The Truth About E-Prescribing

A great idea, poorly implemented, will hurt patients and put doctors at risk.

E-prescribing is here – it’s now available in all 50 states and now mandated where I practice, in New York. At first glance, e-prescribing seems like a concept whose time has come. After all, we’ve grown accustomed to electronic mail, and sharing documents through “the cloud.” We stream music and movies from one account, to multiple devices. We securely send money to Amazon – or our friends – through apps and the web.

So why should something as important as medication be reliant on slips of paper? Paper can get lost, get ripped, and is ostensibly harder to track. So it follows that e-prescribing ought to be safer, allow confirmation of adherence, and give greater insights into medical practice across a state, in real time. As a believer in the power of technology to improve care, I was excited to get my department on board.

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In practice, e-prescribing is a disaster – both for us in the ED, and for our patients – particularly in New York State, which is among the first states to mandate its use. Other states are weighing a mandate; I can only hope we serve as a cautionary tale.

When I first learned about e-prescribing, I naively assumed it would work like other cloud services – patients would be able to go to any pharmacy, present credentials to verify their identity, and then get their prescriptions filled. After all, it’s not like I’m tied to a single ATM, or a single computer that has my Gmail account.

But I was naive. Starting on Easter Sunday* this year, e-prescribing has been mandated for all providers in New York. Why launch this significant, first-in-the-nation** initiative on a major weekend holiday, when key personnel are not around to troubleshoot or answer questions? The lack of foresight in choosing an appropriate launch date* is unfortunately reflected in many other aspects of this legislation.

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The way e-prescribing works here is: patients must designate a pharmacy for their doctors to send prescriptions – and that’s the only place these ‘scripts will go. It’s less like the electronic cloud services we’re accustomed to – and more like faxing, or a phone call – but without the helpful immediate confirmation that the prescription was successfully transmitted (incidentally, in New York, faxing and phoning in prescriptions are now forbidden).

Think about how lousy this is, if you’re a patient:

• You have to know your pharmacy’s mailing address (“it’s the CVS in my neighborhood” won’t do; spending a minute or two with Google Maps is often required)
• If your pharmacy is closed, you can’t fill the ‘script anywhere else until it opens.
• If you gave your doctor the incorrect address (a real problem, in New York City, where there are multiple pharmacies in tight proximity) you’re stuck.
• If your pharmacy has stopped carrying a drug, you’re stuck.
• If your pharmacy has jacked up the price of a drug, or if you have a coupon for another pharmacy, you’re stuck.
• If the prescription didn’t go through (a distressingly common event), you’re stuck.
• You won’t know if the prescribed medication or dose is what you expected, until you’re at the pharmacy. If you suspect an error, or there’s a misunderstanding, you’re stuck.

For patients, the only way to get a prescription fixed, or re-sent, or sent elsewhere, is to go back to the ED, or the doctor’s office, or try to raise us by phoneIt’s a common occurrence these days for a colleague asks me: “Remember that patient you discharged? They’re on the phone, and need help with the prescription.” I’ve got to stop what I’m doing, take the call, log into the EHR, pull up the record, and re-write or re-send the prescription (and hopefully the second time is a charm, because like I said before, phoning a prescription directly to the pharmacist isn’t allowed anymore). On one overnight shift, a patient with a prescription for antibiotics called me three times as he tried to find open pharmacies that would take his insurance.

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Urgent, frustrated calls and return visits related to e-prescribing are happening often enough in my ED (usually every hour or two, during business hours) that we’ve had to assign a PA just to field and manage these calls(in addition to their regular duties). And I’ve started to worry that a lot more patients are giving up and not getting their prescriptions, at all.

New York’s e-prescribing system is particularly troublesome for emergency physicians, as well:

• A significant fraction of our patients have never been to our hospital before and thus, have no “preferred pharmacy” on file.
• Most of our patients seek care outside of business hours, and so even if a preferred pharmacy is on file, it’s unlikely to be available at the time of discharge.
• Some patients have changed address, so the preferred pharmacy on file is out-of-date. Which means we should confirm what’s on file, every time.
• Scheduled drugs require two-factor authentication, meaning besides your EHR password, you’ve got to have a keychain fob or smartphone app available, and previously had it registered with the state
• If there’s an EHR downtime, or your patient is about to leave town, or legitimately can’t recall a pharmacy, you are allowed to revert to paper prescriptions. But for each paper Rx, you must e-mail the state of New York with your credentials and contact information, the patient’s initials, and a reason why you couldn’t e-prescribe – “including the citation(s) to PHL Section(s) 281(3) (b), (d), and (e)” (whatever that means). Each time***.
• Writing a quick prescription for Ambien for a family member about to go on a long flight, or some antibiotics for a colleague with an infection, was always a bit of a gray area but now is technically impossible – unless you’re creating an encounter in your EHR and generating the prescription there.
• In New York we are subject to “fines and jail time” for not complying with this system! But it’s hard to say exactly what the penalties are, and how stringently they’ll be enforced. What’s clear is the hospitals where the EPs work won’t be targeted for fines – they’ll go after individual prescribers.

