E-Prescriptions

Stanley Feld M.D.,FACP,MACE

Newt Gingrich and John Kerry have written a bipartisan article on the way to modernize the healthcare system.

“In the age of the Internet, is it any less inexcusable that we have yet to modernize and transform our health care system?”

Who is to blame for this shortcoming? My answer is all the stakeholders are to blame. There has been increasing mistrust among stakeholders. Physicians have been the weakest political action group along with patients. Physicians are the most vulnerable to attack.

“We have talked long enough about using technology to cut costs and improve the quality of care. Now is the time to act–and the place to start is preventable medication errors.”

I totally agree. Accurate electronic prescribing information would decrease prescription filling errors.

“According to the Institute of Medicine, Americans average one medication mistake for every day spent in a hospital, accounting for more than 1.5 million injuries each year. Medication errors will kill at least seven thousand Americans this year. Of the more than three billion prescriptions written each year, doctors report nearly one billion require a follow-up between providers and pharmacies for clarification. The cost to our health care system is in the billions.”

“One reason for this mess is that 95 percent of prescriptions are transmitted using five-thousand-year-old technology: pen and paper.”

“That is unacceptable. The deaths and inefficiencies of paper prescriptions can be nearly eliminated if we use the same technology that we use in other aspects of our lives. Electronic prescriptions can replace handwritten, misread, and mismatched prescriptions with online, automated, and expert technology.”

I agree with Gingrich and Kerry. However, they do not examine the barriers that have prevented electronic prescription writing. One barrier is physicians must have computer equipment and appropriate software to send an electronic prescription to a pharmacy. Another barrier is the pharmacy must have the ability and willingness to accept and fill the electronically signed prescription. The pharmacy might not have software compatible with the physicians’ software.

“A new study by the Department of Health and Human Services estimates that if 18 percent of doctors in Medicare adopt e-prescribing, the government will save $4 billion and nearly three million adverse drug events can be prevented over five years.”

I believe e-prescriptions are essential and should have been implemented years ago. Let us extend the Department of Health and Human Services estimates. If 100% of physicians would use e-prescriptions and 100% of pharmacies would fill the electronically signed prescriptions Medicare would save $22.5 billion and nearly 16.5 million adverse drug events can be prevented over 5 years.

Gingrich and Kerry put the burden on physicians and suggest penalty for non compliance.

“The problem is that very few doctors use the technology. Of those four hundred physicians polled, only 7 percent actually transmit prescriptions electronically. And 63 percent say implementing the technology is not a priority. Why? It is not always in their immediate financial interest to do so.”

I can sympathize with the physicians who do not want to implement the technology. Many physicians are struggling to make a living even though their retail prices for services seem high. The retail fee is never the fee physicians collect from the third party payers. If a patient is uninsured many physicians will accept the steeply discounted fee Medicare allows.

Let us think about it. Gingrich and Kerry are demanding that physicians who do not have the technology and software spend money to save Medicare $22.5 billion over the next five years. If physicians were willing to spend the money there is no guarantee the pharmacy have compatible software.

“That must change. The federal government can lead by requiring that doctors who do business with Medicare convert to e-prescribing. If a majority of doctors do not e-prescribe a few years down the road, the government should require all doctors to adopt e-prescribing or face financial penalties. E-prescribing should become a condition of doing business with Medicare.”

With Medicare reimbursement declining and start-up costs for computer equipment and programming increasing, many physicians can not afford an isolated system for e-prescriptions. Many clinics have invested heavily in installed legacy systems that do not permit a universal interface with the pharmacies’ equipment. Many physicians are reluctant to spend money on systems that are quickly obsolete and have little payback.

Another issue is the potential abuse of the e-prescribing system by unauthorized persons using the physicians prescribing privileges. Ignored are the costs of installing adequate security and the service contracts.

A simple solution to the problem is to provide the physicians and the pharmacies with free downloadable stand alone compatible programs that can be used for electronic prescription use by licensed physicians and registered pharmacists. These programs could be downloaded from the internet with the appropriate security.

If this were done we would see how quickly the transformation to e-prescribing would occur. An added incentive to the physician could be patient driven. After the government has provided the universal software it could penalize patients if they try to fill a paper prescription by putting a surcharge on the prescription. Those patients should then be given an explanation of the surcharge and instruction on how their physician could remedy the surcharge by a simple internet download. Taking this approach would align the patients’, the physicians’, and the pharmacies’ incentives rather than setting up an expensive bureaucratic system to enhance suspicion and mistrust between stakeholders.

We should learn a lesson from the airlines. The airlines have made us prosumers. The airlines provided the software and education, and got us to do their work. We produce the e-ticket with our own paper and consume the e-ticket with our credit card payment at little cost to the airline. We do the work for the airlines.

I am surprised at Mr. Gingrich and Mr. Kerry advocating a penalty system that could be costly to administer when the solution can be so simple and utilizes the physicians’ patients to enforce a necessary system. You can be sure they did not discuss their idea of penalty with physicians before they wrote their article.