Even When Physicians Adopt E-Prescribing, Use of Advanced Features Lags

Physician practice adoption of electronic prescribing did not guarantee that individual doctors would regularly use the technology, especially its more sophisticated features that the federal government was promoting through financial incentives, according to a national study from the Center for Studying Health System Change (HSC). Just over two in five physicians in office-based ambulatory care reported having information technology (IT) available for writing prescriptions in 2008, the year before federal incentives took effect. Among those with e-prescribing capabilities, roughly a quarter used the technology only sporadically or not at all. Furthermore, fewer than 60 percent of physicians with e-prescribing had access to three advanced features central to the Medicare and Medicaid incentive programs -- flagging potential drug interactions, retrieving formulary information, and transmitting prescriptions electronically to pharmacies -- and under a quarter routinely used all three. Physicians in practices that relied exclusively on electronic medical records were far more likely to report regular e-prescribing use than those with stand-alone systems. Additional gaps in adoption and routine use persisted, particularly between larger and smaller practices.

Physician Electronic Prescribing Adoption and Use Remained Limited

Both public and private sector campaigns to advance health IT had placed e-prescribing -- defined here as using IT to write prescriptions -- front and center because of its potential to enhance patient safety and moderate health care spending growth. To accelerate adoption, the federal government offered financial incentives to physicians who prescribed electronically in outpatient settings. Medicare began paying bonuses in 2009 to qualifying e-prescribing physicians under the Medicare Improvements for Patients and Providers Act (MIPPA). Starting in 2011, under the American Recovery and Reinvestment Act (ARRA), eligible physicians who demonstrated 'meaningful use' of electronic medical records (EMRs) for ambulatory care, including e-prescribing, could receive considerably larger incentives through either Medicare or Medicaid (but not both). Physicians who failed to meet Medicare incentive requirements would eventually face financial penalties.

Baseline data from 2008, gathered before the federal incentive programs launched, showed that physician adoption and use of e-prescribing remained modest despite earlier promotion efforts. Two in five physicians in office-based ambulatory practice (41.9%) reported IT availability for prescription writing in 2008, based on HSC's nationally representative Health Tracking Physician Survey. And having access to e-prescribing did not mean physicians used it consistently. About one in four physicians with e-prescribing access (23.1%) used the technology only occasionally or not at all. Consequently, only about one-third of all ambulatory physicians (32.3%) used e-prescribing as part of their regular workflow in 2008.

Meaningful Use of Advanced Features Lagged Behind

The basic capability of e-prescribing systems -- writing and storing prescriptions digitally -- gave physicians and patients clearly documented medication lists that could reduce prescribing errors and support coordinated care. E-prescribing also provided pharmacies with computer-generated prescriptions, helping minimize errors from illegible handwriting or incomplete information.

To capture e-prescribing's full value, advocates argued that physicians needed to routinely use advanced features such as drug interaction alerts and patient formulary data. These capabilities gave physicians additional information that could influence prescribing decisions. Direct electronic transmission from physician practice systems to pharmacy systems also eliminated manual prescription entry at pharmacies. Despite limited evidence on e-prescribing's effects in outpatient settings, some experts believed regular use of advanced features could cut medical errors, improve efficiency in practices and pharmacies, and boost formulary compliance and generic prescribing.

Research indicated, however, that significant obstacles stood in the way of physician use of advanced e-prescribing features. Systems might lack these capabilities altogether, and even when they were present, practices might not activate them or physicians might not use them consistently for various reasons. To help address these barriers, the federal government folded e-prescribing into the broader requirements for qualifying for Medicare or Medicaid incentive payments under ARRA. To qualify, physicians needed EMRs certified as having specific e-prescribing capabilities and had to demonstrate 'meaningful use' of these certified systems. MIPPA incentives had parallel requirements for system functionality and use, though the particulars differed from ARRA.

The HSC Health Tracking Physician Survey was the first nationally representative survey to report on physician access to and use of multiple advanced e-prescribing features included in the MIPPA and ARRA incentive programs. These features covered: identifying potential drug interactions with other medications, patient allergies, and patient conditions; retrieving patient formulary information; and transmitting prescriptions to pharmacies. According to the survey, these advanced capabilities were not always available to physicians who had e-prescribing, and even when present, physicians did not always use them regularly.

Roughly two-thirds of physicians with IT for writing prescriptions (64.5%) regularly used the drug interaction feature. Slightly more than half (53.7%) routinely transmitted prescriptions to pharmacies electronically, while only 34.3 percent consistently used the formulary information feature. Just three in five physicians with e-prescribing IT (59.4%) reported that all three features were available in their practice, and fewer than one in four (22.7%) used all three regularly. Across all physicians in office-based ambulatory settings, only 9.6 percent routinely used all three advanced e-prescribing features in 2008.

