A total of 114 telephone interviews were conducted with representatives of 97 organizations. Twenty-four physician practices participated, two in each CTS site. Forty-eight community pharmacies also participated, divided between local and national companies, with four pharmacies per site. For each participating national chain drug store, pharmacists were interviewed at a minimum of three different locations. National respondents included representatives of three mail-order pharmacies and three chain pharmacy headquarters and 21 other experts.
and provide more descriptive information on participating physician practices and community pharmacies, respectively. About 70% of practices used EHRs, while the remainder used stand-alone e-prescribing systems, closely representative of the national distribution of physicians registered on Surescripts in 2009.13
Practices and pharmacies used a variety of system vendors and the sample included both early and later adopters.
More than two-thirds of practices estimated they sent at least 70% of prescriptions electronically. Physicians selected other transmission modes—such as print, fax, or phone—when necessary, for example, when prescribing controlled substances, when a patient did not need a prescription filled immediately or expressed a preference for a printed prescription, or when a pharmacy was unable to receive e-prescriptions.
In contrast, more than half of community pharmacists estimated their pharmacy received <15% of prescriptions electronically, with national pharmacies more likely to receive a higher proportion. This rate was low, in part, because many physicians did not transmit any prescriptions electronically. Moreover, community pharmacies noted receiving numerous computer-generated prescriptions that were faxed or printed, sometimes outnumbering e-prescriptions.
Physician and pharmacy respondents generally noted overall satisfaction with e-prescribing and perceived improvements in efficiency and patient safety. However, respondents identified some substantial challenges to fully realizing the anticipated benefits from the transmission and processing of e-prescriptions.
Most respondents expressed satisfaction with the electronic transmission of new prescriptions. Despite the complexity of prescription routing through multiple parties, respondents reported true transmission failures were rare. However, about one-third each of physician practices and community pharmacies noted that, on a daily basis, patients arrived to pick up orders before the pharmacy had received the e-prescription. Practice respondents were more likely to attribute the problem to pharmacy staff being inadequately trained to identify new e-prescriptions, with problems reportedly diminishing as pharmacy staff gained e-prescribing experience. Pharmacists, however, believed that incoming e-prescriptions were easily identified and were more likely to point to physician delays in transmitting the prescriptions or, less commonly, transmission to the wrong pharmacy. Pharmacies typically resolved transmission problems by calling physicians for verbal orders.
Physicians and community pharmacists found that the electronic renewal process was not as consistently successful as new prescription routing and was more difficult to integrate into organization workflows. Respondents, nonetheless, highlighted the time-saving advantages of the electronic renewal process when working properly. A physician respondent from a small family-medicine practice noted, ‘Previously, someone had to get the fax, distribute it, get the approval and call or fax it in…. Now the physician gets… a refill request to their inbox right away and can deny or accept it in seconds. It eliminates handoffs. So instead of 24 h, the turnaround time is an hour.’ On the pharmacy side, according to a manager of a mass-merchant pharmacy, ‘The physician sends me back the exact same everything…. The e-prescription is married to something in my system, so five keystrokes and it's ready to go.’
While both physicians and pharmacies stand to benefit from the increased efficiency of electronic renewals, more than one-quarter of the participating community pharmacies, including 11 of the 24 local pharmacies and three national pharmacies, did not send electronic renewal authorization requests. Eight of these pharmacies lacked the functionality, and the rest chose not to use the feature, mainly to avoid Surescripts transaction fees. Similarly, one-third of physician practices were not set up to receive e-renewal requests or received them infrequently.
Among practices that did receive e-renewal requests, respondents identified ways in which the renewal process broke down, resulting in inefficiencies. For example, they reported that local and national pharmacies able to receive e-prescriptions from the practice did not consistently request renewal authorizations electronically and sometimes sent multiple requests for the same prescription using different means, even after the physician had responded electronically. As one physician explained, ‘Sometimes the patient will call, the pharmacy will fax, and [send something via] Surescripts, all for the same patient, the same prescription, on the same day. That is cumbersome.’
