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The Medicare Improvements for Patients and Providers Act of 2008 includes an incentive program for electronic prescribing, but oncologists report significant difficulties in the program's design and in using available products.
The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 went into effect 8 months ago. Included in this legislation was an incentive program for electronic prescribing that provides an incentive bonus payment of 0.5% to 2% of total Medicare Part B payments for successful electronic prescribers during the next 5 years. After 2013, incentives will end and penalties will be imposed for those who do not participate.
Oncologists report significant difficulties in the program's design and in using available products. Pharmacies are not obligated to accept e-prescriptions; hence, independent pharmacies have been slow to offer the service. Prescribing controlled substances requires a complicated system of checks and cross-checks, and prescriptions for Schedule II drugs still must be handwritten. (For a thorough review of the program including pros and cons, see http://www.asco.org/eprescribing.) In addition, many electronic health records (EHRs) or practice management programs do not integrate this function in their products. This forces practices to use a separate program for e-prescribing, requiring demographic and prescription drug data to be entered twice.
Three practicing oncologists who have implemented e-prescribing in their practice provide their perspectives on the program. They are Robert Miller, MD, managing partner of a group of five oncologists in Sacramento, California; Edward Ambinder, MD, from a two-physician practice in New York, New York; and Liveleen Gill, MD, a solo practitioner in West Seneca, New York.
Robert Miller, MD
Dr Miller describes himself as an early adopter.
“My practice has had e-prescribing for maybe 4 years now, since before the legislation was passed. At that time, we employed eight physicians at two main sites of service.
“We chose a standalone web-based product known as DrFirst by Rcopia [Rockville, MD]. It's a subscription-based module and has a setup cost and an annual fee. Implementation required a one-time data dump wherein all patient demographic information was put into the Rcopia system (HIPAA protected, of course). Since then, with every new patient we've entered the data manually.”
Journal of Oncology Practice: Has it been a smooth transition?
“Early on there was a bit of a learning curve. Some of the physicians were a little slow to accept it, because they weren't comfortable using the computer at the point of care. They wanted to stay on time, and this seemed like an extra step. The staff had to adapt as well. In the past we'd used a pharmacy answering machine on a dedicated line, and one of our highest-paid staffers would have to spend 45 minutes a day listening to those messages. With the electronic system, as long as the pharmacies are on the network, it comes directly to the computer and frees up staff time.
“We were probably the first practice in our city to use eRx, and although many of the local pharmacies had the infrastructure, it wasn't part of their workflow. So some of our patients would show up to pick up a prescription, and the pharmacy would claim we had never faxed it or called it in. We'd have to remind them to check their computer since there is a direct connection with e-prescribing. We struggled with that for about 18 months, but in the last 2 years, all the major chains have become electronically enabled.
“A major motivation was keeping an accurate list of each patient's medications. In the past we would try to xerox patient medication sheets, but compliance wasn't very good. With e-prescribing you can capture everything, even meds other physicians prescribe.”
JOP: And have controlled substances been an issue?
“Schedule II drugs still have to be handwritten. Schedule III-V medications such as hydrocodone or lorazepam can be faxed or sent electronically. We first have to enter the prescription into the Rcopia system, print a hard copy, sign and fax it. That adds an extra step, and there's always the possibility that the pharmacy won't get the fax or will be out of fax paper. It's a pain, but we've got the office workflow down.
“So overall, I think it's been a positive thing for the practice, because we were early adopters. I'm skeptical that the amount of money from the federal government will amount to much. We're tracking it right now, but I'll believe it when it happens.”
Edward Ambinder, MD
Across the country, in New York City, Dr Edward Ambinder implemented e-prescribing 4 months ago using the program AllScripts ePrescribe (Chicago, IL).
“It's free to all practicing physicians in the United States, so it was hard to say no. It's Web-based and works with any desktop browser or smart phone,” said Dr. Ambinder. “I recently began using the mobile version for my iPhone and was surprised to find that the user experience easily surpassed the desktop version.”
JOP: Have you found it useful?
“I would say that it works as advertised. The nice thing about it is that it will give you access to drug interactions and formulary information, as well as information about any other drugs a patient may be taking that you didn't prescribe. I am constantly amazed by the number of drugs patients receive from their providers that they can't remember when they are questioned about their medications.
“It isn't yet connected with my practice management system, which would save retyping demographic information for the patients, but the company makes a program that will bridge that gap for an additional charge.
“So yes, it works, with the exception of not being able to prescribe narcotics or to use it for a handful of patients whose pharmacy is not electronically connected to the system. At this point, narcotics have to be prescribed on prescription pads. Obviously it would be easier if you could do everything electronically, but the laws aren't yet written for that. We have to wait until they are changed by Congress.
“For offices that aren't computerized, this package might be a good first step.”
Liveleen Gill, MD
JOP: Have you implemented e-prescribing in your practice?
“We did, using free software. I don't know if we understand it fully or not, but we did implement it. And we've tried it on a couple of patients.
“Frankly, it is somewhat onerous for a small practice—like PQRI [Physician Quality Reporting Initiative] and the G-codes, both of which were time consuming.”
JOP: Is the financial incentive sufficient?
“No, not at all. I think the only reason I've gone along with this is that it's coming in the future, so we may as well get used to it. But without any significant incentive, we are tempted to forget the whole thing.
“Frankly, payment is an issue. With G-codes, we got paid right then and there. That made sense. Here I'm putting in all this time, and 2 years from now will I really check whether I got paid?”
These physicians illustrate the broad range of experiences with implementing e-prescribing within their practices. Oncologists recognize the increased quality and efficiency that e-prescribing brings to the practice and understand that they will need to adopt in the future, but there are notable hindrances to adoption now. Despite the willingness of the physicians to become early adopters and to endure a significant learning curve, many oncology practices have yet to adopt e-prescribing.
In the end, the decision to implement rests with each individual practice and its attempt to reconcile all of the issues and concerns that accompany the e-prescribing incentive program. Ultimately, the incentive itself may not be the main driver for adoption, but rather patient safety and increased quality in this attempt to bring health care into the digital age.