The prescription pad—that time-honored trademark of medical
practice—may someday be a museum piece.
Electronic prescription transmission (e-prescribing, sometimes denoted by
the shorthand eRx) is coming soon to your office, a dress-rehearsal, advocates
say, for the digital revolution that will overtake America's health care
system when it converts to an electronic health record (EHR) system. Believers
say e-prescribing is more convenient for patient and physician, saving time
And most important, it has been linked with dramatic reductions in
prescribing errors that have resulted in sickness and death.
The Bush administration, political leaders from both parties, physician
groups including APA, and private-sector software manufacturers have all begun
maneuvering toward the realization of a national health information network, a
vision of rapid and secure electronic transfer of patient medical information
across systems and over the span of a patient's life (Psychiatric
News, September 16, 2005).
It is a vision that would essentially relegate the time-honored,
paper-based medical chart to the dustbin of history, and it is one in which
e-prescribing is an integral—and perhaps preliminary—piece.
Not everyone is thrilled with the prospect. The confidentiality of medical
information in the electronic future is a matter of serious concern for many
in medicine, especially psychiatrists. APA's corresponding committees on
Electronic Health Records and on Confidentiality are working on position
papers to outline the vital issues with regard to privacy.
But as is the case with the electronic medical record itself, the benefits
of e-prescribing appear to be so tempting for all parties—physicians,
patients, and the health care system generally—that there is an aura of
inevitability about the movement.
"E-prescribing is coming, whether people like it or not," said
psychiatrist Marc Graff, M.D., a partner physician with the Southern
California Permanente Group and a member of APA's Corresponding Committee on
Electronic Health Records. "I think it's just a matter of time—not
if, but when. And I believe it will result in better clinical care."
Yet for all its apparent benefits, e-prescribing, like the electronic
record itself, is not without hurdles to overcome before it is widely
Robert Plovnick, M.D., M.S., informatics and performance-measure specialist
in APA's Office of Quality Improvement and Psychiatric Services, said that a
number of studies indicate that only a fraction of the nation's
physicians—between 5 percent and 18 percent, depending on the
study—have adopted some form of electronic prescribing.
Most of those who have taken the plunge are physicians working in large,
closed systems such as the Department of Veterans Affairs and, in the private
sector, the Kaiser Permanente Group. The VA has been working with a full-scale
EHR system for several years, and Kaiser is now rolling out its own.
Smaller physician groups have been slower to adopt e-prescribing systems.
According to a January 2006 report by the California Healthcare Foundation
titled "The Prescription Infrastructure: Are We Ready for
E-Prescribing?," the cost for a stand-alone e-prescribing application
(that is, one that operates independently of a full-scale EHR system) is
between $1,500 and $3,000.
That may be a relatively small price to pay for the benefits that can
accrue down the road from greater efficiency. But Plovnick said that another
inhibiting factor is the fact that much of the cost savings is liable to be
reaped not by the physician, but by the health plan or prescription benefit
Moreover, cost is not the only inhibiting factor: some practices may be
reluctant to adopt an e-prescribing system without full-scale investment in
all the other components of an EHR system.
A buzzword in the field of health information technology (IT) is"
interoperability," the ability of information software systems to"
talk" to each other to allow seamless transfer of information
across the health care landscape—a concept that presupposes wide-spread
adoption of computerization.
So the same conundrum complicating investment in an EHR also vexes
physicians contemplating an e-prescribing system: How do they know if the
software they purchase will be compatible with other systems as EHR systems
evolve in coming years? This concern has left many physicians reluctant to
make a substantial investment in a product that may need to be replaced in
The question of whether to adopt eRx independent of a full-scale EHR system
is hotly debated within health IT circles.
"There is wide disagreement about whether eRx can—or even
should—succeed in the absence of a complete electronic health
record," according to a report from the California Foundation for
Healthcare. "A standalone eRx application... costs considerably less
than most EHRs and, when introduced, requires fewer changes in a physician
practice. Proponents of eRx claim that standalone eRx applications are an
intermediate step to EHRs, which, they believe, are still a decade away from
full adoption. However, stand-alone eRx does not offer most EHR features....
Some EHR proponents suggest that if stand-alone eRx succeeds, it will
ultimately slow the wide-spread adoption of EHRs."
