To E-Prescribe or Not? That Is the Question

One morning a week, I work in a community mental health center where e-prescribing has been implemented in accordance with Medicare requirements. I’m often the skeptic about such things, but I could see how e-prescribing might be useful. I assumed the first few months would be cumbersome, but then the system would be populated with information, and with a quick click, scripts would magically go to the pharmacies. Months have passed, and I’m sorry to say that e-prescribing has not gotten easier for me. The system logs me out every 7 minutes, and the number of different screens I need to click through is much less efficient than one might envision. It often take a couple of minutes of clicking, only to discover that the patient does not know the name of their pharmacy, or the pharmacy has a different name from the one they’ve given, or there are many Rite Aids on a given street and I don’t know which is “across from the Giant grocery store.” Today, I called a family member to find out the pharmacy name. In contrast, it takes me under a minute to hand-write a prescription, and e-prescribing has started to feel like a solution in search of a problem. Getting help from colleagues is difficult – the system does not have dummy data to practice with and the patient is in the room when I do this – it’s not a time when I can search for another doctor to hone my technique. Even the IT consultant needed to use her son’s antibiotic prescription to demonstrate the system. Nothing about this process has made me long for e-prescribing in my private practice.

I was going to write this article on how e-prescribing is inefficient and the Medicare penalties for not e-prescribing have come at a time when there is so much else wrong with our broken health care system that could use some fixing. Others have said the time and money required to implement e-prescribing in a private practice outweigh the 1% loss of Medicare revenues they will forfeit.

I did what I do when I want to make sure my own sense of the world of psychiatry isn’t skewed– I asked members on our Maryland Psychiatric Society listserve. My theory was that no one else likes it, either, and in fact, only a handful wrote back to say they are e-prescribing. But to my surprise, everyone who e-prescribes likes it a lot. I was the only disheartened voice. A lively discussion ensued, and other psychiatrists began talking about converting.

“I have e-prescribing as a part of my electronic health record system. It is quick, and I am very happy with it. I also feel it is the digitalized future and there is no stopping it!” wrote Dr. Patricia Sullivan, a psychiatrist in private practice in Columbia, Md.

Dr. Jeffrey Soulen, a psychiatrist in private practice in Ellicott City, Md., also wrote about his experiences over the past three years. Dr. Soulen likes seeing what other physicians are prescribing for his patients. “It’s led to some important discussions about controlled substances I didn’t know the patient was taking.” He likes the convenience of being able to access prescription information from any computer and it saves the time he used to spend calling pharmacies to add refills. “Patients love it. Once they are in the system – which takes a couple minutes the first time – it takes me no more time to send a script electronically than to hand-write it, and by the time they get to their pharmacy later that day, the script is ready for them. No need to bring a paper script and wait.”

Convenience is just one aspect of e-prescribing. The Medicare initiative to promote e-prescribing notes that medication errors are responsible for thousands of deaths every year. The hope is that computer programs will eliminate prescription errors and alert physicians to drug interactions, and will result in lower health care costs as well as decreases in patient morbidity and mortality. Has this proven to be true? It’s hard to figure that one out.

In a study by Dr. Rainu Kaushal and her colleagues in the June 2010 issue of The Journal of General Internal Medicine, the authors reported a seven-fold decrease in errors, from over 42% with written prescriptions to 6.6% a year after converting to e-prescribing. With such a remarkable change, it is worth noting that the authors used a liberal definition of “error” to include incomplete prescriptions that gave the frequency of a dose as “qd” instead of “daily” or “Take as directed.” In another article in the same journal in April, 2011, the group reported a marked increase in e-prescribing errors for first 12 weeks after e-prescribing systems are upgraded, American Medical News reports.

Dr. Kaushal, chief of the Division of Quality and Medical Informatics at Weill Cornell Medical College, said she knew that the transition from paper to electronic was difficult for most physicians. She was surprised to learn that even for experienced e-prescribers, the move to a new system can be challenging. Dr. Kaushal, who was involved in the transition studied for the report, said she found the experience to be “exceedingly difficult.” She wrote:

“We thought it would be more of a seamless transition because people were already accustomed to sitting in front of a computer, entering in orders and so on, so they didn't have to get used to that piece. But each electronic system has its nuances and learning how to utilize it and optimize the physician-computer interaction takes time. Every time a switch is made there are important issues that arise.”

