At a time when consumers shop for cars, financial investments and home mortgages online, electronic prescription for drugs might not seem like much of a stretch.
But a stretch it is. Although much of e-commerce is growing out of its infancy, the computerized prescription is still the baby of the family.
A number of companies, from dot-com start-ups to established types such as Merck-Medco Managed Care, are making forays into the market. But the day is still far away when it's common for a doctor to compose a prescription on a computer screen and transmit it to a pharmacy.
"It's easier said than done to get a physician to electronically prescribe," says Glen Tullman, chief executive officer of Allscripts, a Libertyville, Ill.-based technology company.
The means are available: Technology for widespread electronic prescription services is advancing. But it takes more than developing the right hardware and software, experts say. The move to electronic prescriptions is no less than a transformation of longstanding practice. In fact, it calls for two separate transformations:
* Converting physicians from their current practice of scribbling on prescription pads to electronically assembling the components of a prescription -- the medication, the form it takes, the dosage, frequency and authorized refills -- using a simple computer program.
* Bringing pharmacies into the electronic age, most likely in stages. Or, as illustrated in recent announcements, bypassing pharmacies in favor of Internet-enabled order filling and home delivery.
Such a fundamental shift in the practice of medicine requires acceptance by both patients and physicians, says Elaine Remmlinger, a healthcare consultant at Hamilton HMC, a New York-based healthcare information technology consulting firm. "They have to want to do it," Remmlinger says. Reaching that stage is only the first step in the adoption process, but that first step isn't too far away, she predicts.
The incentives to get with the program include both carrots and sticks: the prospect of practice improvements and the looming threat of sanctions for medication errors.
To see the improvement possibilities, physicians have to make the technology part of their routine. The technology companies that previously sought to lure physicians to stationary PCs are now converting to hand-held devices to keep their prescription software from intruding on practice patterns (Modern Healthcare, Sept. 13, 1999, p. 22).
As a factor in the success of electronic prescribing, "My personal belief is that the hand-held device will prevail," says Stephen Gold, senior vice president of electronic commerce at Merck-Medco, which has a pilot project under way to test the attractiveness of electronic prescribing.
It will be up to physicians to dictate the pace of the evolution, spurred on by proof that electronic prescribing won't be disruptive to their practices and might even add clinical and financial value, Gold says.
"It's not like a light switch," he says. "It's going to take time."
One company that added the hand-held option within the past year is Allscripts, one of several companies participating in the Merck-Medco pilot project. Physicians can use its software to write prescriptions on a PC or a hand-held wireless device. And they can use the Internet to transmit the scrip to a pharmacy.
So far, 3,000 physicians across the country are using the company's system, paying a monthly fee of about $200 for the hardware and software, Tullman says. However, he won't divulge how many prescriptions are being written.
Ned Bauer, M.D., one of 12 physicians at Lake Forest (Ill.) Pediatric Associates, which is using the system, says he prescribes electronically for about 80% of his patients. The practice has been an Allscripts client for about two years. The two-site practice has central computer prescribing stations and has added a number of hand-held devices.
Linda Oberstein, M.D., who practices in San Mateo, Calif., has been prescribing electronically since last year. Using a palm prescriber, Oberstein says she writes 98% of her prescriptions electronically.
She uses a system developed by ePhysician, a Mountain View, Calif.-based vendor that began offering its Internet-based electronic prescription writing service commercially in April. That followed a year of testing in 200 physician offices, during which more than 16,000 electronic prescriptions were sent through the company's server network.
"The only time I use written prescriptions now is if a patient insists," Oberstein says. She says elderly patients sometimes insist on written orders as do patients who want to send prescriptions to mail-order pharmacies.
Oberstein says electronic prescribing saves her time, because she stores a list of her most frequently written prescriptions rather than starting from scratch each time.
By using the Allscripts system, Bauer says he knows immediately if the medicine he is prescribing is included in a health plan's formulary so a pharmacist doesn't have to call to say he has prescribed the wrong medicine.
A fear of litigation ultimately could push more physicians into electronic prescription writing, Allscripts' Tullman says. Electronic prescribing does away with the potential legal problems associated with illegible prescriptions.
And because the prescriptions are computerized, Bauer says he also can more easily track patients to know what medicines they are allergic to or are taking already.
Some in the industry say the movement toward electronic prescription writing has sped up since last year's Institute of Medicine report on medical errors. The report said medical errors -- including medication errors -- kill between 44,000 and 98,000 patients every year.
The Institute for Safe Medication Practices, a not-for-profit group headquartered in Huntingdon Valley, Pa., has called for the elimination of handwritten prescriptions by 2003.
In a "white paper" published in April, the group says electronic prescribing can "contribute significantly" to the prevention of medication errors. "Put simply, handwritten prescriptions ought to be a thing of the past," the institute asserts.
But getting the prescriptions accurately and legibly ordered is only the first of two steps. The scripts have to end up at a pharmacy, and electronic transmissions are a fantasy for the majority of them, experts say.
"There aren't a lot of pharmacies that are ready to accept electronic prescriptions" directly into their computers, says Stuart Weisman, M.D., who founded ePhysician two years ago.
Once received by the ePhysician server network, the majority of prescriptions in the recent test project were then transmitted to fax machines at pharmacies.
Some practice sites using the Allscripts system can electronically transmit their prescriptions directly to pharmacies, Tullman says. Prescriptions must be faxed to pharmacies if they aren't wired to receive them electronically.
At Lake Forest Pediatric, the electronic prescriptions are either sent to the practice's dispensary, printed for a patient to take to a pharmacy or faxed directly to a pharmacy to be filled.
Both technology companies recently signed agreements with an Internet-based health and beauty shopping site that includes an online prescription fulfillment service.
With the consent of a patient, physicians can transmit prescriptions directly to the Web site, called PlanetRx, to be filled by pharmacists at a distribution center in Memphis, Tenn., and mailed to the patient.
The arrangement provides a way to get prescriptions filled electronically instead of staying with printed or faxed forms. But instead of solving the connection problem with local pharmacies, it sidesteps them altogether.
In addition to these dot-com start-ups, venerable companies such as Merck-Medco are staking out a place in the online market.
In 1998, the giant prescription benefit manager unveiled a Web site that enables its eligible health plan members to refill or renew their prescriptions. The company dispenses 65,000 prescriptions each week that originate online.
Deanna Bellandi is a staff writer for Modern Healthcare.