Physicians and pharmacists who have already begun e-prescribing are pioneers of sorts, struggling to break through the tangle of technology and workflow, and clearing a path for others to follow. A new study published online in the Journal of the American Medical Informatics Association examined the experiences of some of these pioneers, concluding that while e-prescribing technology has matured, there is still room for improvement.
The research study, which was funded by the Agency for Healthcare Research and Quality (AHRQ), is based on qualitative analysis of telephone interviews conducted with representatives from 97 organizations in 2010 that were actively transmitting or receiving e-prescriptions via Surescripts. The mix of organizations included 24 physician practices, 48 community pharmacies, and three mail-order pharmacies.
Study participants reported a general satisfaction with e-prescribing for new prescriptions, but the process for renewals — also known as refills — was inconsistent, resulting in inefficiencies on both sides. For example, some practices reported that pharmacies did not consistently request renewal authorizations electronically. One physician reported that “sometimes the patient will call, the pharmacy will fax, and [send something via] Surescripts, all for the same patient, the same prescription, on the same day. That is cumbersome.”
When the renewal process works properly, however, both physicians and pharmacists reported time-saving advantages with the use of e-prescribing, including shorter turnaround time for docs to approve refills and fewer keystrokes for pharmacists to fill the orders.
E-prescribing with mail-order pharmacies is another area in need of improvement, according to three quarters of the physicians surveyed, who reported that the process was unreliable. The problem, according to the mail-order pharmacy respondents, is that few of the e-prescribing vendors that were Surescripts-certified to e-prescribe with community pharmacies were also certified for new prescriptions with mail-order pharmacies. Even fewer were certified for mail-order renewals.
On the pharmacy side, study participants identified three key fields in the e-prescribing system that are likely to require manipulation by the pharmacists receiving the order.
Medication name: Physicians must select medications with more specificity when e-prescribing, making decisions that are usually made by pharmacists for hand-written prescriptions. “No longer now can I just say ‘potassium,’ I have to pick if it’s a tablet, capsule, or liquid — you used to just let the pharmacist and patient deal with that,” said one doc. “Fat fingering,” or inadvertently selecting a drug with a similar spelling, is another problem noted by survey respondents.
Quantity: Physicians reported trouble with accurately specifying quantities for prepackaged or multi use medications — such as pill packs, syringes, inhalers, or creams — when e-prescribing. Pharmacists commented that they must be trained to spot and correct these problems, or they can cause billing issues.
Patient instructions: About half of the pharmacy respondents noted that they often have to re-write patient instructions — also known as the Signatura or ‘Sig’ — so that patients can understand them, much as they do with paper prescriptions. About a third noted that physicians will sometimes provide additional instructions in another field that contradict what is noted in the Sig. This can prompt callbacks, which disrupts the e-prescribing process.
The study concludes that while some e-prescribing challenges will be overcome as physicians and pharmacists gain more experience with the process, there are underlying structural issues that must be addressed by a broad group of public and private stakeholders. Until then, the e-prescribing pioneers will continue to lead the way.