In contrast, Kate L. Lapane, Ph.D., and her colleagues reported in The Journal of Pharmacy Benefits, March/April 2011, a study of 64 e-prescribing practices using six different e-prescribing software programs. In their focus groups, it was noted that prescription errors were still occurring. Prescribers cited difficulties using drop down, menus which resulted in the wrong medication or dose, and problems with small phone screens, as well as access to incomplete information and accidental duplication of prescriptions.

In another study in the Journal of the American Medical Informatics Association (June 29, 2011), Dr. Karen C. Nanji and her colleagues looked at 3,850 electronic prescriptions written over 4 weeks and found an 11.7% error rate, comparable to the error rate with handwritten prescriptions. They noted:

“Providers appear to be rapidly adopting electronic health records and computerized prescribing, and one of the major anticipated benefits is expected to be through medication-error reduction.... Many of these benefits will not be realized if the electronic prescribing applications are not mature and either do not catch or even cause new medication errors.”

I’m left to conclude that the jury is still out, both on whether e-prescribing is time-efficient and on whether it decreases the morbidity and mortality associated with medication errors.

<[QM]>—Dinah Miller, M.D.

If you’d like to read Dr. Jeffrey Soulen’s discussion of what he likes about e-prescribing, please see his guest post on our Shrink Rap blog by clicking HERE.

If you would like to comment on this article here, please register with Clinical Psychiatry News. If you are already registered, please log in to comment.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

One morning a week, I work in a community mental health center where e-prescribing has been implemented in accordance with Medicare requirements. I’m often the skeptic about such things, but I could see how e-prescribing might be useful. I assumed the first few months would be cumbersome, but then the system would be populated with information, and with a quick click, scripts would magically go to the pharmacies. Months have passed, and I’m sorry to say that e-prescribing has not gotten easier for me. The system logs me out every 7 minutes, and the number of different screens I need to click through is much less efficient than one might envision. It often take a couple of minutes of clicking, only to discover that the patient does not know the name of their pharmacy, or the pharmacy has a different name from the one they’ve given, or there are many Rite Aids on a given street and I don’t know which is “across from the Giant grocery store.” Today, I called a family member to find out the pharmacy name. In contrast, it takes me under a minute to hand-write a prescription, and e-prescribing has started to feel like a solution in search of a problem. Getting help from colleagues is difficult – the system does not have dummy data to practice with and the patient is in the room when I do this – it’s not a time when I can search for another doctor to hone my technique. Even the IT consultant needed to use her son’s antibiotic prescription to demonstrate the system. Nothing about this process has made me long for e-prescribing in my private practice.

I was going to write this article on how e-prescribing is inefficient and the Medicare penalties for not e-prescribing have come at a time when there is so much else wrong with our broken health care system that could use some fixing. Others have said the time and money required to implement e-prescribing in a private practice outweigh the 1% loss of Medicare revenues they will forfeit.

I did what I do when I want to make sure my own sense of the world of psychiatry isn’t skewed– I asked members on our Maryland Psychiatric Society listserve. My theory was that no one else likes it, either, and in fact, only a handful wrote back to say they are e-prescribing. But to my surprise, everyone who e-prescribes likes it a lot. I was the only disheartened voice. A lively discussion ensued, and other psychiatrists began talking about converting.

“I have e-prescribing as a part of my electronic health record system. It is quick, and I am very happy with it. I also feel it is the digitalized future and there is no stopping it!” wrote Dr. Patricia Sullivan, a psychiatrist in private practice in Columbia, Md.

Dr. Jeffrey Soulen, a psychiatrist in private practice in Ellicott City, Md., also wrote about his experiences over the past three years. Dr. Soulen likes seeing what other physicians are prescribing for his patients. “It’s led to some important discussions about controlled substances I didn’t know the patient was taking.” He likes the convenience of being able to access prescription information from any computer and it saves the time he used to spend calling pharmacies to add refills. “Patients love it. Once they are in the system – which takes a couple minutes the first time – it takes me no more time to send a script electronically than to hand-write it, and by the time they get to their pharmacy later that day, the script is ready for them. No need to bring a paper script and wait.”

