IMP Question of the Week: E-prescribing

This week's question is from Jean:

Q: Gary, what is your personal take on this e-prescribing mess?

Do you see Medicare? Medicare is huge here. Maine is very old. I have been ignoring e-prescribing. My EMR has it now enabled but it will cost a whopping $1200 a year. I might make more than that in incentives for the first couple of years but then not. Plus you have to code it....

I suppose i could do something free or low cost - but that is double entry.

Anyway what is YOUR take? Thanks.
Jean

A: Jean, thanks for asking and I'm glad to hear that Maine is very old. That means you get to have a steady stream of patients for your practice. Then again, that means putting up with more Medicare hassles. On second thought, you have my sympathies. 

I opted out of Medicare in 2008. I assume you brought up Medicare and e-prescribing together because of Medicare's new E-prescribing Incentive Program. Starting January 1st, 2009, physicians can get an incentive payment for being a "successful e-prescriber": a 2% bonus in 2010, 1% in 2011 and 2012 (assuming the world doesn't end first), and 0.5% in 2013.

Like many things associated with Medicare, it seems kind of complicated: 

1. You must use a "qualified" e-prescribing system such as a stand-alone system or one that is integrated into your electronic health record (EHR).
2. You must report the electronic prescription to Medicare using a special "G-code".
3. At least 10% of your total Medicare charges must use the e-prescribing codes.
4. You have to report G-codes for at least 50% of all submitted claims.

Complicated bureaucracy like this is one reason why I no longer participate in Medicare.

Anyways, if you collect $60,000 from Medicare for the year 2009, then qualifying for the e-prescribing incentive will get you an extra $1200. Just enough to pay for your EHR's e-prescribing service. You break even.

If you collect more than $60,000 in 2009 from Medicare, then you might actually make some money. And if you make less than $60,000 in 2009 from Medicare, you will end up losing money. 

So if you decide to go for the e-prescribing incentive, it probably makes more sense to enroll in a free e-prescribing service such as AllScripts eRxNow. True, it does require you to do double entry, but in a typical small IMP practice where you see less than 10 patients/day, that is not overly burdensome. Plus once a patient has been entered into the system, you don't have to re-enter their information again. 

I did try the eRxNow service for a few months and found it relatively straightforward and easy to use. However, I stopped using it because I found out that I could also e-prescribe using RelayHealth, which I was already paying for. I figured that I might as well get my money's worth.

Both e-prescribing systems are similar in that you have to enter the patient's name and some demographic info. Which brings up my first e-prescribing fact:

1. E-prescribing does NOT save time for physicians.

Writing a NEW e-prescription is always going to be slower than writing a paper prescription. The system won't let you proceed until you have entered in all the required information. Then when you try to find the medication, it may give you more choices than you knew were available. Or it may not have the right medication or dosage in the system at all. 

Fortunately, with time, you get faster. You can have a "Favorites" list of your most prescribed medications with the preferred dosages and directions that you can just point and click on. Unlike new prescriptions, online medication refills can be faster than calling/faxing, especially if you have a lot to do at one time.

You also can't e-prescribe controlled substances, which is probably a good thing, although my prescriptions for Ambien seem to go through without callbacks.

2. E-prescribing does NOT necessarily save time for patients.

Again, if it takes you time to enter the e-prescription, then it takes patients time to wait for you to finish. Even after you hit "Send", things don't always go smoothly. I usually tell patients to give the pharmacy an hour to get their prescription ready. 

I think I must have been one of the first physicians in the area to use e-prescriptions because for the first few months, I would have the pharmacy call me after the patient left and say, "Mrs. Jones is here to pick up her prescription but we haven't received anything yet." And then I would have to give a verbal order. 

Or even worse, after the patient is told there is no prescription waiting for them, they go back later hoping that it will be there now. But you never hear about it until they call or e-mail you to ask, "Did you send my prescription?"

3. E-prescribing still has bugs in the system.

At least once every few weeks, I will get a call from a pharmacy or patient saying that the e-prescription never got through. It seems to happen more when I send an e-prescription to a new pharmacy or to certain e-prescription-unfriendly pharmacies. In almost every case, when I'd tell the pharmacy technician to check their fax machine or e-prescribing system, they eventually found it. It's almost as if the pharmacies don't want doctors to e-prescribe.

Another glitch is when I get a fax from the pharmacy requesting a refill. I send an e-prescription refill and it's done, right? Then the next day, I get the exact same fax. I figured they just haven't had time to figure out that I sent in the refill order. But then they keep coming every day, until I call up the pharmacy and point out that I already sent an e-prescription and to stop sending me these automated refill requests please!

4. E-prescribing might mean safer prescribing.

The proponents of e-prescribing claim it leads to greater patient safety because they are clearer to read with less chance of errors, and that is definitely true. But it is not true that you will have access to your patient's entire prescription history, unless you are the only doctor who ever writes prescriptions for them. It will not have prescriptions written by other physicians, so you still have to get a complete medication history from your patients to check for drug interactions. 

5. E-prescribing makes you look cool.

E-prescribing is the medical IT equivalent of having an iPhone. It impresses upon patients that you are technologically-savvy and ahead of the curve. They probably wouldn't even notice that you can't type. What would be even more impressive is if I could e-prescribe quickly and easily from my iPhone. 

Like many cutting-edge technological advances, e-prescribing is a wonderful concept that in real-life practice, is inconsistent, and sometimes frustrating. For me, it works about 80-90% of the time. I keep plugging away at it because I know that if I stop, it will take that much longer for e-prescribing to be widely adopted. We are the beta testers for the pharmaceutical industry, and if anything, we should be the ones getting paid to work out the bugs in their system.

The Medicare E-prescribing Incentive Program is an example of how well-meaning health care policy decisions to use technology, whether it be EHRs or quality reporting, often don't make the work of primary care any easier, and in fact, adds even more work with burdensome requirements. We need solutions that are simple to understand and implement. 

So, Jean, bottom line is I think e-prescribing is definitely part of the future of medicine, and an important part of my IMP practice. If you decide that now is the right time for you to start e-prescribing, then hopefully it won't cost you too much time or money to implement it. 

Gary Seto, MD

South Pasadena, CA

Comments

[podiatry emr]

From what I have read, e-prescribing will make easy work for the one who works fast and credible compare to paper works. It doesn't mean that it won't work for you if you only have one doctor. There are possibilities that situations will come.

-nj

[jean]

Thanks Gary.
Did someone say that I couldn't type?

I got $30,000 from medicare for 2008 ,so doing this from my emr would cost me time as well as money

It would cost more time and less money using some other methods true.
Double entry seems to incur a higher likihood of mistakes . Therefore e prescribing does not seem to imply saftey for patients automatically While i am particularly attracted to the idea of looking cool ,gosh, I thought I WAS cool, with e faxing which is checked for interactions and doses and automatically has a log of the prescription kept by my emr plus with one click i can also see if the fax went through and was received

I guess i fail to see why e presrcibing- vs legible safety checked prescripions by fax or
"e" is part of the future except in so far as someone with power says I must do it
Thanks for talking to me.
I feel sad.
Jean