Wednesday, May 21, 2008

Why no e-Prescribing in the ED?

As previously reported, we have a wonderful system that permits doctors to order prescriptions online, allowing patients to pick them up directly from their preferred pharmacy. Recently a friend of mine went to our BID~Needham Emergency Department, and came home with a script to get her prescription from our pharmacy. So I inquired. Our ever helpful CIO, John Halamka, explained:

At present, e-Prescribing in the US is generally limited to primary care practices and specialists who act as primary care givers, i.e. cardiologists, ob/gyns, pulmonary docs, etc. Massachusetts is the number one e-Prescriber in the country, yet only 13% of the routable prescriptions in the state go electronically. BIDMC ambulatory clinics use it, and they are routing 35% electronically, increasing every month.

At BIDMC and BID~Needham Emergency Departments, prescriptions are written electronically and printed to tamperproof paper on laser printers in the department. To my knowledge, there are no Emergency Departments in the state using e-Prescribing. Here's the challenge

1. It is currently illegal to e-Prescribe any controlled substance -- pain killer, sedative, anti-anxiety drug etc. Approximately 1/3 of all Emergency Department prescriptions are of this type. Recently, the Massachusetts Department of Public Health was able to get a DEA exemption to test one site (Berkshire Medical Center using Meditech software) to e-prescribe controlled substances. The DEA wants this to be a three year pilot , which illustrates how resistant to change the DEA can be. I've just signed a letter along with many health care standards and pharmacy leaders urging Congress to get involved and accelerate the ability to e-Prescribe controlled substances as a modification to Medicare Part D standards.

2. The real advantage of e-Prescribing occurs when a patient has an ongoing relationship with the clinician and the renewal workflow can be automated. Emergency Department Physicians do not have ongoing relationships with patients (at least most of the time)

3. In my anecdotal experience, many patients visiting EDs do not have a specific pharmacy preference since their ED care is related to trauma, treatment while traveling, or an acute event requiring a medication, but the patients do not take meds chronically. Hence a tamperproof computer generated paper prescription is most convenient for them.


Anonymous said...

This Sunday, I unfortunately had to take a trip to the ER, my first in years. I told my girlfriend to take me to BIDMC because I'm a regular reader of this blog and I wanted to see your work in action. From start to finish, it was as pleasant an experience as I could envision (probably helped by the fact that I went in early on Sunday morning, a very quiet time).

When I left with my crutches and a scrip for a pain killer, it struck me as odd that I had to then go to a CVS and wait for the prescription. This post cleared that up for me. But wouldn't it make sense to at least develop a relationship with the CVS on the corner and ask patients if they wanted the scrip called in there?

EB said...

This is surprising. Working with EDs at hospitals, the #1 prescription is usually antibiotics/steroidals. Unless you count Motrin as a pain killer (which is also available over the counter).

I also think that e-Prescribing for the ED would be ideal and further reduce trafficking and other fraudulent activity that still occurs (although lessened by the tamperproof security Rx paper).

Anonymous said...

Dr Halamka implies that DEA has a tougher stand on Sch 2 drugs than on Sch 3-5 drugs. Yet,doesn't DEA disallow e prescribing for all schedules, unless the pharmacist receives a hardcopy? Does the DEA position require the in-house pharmacy at BIDMC to receive a hard copy of electronic orders before it can send sch 2 meds to patient floors?