I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).
I wrote this piece in December 2007.
The push for electronic prescribing by physicians is accelerating. Mike Leavitt of HHS thinks doctors should get a bonus for doing it (actually, a chance to earn their money back from a planned reimbursement cut). Intel Chairman Craig Barrett, in his role as a member of the American Health Information Community, recently told CMS to use its purchasing power to lay down the law to its doctor vendors. He’s often a simplistic blowhard, but he’s probably right that the customer gets to make rules that suit them.
E-prescribing is theoretically efficient, easy, and secure. Why, then, is the industry still 95 percent based on wadded up, illegible, and easily altered paper prescriptions that are free of any context that could reduce errors, improve formulary compliance, and save time for patients?
I can think of several reasons.
E-prescribing, like almost all aspects of healthcare automation, doesn’t benefit the doctors who have to change their work patterns to use it.
Patients don’t benefit directly, so they don’t really care enough to push their doctors. With paper, they can (as many patients do) not get the prescription filled, save up money to pay for it, or try to order a cheaper supply from Canada or overseas. Paper gives them that control.
Existing e-prescribing systems are generally unsophisticated and lot less functional than you might expect (like not being able to handle pharmacy verification that the prescriptions were accepted and/or filled).
DEA and state regulations vary on what kinds of prescriptions can be issued electronically.
The chicken-and-egg dilemma. Pharmacies aren’t excited about processing prescriptions electronically because physicians aren’t sending them. Physicians don’t send them because, in many cases, the pharmacy is still stuck in yesterday’s world of telephone and fax.
Efficient electronic prescribing requires an electronic medical records system in the doctor’s practice, which is still a tiny minority of them.
That last item is the big one, of course. E-prescribing should be a by-product of documenting a patient visit. It’s just not reasonable to expect a physician to leave the treatment room, fiddle with a standalone e-prescribing system, and re-key duplicate information.
Scrawling out a paper prescription takes a fraction of that time. The act of writing it gives the doctor time to look away from the patient, collect his or her thoughts, and make notes on the ever-present paper chart. The ritual of handing it over offers a chance to counsel the patient and to add finality to the visit. It’s a rule: you put your pants back on while he or she is writing, you take the prescriptions with one hand and shake with the other, and then you beat it so the doc can make their patient quota for the day.
Everybody rolls their eyes at how backward healthcare is, but we’re not alone. It’s very likely that your visit to an attorney, accountant, or mechanic is computer-free, except for your final bill. In fact, here’s a challenge: name any professional other than a physician who is expected to peck clerical work into a computer while consulting with their customer.
That’s why the only answer is to reward doctors (or punish them less, under Leavitt’s proposal) for e-prescribing. If we truly believe that the benefit is significant (do we?) then somebody needs to cover its cost and maybe help out with EMR expenses too. Without either a carrot or a stick, neither electronic prescriptions nor EMRs will ever gain critical mass.