An estimated 1.5 million medication errors occur each year and according to the Institute of Medicine (IOM), e-prescribing may be the key to reducing these risks.

To ward off errors, IOM has recommended that all medications be prescribed electronically by 2010; however, the current situation indicates the initiative has fallen short of its goal.

While the number of U.S. facilities and practices adopting some type of e-prescribing has grown swiftly, those utilizing a full-fledged e-prescribing system are few. In fact, a report by Gorman Health Group in July 2007 showed that less than 30,000 of the more than 900,000 medication prescribers in the U.S. were aggressively utilizing e-prescribing solutions within their practices. Facilities using e-prescribing, however, have reported the technology has saved time, allows doctors to spend more time with their patients, averts lost prescriptions and can save a patient money by its ability to check for cheaper medication alternatives.

While there are other obvious benefits to e-prescribing, including reductions in drug interactions and transcription errors, aligning with CMS' e-prescribing guidelines for meaningful use can be challenging. Meaningful use objectives include having at least 75 percent of all prescriptions written and transmitted electronically. To help meet this goal, CMS has drawn up an incentive program that awards early adopters and penalizes those that do not take on the initiative by 2012, with penalties increasing until 2014 (see table).

For Associated Cardiovascular Consultants, a 34-cardiologist practice that deployed e-prescribing earlier this year, a decline in the amount of errors has already been attributed to the system’s ability to double check drug interactions and obtain patient history, says Donald W. Orth, MD, a cardiologist at its Voorhees, N.J., site. However, e-prescribing also may introduce new problems and give physicians the added possibility to enter the wrong drug, Orth says. “With handwritten prescriptions, it was very easy to write exactly what drug you want,” he says. “Now, health IT gives multiple drug formulas and depending on how big the formulary is and how many drugs are listed in your EMR, if you push the wrong button and don’t recognize a problem, there could be a significant error.”

To gain CMS’ e-prescribing incentives, a facility must “effectively” perform e-prescribing for 25 Medicare-aged patients over a six-month period, says Orth. “The nice thing about CMS is that it encourages e-prescribing use and until this motivation, physicians weren’t really excited about making the switch.”

Even though the practice operates e-prescribing through a qualified EMR and cardiologists prescribe with Express Scripts, a web-based application accessible through mobile devices, the facility still has yet to reap its highly anticipated 2 percent reimbursement from CMS.

Fully connected

Some parts of the nine-hospital MedStar Health System in the Maryland-Washington, D.C., area have been using various aspects of e-prescribing for 13 years. The facility finally connected all the parts with a seamless e-prescribing feature in the EMR to avoid separate web-based applications or standalone e-prescribing systems that have the potential to lead to duplicate medication ordering. “Physicians prefer technologies that are easy and intuitive and the way that this system presents itself is both,” says Peter Basch, MD, medical director of ambulatory EHR and health IT policy at MedStar.

Currently, the system undertakes three levels of e-prescribing: The electronic creation of prescriptions, transmitting prescriptions electronically to the pharmacy and combing pharmacy benefit plans for patient history and prescription coverage. While the facility has reaped benefits from e-prescribing, Basch says meeting CMS’ requirements is sometimes a challenge due to pharmacies that are not linked to the Surescripts network or medications, like controlled substances, that cannot be sent electronically. At MedStar, one million prescriptions were created using the e-prescribing ordering system in 2009, but only 27 percent of these had the capability to be sent electronically to pharmacies, he says.

Kinks in the system such as the inability of mail-ordered pharmacies to receive electronic prescriptions and the incapacity to send controlled substances are reasons why these numbers are so low, even at facilities like MedStar that are progressively working toward the full adoption of e-prescribing. Forty percent of the prescriptions prescribed at MedStar are ordered through mail-ordered pharmacies, and even taking out controlled substances, the number of electronically prescribed prescriptions would still only reach 35 to 36 percent, says Basch. “I would doubt that there is any physician in American who would meet meaningful use criteria as it is currently presented,” he offers. 

Additionally, he says that the e-prescribing ordering process no longer allows patients to “shop around”  for the best medication prices, nor get prescriptions six months ahead of time before filling them because the prescriptions are transmitted and then filled immediately with no wait time. Other problems stem from pharmacies that patients prefer that are not linked to the Surescripts network. “I would never tell a patient to switch to a pharmacy that wasn’t their pharmacy of choice just to satisfy the need to e-prescribe,” says Basch. “We don’t want to miss out on meaningful use. That’s a lot of money and prestige for our health system, but not when it would pressure us into adopting behaviors we don’t want.”

Basch and his colleagues at MedStar Health have put forth comments to CMS asking the agency to modify meaningful use criteria to make it more feasible. “E-prescribing is good and useful, but the process is still immature,” he says. “The threshold now is nearly impossible for physicians to reach, even for those 100 percent invested in e-prescribing.”