Convenience is just one aspect of e-prescribing. The Medicare initiative to promote e-prescribing notes that medication errors are responsible for thousands of deaths every year. The hope is that computer programs will eliminate prescription errors and alert physicians to drug interactions, and will result in lower health care costs as well as decreases in patient morbidity and mortality. Has this proven to be true? It’s hard to figure that one out.

In a study by Dr. Rainu Kaushal and her colleagues in the June 2010 issue of The Journal of General Internal Medicine, the authors reported a seven-fold decrease in errors, from over 42% with written prescriptions to 6.6% a year after converting to e-prescribing. With such a remarkable change, it is worth noting that the authors used a liberal definition of “error” to include incomplete prescriptions that gave the frequency of a dose as “qd” instead of “daily” or “Take as directed.” In another article in the same journal in April, 2011, the group reported a marked increase in e-prescribing errors for first 12 weeks after e-prescribing systems are upgraded, American Medical News reports.

Dr. Kaushal, chief of the Division of Quality and Medical Informatics at Weill Cornell Medical College, said she knew that the transition from paper to electronic was difficult for most physicians. She was surprised to learn that even for experienced e-prescribers, the move to a new system can be challenging. Dr. Kaushal, who was involved in the transition studied for the report, said she found the experience to be “exceedingly difficult.” She wrote:

“We thought it would be more of a seamless transition because people were already accustomed to sitting in front of a computer, entering in orders and so on, so they didn't have to get used to that piece. But each electronic system has its nuances and learning how to utilize it and optimize the physician-computer interaction takes time. Every time a switch is made there are important issues that arise.”

In contrast, Kate L. Lapane, Ph.D., and her colleagues reported in The Journal of Pharmacy Benefits, March/April 2011, a study of 64 e-prescribing practices using six different e-prescribing software programs. In their focus groups, it was noted that prescription errors were still occurring. Prescribers cited difficulties using drop down, menus which resulted in the wrong medication or dose, and problems with small phone screens, as well as access to incomplete information and accidental duplication of prescriptions.

In another study in the Journal of the American Medical Informatics Association (June 29, 2011), Dr. Karen C. Nanji and her colleagues looked at 3,850 electronic prescriptions written over 4 weeks and found an 11.7% error rate, comparable to the error rate with handwritten prescriptions. They noted:

“Providers appear to be rapidly adopting electronic health records and computerized prescribing, and one of the major anticipated benefits is expected to be through medication-error reduction.... Many of these benefits will not be realized if the electronic prescribing applications are not mature and either do not catch or even cause new medication errors.”

I’m left to conclude that the jury is still out, both on whether e-prescribing is time-efficient and on whether it decreases the morbidity and mortality associated with medication errors.

<[QM]>—Dinah Miller, M.D.

If you’d like to read Dr. Jeffrey Soulen’s discussion of what he likes about e-prescribing, please see his guest post on our Shrink Rap blog by clicking HERE.

If you would like to comment on this article here, please register with Clinical Psychiatry News. If you are already registered, please log in to comment.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

One morning a week, I work in a community mental health center where e-prescribing has been implemented in accordance with Medicare requirements. I’m often the skeptic about such things, but I could see how e-prescribing might be useful. I assumed the first few months would be cumbersome, but then the system would be populated with information, and with a quick click, scripts would magically go to the pharmacies. Months have passed, and I’m sorry to say that e-prescribing has not gotten easier for me. The system logs me out every 7 minutes, and the number of different screens I need to click through is much less efficient than one might envision. It often take a couple of minutes of clicking, only to discover that the patient does not know the name of their pharmacy, or the pharmacy has a different name from the one they’ve given, or there are many Rite Aids on a given street and I don’t know which is “across from the Giant grocery store.” Today, I called a family member to find out the pharmacy name. In contrast, it takes me under a minute to hand-write a prescription, and e-prescribing has started to feel like a solution in search of a problem. Getting help from colleagues is difficult – the system does not have dummy data to practice with and the patient is in the room when I do this – it’s not a time when I can search for another doctor to hone my technique. Even the IT consultant needed to use her son’s antibiotic prescription to demonstrate the system. Nothing about this process has made me long for e-prescribing in my private practice.

I was going to write this article on how e-prescribing is inefficient and the Medicare penalties for not e-prescribing have come at a time when there is so much else wrong with our broken health care system that could use some fixing. Others have said the time and money required to implement e-prescribing in a private practice outweigh the 1% loss of Medicare revenues they will forfeit.

