By Pamela Lewis Dolan, AMNews staff.

The American Medical Association has unveiled its enhanced online e-prescribing learning center and opened it up to all physicians.

The learning center, first launched April 1, offers a one-stop shop for physicians seeking information on e-prescribing and advice on how to get started.

The site recently was enhanced to offer additional features, including a system-finder tool that selects three systems for a user based on responses to a brief questionnaire and a calculator to help physicians determine how much they can earn in Medicare e-prescribing incentives (www.ama-assn.org/go/eprescribing).

A recent online survey by the AMA found that e-prescribing use in physician practices has grown to 30% from 13% last year. One reason is that in January, Medicare started providing incentives to doctors who e-prescribe. Those incentives will turn to penalties in 2012. The AMA survey also found that 43% of physicians find the incentive program confusing.

“Health information technology continues to be a hot issue in health care, and electronic prescribing can be a physician’s first step into health IT,” said Joseph M. Heyman, MD, immediate past chair of the AMA Board of Trustees. “Incorporating an e-prescribing system into your practice can help reduce medication errors and drug interactions and also help prepare the practice for future technologies like electronic health records.”

The Centers for Medicare & Medicaid Services rolled out a resource site last year to give physicians information on how to receive the bonus payments (www.cms.hhs.gov/erxincentive/).

SureScripts, an electronic network founded by the pharmacy industry that connects pharmacies and physicians, also started a similar learning center earlier this year (www.surescripts.com/)

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Everyone, it seems, wants doctors to e-prescribe. Physicians are facing an onslaught of government incentives, state and local urgings, and healthcare and consumer organizations’ guilt to make the transition from antiquated paper prescription pads to 21st century electronic prescription systems.

Medicare Incentive Program

The biggest step toward universal e-prescribing was the passage on July 15, 2008 of the new Medicare law that includes an incentive program to increase the use of e-prescribing. Under the measure, physicians participating in Medicare Part D who e-prescribe will receive an incentive bonus of 2% starting in 2009 and for 2010. The bonus goes down to 1% for 2011 and 2012, and to 0.5% in 2013. In addition, Medicare doctors who do not e-prescribe will see their Medicare payments reduced by 1% in 2012, 1.5% in 2013, and 2% thereafter.

Some states are sweetening the Medicare deal. For instance, Tennessee has offered a grant of $3,500 to doctors who e-prescribe for two years. And while New Hampshire has not offered monetary incentives, the state’s Citizens Health Initiative, backed by the governor, developed a plan two years ago to encourage all physicians to e-prescribe by October 2008.

The new Medicare rule has the blessings of the Pharmaceutical Care Management Association (PCMA), which says the policy would save $26.3 billion in the next 10 years. A study commissioned by PCMA found that only 7 percent of physicians e-prescribe. On the other hand, the American Medical Association projects no savings from e-prescribing and is leery of an unfunded mandate on already overburdened physicians complying with Medicare.

So vital to the safety and efficiency of our healthcare system is the need for physicians to make the transition to electronic prescribing, Republicans and Democrats in the House and Senate came together to override President Bush’s veto of the Medicare initiative to push the measure through.

Benefits of E-Prescribing

The benefits of e-prescribing are immense.

Medication errors. The most obvious is the elimination of devastating and costly medication errors due to doctors’ poor handwriting. According to the Institute of Medicine, 7,000 patients die and 1.5 million people are injured annually by medication errors. With an electronic system, patients won’t lose their prescriptions, and pharmacies will fill the right prescription for the right patient.

Contraindications. E-prescribing systems keep track of each drug, its side effects, and its contraindications, as well as all the medications a particular patient is taking, his allergies and drug history. With 1.9 million adverse drug events in the last 10 years, e-prescribing can avoid negative drug interactions. Medicare’s incentive could save it $156 million in five years by reducing adverse drug effects.

Insurance coverage. Also with e-prescribing systems, physicians have complete access to information about their patients’ private or government insurance information and coverage for specific drugs.

Speed. When a physician submits a prescription order electronically to a pharmacist, the patient can leave the doctor’s office and go right to the pharmacy to find the medication waiting for him.

