ePrescribing Complaints Point to Bigger Problems

The widespread inability of electronic prescription services to handle order cancellations is just a point of pain for physicians. Other vexations can affect patient safety.

I recently reported on widespread grumbling at AMDIS about the fact that it is still a rare thing for physicians to be able to cancel an e-prescription order made through the nation's de facto e-prescribing service, Surescripts.

I was only able to get a brief statement from Surescripts at the conclusion of AMDIS, which mentioned "all stakeholder groups" as holding the key to solving this problem, which in the meantime, may be causing who knows how much inefficiency and waste in healthcare – and perhaps, even some harm.

Later, I had a chance to interview Ajit Dhavle, the vice president of clinical quality at Surescripts. I learned, to my surprise, that Surescripts has had the technical capability to move cancellation messages for five years—nearly as long as e-prescriptions have been in widespread use. Why, I had to ask, has it taken so long for the other stakeholders to get on board?

AMDIS: Execs Vent on ePrescribing, MU, and EHR Weaknesses

The main reason: Too many EHRs and technology vendors serving pharmacies need to certify their attempted cancellation transactions, conforming to the NCPDP 10.6 standard, with Surescripts. Some now have, and some still have not.

"The pharmacy system technology vendors are thinking, 'prescribers are not ready,'" Dhavle says. "Prescribers are thinking, pharmacies are not ready. It's a chicken and egg situation."

Industry Responses
After our conversation, I made some inquiries with various EHR vendors and large pharmacy chains.

Epic officials tell me they have been able to handle cancellations since their EHR software's 2014 release.

A Cerner spokesperson says, "Cancellations are on our radar, pending final MU3 stipulations and adoption by pharmacies."

On the pharmacy side, I tried Walgreens, but did not hear back from anyone there. CVS Health is currently piloting the ability to process the cancellation of orders.

"Cancellation of electronic prescriptions is a relatively new functionality in the industry and only a few EHR systems can accommodate it at this time," says CVS spokesman Michael DeAngelis. "CVS Health has piloted the ability to accept cancellations for electronic prescriptions and our goal is to make this functionality available in all of our pharmacies in the near future. We look forward to partnering with health systems and Surescripts to make cancellation of e-prescriptions a more widespread capability in the healthcare industry over time."

During my conversation with Dhavle, when he revealed that Surescripts had solved their portion of this problem five years ago, I again referred back to the room full of annoyed CMIOs at AMDIS who nevertheless see this as Surescripts' problem. Reiterating his June statement to me, Dhavle says "We are actively engaging with all technology vendors, asking them to certify and begin communicating these messages."

I offered that if five years have passed and essentially nothing much has happened, some will question how actively this is being solved.

"Earlier on, the focus was on new electronic prescriptions and refill requests," Dhavle concedes.

And the Faxes Roll On
Another source of grumbling is the industry's continuing use of fax technology. An unnamed physician I spoke with not long ago contends that some national chain pharmacies still fax refill requests to avoid Surescripts transaction charges.

Dhavle says even if this is true, no transaction charges would be avoided, so he doesn't see the logic in such faxing. To be specific, the pharmacy incurs a transaction charge when receiving the new prescription, not when it submits the refill request to a physician, Dhavle says.

But this discussion did prompt me to do some other digging and I discovered another variable that certainly vexes physicians: timing.

According to Dhavle, "We ask prescribers to respond to all pending pharmacy refill requests in a timely manner, within 72 hours, because we are all doing this for the patient, and there is a patient waiting for their medications."

"It's not 72 hours," another source in the e-prescribing industry tells me. "For Walgreens, it's more like four hours." Apparently, Walgreens, and other pharmacies, respond sooner because they lack a level of assurance that the message they sent to Surescripts made it to the physician's office.

Again, the fault may not rest with Surescripts. Acknowledging those refill requests takes people. Algorithms alone aren't going to do it. And overworked physicians have plenty on their plates other than dealing with refill requests. I cannot speak for Walgreens, but I can understand why faxing still happens.

But the net effect of all those faxes being sent anyway is even more distraction and overload on an already overloaded system.

E-prescribing undoubtedly has been a great boon to healthcare. It is often touted as one of the true undisputed success stories of Meaningful Use.

But it's also true that e-prescribing has become very, very big business. According to a report by Persistence Market Research, the global market for e-prescribing, valued at $250 million in 2013, will reach an estimated value of $888 million by 2019, with an annual compound growth rate of 23.5%.

The cancellation scenario I came across at AMDIS now appears to be just one of a myriad of reasons we have to get e-prescribing right, especially as technology drives big profits for technology and service providers such as Surescripts.

Here's a more troubling patient safety example reported in the Philadelphia Inquirer last February:

Electronic prescribing systems currently used by doctors do not communicate discontinued medications to the pharmacy. It's a known flaw that has gone uncorrected by the industry and government since e-prescribing began. Unfortunately, rarely do patients or their doctors remember to communicate to the pharmacy that changes in medication therapy have taken place. But if the pharmacist doesn't know about changes the computer is not reset. The auto-refill system just keeps rolling along, dispensing unneeded and possibly harmful medicines.

It's discouraging sometimes to realize once again that any technology has its good and its bad side. And in healthcare, the bad side can hurt people. Apparently, at least for now, e-prescribing is no exception.