When you look at the mechanics of e-prescribing, it’s not hard to understand why adoption was lagging across the US. While some estimates say more than half of prescriptions in the US today are now e-prescribed, as of late last year only 4% of providers were using systems for prescribing opioids or other scheduled drugs. Standards for e-prescribing of controlled substance (EPCS) were chosen by the DEA back in 2010 but because of hassles with transmitting and picking up the prescriptions, patients and providers just found the paper solution preferable.

Proponents of e-prescribing say it’s safer, because of improved legibility and improved tracking. But our paper Rx were already computer-generated, easy-to-read printouts, from our EHR (where they were logged, and subject to reports and audits). As for up-to-date tracking of controlled substances, New York State implemented a comprehensive PDMP (prescription drug monitoring program) called iStop back in 2013 – it’s actually been mandated that providers check it before issuing any new non-emergent prescriptions for scheduled drugs. Since it worked for years before EPCS was law, I’m forced to conclude that government tracking of prescriptions was already possible in the paper era.

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So I’m not really seeing the benefit from this new system. Sure, e-prescribing could be convenient in certain situations, for example, a primary care doctor managing longstanding patients with multiple comorbidities. But for an emergency physician who wants to prescribe some antibiotics to a new patient with a UTI? What used to be effortless now takes a couple of minutes to look up pharmacies, check addresses, confirm hours of operation, transmit, and hope it goes through without incident. Multiply that by a few dozen patients a day and you’re seeing a real hit to productivity. I can’t say it’s worth it.

The two-factor authentication required for scheduled drugs is another aspect that sounds good in theory, but has been a huge headache to implement. The idea is: a doctor has to carry an app on his or her phone, or a keychain fob, that is registered to only that doctor. A tap on the phone, or fob, generates a new 6-digit passcode every 30 seconds. The doctor must enter that passcode alongside his or her password, to e-prescribe the scheduled substance. The challenge has been registering these apps and distributing these devices – even if 95% of the department get it done, that’s still 5% that aren’t able to prescribe anymore (I’m the guy that has to harass the stragglers). And those that do register are still subject to dead batteries, or IT errors in registration that render their devices useless (I’ve filed a dozen help-desk tickets about registrations that didn’t work – or unexpectedly got un-registered. Suffice to say, there are multiple potential points of failure).

We already have to enter our passwords to log into the EHR, and again to prescribe a controlled substance. We have to change our passwords every few months, already. Were there really so many cases of stolen passwords (or doctors forced to enter their password at gunpoint) that we had to adopt two-factor authentication? It’s too late to ask now; this is the law of the land.

Sure, while I think it’s safe to call it a disaster for EPs in New York, it’s not an unmitigated one – e-prescribing waivers were granted, if you were using an older charting system that couldn’t support the new requirements. NY-ACEP may propose measures to make it easier for EPs to report paper prescriptions in bulk, for instance after a downtime, or once a quarter. And our EHR offers a few nice touches for new patients with no preferred pharmacy on file – it automatically suggests the pharmacies nearest to the ED, and nearest to the patient’s address, as options for routing the prescriptions.

But that’s not nearly enough to offset the problems patients and providers are experiencing. We should have reports soon on how e-prescribing is working in New York – how many prescriptions didn’t go through, or went through but didn’t get filled. How many doctors without waivers were forced to print, and subjected themselves to fines or incarceration. I suspect the numbers will be much worse than lawmakers ever expected. And I hope the New York experience thus far leads to improvements here, and gives other states some guidance, as they move ahead with their own implementations.

* The date of March 27, 2016 was ‘chosen’ because the law was originally passed on March 27, 2013 – and keeping the dates lined up is apparently more important than launching a mandate on a holiday.

** New York is the first state in the nation to mandate e-prescribing, under the threat of penalty to the provider (jail or fines, though we’re lacking guidance as to how much money or time a paper prescription will cost us). Minnesota the first state to mandate e-prescribing, back in 2011, but explicitly stated there would be no fines or other penalties to noncompliant providers.

*** This email exception concession was a last-minute announcement, which makes me think the state is serious about pursuing penalties for those who continue to write paper prescriptions and don’t email an explanation. See this PDF FAQ for all the email requires (questions 138-143)