Merger Spurs Use of E-prescribing

Entrepreneurial companies have not been waiting for the government to encourage physicians to e-prescribe. Up until recently there were two private, competing electronic prescription networks that have been developing their own e-prescribing infrastructure and vying for the attention of physicians.

One is SureScripts, begun in 2001 and based in Alexandria, VA, which is owned by the retail focused National Association of Chain Drug Stores and by independent pharmacies represented by the National Community Pharmacists Association.

The other is St. Paul-based, RxHub, owned by three major drug benefit managers and leading mail-order pharmacies CVS Caremark, Express Scripts, and Medco Health Solutions.

The two companies recently announced a merger of their integrated network, to be called SureScripts-RxHub. It’s a seemingly perfect match, as SureScripts routs prescriptions to pharmacies, while RxHub coordinates information about insurance coverage and offers mail-order pharmacy services.

The new company wants to be a major force in creating a national electronic health records system in the country that connects physicians, pharmacies, and insurance companies. Physicians can electronically send prescriptions directly to pharmacies and to mail-order suppliers. And the technology will be easier to use, as companies that make the software and hardware will need to be certified by both SureScripts and RxHub.

Will Doctors Really Change?

Some say the Medicare incentives will result in a doubling of the number of doctors who e-prescribe, while others are skeptical that the mandate will see any discernable changes. Doctors are notoriously reluctant to change their ways. High start-up costs for the technology and the learning curve to be comfortable with the software are contributing to the reluctance. Currently only 2 percent of the 1.5 billion annual prescriptions received by pharmacies are submitted electronically.

Concerns about E-Prescribing Technology

Understandably, some physicians, organizations, and consumer groups are concerned about the safety of electronic systems. Human error is still a factor, as doctors could type in the wrong prescription they intended or the wrong dosage. In addition, a pharmacist could misread the drug or misinterpret directions for the medication.

Cost is another main factor. The Medicare program provides no per-prescription cost incentive for e-prescribing. Moreover, some industry analysts say the few thousand dollars physicians will receive in incentives will make them only break even after spending an equal amount in upfront technology investments. Physician groups say the monetary incentives to switch to e-prescribing need to be higher.

Privacy concerns are common, as some groups are itchy about vast amounts of patient data sitting in one network and passing through various doctors’ offices, insurance agencies, and drug stores. There’s also the risk of hackers and identify theft. Patients and physicians need to be confident that sensitive medical information will be used properly and not resold or tampered with.

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With a host of new incentives, doctors are finally beginning to scrap pen and paper in favor of electronic prescriptions.

Medicare began paying doctors a bonus if they switch their patients over to e-prescribing. Some private health plans also have begun offering extra payments along with free equipment, such as digital handheld devices. And a coalition of technology companies is giving doctors free software to encourage them to ditch their paper prescription pads. As a result, the number of physicians prescribing medicines electronically has more than doubled in the past year to about 70,000, or about 12% of all office-based doctors.

E-prescribing allows doctors to transmit prescriptions via a secure Internet network directly to pharmacies using an office or laptop computer or a digital handheld device. The practice has been shown in studies to reduce prescription errors and to cut costs for consumers and health-care providers. It also encourages patients to get more of their prescriptions filled, because it reduces the time spent waiting at drug stores. The Obama administration’s plan to invest $50 billion over five years to encourage broader adoption of health-information technology is expected to include additional incentives for electronic prescribing.

But there are still barriers to full-fledged adoption of e-prescribing. Federal drug laws, which are under review, prohibit electronic prescribing of controlled medications such as narcotics, insomnia drugs and anti-depressants. Safety experts also warn that selecting prescriptions on a computer screen can cause a doctor to inadvertently enter, for instance, a quick-release version of a drug instead of a long-acting formulation because they appear in sequence on an e-prescribing program.

Michael Cohen, president of the Institute for Safe Medication Practices, which analyzes medication errors, says the group favors adoption of electronic prescribing. Still, Mr. Cohen advises patients as a backup to leave their doctor’s office with verbal instructions and a printed version of the prescription that includes the name, dose and directions for use.

