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Digital Rx

by Polly Schneider

February 1998 - Healthcare Informatics

THE AUTOMATION OF medication ordering is one of the most obvious transactions in healthcare because of the opportunities to save a great deal of time and money, now spent by physicians, their staff and pharmacists, reconciling orders over the phone. Electronic prescribing through both proprietary networks and the Internet has become widely available by many vendors and represents a large market opportunity--an estimated two billion prescriptions are filled annually. But getting physicians to use computers when they prescribe, and working through the technical glitches on the pharmacy end of the transaction continue to impede progress.

The electronic prescribing craze that started a few years back has been fraught with difficulties, but the resistance of physicians to the concept has been the greatest obstacle and caused some large vendors to pull out in 1997. "Everyone has discovered that we forgot to ask doctors if they really wanted this," says Chuck Reed, president of the American Society for Automation in Pharmacy. "It doesn't really fit in with their workflow."

Avoiding drug events
Proponents of the technology, however, claim that with the right value-adds, physicians will be willing to change the way they work. Advanced Health Med-E Systems, Chicago, subsidiary of practice management firm Advanced Health Corp., is one of the few companies offering a product that takes advantage of the Internet. The company's e.RX prescription writing software has a drug utilization review (DUR) engine that allows physicians, at the time of ordering, to access databases from a central server on the Internet or their intranet with drug interaction and dosing information--important in helping to prevent the growing problem of adverse drug events (ADEs). Various studies have shown the impact of ADEs on the nation's healthcare system. One from the journal Therapie, May 1996, suggests that drug-related illnesses account for 5 percent to 23 percent of hospitalizations, 1.75 percent of ambulatory visits and one in 1,000 deaths.

Managing formularies
Yet the Byzantine problem of formulary management alone may be incentive enough for physicians to use computers for prescription ordering, according to Lyle Berkowitz, an internist with Northwestern Memorial Hospital in Chicago, and medical director for Advanced Health Med-E Systems. His patients are covered by some 30 to 40 different insurers. "If I am lucky, about once a year I get a booklet from these groups concerning their formulary, and then they may update it during the year and send me a letter. The truth is--I cannot keep track of all these formularies." Advanced Health is also incorporating formulary data into its offering, which allows physicians to screen drugs for compliance when they write the prescription--avoiding time-consuming games of phone tag with the pharmacist later.

Applications that offer immediate value to physicians--formulary and ADE checking--may be the catalyst to move prescription automation forward. "I see e.RX as a product that allows physicians to begin to experience the benefits of how computers can help them in their clinical practice," Berkowitz says. The product is available for free to physicians and is now being distributed through the Physicians' Online network. Advanced Health has contracts pending to sell the product to HMOs.

Automating refills
The automation of refills--which accounts for the majority of prescription transactions and a substantial number of phone calls to the physician office every day--is another value-add of such systems since prescriptions are already in the system and can be approved online. "This is a huge time-saver for doctors and for the pharmacy," says Jack Guignan, president of ProxyMed, Inc., Ft. Lauderdale, Fla., a clinical database and EDI provider for healthcare. Its multiprotocol network, ProxyNet, handles claims, prescriptions and laboratory transactions. The company's acquisition last year of IBM's electronic prescription product Prescribe brought contracts with national chains Walgreens, Walmart and Eckert's: ProxyMed is now generating 150,000 electronic prescription transmissions a month to 10,000 pharmacies. Guignan expects the business to double by the end of the second quarter through relationships with practice management software vendors.

Still, it all comes back to physician workflow and whether the process is as easy as using a prescription pad. "In developing this, your only competition is that piece of paper and pen," says Pat Peneer, product manager for National Data Corporation's competing product, Prescription Network Manager. To make the system really useful, adds Berkowitz, there must be an interface to the practice management system so that the doctor can see all of the patient's administrative data, including insurance information, and the prescription can then be stored in the medical record.

"Unfortunately, computerization of the workflow has not been done very well yet," notes Berkowitz. "Even if it is a portable device, it is still bigger than the prescription pads. So the efficiency more likely comes when they need to refill a list of medications, or when they avert an interaction which would cost them time later on."

