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E-Prescribing is E-Slow


 

Health information technology, including e-prescribing, is “truly on the national marquee,” according to Carolyn M. Clancy, MD, director of the Agency for Healthcare Research and Technology (AHRQ). Speaking at the Annual Conference of the Healthcare Information and Management Systems Society earlier this year, she said, “Americans are quickly coming to understand how much we have to gain from health information technology (HIT). And one thing about Americans—we don’t like to wait.”

Clancy and other government officials have been pushing for widespread implementation and use of e-prescribing and other HIT in hospitals and other care settings. In 2003 the Medicare Modernization Act included a provision offering grants to physicians who implement e-prescribing systems. While all of the talk and action have stopped short of mandating the use of this technology, the handwriting is clearly on the wall. Like it or not, e-prescribing is part of healthcare’s future.

Yet despite all of these efforts on behalf of HIT few physicians are jumping on the e-prescribing bandwagon. Current estimates show that only between 5% and 18% of physicians and other clinicians use e-prescribing.

Nonetheless, while few physicians use these systems, they clearly see their value. In one survey, 78% of physicians say they believe that within the next seven years e-prescribing will account for more than half of the prescriptions written; and 75% cited reduced medication errors and time savings as two benefits of this technology.1 Another survey showed that while only 5% of physicians say they use their handheld computers for prescribing, 100% say that they use their PDAs for drug information.2

Despite the technology’s benefits, there are many reasons hospitalists and other physicians have resisted the call of e-prescribing. However, it behooves these practitioners to know about e-prescribing, consider how they might implement various technologies in their prescribing practices, and become involved in HIT initiatives at their facilities.

While there is much disagreement about the use, benefits, and drawbacks of e-prescribing, there is little doubt that government agencies, regulatory bodies, and third-party payers will continue to push for the widespread implementation of such technology in the coming years.

Money Matters: Costs Can Keep Hospitalists from E-Prescribing

E-prescribing is not widespread among hospitalists and other physicians, suggests Philip Strong, MD, IT physician liaison at El Camino Hospital and a hospitalist with the El Camino Medical Center in Mountain View, Calif.

Mark Zielzinski, chief information officer at El Camino, says that e-prescribing doesn’t really fit well with what hospitalists do.

E-prescribing is “wonderful in the physician’s office,” he explains. This is because the community-based physician writes many prescriptions every day and needs to communicate prescription information to a wide array of facilities and pharmacies.

“Hospitalists write far fewer prescriptions than attending physicians,” says Ronald Newman, MD, medical director of the hospitalist program at Beverly Hospital in Beverly, Mass. “I don’t write more than five a day.” An e-prescribing system simply isn’t practical for him.

Dr. Strong suggests, however, that the lack of enthusiasm for e-prescribing has more “to do with dollars. Systems are fairly expensive,” he says because a good system could cost as much as $150,000.

Why so much? “For a system to make sense and create more work for hospitalists, it has to interface with whatever system a hospital is using for pharmacies in the area,” explains Dr. Strong. And this can be expensive.

The cost for an individual physician or a small practice to implement e-prescribing seems much more reasonable. However, Dr. Zielzinski says that this represents only about 20% of the total cost of new technology.

“Think of what you spend when you get a home computer,” he says. “Say you spend $1,000 for the PC itself. Then you have to buy software, Internet access, a printer, and other accessories. Then you have to take the time to learn to use it all. Consider everything you spend in five years, and that $1,000 is a drop in the bucket.”

Dr. Zielzinski emphasizes that it’s not just the money that keeps hospitalists and other physicians from using e-prescribing. “Physicians have an intrinsic sociological resistance to change. After all, they are accustomed to evidence-based care and they are expected to have evidence to back up their decisions and actions,” he says, adding that “it takes a new clinical technique, theory, or practice an average of 17 years to get into mainstream practice. So how can we expect to accept new technology just like that?”

