Rx in search of a digital cure

Is e-prescribing finally ready to take off?

Published in: Baltimore Business Journal
Issue/Volume: Friday, March 27, 2009
Written by: Scott Graham

3/27/2009 – Admitted to the hospital more than a month prior with first- and second-degree burns after jumping into a hot bath, Josie was thin, pale, thirsty and despondent. She was quickly given two shots of Narcan, a stimulant, and a liter of water before her doctor gave verbal orders that she was not to be given any more methadone.

But about six hours later, a nurse told Sorrel King the orders, which were never documented, had been changed and gave Josie a shot of the pain-fighting narcotic. Within a few minutes, Josie’s heart stopped beating and she was rushed back to the hospital’s pediatric intensive care unit.

Two days later, Josie King died.

And more than eight years after her daughter passed away, Sorrel King wonders whether a more formal way of prescribing drugs electronically could have saved her daughter.

“Honestly, I think it could have,” said Sorrel, who with her husband Tony launched the Josie King Foundation to advocate for young patients’ safety. “They may have had to enter Josie’s weight with the methadone dosage or something that would have alerted them to a problem. That little bit could have saved her.”

The federal government — specifically the Centers for Medicare and Medicaid Services in Woodlawn — agrees. That is why it wants all health care providers — primary care physicians and outpatient surgeons chief among them — to begin electronically prescribing medications by 2012.

In 2007, just 6 percent of about 35 million prescriptions nationwide were transmitted electronically, according to SureScripts, which operates the country’s largest e-prescribing system. In Maryland, just 3.17 percent of all prescriptions were done electronically, and the state ranked sixth in total e-prescriptions that year.

Those numbers likely have grown, but not by much, health care experts say. Despite a carrot-and-stick approach by CMS and federal stimulus money to entice doctors to begin e-prescribing this year, the number of physicians doing it is still scant, said Ritu Agarwal, director of the Center for Health Information and Decision Systems at the University of Maryland’s Robert H. Smith School of Business.

Waiting for the consolidation

While e-prescribing — and the greater gravitation toward transmitting health information online — is gaining clout as a way to improve patient safety, it is still rife with shortcomings and unintended consequences. A lack of transmission standards, proliferation of e-prescribing systems and hodgepodge of state and federal regulations have many health care providers wondering why they should invest the time and energy to wrestle with the technology.

“What you have is a logistical nightmare; pharmacists and doctors have different systems,” said Dr. Steve Wienner, owner and manager of Mount Vernon Pharmacy, which installed an $1,800 e-prescribing system almost three years ago to compete with chain pharmacies such as CVS, Rite Aid and Walgreens. Still, Mount Vernon Pharmacy receives about six e-prescriptions a day; the average pharmacy fills about 200 prescriptions a day.

E-prescribing also comes with a hefty price tag many small physician practice groups can’t afford to pay, particularly as their margins narrow and the recession lingers. A top-of-the-line electronic health records systems with e-prescribing capability can cost more than $10,000. A basic, standalone e-prescribing system can cost about $1,800, but that does not include monthly maintenance fees of up to $25 and, in some cases, per transmission charges of 25 cents.

“When it comes to health IT, I’ve been drinking my fair amount of Kool-Aid. But there are a lot of challenges in e-prescribing,” said Dr. Christoph U. Lehmann, director of clinical information technology for the Johns Hopkins Children’s Center and designer of two e-prescribing systems. “It ain’t as simple as just putting a computer in a hospital.”

Or maybe it is. At its most basic level, e-prescribing is something akin to a sophisticated e-mail system. It’s another way of communicating a prescription to a pharmacist — handwritten, over-the-phone and faxed transactions being the other modes of prescribing.

E-prescribing is intended to improve patient safety and eliminate medical errors by taking the guesswork out of reading a doctor’s handwritten prescription. The joke about a doctor’s handwriting withstanding, it can be difficult to read the dosage and frequency of a prescription scribbled on a notepad, Wienner said.

It is estimated that more than 30 percent of all prescriptions require a call from the pharmacist to attending physician to clarify a handwritten prescription.

E-prescribing advocates say the systems also can improve the efficiency of a physician’s practice, eliminate tampering with a prescription and resolve on the front end any question as to whether the medication is covered under the patient’s health insurance plan.

But the kinks have yet to be worked out. Without standard software, information entered into the e-prescription by the physician may not translate correctly into the pharmacist’s system. Different codes for the medication’s dosage and usage may require a callback or result in a faulty fill.

That concerns any physician who hasn’t already adopted e-prescribing, said Gene Ransom, executive director of MedChi, the state’s medical society. And until a standard system is in place, doctors will continue to hold out, he said.

“We want to buy the VHS system, not the Beta system,” Ransom said. “We want to make sure we pick the right system, one that’s going to be around for a long time.”

The universal system could be in place by 2011, said Dr. Peter Kaufman, a gastroenterologist and chief medical officer of DrFirst, a Rockville-based company that developed and sells a standalone e-prescribing system.

It all comes down to cost

Meanwhile, the federal government and private health insurers — both of which stand to gain the most if e-prescribing succeeds in reducing errors and lowering health care costs — are dangling federal stimulus cash and other incentives in front of leery physicians.

For all its benefits and quirks, the obstacle looming largest over widespread adoption of e-prescribing is the cost of the system, its maintenance and training of staff.

In some ways, the timing could not be worse for physicians to plunk down thousands of dollars for new technology. Sagging reimbursement levels, the rising cost of other supplies and the pinch of the recession are causing many physicians to trim expenses.

That is where health care’s federal and private payers come in, said Shannon Nelson, director of primary care operations for UnitedHealthcare, the Minnesota-based health insurance giant that does business in Maryland. “Unless payers fund [e-prescribing], doctors won’t get involved on their own,” she said.

The federal government, through CMS, is offering a 2 percent bonus on Medicare reimbursements to doctors who begin e-prescribing this year or next. In 2011 and 2012, that reward drops to 1 percent. By 2012, physicians who are not e-prescribing will be hit with a 2 percent penalty on Medicare reimbursements.

And with $19 billion of the $787 billion federal stimulus package expected to go toward health care information technology, developers of new e-prescribing systems are lining up for some of that cash.

“If you’re thinking about [getting an e-prescribing system] sometime soon, that sometime soon should be this year or next,” said Dr. Peter Basch, medical director of ambulatory clinical systems for Columbia-based MedStar Health, which has about 500 of its 1,000 doctors using electronic health records with e-prescribing capability.

UnitedHealthcare is among the insurers covering as much as 75 percent of the cost of some e-prescribing systems and rewarding physicians for using electronic health records, including e-prescribing. Doctors contracted with CareFirst BlueCross BlueShield, the region’s largest health insurer, can receive more in reimbursement cash if they e-prescribe, said Dr. Jon Shematek, the insurer’s senior vice president and chief medical officer. The incentive is part of the CareFirst Quality Rewards program, but less than 10 percent of CareFirst’s physician network is e-prescribing, Shematek estimated.

“While it’s not a panacea, we do see the value to the technology,” he said. “But doctors will need to see it can really help them take care of patients before they get involved.”