Study Exposes Electronic Prescribing's FlawsStudy Exposes Electronic Prescribing's Flaws

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Electronic prescribing is plagued by numerous interface problems and communications gaps between physician offices and pharmacies, according to a study recently published in the Journal of American Medical Informatics Association. Some of the deficiencies reflect underlying structural problems in the electronic prescribing software that many physicians use.

Conducted by the Center for Studying Health System Change (HSC) and sponsored by the Agency for Healthcare Research and Quality (AHRQ), the study is based on 114 phone interviews performed in 2010 with representatives of 24 physician practices, 48 community pharmacies, and three mail-order pharmacies actively transmitting or receiving e-prescriptions via Surescripts.

One surprising finding: While electronic prescription renewals saved physicians time, they posed bigger routing problems than new prescriptions did. "Physicians and community pharmacists found that the electronic renewal process was not as consistently successful as new prescription routing and was more difficult to integrate into organization workflows."

One reason is that a quarter of the participating community pharmacies didn't send electronic renewal authorization requests. "Eight of these pharmacies lacked the functionality, and the rest chose not to use the feature, mainly to avoid Surescripts transaction fees. Similarly, one-third of physician practices were not set up to receive e-renewal requests or received them infrequently," the study said.

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Some pharmacies sent several renewal requests for the same prescriptions, both electronically and over fax. Other drugstores had difficulty handling online renewals that patients, rather than the pharmacies, had requested from physicians; instead of letting them go directly into the pharmacy system, they entered them manually.

Three-quarters of the physician offices experienced difficulties in prescribing electronically to mail-order houses, six of which were online with Surescripts at the end of 2010. The practices expected the transmission of prescriptions to these mail-order companies to be identical to pharmacy routing. But few of the e-prescribing vendors (including EHR vendors) certified by Surescripts for pharmacy routing were certified to send scripts to mail-order systems.

"Since the time of the interviews, transmission network changes have been implemented to enable more e-prescribing vendors to route new prescriptions electronically to mail-order pharmacies, but changes to support e-renewals lag," the study noted.

The paper also cited serious underlying problems in physicians' identification of medications and their instructions to patients. As a result, pharmacists said, they often had to manually enter these elements of e-prescriptions, which made e-prescribing less efficient.

Physicians complained that there were far too many choices in their e-prescribing programs, making it difficult to select the right drug. Also, the NDC classification used to standardize identification across different drug-database vendors often did not match how medications were described in pharmacy information systems.

"Moreover, both physician and pharmacist respondents explained that physicians must select medications with more specificity when e-prescribing, making decisions about packaging, drug form, or other features that commonly are made by pharmacists for hand-written prescriptions, sometimes leading to more pharmacy follow-up," the study pointed out.

Some of these issues are being addressed. For instance, the researchers observed, experts have recommended that a technical standard called RxNorm replace NDC as the main identifier of drugs. "RxNorm could help reduce drug selection inefficiencies and potential errors by better conveying physicians' clinical intent without requiring them to over-specify their choice and allowing pharmacists to use that information to select the most appropriate medication."

The issues described in this paper are coming to the fore just as electronic prescribing is taking off. Surescripts recently announced that more than half of office-based physicians are now prescribing electronically. That percentage is sure to rise as more physicians acquire EHRs and seek to show Meaningful Use, which requires that they send at least 40% of their prescriptions online to pharmacies.

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