I’m part of an eight-hospitalist team, and we could use an e-prescribing system that our medical group has deployed, but we don’t. To use e-prescribing would require an extra step of work for us. We already have to dictate discharge notes and handwrite prescriptions. We don’t have the ability to substitute e-prescribing; it would just be an additional tool—and an additional step that would slow down our discharges.

—Philip Strong, MD

Practical Protests: When Systems Hinder Efficiency

Another barrier to hospitalist acceptance of e-prescribing and other technology is that it sometimes takes longer to use, especially at the beginning.

“I’m part of an eight-hospitalist team, and we could use an e-prescribing system that our medical group has deployed, but we don’t,” admits Dr. Strong. “To use e-prescribing would require an extra step of work for us. We already have to dictate discharge notes and handwrite prescriptions. We don’t have the ability to substitute e-prescribing; it would just be an additional tool—and an additional step that would slow down our discharges.”

Dr. Newman agrees that physicians won’t use time-consuming technology. “Many systems take a lot of time to learn to use efficiently and effectively,” he says. “Physicians are afraid that these systems, such as e-prescribing, will slow them down and hurt their efficiency.”

He says hospitals are concerned about this and are waiting to implement systems they know physicians will use.

Eric Reines, MD, vice president of North Suburban Hospitalists PC and a hospitalist at Beverly Hospital, confesses to being a techie who enjoys this stuff. He says, however, that “most of the e-prescribing systems I’ve seen have been very poor. I like technology, but I won’t use a clunky system.”

Ease of use is essential for hospitalist acceptance of e-prescribing systems. “You can’t have a system with boxes popping up all over the screen and small black and white type that you can’t read,” says Dr. Reines. “Hospitalists and other physicians just won’t use these.”

Implementing systems that physicians don’t like is a worry that IT developers at hospitals think about about continually, confesses Dr. Zielzinski. “The biggest thing that keeps me awake at night is worrying that physicians will say, ‘This takes too long,’ ” he says, emphasizing that it’s important to educate physicians about how to use systems to make the most of their features and maximize efficiency.

While hospitals are concerned about how physicians will react to the implementation of technology, physicians’ general resistance to using e-prescribing actually could be a boon for hospitalists.

“Attending physicians aren’t likely to leave hospitals because they are required to use e-prescribing or other technology, but they might be more inclined to turn patients over to hospitalists at these facilities so that they don’t have to use these systems,” says Dr. Newman.

We've come a long way, baby: Standards for CPOE intercept 50% or more common prescribing errors-a major improvement when you consider the problems that resulted from handwritten scripts over the years.

We’ve come a long way, baby: Standards for CPOE intercept 50% or more common prescribing errors—a major improvement when you consider the problems that resulted from handwritten scripts over the years.

Vendor Vexation

Physicians often face the challenge of finding systems and software that integrate successfully with other systems and settings. Dr. Reines says vendors don’t always make widespread system compatibility a priority during product development.

Some data further suggest that e-prescribing products don’t always meet users’ needs. A report commissioned by the California Health Care Foundation evaluated 19 e-prescribing product vendors and found only four offer practical alternatives to more costly and complex prescription writing solutions.

CPOE First … Then E-Prescribing

Before you jump into e-prescribing, Dr. Strong suggests that more hospitals need to implement computerized physician order entry systems (CPOE). CPOE goes beyond prescriptions and enables physicians to electronically order everything from laboratory tests and dietary interventions to nursing care.

CPOE isn’t new; El Camino has used such a system for 30 years. “We are big-time believers in CPOE,” says Dr. Zielzinski. “It has enabled us to reduce a lot of errors.”

Dr. Strong adds that “these systems are better for overall patient through-put. The routing happens as soon as I input the order. There are no faxes, no paperwork, and no delays.”

Other groups also have long promoted the benefits of CPOE. For example, the Leapfrog Group, an organization of large healthcare purchasers, has suggested standards for CPOE systems that can intercept 50% or more of common serious prescribing errors. At the same time, a number of studies have been published documenting the value of CPOE in reducing medication errors and preventable adverse drug events.

