E-prescribing: nascent industry or uncertain future?
While handhelds make e-prescribing relatively easy, obstacles are limiting the technology's use
Copyright © 2002 by the American College of Physicians-American Society of Internal Medicine.
By Bryan Walpert
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Gone are the days when Bryan A. Bognar, FACP, lugged prescription pads around the office.
Today, the internist at University of South Florida Physicians Group in Tampa, Fla., writes prescriptions on a Compaq iPAQ using TouchWorks Rx+ software from Chicago-based Allscripts Healthcare Solutions.
Physicians like Dr. Bognar say that e-prescribing delivers some big benefits. If a drug is not listed on a patient's formulary, for example, his personal digital assistant (PDA) alerts him so he can choose an alternative, helping him avoid pharmacy callbacks. 
If the drug might interact with another treatment he's already prescribed, the PDA flashes an alert. And when it comes to refills, he simply pulls up the old script to avoid rewriting the patient's name or dosage.
When he's done, Dr. Bognar simply presses a button to either print out the prescription on copyproof paper or fax it to the patient's pharmacy. The ability to see a patient's medication history, choose formulary medications and check for interactions "is invaluable," Dr. Bognar said.
Still, he is something of a pioneer. Prescription-writing for the PDA has not seen the success predicted by early visionaries, in large part because of what physicians see as obstacles.
Many physicians, for example, say it's still faster to whip off a prescription by hand. Others are frustrated with e-prescribing because there is no easy way to send prescriptions directly from handheld computers to pharmacy computer systems. Physicians must spend their time printing out PDA-generated prescriptions and faxing them to pharmacies.
As a result, many physicians use handheld computers to look up drug information, but few are taking full advantage of prescription-writing technology. Only 6% of physicians, for example, wrote prescriptions on a desktop or handheld computer in 2001.
The e-prescribing industry's growth has been further hampered by the number of e-prescription products that have disappeared from the market. ParkStone Medical Information Systems is a case in point: After declaring bankruptcy, its assets were purchased by PacifiCare Health Systems in Costa Mesa, Calif. The health plan combined the software with another product it purchased, Rx-Connect.
"Years ago, e-prescribing was thought to be the way to grab the brass ring quite easily," said Brandi Comi, sales and marketing manager for MEDeMORPHUS Healthcare Solutions, the new name for the combined Rx-Connect and ParkStone product. "In fact, it's quite complicated."
Here is where e-prescribing stands today—and a look at its future.
'True' e-prescribing
At the most basic level, physicians can use PDA software to check for drug information. A good example is the San Carlos, Calif., company ePocrates, which provides drug information but not e-prescription software. The ePocrates program, which is used by more than 250,000 physicians, provides pricing, dosing, drug interactions, contraindications and off-label indications on devices that use the Palm operating system.
"I know the significant interactions," said Michael J. Baime, ACP-ASIM Member, an internist with Penncare at Rittenhouse Square in Philadelphia and an ePocrates user. "But if it's a drug I'm not familiar with, the software is very helpful."
For the moment, ePocrates is available only for PDAs that use the Palm operating system. Last spring, however, Thomson Medical Economics in Montvale, N.J., released mobilePDR for both the Palm and Pocket PC operating systems. The software contains about 1,500 monographs (though not drug prices) for commonly prescribed drugs.
Still, ePocrates and mobilePDR are not examples of true e-prescription software. More comprehensive programs allow physicians to actually write prescriptions on their handhelds. And in some cases, the software automatically checks for drug interactions.
As soon as a physician clicks on or taps the word "prescribe" with the TouchWorks Rx+ system from Allscripts, for example, the software checks the new script against existing medications and warns of any interactions. It does the same for drug-allergy interactions and even reactions between prescription drugs and herbal remedies like St. John's wort.
Many vendors, however, offer products that do not automatically check for drug interactions. iScribe from Irving, Texas-based AdvancePCS, for example, currently does not offer any integrated drug information. ePhysician, which is based in Mountain View, Calif., offers physicians only the option to go to a database to look up interactions when they write prescriptions.
