Friday, March 21, 2008

Benefits of electronic prescription ordering

I am hoping that our CIO, John Halamka, will provide more details on his blog in the coming days, but I wanted to jump the gun a bit and do a bit of bragging. In CIO-speak, he notes in an email to me:

In 2007, we went live with integrated e-Prescribing within our enterprise electronic health record via the MA-Share rxGateway, our statewide health information exchange collaboration of payers and providers. We had to redefine workflows, cleanup old prescription data and refine the our existing applications to adapt to the new features of e-Prescribing (eligibility checking, formulary enforcement, medication history display and prescription routing).

We started this as a pilot program with our hospital-based primary care doctors. They can now, with the click or two of a computer mouse, send prescription orders to any pharmacy in Massachusetts rather than having to call them in or have the patient deliver a paper order slip. Louise, the practice manager of this group, reports the following benefits, so far:

Significant improvement in efficiency and patient satisfaction in the time for prescriptions to reach the pharmacy. With e-Prescribing, orders travel quickly to pharmacies. Previously, when we called things in it could take up to 2 days for the order to be called to the pharmacy. We have also seen a decrease in medication errors, in terms of wrong patient, wrong medication, wrong dose, in that e-Prescribing has decreased the potential for "communication errors". We are able to track prescriptions more efficiently. With the paper call-in system, orders were all over the department being called in by so many people. Now we can look in WEBOMR and quickly determine where a prescription is in the process (i.e. in queue, transmitted successfully, transmission failed, etc).

Prior to full implementation of e-Prescribing by doctors and NPs, Medical Assistant call-in of prescriptions averaged 350 prescriptions per day. This has now been reduced to 80/day approximately. This will reduce to about 30 once the residents move to e-prescription in April. Each call-in averages 4 minutes per prescription, a savings of 23 hours or approx 3 FTE worth of work per day. The Medical Assistants are now available to more consistency perform the core work required to support the patients, providers, and practice. Previously, inconsistency, the inability to predict if you will have adequate support during your session, had been a major complaint from the doctors and nurses.


Anonymous said...

Prescriptions get there so quickly after the doc sends it in that I actually had a call from the pharmacy reminding to pick them up. It had already had been sitting a couple of days.

Daniel Sullivan said...

Actually, Paul, we can't send an rx to any pharmacy in MA. The pharmacy must be be connected with Surescripts, which does the electronic part of the transaction. All of the pharmacy chains participate, but very few independent pharmacies do.


Anonymous said...

Right, sorry.

Medical Quack said...

One other stumbling block that is making adaption slow is the DEA processes...they still want paper. As the old saying goes, "it will take an act of Congress to change things", but in this case it is true.
I have heard the same from many physicians who currently use e-prescribing..when it comes time to a DEA monitored drug, put the computer down and go back and grab the pen and paper.
My own personal opinion is that I would believe an audit trail would be easier to track if needed, but not being on the other side, there may be other reasons for the delay. The Senate keeps asking for the Department of Justice for some progress.

e-Patient Dave said...

I've been using this for years (prior to the current version John describes), and as a patient it's great.

There are stress-reducing aspects, too. In the midst of my crisis last year it was VERY good to have one less #$%! errand to do; to the contrary, we could do other errands as necessary on the way home from the hospital, and Walgreens sent a text message to my phone when it was ready so we could just drive through.

We had a clear sense of someone taking a load off us, however small ... a real "customer service" benefit, on top of all the other benefits.

Anonymous said...

Electronic prescribing has been an exciting developement for our patients and for our practice staff. I write to add my own sense of some of the benefits of ePrescribing as it is evolving at BIDMC. I wear 3 hats here: (1) a primary care doc in HCA; (2) the medical director of HCA; and, (3) co-chairperson of BIDMC's Pharmacy and Therapeutics Committee.

First, it's wonderful to be able to shoot a script to a pharmacy and verify receipt, often while still on the phone with a patient with an acute issue. Also, our nurses are able to tee up a list of prescription renewals for my review and signature without the need to tie up our phone staff -- so they can attend to patients' needs -- or the pharmacies' personnel. All the scripts that go electronically get a nice scrubbing through drug-drug and drug-allergy interaction testing in our electronic record to identify problems before they are sent -- also true of our printed prescriptions.

As DJS -- our associate medical director and another HCA primary care doc -- pointed out, electronic prescribing through this system works only with the big chains in Massachusetts at this point. This is too bad, as many of the independent small chains and stand-alone pharmacies often give great personalized service to patients, but can't benefit yet from ePrescription. I need to defer to John Halamka about when/if they will be able to play.

An exciting next step will be the ability to send prescriptions to mail-order suppliers (Pharmacy Benefit Managers -- PBMs -- such as Express Scripts and others). Our practice has had significant difficulties collectively with PBMs in the past, as their phone and fax systems are variably clunky and many faxed scripts are somehow "lost" on the PBM end. As a result, our policy has been to print and have the patient mail these prescriptions which, while slower, works reliably. It will be a boon to patients and to us to have the ability to send 3 month supplies with refills for a year electronically with the same kind of electronic verification we now get with local chain pharmacies.

This new enhancement is already in test, and DJS has been one of the testers.

Related to this new development is automatic formulary checking -- developed by the BIDMC IS folks. This is a great feature that shows whether a prescription we are generating is covered under a patient's insurance and at what "tier" -- which determnines copayment -- and suggests alternatives so we can get it right the first time at the least expense and hassle to a patient.

There is a lot of concern nationally about fraud using paper prescriptions, e.g., a paper prescripiton for a potent narcotic being altered from #5 to #50 or from #30 to #300, or to a different agent. CSM has mandated the use of tamper-resistant prescriptions. Eprescribing offers the ultimate in tamper-proof prescriptions.

A major problem is the fact that "scheduled medications" (narcotic pain medications, some insomnia and anxiety medications, etc.) can not be routed electronically. The Commonwealth of Massachusetts has been very forward-thinking about moving the ball but we are all stymied by existing federal regulations.


Anonymous said...

As an employee of BIDMC I'm disappointed that any individual's use of eRx is dependent on a department's eventual acceptance of its use. If the dept doesn't want to move forward, but a specific clinician would like to, why can it not be activated for that individual?

Daniel Sullivan said...


The ability to erx is "turned on" by individual prescriber, so I think a specific individual could request to be added. But I can understand why a department might not want to have only some providers doing this.

It's puzzling to me why a department would not be willing to use this - it is not more work, and it improves care.

"signing off queue" - having a clinician sign an electronic rx that was entered for the clinician by an RN - is potentially more complicated, because current state regulations mean that the rx can't actually go to the pharmacy until the MD or NP signs off. However, the HCA practice at BIDMC has been pretty successful with this despite having many part-time clinicians