I did what I do when I want to make sure my own sense of the world of psychiatry isn’t skewed– I asked members on our Maryland Psychiatric Society listserve. My theory was that no one else likes it, either, and in fact, only a handful wrote back to say they are e-prescribing. But to my surprise, everyone who e-prescribes likes it a lot. I was the only disheartened voice. A lively discussion ensued, and other psychiatrists began talking about converting.

“I have e-prescribing as a part of my electronic health record system. It is quick, and I am very happy with it. I also feel it is the digitalized future and there is no stopping it!” wrote Dr. Patricia Sullivan, a psychiatrist in private practice in Columbia, Md.

Dr. Jeffrey Soulen, a psychiatrist in private practice in Ellicott City, Md., also wrote about his experiences over the past three years. Dr. Soulen likes seeing what other physicians are prescribing for his patients. “It’s led to some important discussions about controlled substances I didn’t know the patient was taking.” He likes the convenience of being able to access prescription information from any computer and it saves the time he used to spend calling pharmacies to add refills. “Patients love it. Once they are in the system – which takes a couple minutes the first time – it takes me no more time to send a script electronically than to hand-write it, and by the time they get to their pharmacy later that day, the script is ready for them. No need to bring a paper script and wait.”

Convenience is just one aspect of e-prescribing. The Medicare initiative to promote e-prescribing notes that medication errors are responsible for thousands of deaths every year. The hope is that computer programs will eliminate prescription errors and alert physicians to drug interactions, and will result in lower health care costs as well as decreases in patient morbidity and mortality. Has this proven to be true? It’s hard to figure that one out.

In a study by Dr. Rainu Kaushal and her colleagues in the June 2010 issue of The Journal of General Internal Medicine, the authors reported a seven-fold decrease in errors, from over 42% with written prescriptions to 6.6% a year after converting to e-prescribing. With such a remarkable change, it is worth noting that the authors used a liberal definition of “error” to include incomplete prescriptions that gave the frequency of a dose as “qd” instead of “daily” or “Take as directed.” In another article in the same journal in April, 2011, the group reported a marked increase in e-prescribing errors for first 12 weeks after e-prescribing systems are upgraded, American Medical News reports.

Dr. Kaushal, chief of the Division of Quality and Medical Informatics at Weill Cornell Medical College, said she knew that the transition from paper to electronic was difficult for most physicians. She was surprised to learn that even for experienced e-prescribers, the move to a new system can be challenging. Dr. Kaushal, who was involved in the transition studied for the report, said she found the experience to be “exceedingly difficult.” She wrote:

“We thought it would be more of a seamless transition because people were already accustomed to sitting in front of a computer, entering in orders and so on, so they didn't have to get used to that piece. But each electronic system has its nuances and learning how to utilize it and optimize the physician-computer interaction takes time. Every time a switch is made there are important issues that arise.”

In contrast, Kate L. Lapane, Ph.D., and her colleagues reported in The Journal of Pharmacy Benefits, March/April 2011, a study of 64 e-prescribing practices using six different e-prescribing software programs. In their focus groups, it was noted that prescription errors were still occurring. Prescribers cited difficulties using drop down, menus which resulted in the wrong medication or dose, and problems with small phone screens, as well as access to incomplete information and accidental duplication of prescriptions.

In another study in the Journal of the American Medical Informatics Association (June 29, 2011), Dr. Karen C. Nanji and her colleagues looked at 3,850 electronic prescriptions written over 4 weeks and found an 11.7% error rate, comparable to the error rate with handwritten prescriptions. They noted:

“Providers appear to be rapidly adopting electronic health records and computerized prescribing, and one of the major anticipated benefits is expected to be through medication-error reduction.... Many of these benefits will not be realized if the electronic prescribing applications are not mature and either do not catch or even cause new medication errors.”

I’m left to conclude that the jury is still out, both on whether e-prescribing is time-efficient and on whether it decreases the morbidity and mortality associated with medication errors.

<[QM]>—Dinah Miller, M.D.

If you’d like to read Dr. Jeffrey Soulen’s discussion of what he likes about e-prescribing, please see his guest post on our Shrink Rap blog by clicking HERE.

If you would like to comment on this article here, please register with Clinical Psychiatry News. If you are already registered, please log in to comment.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.