Callbacks and legibility
One of the most highly-touted uses of PDA prescription software is the ability to check a script you're writing against the patient's formulary at the point of care.
iScribe, for example, offers formularies from 2,200 health plans and allows physicians to select up to 20 of the drug lists they encounter frequently. When those formularies change, iScribe automatically updates the information when physicians "hot sync" their PDAs to a personal computer linked to the Internet.
Most vendors alert physicians to the formulary status of each drug. Allscripts, for example, places an icon next to each drug name: green for formulary, red for nonformulary and yellow to indicate that the drug is formulary but not preferred. (To help colorblind users, the icons also contain smiling and frowning faces.)
By checking the formulary, physicians avoid callbacks from pharmacists who want to switch to a covered drug, cutting down on both the hassle factor and staff time. It also helps prevent patients from walking away from prescriptions that aren't covered by insurance—and too expensive to pay for out of pocket.
Some analysts, however, question the usefulness of many of the formularies being offered by e-prescription vendors. Chelle Woolley, vice president for marketing at the St. Paul, Minn.-based RxHub, said that formularies provided by some vendors give information on large plans, but not necessarily smaller plans that may offer slightly different benefits. That can be a problem because large companies often negotiate slightly different formularies for their employee groups—-differences that generic formularies will miss.
A solution may be on the horizon. RxHub, a joint effort of three pharmacy benefit management companies to streamline electronic prescribing, plans to provide physicians with downloadable patient-specific formulary information for PDAs, Ms. Woolley said. The system was being tested this summer; a general release is expected by the end of this year.
Despite its limitations, some physicians say the ability to check formularies from a PDA has been helpful, even when the process is not automated. Robert H. Finley, ACP-ASIM Member, who uses e-prescribing software from MEDeMORPHUS, said he now avoids most of the dozen callbacks he used to get each day from pharmacists who wanted him to prescribe Zestril, for example, instead of Prinivil.
"I don't get those phone calls anymore," said Dr. Finley, an internist and geriatrician with Gateway Internal Medicine in Anaheim, Calif. "They have decreased tremendously."
Because physicians print or fax e-prescriptions, handheld computers also help prevent handwriting problems. This not only cuts out pharmacy callbacks, but it can also prevent bad guesses, said Christine Smith-Stetler, RN, director of clinical education for Allscripts.
As an example of what can go wrong, she pointed to a 1999 jury ruling that awarded $225,000 from a Texas cardiologist to the family of a patient who died after receiving the wrong prescription. The pharmacist had misread the physician's handwriting.
For some physicians, the legibility issue is the one that drives them to e-prescribing. "I want a legible record, both for myself and my staff and for the pharmacists," said Elizabeth Beautyman, MD, a solo internist and hematologist in Manhattan who uses an old version of the ParkStone prescription software on her Casio handheld and sends it by infrared beam to a printer.
Though "pharmacists did a pretty darn good job" of reading her handwriting, Dr. Beautyman said, "they would sometimes call and say, 'I can't read this.'"
Prices to be determined
E-prescribing software comes in several forms and price levels. Basic software such as ePocrates and mobilePDR, which allows physicians to look up drug information, is on the Internet free of charge.
Pricing more comprehensive e-prescription programs is difficult because these services are so new. Some vendors are eating costs during early beta testing and roll-outs. MEDeMORPHUS, for example, began charging a monthly fee after an "incentive period" ended this fall. At press time, company officials said they hadn't decided whether to pass on installation costs that the company now absorbs.
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As vendors prepare to roll out e-prescribing technology, many are wondering who will pay for it. |
Several vendors said they charge—or plan to, once early roll-outs are complete—$25 to $50 per physician per month. Others, such as Allscripts, declined to provide a price range, saying prices vary by the size of the group and the type and length of the contract. Though some "early adopters" now using or testing software are willing to pay monthly fees, some analysts question whether most physicians would follow suit.
The issue of price gets at one of the biggest questions the industry is facing: Who ultimately will pay for e-prescription? How much are doctors willing to spend in monthly fees, and how much of the software and transmission costs might have to be funded by other interested parties, such as pharmacy benefit management companies?
