Views on Electronic Prescribing (eRx)

I worked on eRxing when I first joined Express Scripts back in 2001. At that time, it was a huge focus with the recent investment in RxHub with Medco and Caremark. Everybody was drawing these hockey stick projections on adoption.

So, what happened…

  • Physicians began to use the technology in limited numbers and most of them ended up with equipment that didn’t work or didn’t seem more efficient that writing a paper prescription.
  • Vendors came and went so there wasn’t much stability.
  • The technology focus shifted to EMRs (Electronic Medical Records) which might have some eRxing technology embedded in it.
  • According to one slide I saw at a recent conference, there are estimated to be about 22% of registered physicians with the technology by the end of 2008 and 10% who actively use it.

The problem was that there wasn’t much alignment of incentives. A problem that I don’t see getting solved anytime soon. There is some legislation now to help drive adoption. Physicians who use the technology can get bonus payments from CMS in 2009.

I am still a skeptic.

Let me provide some representative perspectives (as I see them):

  • Consumers:
    • Generally, very positive.
    • You mean my physician will route my prescription electronically to the pharmacy of my choice, and it should be ready for me to pick it up when I drive there in 20 minutes. That’s convenient. (Something made a lot easier when RxHub and Surescripts decided to combine efforts earlier this year.)
    • Less errors is a good thing. (The study To Err Is Human really began this focus several years ago and more recent estimates are that 1.5 million people are affected by pharmacy errors each year.)
    • Why is my physician staring at a computer when they should be talking to me.
    • If this was done electronically, why do I still show up at the pharmacy and find out my drug isn’t covered (or not on formulary). (About 40% of claims are blocked for some administrative or clinical reason today.)
  • Physicians:
    • If this is easy (and inexpensive), I am happy to use this.
    • Is this faster than just writing a prescription on a piece of paper?
    • How much additional revenue do I generate from CMS and what do I have to do to earn that?
    • Patients like to leave with a prescription in hand. (Something that was solved by creating a printed “receipt” while also sending it electronically to the pharmacy.)
    • Who’s going to support this when it goes down? (For a small practice or individual physician, there are no onsite IT resources.)
    • This doesn’t fit into my workflow. (A lot of this is a generational issue. Medical school students are used to using technology as part of the process.)
    • This is easy. I can write a macro that when I write for a certain diagnosis code it brings up my typical set of prescriptions. (The tech savvy physician’s response.)
    • I can’t remember all the different formularies (i.e., drug lists) so this will be a lot easier.
    • I get paid per visit so what will this do to increase my visits? (Even though they get hit with a lot of callbacks after prescribing, doctors don’t feel this pain today since it is handled by their staff.)
    • I hope there’s not a bunch of advertisements on this.
    • By telling me whether my patient is compliant with the prescription I gave them, you are giving me new insight. (This is a definite value add that I know companies like CVS Caremark are working on with their eRx solutions.)
  • PBMs:
    • If physicians actually use this, we can really manage trend at lower cost by pushing edits to the POP (point-of-prescribing).
    • What additional information can we provide the physician that will improve adherence? What will the consumer reaction be?
    • What additional information can we provide physicians about poly pharmacy or patients that get multiple prescriptions from different physicians? Who should take action on this?
    • How much will the physician do with the patient sitting right there? Will they check formulary status? Will they switch drugs if there is a step therapy or prior authorization required? Will they take the patient’s credit card down to send the prescription to mail order? Will they take care of the edits (I.e., Drug Utilization Review…drug-drug interactions) that the pharmacy does today?
  • Pharmacies:
    • Will we get clean prescriptions (i.e., no additional work required other than filling it)?
    • How do we let the patient know when to expect the prescription to be ready for pick-up? (This can vary from 10 minutes to ½ a day depending on how busy the pharmacy is.)
    • How will we handle a new patient where we need billing information and allergy data?
    • How does that change our job as a pharmacist? Are we relegated to simply filling Rxs and no longer helping the patient manage their benefit?
  • Pharma Companies:
    • Will PBMs and their clients (managed care plans, unions, government entities, employers, TPAs) be willing to adopt more aggressive plan designs that defeat our detailing and marketing efforts?
    • How does this change the importance of formulary positioning and rebating?
    • How does this change our marketing strategies? (There are a lot of bright people in this industry so it’s not going away.)
    • If they physicians really use these, can we push advertisements (or let’s call them virtual detailing sessions) to the device (PDA, computer)?
  • Other:
    • Can you believe the errors in the industry? This will fix everything.
    • Why won’t someone want to adopt this technology?

Nothing is ever simple. This is a case of great intentions with lots of money and expertise being spent to solve the problem. But, aligning incentives and changing behavior is hard.

Will it happen? Yes.

Let’s put it this way…if it takes over 15 years for best practices in medicine to be adopted, how long will it take for this to be adopted?

One Response to “Views on Electronic Prescribing (eRx)”

  1. George Van Antwerp Reply December 15, 2008 at 8:56 pm

    I will comment on my own post in advance…

    Yes. It is a little cynical. It’s not to say that the vendors don’t have some very nice technology. It’s also not to say that this should be done and makes lot of sense.

    The question in my mind is what does everyone want / expect from the technology, and I don’t think they are the same.

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