Technology: Is E-Prescribing Worthwhile?

You’ve been handwriting prescriptions for years, and it’s worked pretty well for you. It takes only 10 or 20 seconds to dash off a script; nobody has sued you over anything you’ve prescribed; and you don’t have to mess with a computer while seeing patients.

Still, pharmacy calls are driving your staff crazy, and once in a while, a pharmacist notifies you about a potential drug interaction. So you wonder whether electronic prescribing might protect patients from harm, and whether it could make your office more efficient.

Studies show that e-prescribing does in fact improve patient safety. For example, in 2003, three Massachusetts health plans gave e-prescribing software licenses and PDAs to 3,400 physicians and nurses. In 2007, with the aid of computerized drug/drug and drug/allergy alerts, the collaborative’s providers wrote nearly 5 million electronic prescriptions - and changed 104,000 of them because they were potentially harmful.

The Henry Ford Medical Group in Detroit had a similar experience in early 2005, when the group started piloting a standalone e-prescribing program. By July of the next year, 600 of its 800 doctors had access to it. During that period, more than 98,000 prescriptions - including 7,300 that might have caused drug allergies - were changed or canceled as a result of automatic alerts. Three-quarters of Henry Ford’s doctors say e-prescribing improves the quality of care and makes patient care safer.

Some private practice doctors agree, too. “Patient safety is definitely increased by reducing errors in the transcribing process” at the pharmacy, says Bernd Wollschlaeger, a family physician in Miami who uses the iScribe program. Azar Korbey, a family doctor in Salem, N.H., stresses the importance of legibility and drug/allergy alerts. He says his Allscripts e-prescribing program has warned him against prescribing the wrong medication a number of times.

Solo family practitioner Allen Warrington of Wilmington, Del., has found that e-prescribing gives him more accurate medication lists, his office manager and wife, Deborah Warrington, notes. Two-way online connectivity with pharmacies - now available with most chain stores and some independent pharmacies - reveals whether patients are refilling their prescriptions, and whether it’s time to call them back into the office for a blood test.

After a year of using the DrFirst Rcopia program for free, (courtesy of Delaware Blue Cross and Blue Shield), the Warringtons have decided to subscribe. “There’s no question that it’s better, more accurate care,” Deborah Warrington says.

The cost of e-prescribing

That’s all very nice, you say, but what will it cost me, and how will I recoup that investment?

“Standalone” programs - those that aren’t part of an EMR system - are not expensive. For example, DrFirst, which hosts its Rcopia software on the Web, charges $799 per physician, per year for use of the program and a service that includes online connections to pharmacies and regularly updated formulary and drug databases.

PocketScript, made by Zix Corp., costs $600 a year (although health plans sponsor most subscriptions). ERX NOW, a Web-based program, is free. Corporate sponsors - including Microsoft, Cisco, Dell, Fujitsu, Sprint, Aetna, and Wellpoint - foot the bill. They also pay for a drug database, formulary lists, and a connection to SureScripts, the company that links physician offices online to most pharmacies.

An interface between a practice management system and an e-prescribing program typically costs about $2,000 - a pretty hefty price tag at first glance. But by avoiding dual entry of patient demographic and insurance data, the interface actually saves money in the long run, says Rosemarie Nelson, an MGMA consultant based in Syracuse, N.Y. If you still don’t want to invest in this program, she adds, your vendor can “dump” your existing demographic data into the e-prescriber for just a few hundred dollars. But here’s the caveat: Your staff will have to enter data twice on new patients.

If you choose eRX NOW , a practice management interface is either free or almost free. A number of vendors, including Allscripts, supply it gratis. If you have a practice management program that’s not made by one of those companies, you can have an interface written for $295; maintenance costs are $19.99 a month.

Many practices already have most of the computer equipment they need for e-prescribing. While standalone programs are usually designed for PDAs, they can also be used on desktops, laptops, and tablet PCs. So if you want to use the desktop that’s already in your office and write prescriptions on it at the end of visits, that’s perfectly OK.

