There are numerous challenges to widespread adoption of e-prescribing. Recommendations from the report "Overcoming Ambulatory E-prescribing Adoption Challenges: Governments Shaping Innovation on Behalf of Individual Stakeholders (pdf)" are reported below.
Note: The report was written for the IBM Center for Business of Government but there wasn’t any interest from government healthcare policy makers so the report was never published. The report is available on SSRN.
The obstacles faced by end users of e-prescribing software focus on duplicative steps and an inflexible process, especially for patients choosing if and where a prescription is to be filled.
E-scripts that can be put in a pending state open up several possibilities for innovation. The workflow would allow medical staff, rather than prescriber, to assist the patient choose the preferred dispenser for a particular e-script. A self-service internet kiosk can be set up for patients to make cost comparisons. A pending state allows medical staff to push the prescription once lab results are received. Once patients decide to fill a prescription they can notify the pharmacy (in person or electronically).
Any efficiency gains in pre-adjudication are negated because of the absence of an adjudication status. Affix to the e-script an adjudication status and an expiration date at the point of prescribing.
E-prescribing reduces collaboration opportunities since most callbacks will now be done electronically via messages. Advocates of e-prescribing suggest that, for efficiency sake, prescribers batch all their pharmacy responses together. Pharmacists already complain about the interruptions caused by a flurry of prescriber calls before lunch and close of business.
These clinical recommendations reflect that technology alone will not reduce adverse drug events (ADEs). All parties throughout the e-prescribing process have a role to play and their vigilance and a means to report problems will ultimately reduce the incidents of medication error in the ambulatory setting.
The role of e-prescribing should be viewed in the context of medication management, not limited to error reduction due to eliminating illegible handwriting.
The transmitted e-script is perfectly legible but contains errors such as a prescriber picking a sound-alike drug by mistake, inadvertently selects the wrong dosage, or potentially working on the wrong prescription when multiple patient records are open. The pharmacist still has the error-checking role even in an e-prescribing process.
Most if not all e-prescribing systems require the prescriber to do data entry – not type the order. This leads to e-iatrogenesis type of errors.
Mere participation in a non-punitive error reporting system is an indicator of medication error reduction. Easy access to a voluntary non-punitive error reporting system should be provided.
Pharmacists gain context about the medical condition from the list of medications found on a paper prescription. E-prescribing removes this context since every medication is potentially sent on a separate e-script to potentially different dispensers. Equivalent context must be provided.
More research is needed on alerts. Government should fund several competing open-source warning and alert systems that can be integrated by any software provider involved in e-prescribing.
E-prescribers are ignoring alerts and warnings because they don’t see any value. Pharmacists have ignored them for years because the alerts lacked specificity. Adding some value and using intelligent systems might provide the incentive for prescribers to pay attention to alerts.
Patients don’t immediately benefit from the early stages of e-prescribing adoption. While lower medication costs and fewer medication errors are touted, these come from more advanced versions of e-prescribing than currently being deployed. The only immediate benefit cited is that the prescription will be ready for pickup in ten minutes. Then again, the only patients who benefit are those who know the exact pharmacy address (most don’t) and are well known to the pharmacist.
3.1 Cost comparison tools
Encourage development of multi-formulary prescription medication cost comparison tools.
3.2 Lowest Cost or Highest Adherence?
E-prescribing is being touted as lowering the cost of prescription medications through greater formulary adherence. Perhaps the more important question is the role that e-prescribing plays in supporting patient adherence to their medications.
A privacy tradeoff model to examine what benefits accrue from particular pieces of information.
These recommendations address the reluctance of pharmacies, primarily independents, to adopt e-prescribing. Chain stores have established their own volume pricing agreements and most chain pharmacists are unaware of the fee being paid.
In order to reach a critical mass for e-prescribing, governments must encourage adoption to as many physical pharmacy locations as possible. Pricing for transmission fee based on a per location basis with the lowest volume dispensers receiving the best rate.
Pharmacy networks have large up-front costs for software and infrastructure. However, once this infrastructure is established, the marginal cost of transmitting an e-script is small. Pricing for transmission fee based on future volume with government guarantees for the differential.
E-prescribing shifts the costs among the various stakeholders involved in processing a prescription. An electronic transaction facilitates tracking inefficiencies that arise during the process and holding inefficient partners responsible for the cost of inefficiency imposed on others. Costs that are incurred along the prescribing value chain can now be monitored.
Given that elderly most likely wait until first week of the month to get medications (i.e., enough cash flow to make the payment), likely that many e-scripts would not be picked up until funds available. While not conclusive, there appears to be a spike in medication errors the first week of the month whose likely contributor is the increased workload as more scripts filled. If e-scripts can be scheduled for a later date, a smoothing of the dispensing demand may be possible.