Ohio doctors seem reluctant to give up their prescription pads, according to findings by Surescripts, the largest national prescription network.

The state lags far behind the nation’s leaders when it comes to sending prescriptions electronically over the network, which covers all major chain pharmacies, such as CVS and Walgreens, as well as 10,000 independent pharmacies.

In 2008, Ohio doctors electronically routed just 4.67 percent of prescriptions, Surescripts reports. Massachusetts tops the list for the second consecutive year with 20 percent — more than four times Ohio’s rate.

Electronic prescriptions, colloquially known as e-prescriptions, allow doctors to monitor and control treatment more efficiently. By getting rid of paper prescriptions and illegible handwriting, e-prescribing also reduces the risk of medical errors.

With the click of a mouse, doctors are able to pull up information about the patient’s insurance coverage when prescribing treatment. Easy access to comprehensive patient information allows doctors to prescribe alternative generic drugs to bring down the cost of medication, said Surescripts spokesman Rob Cronin.

The number of prescriptions routed electronically nationwide grew from 29 million in 2007 to 68 million in 2008, and the number of e-prescribers jumped 12 percent.

“One thing that gets the most focus with e-prescriptions is patient safety,” Cronin said. “The doctor can use software that provides them with a complete view of the patient’s medical history.”

Although the national rate of e-prescription use hovers at about 10 percent, John Halamka, an expert on e-prescriptions and chief information officer at Harvard Medical School, expects to see “rapid increases in e-prescribing volumes” next year, as use of electronic prescriptions will likely be a requirement for receiving stimulus money.

Barriers to adopting e-prescribing technology at hospitals and doctor’s offices include initial and long-term costs and confusion about competing product offerings, Halamka said. The cost to implement e-prescribing can range from $1,000 to $10,000 per physician in the first year and $250 to $3,000 in subsequent years.

Many physicians at University Hospitals in Cleveland and the Cleveland Clinic already e-prescribe, and other hospitals and health centers in the area plan to implement e-prescribing technology along with electronic medical records in coming years.

Jeffrey Sunshine, interim vice president and chief medical information officer at University Hospitals Case Medical Center, said that the use of e-prescriptions facilitates the transfer of patient data.

“Patients often see many doctors, so it’s important to have a central list of medications that the patient is on so we don’t duplicate others’ efforts.”

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In a recent study, researchers found that physicians override more than three-quarters of drug interaction alerts provided by e-prescribing software. These alerts are decision support tools for physicians in order to avoid errors related to drug interaction and/or allergic reactions, together called adverse drug events or ADEs.

ADEs are a major focus of the Obama administration in eradicating human error and in turn increasing overall health care system efficiency. A reduction in adverse effects increases the quality of patient care while reducing health care costs through the elimination of unnecessary medical care (fixin’ you up after an ADE injury).

The scientific literature reports that one-quarter of patients experience an ADE episode and one-third of those are preventable. Yikes. In this recent study, a tri-state approach yielded similar findings to traditionally smaller studies—physicians override alerts frequently. Physicians, on average, received an alert for almost 7 percent of their prescriptions (over 3 million records were sampled)—of those, they accepted only 9.2 percent of drug interaction alerts and 23 percent of allergy alerts. There is no specialty that overrides more than another though the majority of the sample was primary care physicians. Should we be concerned? Well, yes and no.

Luddite Distrust or Decision Support Overkill?

Why are physicians overriding alerts at such high rates? Researchers are not clear about why physicians override the alerts but they suggest that 1) generally, the alerts are inadequate; 2) physicians discriminate based on the type of drugs a patient is taking (heart issues are weighed more seriously than less potentially emergent conditions); 3) unless addressed, physicians will develop “alert fatigue” and continue to be dismissive of alerts to the detriment of patient health.

So, maybe docs don’t trust technology to guide them in their decision-making and are uncomfortable using an electronic format? The study found that, on average, physicians had over a year’s worth of experience using an e-prescribing system. It appears that Luddite tendencies are not to blame for physicians overriding habits but rather an annoyance with many alerts that do not mirror the clinician’s knowledge base. According to users, the e-prescribing alerts are like a hyperactive child that asks you ten times to eat candy when you said “no” the first time. The complaint is that by alerting doctors numerous times and hyping up potential threats (not discriminating enough regarding what is a high alert interaction versus a more moderate ADE) threatens the utility of the entire system. The problem is a lack of congruency between clinical decision support and physician’s experience and practice style.

Matching Physician Insight with Electronic Ease

Clinical decision support regarding ADEs must be an important part of patient care. The system, however, is clearly imperfect. Physicians maintain that the clinical decision support around prescribing is inadequate. Researchers argue that software companies and their partners should take into account clinician insight and alert override practices. In short, software systems should alter alerts based on the acceptance and override rates by clinicians themselves.

While this appears to be good advice, there also needs to be attention paid to the patient outcome. How did the patient fare when there was a drug prescription override? Is the physician prudent in overriding an ADE alert? These are important questions yet to be addressed by researchers and software companies engaged in clinical decision support.

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http://ohmygov.com/blogs/general_news/archive/2009/05/04/e-prescribing-systems-challenged-by-doctors.aspx