On the surface, electronic prescribing is a technological dream come true for physicians, patients and pharmacists.
By simply hitting a few buttons on a hand-held computer or touching icons on a computer screen, a physician can check patients' medical and drug histories, disease management protocols and insurance carriers' drug formularies. Then the doctor can write a prescription with a keystroke and send it to the pharmacy or fill it there in the office.
Using this method, the doctor obtains the necessary information to make a well-informed medical decision, the pharmacist gets a legible prescription that complies with formulary guidelines, and the patient gets the proper medication.
Despite these benefits, electronic prescribing remains more promise than reality. While the technology exists, barriers such as conquering the complexity and cost of installing a system and getting physicians and pharmacies to buy in keep it from happening.
According to current estimates, only about 2% of physicians write electronic prescriptions, or "E-scripts." And very few of those doctors use complementary technology, such as drug formulary guidelines or disease management databases.
"(1998 was) the first year we saw any of this going on in physician offices," says Brian Stuhlmuller, president of MediMedia InfoScan, a North Wales, Pa.-based company that supplies formulary databases to support electronic prescribing. "It's in the pilot stage. In 1999 I believe we will see somewhere between 2,000 and 5,000 physicians actually using a system that will write and transmit E-scripts. Once the cost benefits and medical benefits are realized, those numbers will explode."
The cost of installing an electronic prescribing system depends on how technologically well-equipped a practice is, making an across-the-board estimate difficult. According to one estimate, from Chicago-based Allscripts, setting up physicians with hand-held computers and software for in-house prescribing costs $2,000 per doctor. Offsetting those initial costs, however, are potential savings through improved compliance with insurers' drug formularies.
One factor helping drive change is the movement of many procedures out of the hospital and into physicians' offices, says Glen Tullman, Allscripts' chief executive officer. "Treatments that you would have had to go to a hospital for in the past are now handled in the physician's office," Tullman says. "I believe doctors want that, but they also need help with the administrative burden that comes with it."
As the world of medicine becomes more complicated, some hope electronic prescribing can help put physicians back where they belong -- at the center of patients' healthcare.
"Doctors would appreciate getting information (about formularies) upfront, instead of being browbeaten on the back end," says Dan Segedin, vice president of product development for PCS Health Systems in Scottsdale, Ariz., one of the nation's largest pharmacy-benefit management companies. "Having the drug histories of patients so they understand drug interactions and medical history will help doctors practice better medicine. Most of the excitement and savings are through the doctor making a better medical decision, treating the patient better and avoiding hospitalization."
In addition, computers can help reduce the chance of negative drug interactions. Segedin says industry sources estimate almost 50% of all prescriptions are mishandled or not complied with. Prescriptions aren't filled properly or quickly for various reasons: A physician's handwriting might be illegible, there could be a formulary claim problem, or the patient may not have it filled or pick it up. Electronic systems can notify the physician when a patient neglects to pick up a prescription so the doctor can follow up on the case.
Down the line, proponents believe, adjuncts to the electronic prescription-writing system -- drug formulary compliance, disease management and drug utilization reviews -- may provide the impetus needed for the breakthrough growth of electronic prescribing. In addition to helping ensure compliance with formularies, electronic systems also can reduce the number of claims HMOs reject for drugs they don't cover.
Drug formulary compliance can alleviate a physician's administrative headaches and may help fund the E-script revolution. Using a system equipped with a database containing all participating insurance carriers, a physician can quickly determine if a drug is on the formulary of a patient's insurer. If the physician chooses to prescribe a drug that isn't on the formulary, he or she can use the database to find the proper procedure for getting the insurer to make an exception. This streamlines the claim adjudication process, saving time and money for the doctor, the patient, the pharmacy and, particularly, the insurer.
"Currently, we are educating HMOs on how this helps them," Stuhlmuller says. "In some instances, HMOs are paying for it because it will impact compliance. We know doctors will comply with formularies if they are presented the information in a reasonable fashion. Doctors will not run to a book every time they write a script. Now in five to 15 seconds, we can provide them with data sets of formularies only in their area.
"Up until now, HMOs haven't seen the value of electronic scripts. But now we're asking HMOs what increased compliance will mean to them."
Stuhlmuller says he piqued the interest of one Illinois-based HMO, which he declined to name, by demonstrating that electronic prescribing would increase compliance to 98% from 92%, saving it $15 million a year. "And that is only impacting a small percentage on big (cost) category drugs," he says.
One physician who can testify to the usefulness of electronic prescribing is Azar Korbey, M.D., a family practitioner in Salem, N.H. Korbey's two-physician practice got a break on software costs in return for testing a top-of-the-line Allscripts system that includes an in-office pharmacy.
"It's a point-of-care issue," Korbey says. "I know the patient is getting the prescription right away, and it gives me the opportunity to discuss how to take it. Plus, in this day of managed care, the system resolves formulary problems in conjunction with the (drug utilization review)."
Korbey says the entire process takes him about one minute, with most of the time spent printing a label or sending the prescription electronically. "With managed-care and formulary issues, I don't see how the average doctor who wants to practice decent medicine and save money can do without this eventually," he says.
As for the in-office pharmacy, Korbey says it pays off for him because of volume: He fills about half his prescriptions in-house.
"Managed care doesn't create large reimbursement for drugs," he says. "I process 30 to 40 prescriptions a day and make about $60 a day. That doesn't sound like much, but it pays for the system in a year."
For now, Korbey remains the exception. Cost -- real or imagined -- keeps many doctors out of the process altogether.
Tullman says Allscripts is working to make electronic prescribing easier and more affordable, something he acknowledges hasn't happened yet.
But Korbey notes that Allscripts' installation estimate of $2,000 per doctor doesn't address additional costs, such as connecting to the pharmacy. And many practices are barely computerized, making electronic prescription writing a distant goal.
Another barrier is lack of outside pharmacy connectivity because many pharmacies use proprietary systems or incompatible computerized hookups.
Still, some doctors use just a portion of the system. Chicago-area Lakewood Pediatrics has a small in-house pharmacy and a basic system that checks health plan formularies. The 11 physicians in the practice use voice mail to call in orders to the pharmacy.
Physicians in the practice say they will eventually enhance the system out of necessity. They would not disclose the cost of the system.
All parties interviewed say knowledge of the system reduces concerns about the privacy of medical records. The National Council for Prescription Drug Programs has created national pharmacy standards for electronic prescriptions, and most are sent over secure private modems.
"In fact," Tullman says, "it is more private and definitely more efficient than paper scripts."
Still, many questions must be answered before the era of electronic prescriptions arrives. Stuhlmuller predicts penetration will be slow over the next five years and then take off. In 10 years, he envisions doctors wearing headsets and completing the whole process via voice recognition. "Once you reach a critical mass, doctors will realize you have to do this because the competition will require it," Stuhlmuller says.
Korbey says growth will be slow because of his colleagues' reluctance to accept technology. "Look at the computerization with the medical community," he says. "That's where the low penetration is. I know many doctors who don't even have electronic billing and claims. Until doctors get electronic medical records in their offices, they aren't going to consider electronic prescriptions."
Stuhlmuller is more optimistic. "The thing that will emerge is more best practices," he says. "Doctors will be more aware of the implications of therapeutic strategies. As more and more work is done, we can assemble more history and detail the savings and the improvement of therapies. Doctors can begin practicing within a community of doctors and not just alone. That's about as compelling as it gets."
W.A. Weronka is a healthcare communicator based in Los Angeles.