What Are the Challenges to E-Prescribing Adoption?

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E-prescribing can streamline work processes and make the system run efficiently if the right tools are available in the right setting. Change can be difficult; however, e-prescribing may enable your practice to more effectively manage medications for your patients. Challenges that have hindered more widespread adoption are described below. For those who decide to go forward with e-prescribing, Section II of this guide addresses these challenges and obstacles in greater detail, and offers guidance and strategies for making your transition to e-prescribing as smooth and trouble free as possible.
1) Financial Cost and Return on Investment (ROI):
Prescribers, especially those in small practices and in inner city or rural settings, may believe they bear more than their fair share of the cost of e-prescribing, since other stakeholders also benefit from the savings and quality improvements that are achieved, or receive fees from the use of e-prescribing. Physician practices need to invest in hardware and software, and cost estimates vary depending on whether an EHR system is adopted or a stand-alone e-prescribing system is used. Even physicians receiving free e-prescribing systems may face financial costs in the areas of practice management interfaces, customization, training, maintenance, and upgrades as well as time and efficiency loss during the transition period. Large urban practices have been the sites of most successful implementations and can achieve a positive ROI in as little as 1-2 years for e-prescribing and EHR systems, but it may take longer for small practices in rural and inner city settings to achieve a ROI. Recent research by the American Medical Association found that, due to these benefits, physicians who use an e-prescribing system are significantly more satisfied with their prescribing process than physicians who continue to handwrite prescriptions.
.2) Change Management: It is important not to underestimate the change management challenges associated with transitioning from paper prescribing to e-prescribing. In a busy practice setting where providers and their staff are accustomed to their current management of patient prescriptions, change management is important. Furthermore, if some of the providers and staff are particularly technology averse, it can be difficult to get everyone onboard with such a dramatic change. It is difficult and time consuming for practices to figure out how to change workflow around the management of prescriptions when e-prescribing or EHR systems are introduced. The change requires adequate planning, training, support, and continuous quality improvement for effective management.
3) Workflow: New systems, particularly in the beginning, are likely to add time to tasks like creating new prescriptions or capturing preferred pharmacy information at patient intake, and this can be a barrier.
Workflow changes are greater with a full HER system as compared to stand-alone e-prescribing systems, but either way, practices often experience lost productivity during the transition while they modify the practice workflow and become adept at using the system. In addition, roles and responsibilities in the practice may change, such that activities that staff handled in the past (such as preparing a paper prescription for signature) may need to be taken on by physicians. Despite the fact that efficiencies and time savings can be gained within the practice by automating renewal authorizations, workflow change remains difficult. Practices would benefit from additional resources to support them during this transition and to help them know where to turn when they encounter issues.
4) Controlled Substances: Because the DEA currently prohibits electronic transmission of prescriptions for controlled substances, both physician practices and pharmacies are forced to use different workflows to manage these prescriptions. This adds complexity to the prescribing process and is a barrier to adoption and use of e-prescribing, given that, according to AMA estimates, about 20% of all prescriptions are for controlled substances. Typically, the vendor system forces prescriptions for controlled substances to be printed. A specific type of registered paper may be required and some systems can be set up to print the prescription on printer friendly versions of this registered paper that the clinician then must manually sign. This requires either a separate dedicated printer or a specialized printer that can switch to the specialized paper on demand. The printer must also be kept in a secure area. The provider can still use his e-prescribing or EHR system to generate and document all prescriptions; however, prescriptions for controlled substances cannot be transmitted electronically. In the summer of 2008, the DEA issued a proposed rule to allow controlled substances to be e-prescribed, and public comments on the proposed rule were due September 25, 2008.
5) State Regulatory Restrictions: Although all states allow electronic prescribing, there remain some regulatory restrictions to be resolved. An example is the requirement by Medicaid in New York State to have “dispensed as written (DAW)” in a handwritten form. There are many ongoing efforts in place to resolve these issues.
6) Hardware and Software Selection: Choosing the right software and hardware and supporting it after installation can be a daunting task for some physician practices, especially small practices that are extremely busy, experiencing declining reimbursements, and lack expert information technology staff. Some struggle with how to get started, vendor selection, negotiation, implementation and long term support. Section II of this guide will help you decide what kind of system will best fit your practice, and how to go about selecting and deploying the system you choose.
7) Limitations on E-Prescribing System Remote Access:
There is often no easy remote access option. In rural areas there may not be many options for consistent remote access services due to cell phone gaps for digital service and limitations of broadband Internet service.
8) Pharmacy, Payer/PBM and Mail Order Connectivity: Not all pharmacies are connected to SureScripts-RxHub—about 3% of chain pharmacies have yet to be connected and approximately 73% of independent pharmacies are not connected even though the vast majority of them are using certified software. Some Pharmacies who already have e-prescribing capabilities may be unwilling to “switch on” e-prescribing capability until there is a sufficient number of e-prescribers in their area, because they do not want to pay a fee for each prescription received electronically. Not all payers/PBMs are connected to deliver formulary, eligibility, or medication history information, and not all mail-order pharmacies are electronically connected. Few Medicaid systems participate. While the majority of payers and PBMs are connected (representing about 200 million lives), if the formulary, eligibility, or medication history information is not comprehensive enough, prescribers may choose not to look at the data because they do not have confidence in its accuracy or completeness. Lastly, e-prescribing in rural areas can be more difficult if there is a lack of broadband Internet access.
9) Medication History and Medication Reconciliation: E-prescribing can help provide information to prescribers at the point of care on what medications their patients are taking, and have taken in the past. However, it is difficult to place absolute confidence in the completeness and currency of this information, since medication histories must be reconciled from multiple sources. Prescribers should always consult with their patients about what medications they are taking to validate the medication history information that is available through e-prescribing and update the records accordingly.
10) Medical History Information: Not all stand-alone e-prescribing systems include other patient medical history information (such as a problems list), which could impact a prescriber’s medication decisions. This type of information would be included in an EHR system with e-prescribing.

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