A wireless network is essential if you’re going to prescribe on a PDA or a laptop while in the exam room. The cost of a wireless setup ranges from about $70 for a home-style system to a few hundred dollars for one designed for small businesses. Larger offices will have to spend more to deploy extra access points.

A high-speed Internet connection might be an added expense if your practice doesn’t already have one (although these days most do). If you have a smart phone and want to send your prescriptions over a cellular network, you’ll pay a data charge of $40 to $60 per month.

Not counting software charges, Nelson estimates that a small practice can set up an e-prescribing system from scratch for about $5,000; including $3,000 for the computer and networking gear and $2,000 for the billing system interface.

How e-prescribing increases efficiency

When physicians e-prescribe, nurses spend less time on the phone with or managing incoming faxes from pharmacies. What’s more, staffers no longer have to pull and file charts; they just insert an e-script printout in the paper record. Of course, if a physician prefers to look at the chart for every renewal, this efficiency is lost. But the decrease in pharmacy callbacks is still significant.

Azar Korbey, MD, figures that improved legibility and his vetting of prescriptions for formulary compliance and drug interactions cut druggist calls by 20 per nurse per day. With each phone call lasting about eight minutes, he calculated a few years ago that each of his nurses saved two hours daily as a result of e-prescribing. Now that he has two-way communication with pharmacies, he says, he’s also avoiding refill calls triggered by patients.

Other e-prescribing physicians say their practices are saving an hour or two a day on pharmacy calls. What’s that worth in dollar terms? According to an MGMA study, administrative work related to prescriptions - including pharmacy calls - costs the average full-time physician $15,700 per year. E-prescribing can cut that cost in half, says Cameron Deemer, president of DrFirst.

However, the savings may not be obvious to physicians. “The downstream benefit to providers is indirect, because it improves the operations of the practice,” Nelson points out. “They’re actually going to save dollars, but they’re not going to eliminate an employee, so they don’t see that.”

Nelson says it costs between $5 and $12 to pull and file a chart. If your office does that 20 times a day just for renewal requests, that task alone is costing you $100 to $240 every single day. Even using the low number, that’s a cost of about $26,000 a year just to fiddle with charts. E-prescribing can make a big dent in that expense but, unfortunately, not eliminate it.

For one, if you don’t have an EMR, your staff still has to pull charts to file printouts of electronic prescriptions. Also, it’s going to take several months for all of your patients on long-term medications to come in, and when they do, your staff may have to pull their charts to enter their drugs into the e-prescriber’s database. Based on her measurements of improved efficiency, Nelson figures that practices can break even on their investment in e-prescribing within six to nine months.

In addition to money, you’ll save on time as well. Korbey has used the time savings to expand his operations. Instead of laying people off, he redefined their roles. His practice now dispenses drugs and provides various ancillary services including lab tests, nerve conduction studies, diabetic eye exams, Holter monitors, bone-density studies, and aesthetic laser treatments. And Wollschlaeger, who practices without a staff, says he’s able to see more patients in the 45 minutes a day that e-prescribing saves him.

Impact on physician work flow

You may find that when you begin to prescribe electronically, it may take you more time to write a prescription than it used to. “Almost all processes on the computer take you longer,” says Steven Von Elten, a family physician in Warrenton, Va., who’s been using Rcopia for two years. “But one of the benefits of e-prescribers is that you can keep commonly used prescriptions on a favorites list.”

That saves him time by allowing him to quickly select a favorite rather than having to pick one from a long list of therapeutic alternatives. The program also helps him avoid pharmacy calls by telling him whether the drug he chooses is on a plan’s formulary; if not, it recommends other medications.