Despite the benefits of CPOE, hospitals have been slow to implement it and many physicians oppose its use. “It’s high time we got over that,” says Dr. Strong. “We need to embrace CPOE now. If we do, e-prescribing won’t be such a shock when it comes down the pike.”

When e-prescribing piggybacks a good CPOE system, it will make more sense. “And when e-prescribing is done well, it will make more sense for physicians to embrace it,” he says. “Until then, it doesn’t make sense for most common situations.”

Dr. Zielzinski agrees that physicians and others need to get over their fear of CPOE. “I think you’ll find that CMS, JCAHO, the Leapfrog Group, and others will push more and more for this to happen. It’s the right thing to do.”

When Hospitalists Embrace High Tech

It is important to emphasize that many hospitalists and other physicians embrace technology. “The reality is that physicians come [to El Camino] because of our technology—it’s part of our culture,” says Dr. Zielzinski. When hospitalists join the El Camino staff, they go through a high-tech orientation with a physician trainer.

Pediatric Hospitalist Bettina Ackerman, MD, uses e-prescribing at her facility, Children’s Hospital of Pittsburgh (Pa.), and she likes the system. She admits that certain aspects of the technology can be cumbersome.

For example, “it’s much easier to handwrite certain information, such as complicated dosing instructions that require a lot of text,” she says. Nonetheless, she has seen the benefits as well. “It has drastically reduced medication errors in our hospital. And there is an efficiency that wasn’t there before.”

Dr. Reines stated that hospitalists are like other physicians: Some of them like e-prescribing and other technology, while others don’t. Age isn’t always a predictor, he emphasizes, noting that he is “the oldest physician in his group but I’m also the most interested in technology.” However, he suggested that hospitalists who are “fresh out of training are more used to technology such as e-prescribing. They kind of expect to use it.”

The Hospitalist’s Role … Starting Now

Dr. Strong suggests that hospitalists need to be part of the IT solution. In fact, they already are actively involved in his facility. “It is important for hospitalists to know what HIT their facilities are using and considering for purchase,” he says.

Dr. Reines agrees that physicians need to be active in IT decisions at their hospitals. “I’m on the tech committee at my facility, as are several physicians,” he explains, adding that they have strong opinions and specific input on what they want HIT programs and systems to do, what information they need, and how they expect technology to work to enhance their efficiency and benefit their patients.

Hospitalists who work at teaching hospitals can have a role in educating students about technology. “We need to look at learning opportunities that involve technology,” says Dr. Reines. “And we should encourage people not to be afraid of technology or change.”

Why Bother?

If there are so many barriers to e-prescribing and so many contraindications to its use, why should hospitalists bother with this technology?

While there is much disagreement about the use, benefits, and drawbacks of e-prescribing, there is little doubt that government agencies, regulatory bodies, and third-party payers will continue to push for the widespread implementation of such technology in the coming years.

For example, JCAHO’s establishment of the medication reconciliation process, whereby hospitals and other healthcare providers are expected to compile and use medication lists whenever patients move to a new setting will make e-prescribing more important and practical for hospitalists.

“The need to reconcile our patients’ medications at admission, during their stay, and at discharge will spur a greater need for e-prescribing,” says Dr. Zielzinski.

Dr. Ackerman urges her colleagues to learn about e-prescribing and other systems now. However, she also encourages “the powers that be” to provide more specific guidance on HIT to help physicians and others make the best use of it.

Although he doesn’t use or have a real need for e-prescribing, “I certainly think we will be seeing more hospitalists and hospitals using these systems in the coming years,” says Dr. Newman. “The opportunity—however small—to prevent certain types of errors will make it worthwhile eventually in most settings.” TH

Writer Joanne Kaldy is based in Maryland.

References

  1. iHealthbeat. Survey: few docs use PDAs for e-prescribing. Sept. 8, 2005. Available at ihealthbeat.org. Last accessed Sept. 14, 2005.
  2. Mobile Village. Docs embrace handheld e-prescribing to save time, prevent errors. Mobile & Wireless News. Feb. 7, 2003.

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