Why we Delayed e-Prescribing for a Year

Perhaps nowhere in the blogosphere does one find more spirited healthcare IT debates than on the subject of e-prescribing.  Go to KevinMD.com and see a recent post, Why are most physicians writing their prescriptions by hand? The debate in the comments section ran for almost a month after its posting.

To supporters of e-prescribing (mostly IT folks) it’s a no-brainer.  No more non formulary scripts, no more messy doctors handwriting, far fewer errors, data capture for performance review, etc.  You can check your prescription against the patient’s drug allergies and check for drug-drug interactions.  When your patient arrives at the pharmacy the electronically transmitted prescription is waiting for him/her.  What’s not to like?

Opponents of e-prescribing (mostly docs) will be glad to tell you.  Why take something so simple and make it so complicated?  The technique of paper script writing has withstood the test of time for over 50 years.  A paper script takes only a few seconds to write.  An e-script may take over a minute.  For e-prescribing the doc has to do all the work (and foot the bill), yet the beneficiaries are everybody else except the physician.

The debate is a classic example of how IT folks and MDs see the world differently.

Our experience preparing to implement e-Rx has been very revealing.  About 18 months ago we began to research the only integrated e-Rx product available for our EMR.  I brought a very primitive preconception of e-Rx to the table:  Complete the script on screen just like we are doing now, push SEND instead of PRINT, and that’s it.  There should no significant changes to our existing workflow.

I was going through the online demo when I noticed something I thought was unusual.  The e-Rx app was “updating” the patient’s chart long before the prescription was written.   Exactly what was it updating?

The answer I got was very concerning.  The e-Rx app accesses a pharmacy database called Surescripts, which contains data on recently filled prescriptions.  When the e-Rx app is run it creates a behind-the-scenes “parallel list” of medications for each patient based on recently filled prescriptions.  Well, not exactly…the database includes only those meds on which a pharmacy claim was filed.  If the medication was purchased with cash it doesn’t show up in the Surescripts database, so it doesn’t get uploaded to your EMR either.

Why did this bother me so much?  Every other method of chart updating currently used by our EMR – manual data entry, document scanning, patient portal, HL-7 update – has a historical precedent in the paper chart system.  The e-Rx update does not.  We have never had pharmacies push data to us before.

“Welcome to the world of health information exchange!” the IT folks say.  In fact the tech support information I found promised even more functionality in the future.  If a patient fails to pick up the prescription within 30 days, “the system” will notify the physician.  From an IT standpoint it looks great, and soon it will get even better.

Not so fast.  To the physician this looks very different than it does to the health IT professional.

E-Rx (at least the application we need to use for our EMR) introduces a potential new standard of care into the doctor-patient relationship.  Current standard of care recognizes only one source of information regarding patient medications – the patient himself.  If the patient forgets to tell me he/she is taking a critical heart medication that is the patient’s error, not mine.  But what if the e-Rx app uploads data to my EMR showing that the patient has recently filled a prescription for heart medication?  I obtained 2 medical-legal opinions and both concur that the physician is responsible for knowing what is uploaded to the EMR regardless of how the EMR handles that data once it arrives.

To make things worse, the list is not accurate – since the Surescripts database only includes medications paid for by insurance, our hypothetical heart medication might not be there either.

The soon-to-arrive 30-day notification feature has the same problem.  What if the system notifies me that a patient fails to fill a prescription?  Am I now liable for the patient’s non-compliance?  Must I then assume the expense and liability for making “nanny phone calls” to these patients to remind them?

There are also workflow issues.  Uploading prescription data forces us to create a medication reconciliation step to match the database med list with the list provided by the patient to resolve any discrepancies.  Maintaining the medication list is already the single most burdensome part of our data entry.  This would make it much worse.

What looks great through the eyes of IT doesn’t look so good to the physician.  Don’t misunderstand me.  Like all physicians I support steps that improve patient care and improve patient compliance.  But unlike the IT folks we understand that more data is not necessary better.  Too much data creates “white noise”, interfering with our ability to assimilate the useful data.  Furthermore, more information creates more expense; it is inappropriate to expect physicians to assume such a large proportion of the burden.  Some future model of health care delivery, such as an accountable care organization or medical home, may be able to handle this issue better.

About the author

Dr. Michael Koriwchak

Dr. Michael Koriwchak

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery.
After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations.
Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia.
With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

4 Comments

  • Nice points raised in the blog, Mike. We have use Surescripts for years (mainly because our EMR is Allscripts) and have essentially ignored the pharmacy information push. It is incomplete and inaccurate for reasons you well described. On that note, ,the automated insurance verification checker is also buggy so we ignore it as well and use time tested methods.

    I do think that writing prescriptions, however, is easier with EMR. I like the immediate documentation, realtime interaction and formulary checking.

  • Very interesting.

    Read this as well:

    “Emerging Trends in Electronic Health Record Liability”

    http://www.dri.org/(S(zgpew245uf2ywz45b5jkgp55))/articles/MedicalLiability/FTD-1007-Brouillard.pdf

    e.g.,

    “…Another interesting case tried to use a pharmacy’s participation in a state-mandated electronic database as a ground for expanding liability to third persons. Sanchez v. Wal-Mart, 221 P.3d 1276 (Nev. 2009). The case involved a woman who instigated a car accident while under the influence of prescription drugs, resulting in the death of another motorist and the injury of yet one other. The appellants sued a number of pharmacies that had filled multiple prescriptions for the motorist who caused the accident. Nevada has a statutory scheme requiring the pharmacies in question to participate in a computerized, prescription- tracking system designed to identify prescription drug abuse. While the appeal was unsuccessful for a number of reasons, one of which was that the pharmacies did not have direct access to the database, it does again raise the fundamental questions, if health providers add new data sources about patients to existing sources, does it create obligations to the patients or others, and if so, when? In San-chez the issue was not so much the medical status of the initial tortfeasor, the woman who caused the accident, as it was her substance abuse, which was dangerous to third parties. If such information is made available to providers, plaintiffs may continue to claim that knowledge of a patient’s dangerousness creates special obligations…”

  • Your “white noise” comment is very important. I set up my own template for a physical examination/medicalconsultation many years ago. It had some simple bolding and underlining to make the overall outline clear. It may have run four pages, but I got notice from patients that the anesthesiologist or nurse at their surgery said it was great.
    I left my solo practice and joined a group. We use Allscripts and the white noise is pretty loud. Our nurse enters some history and if she gets hyperthyroidism and hypothyroidism confused, I am unable to edit/change it.

    We are not “there” yet. Our office has been using Allscripts for 3 years or so and it is sluggish. I was much faster with pen and paper and my handwriting was generally legible. I did not have the thorough RoS with each visit that is expected often today, that works best with those click box things. Maybe we have too many “Impossible Days”

  • I’d suggest not advocating throwing out the baby with the bathwater because your EMR has an implementation issue. A new cardiac medication is not white noise … your EMR needs to indicate to you that a new medication has been added to the list of current medications.

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