Monday, August 2, 2010

Is the pen mightier than the PC?

When it comes to prescribing, it appears so. A new report from the Center for Studying Health System Change finds that most physicians write their RX scripts by hand, despite financial incentives for physicians to adopt electronic prescribing. Even those who have e-RX systems do not always use them, and when they do, they may not to use the features that were anticipated to have the biggest impact on improving prescribing practices.

HSC's nationally representative Health Tracking Physician Survey finds that "two in five physicians in office-based ambulatory practice (41.9%) reported that information technology was available in their practice to write prescriptions in 2008 ... Moreover, physicians who had access to e-prescribing did not necessarily use it routinely. About a quarter of the physicians reporting availability of IT to write prescriptions (23.1%) used the technology only occasionally or not at all. So in 2008, about one-third of all physicians in ambulatory settings (32.3%) routinely used e-prescribing." Advanced features - drug information alerts and patient formulary information - were used even less frequently.

Primary care physicians were more likely than medical and surgical specialists to use e-prescribing, as were physicians in larger group practices.

The low adoption rates for e-RX suggests to me that financial "carrots and sticks" may not be enough to drive adoption of health information technology. Medicare will pay a 2% bonus of total allowed charge to physicians for use of e-RX systems through 2013, but penalties will go into effect in 2012 on those who do not. Even larger chunks of money are available for physicians who adopt "certified" electronic medical records for meaningful use (including e-prescribing).

I am not sure why more physicians aren't using e-RX systems. Is it because of cost? Force of habit? Or do the systems themselves lack user-friendliness and functionality?

Whatever the reasons, it doesn't bode well for the government's goal of getting a certified electronic health record in every practice. The HSC authors note, "the challenges to implementation of EMRs as a whole are substantially more complex than e-prescribing. And, EMR technology is much less mature, suggesting that policy makers should expect a substantially longer time horizon to achieve meaningful use of health IT than the five- to six-year horizon of the Medicare and Medicaid incentive programs."

Today's question: Why do you think physicians are slow to adopt e-RX, even with the government"s "carrots and sticks"?


DrJHO7 said...

Why do you think physicians are slow to adopt e-RX, even with the government"s "carrots and sticks"?

1. it's expensive to implement the technology if you have to pay for it yourself, and there are monthly ongoing costs. The 2% gov't incentive would not be worth it.

2. those who aren't doing it aren't convinced of the benefits. The script pads they have now work fine.

3. even if it's free (when i was in another practice a few years back, local Blue Cross subsidized the cost of an eRx system for primary docs), it's tricky to learn for staff and docs, which means down time and decreased revenue during training, doesn't always work well (the PDA based wireless system we were given was clutzy, time consuming and unreliable, but the PC part of it worked great for our MA's - it beat calling pharmacies on the phone for regular refills).

4. The only setting in which e prescribing is really worth it is if it's already integrated into a full service ehr. Then the record keeping is great, the functionality is great and the extra 2% from CMS is easy - just report the proper G-codes ( although, we haven't seen the money from 2009 yet - wondering if this will be a big empty promise like PQRI was - what a waste...)

In short, all the CMS' incentive program for eRx did was pat docs on the back who were already doing it.

You're right - implementation of an ehr is one thing. Meaningful use is entirely another. IMO (and in my experience), it takes 2-3 years from conversion to an EHR, with the significant learning curve, acquisition of proficiency, entering of structured history data, implementation of lab and xray and hospital interfaces, and learning about sophisticated reporting procedures with proper training/coaching before you are ready to fly with the rather ambitious and not-entirely pertinent "meaningful-use" work orders. I anticipate that percentage ehr adoption by docs, as encouraged by REC's, will be below the desired curve, as will those who successfully pull off meaningful use.

The caveat is: it's so worth getting to the other side of using a good ehr, I'd never go back. But the mountain you have to get over to get it done is very high and very painful - would not want to live through that again - but that's like alot of mountains we climb in this career. Who would want to do med school, internship or residency again? Eventually, most of us will use ehr's because...we should.

Jay Larson MD said...

The pen is not mightier than the PC, just faster.

DrJHO7 hits the nail on the head. Incorporating electronic anything into a medical office has a very steep learning curve. Work flow is seriously impacted until efficiency is obtained, which takes several months-years.

Current e-prescribing advanced features can be more annoying than beneficial. Warnings pop up so often that they are often ignored.

With that said, being amongst electronics and not around tree pulp and ink is worth the painful trip.

Arvind said...

Please see my response to Dr. Barr's blog on AmericanEHR.

Just want to add the idea that you, Bob, and the ACP must convince the govt that the best incentive to incent use on technology would be to allow the cost to be passed on to the customer, like all other for-profit service industries do. Price-fixing with a 2% "incentive" will have very few takers - I can make 20% more if I saved 2 minutes on each patient's scripts every day. Simple economics, my dear Bob, is the answer.