Yes, you read correctly: You can bounce your potential prescription off your patient’s insurance formulary - talk about a time-saver for both you and the patient. Formularies in many e-prescribers come from RxHub, a company formed by three big pharmacy benefit managers that now includes many health plans. RxHub says it has eligibility data, formularies, and claims histories on more than 200 million people.

You won’t find data on all of your patients; many Medicaid programs, for example, aren’t included. Cameron Deemer estimates that formulary “hit rates” average about 70 percent. Not perfect, but not bad either.

The leading e-prescribing services also provide physicians with community medication histories that allow doctors to see what other providers are prescribing for their patients. In some metropolitan areas, the hit rate for those histories is 90 percent, says Deemer; overall, he figures, med lists are available for about 55 percent to 60 percent of patients. But that estimate is rising rapidly now that SureScripts is rolling out medication histories based on pharmacy records, rather than claims data. Not only are more patients included, but so are their over-the-counter pills and the drugs they paid cash for.

The value to physicians can be considerable. For example, Deborah Warrington points out that her husband-physician can find out whether a cardiologist has changed a patient’s blood-pressure medications without the patient mentioning it to him. Also, it has allowed him to detect patients who have been “shopping” at other practices for narcotics.

Of course, it takes time to go through these computer screens, and because of this, you might believe that e-prescribing would slow you down too much. But doctors experienced in using the technology say that any extra time spent on writing a new prescription is more than counterbalanced by time savings on refills. Wollschlaeger says it takes him about 20 seconds to write an Amoxicillin prescription for a new patient, less time for an established patient. And he can click off half a dozen renewals in 10 to 15 seconds.

Linda Green, an allergist in Haverton, Pa., who uses eRX NOW, says, “That refill is so painless. You see the task on the screen and just click through the options, and the refills are done. And it’s easy to print reports on what prescription they’ve been on and what the refill is for.”

Other issues to consider

If you are a physician who’s currently considering the purchase of an EMR, a big question you’ll want to ask about e-prescribing is whether you’ll be able to transfer your medication data from a standalone eRx program to the new EMR. Nelson says not to worry; in most cases, it shouldn’t be a problem. “It’s more likely than not that that data can be converted and uploaded - at least the existing med lists. That will put you further ahead than if you were converting from your paper chart alone.”

That raises the issue of how you get your medication lists for established patients into the e-prescriber. You can have a staffer enter lists before each patient comes in, but that’s laborious. A better solution, suggests Lee Shapiro, president of Allscripts, is to use the electronic histories provided by RxHub and SureScripts to create part of the list. Then you can ask the patient what else he or she is taking. Warrington says her practice has saved a lot of work with this approach.

E-prescribing can create multiple work flows. When your system can’t find the formulary for a patient’s plan, for instance, you have to look it up elsewhere. Also, physicians still have to print out prescriptions for some kinds of controlled substances, although the DEA recently requested a change in those rules to allow for electronic prescribing. You might also have to fax a prescription to a drugstore that doesn’t accept electronic prescriptions. SureScripts and some EMR vendors will computer-fax your prescriptions to those pharmacies, however.

But what a boon to be able to prescribe remotely - from home or during rounds, perhaps - through e-prescribing, thereby eliminating inconvenient and time-wasting trips to the office. Also, you might be able to score a discount from your malpractice insurers if you switch to prescribing electronically.

And physicians say patients like having their prescriptions waiting for them at the pharmacy - a factor that might give you a competitive advantage. Finally, note that converting may not always be a choice, as healthcare stakeholders are stepping up pressure on Congress to mandate e-prescribing. A bill introduced by Sen. John Kerry would financially penalize doctors who don’t e-prescribe, starting in 2011.

So even if you’re hesitant to change how you work or to invest in a new technology, it’s definitely time to consider e-prescribing.

Ken Terry is a New Jersey-based freelance writer and the author of the book “Rx for Health Care Reform.” He can be reached via bkeaveney@physicianspractice.com.

This article originally appeared in the May 2008 issue of Physicians Practice.