Pharmacists explained that follow-up is necessary if physicians do not respond in a timely way, for example, within 24 h as Surescripts recommends. A pharmacist from a national pharmacy chain explained, ‘Our system automatically generates the request. If they [don't] respond, that's where we run into problems. We fax the next day because we can't send a duplicate request electronically.’ Another pharmacist noted that his system is set up to automatically resend an e-fill request every 72 h until the initial request is marked as complete.
Inconsistent pharmacy renewal request methods reinforced inconsistent modes of response from physician offices, making it more difficult for both parties to ensure that the prescription is filled and that their systems are updated. Pharmacists reported that physicians often approve electronic requests by fax or phone. They also noted that physicians often mistakenly deny the request and then send the same prescription as a new order. In contrast, multiple physician respondents noted that they typically try to respond to all renewal requests electronically, regardless of delivery mode, to capture the prescription in their e-prescribing system and to convey to the pharmacy that they are enabled for electronic renewals.
When physicians transmitted prescription renewals without responding to a pharmacy request, pharmacists typically had to enter the prescriptions as if they were new, losing efficiencies from auto-population. Both pharmacies and physician practices also had to manually update their systems' message queues, for example, by deleting any pending requests.
Mail-order pharmacy connectivity
Electronic routing for new prescriptions and renewals with mail-order pharmacies posed additional challenges, with about three-quarters of the physician practices experiencing difficulties. Many practices were not sure which mail-order pharmacies accepted e-prescriptions and believed that, even when a mail-order company did accept them, the process was unreliable. According to a nurse in one practice, ‘We are nervous about sending electronically to mail orders. The success rate isn't high…. If it doesn't go through, I will fax it. We can lose four or five days though… finding out that it never went through.’ Respondents also largely noted that renewal authorization requests from mail-order pharmacies were received only by fax. In response to these challenges, some practices first tried electronic routing for new prescriptions or renewal responses, followed by faxing or printing the prescription if unsuccessful. Others simply avoided electronic communication altogether by routinely faxing or printing all mail-order prescriptions.
Practice respondents were surprised by these challenges, expecting electronic routing to function identically for community and mail-order pharmacies. However, as mail-order pharmacy respondents explained, few e-prescribing vendors that were Surescripts-certified to e-prescribe with community pharmacies were also certified for new prescriptions with mail-order pharmacies, and even fewer were certified for mail-order renewals. As a result, while some practice respondents believed they were sending prescriptions electronically when they selected mail-order pharmacies from the e-prescribing directory, the mail-order pharmacies noted most e-prescriptions from Surescripts were delivered by fax. For the same reason, most mail-order renewal requests also were sent by fax. These connectivity barriers arose because the new Surescripts organization, formed from a merger of SureScripts and RxHub in 2008, continued to maintain two legacy transmission networks.
Some mail-order pharmacies addressed these barriers by converting all e-prescriptions to images and processing them with fax and paper prescriptions in a single workflow, while others maintained dual workflows, processing e-prescriptions separately. Since the time of the interviews, transmission network changes have been implemented to enable more e-prescribing vendors to route new prescriptions electronically to mail-order pharmacies, but changes to support e-renewals lag.
Pharmacy processing of e-prescriptions
Most pharmacies received new e-prescriptions directly into their pharmacy systems for processing. However, two mail-order pharmacies and six community pharmacies—including local and national retailers—continued to manually enter all e-prescriptions. Most of these pharmacies, though, were implementing new systems with automated processing.
The majority of the remaining pharmacies processed e-prescriptions similarly. Once the pharmacy staff were alerted to a new e-prescription and opened it, the system attempted to match the patient and physician. Staff sometimes had to manually select the correct individual from a computer-generated list of options or create a new profile.
Staff then processed each prescription element, either clicking on the information in the view screen to import it into the corresponding pharmacy system field or visually verifying the information if the field was auto-populated. Pharmacists reported that the necessary fields were typically complete in e-prescriptions, unlike paper prescriptions. When needed, pharmacy staff typed in or edited text in a field or selected an entry from computer-generated options. Three prescription fields commonly required manual manipulation—medication name, quantity, and patient instructions (also known as the Signatura or ‘Sig’).