Getting pharmacies online
Equally vexing is making the connection with the pharmacy--data content and interface standards necessary for pharmacies to receive electronic prescriptions have not matured, and many state regulations do not yet allow prescriptions in an electronic format. Until these issues are resolved, the prospect of any kind of electronic connection--Internet or otherwise--is out of the question for most pharmacies. ProxyMed uses the Script standard endorsed by the National Council for Prescription Drug Programs. Pharmacy software vendor CRX Pharmacy Systems, Glen Allen, Va., endorses another standard called MEDPRE, backed by the American Society for Automation in Pharmacy, because of concerns the company has with standards that allow prescriptions to go through a pharmacy benefit manager or other third party which could control where the prescription is filled, according to company spokesperson Allen Novak.

More electronic benefits
Yet the benefits of electronic prescribing may appear more quickly for pharmacies. In Reed's view, the biggest gain for the pharmacy may be in the processing of refills because of the volume of phone calls it could reduce. According to Guignan, pharmacies can save 30 percent on prescriptions that are automated. Ideally, an online prescription can reduce the need to enter data and make orders clearer. If the formulary and dosage/drug interaction checking also have been performed, there could be substantial time savings since traditionally, the pharmacy handles this, according to Ron Robb, director of pharmacy and ancillary applications at Burlington, Vermont-based IDX Corporation. IDX is considering electronic prescribing, but for now, its systems for pharmacy and practice management only allow the faxing of prescriptions. Still, says Robb, faxing has made a difference to the company's customers by making orders more legible and complete.

For many pharmacies, the cost of supporting electronic prescribing is still prohibitive because of the transactions fees they pay the EDI network, according to Reed, who is also senior vice president of CRX Pharmacy Systems, Glen Allen, Va. This, he says, is where the Internet may provide the answer. "With the Internet, you can afford to check your mail regularly, you can afford a full-time connection, and it's universal."

The Internet vs. EDI
Advanced Health E-Med Systems' e.RX software can run over the Internet or in an intranet. "The advantage of the public Internet is we can offer the system to more people," says Berkowitz. "There are certainly sophisticated IDSs with nice intranets set up, but it's much more difficult for the smaller groups to have access to those intranets." Another Advanced Health product, Med-E-Practice, is an electronic medical record system with prescription modules designed for the IDS or other large organizations with a robust network infrastructure.

Security, particularly with transactions containing data as sensitive as medications, is an issue keeping many away from Internet-based prescriptions. Advanced Health is using 128-bit encryption technology, the strongest encryption available, to secure transactions in both systems.

Policing security
Yet having a sound confidentiality and security policy is equally as important as having the latest security technology, stresses Harry Rhodes, RRA, health information management practice manager with the American Health Information Management Association, Chicago. Rhodes' concern with electronic prescriptions is that people may overlook the sensitivity of such transactions that are so commonplace. "Because you have so many transactions and organizations are trying to process these quickly for patients....you can become too casual about it."

Providers should also have policies regarding the appropriate use of patient databases: Rhodes cites cases where pharmaceutical companies have obtained or purchased patient medication histories to use for their own marketing purposes.

Even though the widespread availability of advanced encryption technology is mitigating the risks of using the Internet for sensitive transactions, there are still advantages in using a third-party EDI provider, according to IDX's Robb. EDI firms like National Data Corporation (NDC), ProxyMed, Envoy and NEIC have exclusive contracts with many of the major pharmacy chains for claims processing. These firms are also beginning to provide other offerings like clinical databases with drug or formulary information. NDC recently signed an agreement to distribute data from formulary publisher InfoScan, Horsham, Pa. EDI providers in turn depend upon their relationships with software vendors to penetrate the physician market. Although IDX will likely offer electronic prescribing through an EDI provider, Robb admits: "Ultimately doing this on the Internet makes sense."

A new business model
Peneer does not believe the Internet is a threat to NDC's business. "There are still value-adds we can offer beyond the transaction. It doesn't take us out of the business but it changes the business model." The company is not yet delivering prescriptions electronically, although a pilot is under way. "Right now it's a slow market," he says. "With the pharmacy the benefit almost appears immediately, for the physician the benefit is one that builds with use, so it's a little tougher sell to get started." ProxyMed will release this quarter a browser version of its prescription writer that could be used in an intranet.

Despite its slow adoption, automating prescription management is only going to become more attractive, even necessary, as the volume of new drugs on the market continues to mushroom with technological advancement and FDA reform. Says Berkowitz: "Since I've been out of residency only a couple years it's amazing how many new drugs are out. It's very hard for doctors to keep up. That's the major benefit of using a computer as sort of a peripheral brain."

Polly Schneider is senior editor at Healthcare Informatics.

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