We Should Not Be So Quick to Rush into E-prescribing

I work in the Washington, DC area in a private, two-physician, primary care practice. I am a believer in the intelligent application of healthcare information technology; the EMR system that I designed and have been modifying for the past 18 years works very well within my practice setting. However, I have noticed increased pressure on physicians to adopt CCHIT-certified EMR systems, e-prescribing, and other forms of health IT. The federal government, insurance companies, and vendors have been pushing ill-advised health IT policies that if implemented would be disastrous for physicians, especially those who practice in solo or small group settings.

An article published January 21 in the Wall Street Journal (WSJ) provided several examples of the kind of dangerous thinking that is driving the debate over health IT. It presented many of the familiar top-level rationales supporting e-prescribing favored by many non-physicians, who don’t understand the complexities of patient care. Unfortunately, many politicians have been convinced that expensive EMR systems, with their ability to electronically prescribe, will save money and lives, and will generally be a good thing for healthcare in the United States. This apparently includes President Obama, who has sought advice on health IT from Allscripts CEO Glen Tullman; if Tullman’s views become policy, it would likely result in more unfunded and unproven health IT mandates.

Free, but at what cost?

The WSJ article described Allscripts software as “being offered free to doctors.” Allscripts is not really free, because it does not integrate with the vast majority of EHR systems. If a physician does not buy the Allscripts EHR, then he or she will be forced into an unworkable double-entry situation, which will intrinsically increase the chances of making a prescription error. Providing free software is simply an Allscripts marketing ploy to get physicians accustomed to using its software.

The WSJ article also noted that Allscripts software “displays a green smiley face next to generic and on-formulary drugs, and a red frowning face next to more expensive nonformulary drugs.” The implication being that this is an essential feature for promoting cost savings. Yet there are already several software programs (many of which, such as Epocrates, are available for free) that can be installed on almost any platform, including smartphones and PDAs, and that provide formulary data and drug-drug interaction alerts. Yet, despite the widespread availability of these applications, physician uptake has been slow.

The bottom line

Physicians on the front lines must be aware of news and information about health IT that appears in newspapers and other media likely to be read and seen by patients and policy makers. Typically, these articles and news reports treat health IT as an absolute good and report on proposals to promote widespread implementation as if the big questions have already been settled and all that remains is to work out the details. As we all know, however, these accounts only provide a partial picture. They rarely acknowledge that most doctors do not want to buy or use CCHIT-certified EHRs or e-prescribing because they are expensive workflow killers that will make their lives more difficult.

E-prescribing requirements have been pushed on providers by non-tech-savvy politicians and by EMR vendors who are trying to make a fast buck on the backs of physicians. They were signed into law despite the lack of good prospective studies demonstrating that e-prescribing actually saves money and avoids errors in the ambulatory setting. In fact, the US Pharmacopeia fifth study of medication error showed that data input errors far exceed handwriting errors (13% vs. 2.9%, respectively). We need more studies performed by neutral researchers before we can decide whether a forced and costly e-prescribing implementation mandate is really a prudent idea.

We shouldn’t completely scrap the idea of full-scale e-prescribing, but we should push for a truly free, open-source product that can be used by virtually any EHR and is funded and provided by Medicare. But this cannot be an all-or-nothing proposition. CMS must still accept typed prescriptions that are printed out by basic EMR systems. Fax machines should also be reinstated as an e-prescribing option.

We need to move forward with all health information technology, including e-prescribing, in small steps with continuous revisions and quality improvement along the way.

Alberto Borges, MD, is in private practice and is an assistant clinical professor of medicine at The George Washington University School of Medicine and Health Sciences in Washington, DC. Check out his website at http://msofficeemrproject.com.