Estimated reading time: 4 minutes, 39 seconds

In Sept. 2009 alone, the FDA approved 126 prescription medications for the market, either as entirely new drugs or under new labels. Consider that this is only the latest round of approvals. Consider that there are literally thousands of medications that can be purchased at retail pharmacies in the U.S. Consider that there are thousands more than can be simply picked up in any grocery store "Personal Care" section. How can a doctor or a practice possibly keep track of all of the potential interactions (and allergies) for each patient, considering that patients may be taking a lengthy list of prescribed and over-the-counter drugs, while also possibly eating foods that have an impact on how medications work?


Easy to Imagine, Hard to Implement
The answer is simple, says Debra McGrath, a senior vice president with the Atlanta-based Coker Group. "You need to have some kind of an electronic system to be doing true drug-to-drug, drug-to-allergy and drug-interaction decision making," she says. E-prescribing tools are baked into current electronic health record (EHR) systems. Standalone e-prescribing systems are also available, but McGrath says the standalone systems have a major drawback. "The problem is that if I'm in a multi-specialty practice, if 10 of the 25 doctors are using them, and 15 are not, then I'm not going to have a complete med list on that patient."

McGrath emphasizes that it would be highly unlikely for a practice of that size to have complete buy-in by the physicians, and that such systems, to work at the practice level, would also have to somehow have information from other sources to complete the drug picture for even a single patient -- from other practices, from pharmacies, and from the patient herself. In other words, it's simply not a reliable solution.

"The sweet spot is to get all physicians using EHRs that have the capability of interacting with all systems across location or care, so that everybody's on the same page," says McGrath.

Progress Includes National e-Prescribing Network
There's a long way to go, even with substantial progress that's been made in EHR and electronic medical record (EMR) systems over the past decade. Helen McFarland, writing in Medscape CME in 2001, pointed out that identifying drug interactions, even when most of the required patient information was available to pharmacists, remained problematic. "The primary limitation is the immense amount of data on drug interactions and the absence of methods to disseminate the information rapidly," she wrote. "Other problems include a lack of epidemiologic information and the complexity of patients (multiple diseases, multiple medications)."

Because of the rapid and large increases in computing power (and the growth of the Internet) since McFarland wrote, it's now easier to imagine efficiently and quickly handling huge amounts of complex data, especially when information is entered by physicians in a uniform, integrated fashion -- which is what EMR and EHR systems require.

McGrath points to Surescripts as a company leading the way to an integrated system that reconciles patients' medication lists up to the pharmacy level. St. Paul, Minn. and Alexandria, Va-based Surescripts, which merged in 2008 with RxHub, currently provides an e-prescription service that, it says on its Web site, links prescribers to "all of the nation’s major chain pharmacies (e.g. Walgreens, CVS/pharmacy, Rite Aid, Wal-Mart), many of the nation’s leading payers and PBMs (e.g. Aetna, CVS Caremark, Express Scripts, Medco, Wellpoint) and over 10,000 independent pharmacies nationwide."

Overcoming Physician Resistance
Right now, says McGrath, pharmacies are usually relied upon for spotting potential drug interaction problems. In a system that will work, says McGrath, pharmacies may still be the last bastion, but physicians treating a patient will have a complete medications picture available to them, as well. The major hurdle is convincing practices and individual physicians to change the way they work -- specifically, to adopt EHR and EMR. "With e-prescriptions we can know that the right medication was prescribed at the right dosage for the right person and that the prescription was taken to a pharmacy and picked up," she says. "From there, I can also see what other medications that patient has been prescribed. The power of these systems is huge."

But many doctors are reluctant to adapt EHR and EMR (and hence e-prescribing), because of the perceived financial cost and also, says McGrath, because many physicians simply don't realize how much work their support staff does in the prescription process. But with an average of 2.3 prescriptions written during the average office visit and fewer than half of drug-drug interactions identified by physicians, according to a recent University of Arizona study, this has to -- and will -- change.

McGrath points out two major reasons why change is inevitable: 1) e-prescribing saves money; and 2) "It's good medicine, and we all have to come to an understanding that what we're doing today is not working." She says that when she demonstrates how easy e-prescribing is, and then draws the clear line between a simple system that reduces the need for many support staffers, most doctors are convinced. And the low-cost of e-prescription systems -- she estimates approximately $30 per month per physician -- speaks for itself.

The Takeaway
Practices of all sizes can benefit from adapting e-prescribing, especially when it's part of an integrated EHR/EMR system. There's an initial cost to a practice -- the systems cost money and changes in workflow temporarily slow things down. But financial incentives are also available to some practices switching over, and initial costs are, in the long run, superseded by long-term savings. But the most important point shouldn't be lost on even the most jaded Luddite: "It's good medicine." Last modified on Monday, 10 June 2013
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