators and local pharmacies, to implement and maintain the system. Practices continued to devote staff resources for maintenance well after e-prescribing products were in use.

The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded principally by the Robert Wood Johnson Foundation and is affiliated with Mathematica Policy Research, Inc.

Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org.