E-prescribing can catch many dangerous mistakes, studies show. The software automatically checks a patient’s drug history for potential hazards such as improper dosages, medication allergies and adverse interactions with other drugs the patient is taking. More than four billion prescriptions are written in the U.S. annually, and studies show that as many as 4% contain an error with serious patient risks.

“There are more than 1.5 million people hurt every year by preventable medication errors, and the evidence is strong that patients are far better off when we e-prescribe than when we don’t,” says Janet Marchibroda, chief executive of eHealth Initiative, a nonprofit that includes public-health agencies, consumer groups, health plans and technology companies.

Cost Savings

Electronic-prescribing systems also can save patients money by allowing doctors to check, with a patient’s consent, the relative cost of co-payments for generic, formulary and nonformulary drugs in a patient’s health plan. The main software program being offered free to doctors, by Allscripts Inc. and a coalition of technology companies and health plans, displays a green smiley face next to generic and on-formulary drugs, and a red frowning face next to more expensive nonformulary drugs.

In a study published last month in the Archives of Internal Medicine, researchers at Brigham and Women’s Hospital found that e-prescribing systems that allow doctors to select generic or lower-cost medications can reduce annual costs of delivering drugs to consumers by $845,000 for every 100,000 patients.

Linda Green, an allergist in Havertown, Pa., began using electronic-prescribing software two years ago. She says e-prescribing has enabled her to see a list of medications her patients may have neglected to tell her about, “and I’ve had a few surprises that had an impact on the medication I was about to prescribe.” Moreover, she says, “when you are faced with a patient who is complaining of having trouble paying for medication it makes you think, maybe I can prescribe this cheaper one instead, and having their formulary information in real time makes that much easier to do.”

Virtually all chain pharmacies and about 45% of independent pharmacies now accept electronic prescriptions, says Rick Ratliff, co-chief executive of SureScripts-RxHub. The company, which has patient information from pharmacy-benefit managers, operates the main network over which prescriptions are transmitted electronically. The company stores data on more than 200 million insured patients and provides physicians with ready access to information on patients’ medication histories and which medicines are covered by their health plans.

Electronic Records

E-prescribing also is expected to encourage broader use of electronic medical records, which includes such features as storage of full medical histories, lab reports, and programs that let doctors send alerts and reminders to patients. The cost of the technology to maintain full electronic medical records is roughly $25,000 to $45,000 per physician. While free software and hardware programs are being offered to some doctors, generally the cost of a stand-alone e-prescribing system, including software and training, ranges from $500 to $2,500. The system can later be incorporated into a medical-records system.

The Center for Medicare and Medicaid Services, the federal agency that oversees Medicare, this month began paying doctors a bonus to e-prescribe. The bonus amounts to 2% of charges billed to Medicare for 2009 and 2010, and declines to 0.5% by 2013. Current estimates are that the bonus program could yield an additional $1,700 to $3,500 a year for a doctor.

Medicare Penalties

Medicare also plans a penalty for doctors who don’t e-prescribe. These physicians will have their Medicare reimbursements reduced by 1% beginning in 2012, and by 2% in 2014 and beyond.

Consulting firm Gorman Health Group estimates that the federal government could reduce its health-care costs over 10 years by at least $26 billion by offering bonuses and requiring that all prescriptions for drugs covered by Medicare be sent electronically. The program also could prevent 1.9 million adverse drug events, Gorman predicts.

Fully 20% of prescriptions are never filled because patients don’t bother to take them to the pharmacy, according to the Healthcare Information and Management Systems Society, a trade group. John Alders of Salem, N.H., recently injured his elbow pulling the cord on his snow blower. The 49-year-old Web site designer went to his doctor, Azar Korbey, who sent an electronic prescription to a local pharmacy. By the time Mr. Alders got there 15 minutes later, it was ready. “Pretty much the entire transaction is finished while you are in the exam room,” Mr. Alders says. “Being able to do that makes it more attractive to be a part of Dr. Korbey’s practice.”

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