This study was conducted to better understand the expectations and the potential barriers and challenges associated with the adoption and use of EPCS at the prescriber level. Although this survey is limited to one region, BHS represents a broad range of specialties, typical of what a community requires, and a model that commonly exists across the nation. The two hospitals and their medical staff provide coverage for most of the county. The information gleaned from the study and the survey of prescribers will provide insight for those implementing the requirements of the DEA IFR nationally. Provider attitudes toward EPCS were generally consistent with many of the attitudes toward technologies that facilitate adoption: physicians most familiar with e-prescribing had more positive expectations for EPCS and its ease of implementation; and perceived benefits were generally high, but the expected burden was also measurable.
Prescribers seemed comfortable with prescribing controlled substances, with a majority of them feeling comfortable in their ability to identify patients trying to obtain prescription drugs for abuse or diversion. This high comfort level may be due in part to the fact that most of these prescribers attended extensive pain management training sessions conducted at BHS over several years.31
Overall, 43% of the prescribers surveyed in this study had adopted e-prescribing as of 2009, equivalent to Massachusetts overall in 2008 but below the 57% reported in 2009.32
This is higher than the national estimate of 25% for office-based prescribers.33
Although the number of prescribers adopting e-prescribing has doubled each year since 2007, the adoption rate of e-prescribing is still far from universal.34
Consistent with our findings, one study found that while many physicians in office-based ambulatory practices used e-prescribing, only 10% routinely used several key features (ie, to obtain information about potential drug interactions and patient formulary).35
In the current study, the most popular features were those that improved patient management (eg, viewing patient history) or workflow efficiency (eg, automated prescription renewals). Over one-third of prescribers never used system features such as viewing the formulary or other prescribers' prescriptions, which might be related to the limitations of the technology noted earlier. One finding of concern was that 58.8% of prescribers did not or seldom (once or less per week) responded to drug interaction alerts. This corroborates findings showing that prescribers often override medication alerts for drug interactions or allergies generated by e-prescribing systems.36
As these advanced features are critical to the expected benefits of an e-prescribing system, barriers to meaningful use remain a challenge, even when physicians have access to such a system.
While the vast majority (71.8%) of e-prescribers in our study were satisfied with their system overall, several issues emerged, such as occasional unreliability, delays in the completion of a prescription at the pharmacy, and pharmacist calls, even with electronically submitted prescriptions. This highlights the fact that although e-prescribing has been shown to dramatically reduce medication errors, challenges to efficient processes and errors still persist. Errors or ambiguities can be attributed to technology factors (eg, poor user interface design, poor entry form design), end user factors (poor knowledge of the e-prescribing platform or other clinical information, etc), or environmental factors (eg, lack of time, poor location of computer).37
In our survey, 12% of the prescribers admitted that they did not feel comfortable with using the system (eg, the interface, decision support).
Overall, the majority of prescribers expected EPCS to improve patient management and efficiency, although one-fourth expected that adopting EPCS would initially disrupt their practice, including the workflow, which historically involved handing the patient the prescription while educating the patient about the medication, its side effects, and its effectiveness. The prescribers surveyed indicated that they expect EPCS to reduce medication errors, improve work flow and efficiency of practice, help identify diversion or misuse of prescriptions, and improve the management of patients' pharmaceutical therapy within their practice. This is consistent with a survey of IT healthcare professionals in which respondents expected EPCS to improve the workflow in the clinical practice (45% of respondents) and improve patient safety (31% of respondents).38
The expectations of prescribers already using e-prescribing were for the most part more positive than those not electronically prescribing, consistent with our conceptual framework that those most familiar with a new technology would be most likely to adopt it. Relatively few prescribers, experienced or not, expected EPCS to bring significant financial savings to the practice, cause depersonalization of the patient's care (by limiting in-person returns for renewals), or breaches of patient confidentiality, although those familiar with e-prescribing were less concerned about breaches of confidentiality.
One main issue that prescribers encountered with paper prescriptions was the high rate of prescription errors. A majority of prescribers expected EPCS to improve the accuracy of prescriptions, reduce medication errors, and result in fewer pharmacy call-backs. Another reported issue with paper prescribing of controlled substances was the high rate of lost prescriptions and prescription fraud or forgery. EPCS should almost completely eliminate the problem of lost prescriptions (by directly transmitting to the pharmacy) and prescription forgery (by eliminating prescription pads). Most prescribers also expected EPCS to help them identify other forms of diversion and misuse of controlled substances such as doctor shopping.
While most of the suggested EPCS security measures were viewed as inconvenient with advantages outweighing the burden, one-third of the prescribers reported that they would use paper prescriptions rather than electronic if required to carry the signature token at all times. It is important to note that in later stages of the project, use of the signature token has not been mentioned as a major barrier to prescribing. This reduced burden may be a result of providers identifying strategies to maintain sole control of the signature token such as keeping it on a key ring or locked in a desk drawer if use is infrequent.
The IFR requires providers to continue many of the tasks required in this research and demonstration project, including identity proofing, using two-factor authentication as part of signing and transmission, using one signature per patient per prescription, and reporting security incidents within a specified time. The basic process for EPCS nationally will be similar to that used in our study, and most security features appeared acceptable to prescribers in this survey. The use of a security token, the most objectionable feature, may be replaced by other two-factor authentication methods. Thus, providers may look forward to the availability of other authentication technologies, including the use of biometrics, which the DEA allowed in the IFR. At the same time, it must be noted that infrastructure costs and technical complexities limit the scalability of such approaches.
New tasks that will be required with EPCS include at least one provider participating in setting access controls at the local level for other prescribers in a practice, and reviewing daily internal reports of auditable events prescribed in the IFR. It remains to be seen what effect these additional tasks will have on the acceptance of EPCS among providers, and whether the additional security measures will inhibit adoption.