Wide Gap Between Vision for E-Prescribing and Reality in Physician Practices
Physicians Report Major Barriers to Using Advanced E-Prescribing Features
April 3, 2007
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WASHINGTON, DCWhile physicians who have embraced e-prescribing
wouldnt 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
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
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 datas 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 nations
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
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.