To complicate matters, some vendors now offer e-prescription software services in only certain parts of the country. MEDeMORPHUS is currently available only in California, although the company plans to roll out the product next year to physicians in other states where PacificCare, its parent, has a presence. It will later be expanded nationally. And earlier this summer, iScribe was available only to physicians sponsored by certain health plans, though a full-scale roll out is planned by year-end.
A nascent industry?
The spotty price information and uneven availability of e-prescribing software underscore the nascent—and some say shaky—nature of the industry.
One ongoing obstacle to the widespread adoption of e-prescription is speed. Some physicians say they simply don't want to spend time tapping out a prescription that they can write in a few seconds by hand.
"I think the big holdback is making sure it's time-neutral," said Holly Whitaker, director of consulting and practice lead for health care at Watertown, Mass.-based Arcstream Solutions, which helps hospitals integrate technology.
Advocates like Dr. Finley from Anaheim, however, say that it's already considerably faster to use e-prescribing, particularly when you have to take care of several refills. "You don't have to reenter all the information about name and address and date," he said.
There are also looming regulatory hurdles. While some large chains like Walgreens accept certain types of electronic prescriptions, some states either forbid e-prescribing or have yet to come up with regulations.
Projects by RxHub and the Alexandria-based SureScript Systems are building networks that would make it easier to send prescriptions, but they are currently pilot testing their systems. "Nobody can say they have 75% of the retail pharmacies in their system," said Mark Bard, president of Manhattan Research in New York. "It's a lot more work than anybody thought."
While vendors say they can see electronic transmission on the horizon, they acknowledge that most physicians simply aren't ready. Faxing is a close second to sending prescriptions electronically, but it still requires collecting fax numbers for local pharmacies—and even then, faxes don't go always go through. The time-consuming alternative of printing out prescriptions is "a completely unacceptable solution" for most physicians, said Richard Fiedotin, MD, a co-founder of ePocrates.
"The technology is not quite ready for physicians and vice versa, and that's the challenge," said Michael Palmer, partner in the health care practice of Accenture, a Boston-based consulting firm specializing in technology. "We have a way to go before it really takes off."
The following products are some of the more popular applications physicians use for electronic prescribing on their personal digital assistants (PDAs). For a more complete list of PDA software, see our Buyer's Guide.
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ePhysician Practice
ePhysician Practice's electronic prescribing software allows physicians to write and transmit prescriptions from a PDA. A drug reference component lets users check a database with more than 3,000 drugs in 26 different therapeutic classes. The company also offers charge capture and patient management software. Available for Palm-based PDAs only; contact ePhysician for pricing information. -
ePocrates
ePocrates offers three electronic prescribing products:-
ePocrates Rx provides peer-reviewed drug information on more than 2,600 drugs. The software includes drug interaction information and off-label uses.
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ePocrates Rx Formulary combines the above features with an integrated formulary function.
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ePocrates ID is a drug reference/ checking application for infectious disease specialists.
All three programs are free and available for Palm-based PDAs only.
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iScribe Electronic Prescribing
iScribe Electronic Prescribing provides information on 8,000 drug formularies and medical supplies. iScribe iFormulary offers formularies from 2,200 national and regional health plans.The software is available only to "sponsored" physicians at this time, but you can put your name on a list that will be used to find future participants on the company's Web site.
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mobilePDR
This handheld version of the "Physicians' Desk Reference" (PDR) works on both Palm- and Pocket PC-based PDAs. Information for each drug includes indications and contraindications; warnings and precautions; adult and pediatric dosing; adverse reactions; and the page number where the drug appears in the print PDR.The product is free for qualified physicians, nurses, and other health care providers.
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TouchWorks Rx+
TouchWorks Rx+ features drug- and allergy-interaction checking, as well as plan-specific drug formularies. TouchWorks Rx+ is part of a larger package of software from Allscripts Healthcare Solutions that allows physicians to start with a single application and move to a complete electronic medical record.Available for Pocket PC-based devices; contact Allscripts for pricing information.
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