When physicians select a medication, the data field typically contains a single string with the drug name, strength, and dosage form, which is transmitted to the pharmacy along with the Food and Drug Administration National Drug Code (NDC). Although NDCs are used to standardize medication identification across systems using different drug-database vendors, there is no central, up-to-date source for a unique NDC for each clinically distinct drug.7
If the NDCs in the e-prescription and the pharmacy system do not match, the data cannot be auto-populated and the pharmacist must rely on the transmitted information to manually select a medication from the pharmacy database.
Moreover, both physician and pharmacist respondents explained that physicians must select medications with more specificity when e-prescribing, making decisions about packaging, drug form, or other features that commonly are made by pharmacists for hand-written prescriptions, sometimes leading to more pharmacy follow-up. In an example provided by an independent pharmacist, ‘A doctor might pick ‘minocycline tablet, 100 mg.’ He wouldn't intentionally select this because it's seven times more expensive than capsules…. In the past, the doctor would have called in simply ‘minocycline.’ I would pick ‘capsules’ in the system because I know the cost difference. When the doctor puts in ‘minocycline tablets,’ I, as a pharmacist, can't change that. I have to give what they said.’ Physician respondents confirmed this problem, as one physician in a small practice noted, ‘No longer now can I just say ‘potassium,’ I have to pick if it's a tablet, capsule, or liquid—you used to just let the pharmacist and patient deal with that.’
Physicians elaborated on the challenges in selecting the intended medication given the overwhelming number of different forms and strengths of medications available in a search query. A physician respondent observed, ‘On my preference list, there are 19 adult and pediatric dosings for amoxicillin. If you don't have a preference list, you're searching in the general database, which is an absolute nightmare. There are two full screens with 60 entries for variations on the theme of amoxicillin… and that's a good situation.’ As another example of ‘over-specification,’ physicians may have to choose from among different generic drug manufacturers. Pharmacists noted that stores stock only a limited number of manufacturers of any particular generic, making it difficult for the pharmacy system to match to the manufacturer specified in the e-prescription. Physicians and pharmacists also noted the serious problem of ‘fat fingers,’ or inadvertently selecting a drug with a similar spelling but a different clinical purpose than the intended medication.
Pharmacists and physicians both noted that physicians face challenges accurately specifying quantities for prepackaged or multi-use medications—such as pill packs, syringes, inhalers, or creams—in e-prescriptions. E-prescribing systems typically list such medications by the container or package, rather than the individual dosing units, which can cause physician confusion in selecting the appropriate quantity. Pharmacists commented that callbacks were typically unnecessary, but staff must be trained to recognize and correct this type of problem, especially since pharmacists must specify the quantity of the active ingredient on insurance claims. Observed a pharmacist in a national chain location, ‘With inhalers, prescribers usually enter the quantity ‘1,’ if you don't change that, you'll be billing (the insurer) for 1 g but it weighs 17 g so you'll be shorting yourself. It's the same with Enbrel, an injection medication that is 3.92 g. You have the potential to lose $3000 if someone is not paying attention.’
Nearly half of pharmacists noted that patient instructions typically had to be rewritten for patients to understand. As an independent pharmacist explained, ‘A lot of times we can't copy the directions word for word because the patient doesn't understand them, just like with paper prescriptions. We have to go in and erase ‘t.i.d.’ and put in, ‘One tablet three times a day’.’ While some e-prescribing systems may facilitate writing instructions in English, pharmacists indicated that, even when not in Latin, Sigs often were written for the pharmacist and needed editing to be more patient-friendly.30
About a third of pharmacists noted another challenge: the potential for physicians to provide additional instructions in another field, such as the extended instruction or comment box, that contradict what is stored in the Sig field. This sometimes prompts callbacks, as a respondent at one local chain explained, ‘We'll see ‘Take one tablet.’ Then it will say below in the notes field, ‘Take two tablets in the morning.’ It's like the first part is automatically filled in for the doctor…. We normally look in patient history…. If we see one tablet used in the past, then we keep it at one tablet; otherwise we call the physician.’ While some physicians confirmed that this problem could arise in their e-prescribing system, it is unclear how dependent this problem is on specific system designs.