But for small group practices, piecemeal adoption of EHRs may make sense;
an e-prescribing system, for instance, may be of more value to a small group
practice than to a large group "whose greater concern is reducing the
cost of chart pulls and transcriptions rather than fixing prescription
workflow problems," according to the California Foundation for
"Consequently, for the vast majority of doctors in small practices,
adoption of these technologies will likely be a collage of stand-alone eRx and
EHR," the report concluded.
Despite the hurdles involved in making the transition, psychiatrists at
Kaiser and the VA who have experience with e-prescribing say they would not
turn back the clock.
They emphasize the practical efficiency of a process that eliminates
time-consuming faxes and phone calls to and from patients and pharmacies. And
they extol the power of a system that puts enormous amounts of information at
a doctor's fingertips.FIG2
"Whenever a patient arrives—and I have over 1,500
patients—I can get a snapshot right away of every medication he or she
is on," Graff told Psychiatric News.
He said that the Kaiser e-prescribing system, known as E-Script, has been
in place for several years, a preliminary step to the rollout of Kaiser's Epic
software for EHRs. (Epic is already up and running at Kaiser in other areas of
Graff described a system in which the choice of medication, dosage, and
refill duration are automated and virtually fail-safe, with a 10-minute window
in which physicians can review the order for inaccuracies or typographical
errors before it is sent off to the pharmacy. A separate application that can
be run simultaneously with E-Script provides information about potential
drug-drug interactions, he said.
For physicians working in closed systems like Kaiser, with its own internal
pharmacy, eRx may be a natural. But how will it work for physicians whose
patients may go to any of dozens of local pharmacies?
Plovnick reported that several companies are now offering electronic
connectivity between physician offices and chain and community pharmacies in
anticipation of widespread adoption of eRx. Among these are SureScripts, at<www.surescripts.com>
and RxHub, at<www.rxhub.com>.
SureScripts was founded in 2001 by the National Association of Chain Drug
Stores and the National Community Pharmacists Association. RxHub was the
creation in the same year by three leading pharmacy benefit managers,
AdvancePCS, Express Scripts, and Medco Health Solutions.
It is at the VA where e-prescribing appears to have reached its highest
level of maturity so far in efficiency, automation, and error prevention.
Psychiatrist Peter Fore, M.D., also a member of APA's Corresponding
Committee on Electronic Health Records, said that the VA's e-prescribing
system—a component of a full-scale EHR system—is graphically
driven, providing point-and-click convenience.
The clinician logging into the system can pull up what looks like a typical
medical chart for any patient, with a series of tabs that can be selected
depending on what the clinician needs to do; medications are grouped according
to class—antidepressants on one screen, with standard dosages and tabs
for modifying orders.
Fore told Psychiatric News a key feature of the VA eRx system is
direct provider entry. "This means physicians have to actually enter the
order themselves as opposed to having a clerk enter it," he said."
The problem with letting others do the entry is that you get all kinds
of handwriting and transcription errors. When we initiated direct provider
entry, it dramatically decreased the error rate."
Fore is acting director of the mental health service line at Jesse Brown VA
Hospital in Chicago.
Before the order goes to the pharmacy, the system checks for interactions
with other drugs taken by the patient, providing pop-up alerts to the
clinician if the dosage selected is not standard or if the patient had a prior
allergic reaction to the medication. The system will also check critical lab
values that may affect the selection of medication or dosage, Fore said.
Finally, there is an order review during which the physician can see the
prescription before attaching an electronic signature. "Basically the
system asks the clinician, `Are you sure you want to do this?'" Fore
explained. "The physician always has the option of overriding the alert,
which may require a written explanation."
Computerization of error prevention extends to the inpatient unit. There,
medications come from the pharmacy in a plastic bag with a bar code; each
patient has a bar code on his or her wristband, and nurses carry a laptop that
scans the codes to make sure there is a match between the patient's and
medication's bar codes, Fore said.
Are there any downsides to the system? Fore and Graff agreed that
computerization renders everyone a prisoner of the system's "bad
hair" days; when it's down—which both say is rare—everything
But Fore said he is a fan of e-prescribing and that for most VA physicians
there is no turning back. "There was some reluctance at first on the
part of clinicians," he said. "Some of them thought it was
demeaning having to type in their own orders. But with time and experience,
everyone has bought into the system. There is really no other way to