Electronic Medical Records and E-Prescribing

Prescriptions could be generated electronically through stand-alone e-prescribing systems or through modules built into electronic medical records. Stand-alone systems cost less and were simpler to deploy than full EMRs, and many viewed them as a stepping stone to broader EMR adoption. EMRs, by contrast, wove e-prescribing into the physician's overall clinical workflow and gave prescribers access to complete patient records -- including lab results -- when making prescribing decisions.

Among all physicians with IT for writing prescriptions, roughly half (50.6%) reported their practice used an EMR exclusively for patient records, 19.3 percent reported no EMR at all, and the remaining 30.1 percent used a combination of EMR and paper records. Physicians in fully EMR-based practices were assumed to use the EMR's e-prescribing module, while those in practices without any EMR were assumed to use stand-alone systems.

Physicians in practices using EMRs exclusively were more than 1.5 times as likely to use e-prescribing regularly compared with those relying on stand-alone systems (91.0% versus 56.9%). Likewise, EMR-based physicians were significantly more likely to use advanced features consistently, despite only minor differences in feature availability between the two groups. EMR-based physicians were nearly twice as likely as those on stand-alone systems to report regular use of all three advanced features (29.6% versus 15.5%).

E-Prescribing and Practice Size

Consistent with patterns seen in other health IT, physicians in larger practices were substantially more likely to report having IT for prescription writing. Physicians in group or staff health maintenance organizations (HMOs) reported the highest adoption rate at 91.5 percent -- a threefold difference compared with solo practitioners, who reported the lowest rate at 30.1 percent. Gaps in routine use were smaller, though still notable. Among physicians with e-prescribing, nearly all HMO-based physicians (94.2%) used it routinely, compared with 68.8 percent of solo practitioners.

Differences in access and use also appeared by specialty and age, though these gaps were narrower than those related to practice size. Medical and surgical specialists were somewhat less likely to adopt and regularly use e-prescribing than primary care physicians. Access and use also declined with physician age. Among those with IT for writing prescriptions, two-thirds of physicians over 60 (66.5%) used e-prescribing routinely, compared with 87.2 percent of the youngest physicians surveyed (ages 29 to 40).

Some of the variation by practice size was likely tied to higher EMR adoption rates in larger practices. When the analysis was limited to physicians in fully EMR-based practices, differences in adoption and routine use by practice size narrowed considerably. Similarly, older physicians' lower access to e-prescribing may have reflected their greater likelihood of working in smaller, less technology-equipped practices.

Achieving Meaningful Use of E-Prescribing

E-prescribing adoption remained low, especially among the half of all physicians who practiced solo or in groups of two to five. And among those with e-prescribing capabilities, many did not use it regularly, with even fewer using advanced features consistently.

Federal incentive programs were explicitly designed to address barriers to effective e-prescribing and EMR use. Incentive payments depended on having EMRs with advanced features meeting technical standards, hitting specified use targets, and reporting on clinical quality. These requirements were set to expand in stages. For instance, the initial phase would measure just two e-prescribing features -- electronic prescription orders and electronic transmission of prescriptions to pharmacies.

In an encouraging development, following the MIPPA incentive program's launch, Surescripts -- the primary e-prescribing transmission network -- reported that while the overall share of electronically transmitted prescriptions was still small, the volume rose 181 percent and the percentage of prescribers transmitting electronically more than doubled between 2008 and 2009.

Physician experiences with e-prescribing adoption and use served as an early indicator of both the rewards and difficulties federal policymakers would encounter in trying to expand meaningful use of health IT. E-prescribing was one of the most established forms of health IT and health information exchange, yet barriers to effective use persisted. The relatively modest use of formulary information, for example, may have reflected physicians' reluctance to rely on what they saw as incomplete or inaccurate data. Research also showed that physicians suffered from 'alert fatigue' given the way health IT systems were designed, and such usability problems needed resolution to fully realize e-prescribing's benefits. Additionally, some retail and mail-order pharmacies did not use e-prescribing for part or all of their transactions. These examples illustrated that stakeholders well beyond the provider community needed to be engaged for health IT to work effectively. While the federal incentive programs and additional ARRA funding for health IT infrastructure did not directly tackle these issues, broader adoption of e-prescribing and EMRs could give other parties stronger incentives to help remove barriers.

The challenges of implementing EMRs as a whole were also far more complex than those surrounding e-prescribing. EMR technology was considerably less mature, suggesting that policymakers should anticipate a much longer timeline to achieve meaningful use of health IT than the five- to six-year window built into the Medicare and Medicaid incentive programs.

Sources and Further Reading

Johnston, Doug, Eric Pan, and Jan Walker. "The Value of Computerized Provider Order Entry in Ambulatory Settings." The Journal of Healthcare Information Management, Vol. 18, No. 21 (Winter 2004).

Surescripts. "Advancing Healthcare In America: 2009 National Progress Report On E-Prescribing." (2010).

eHealth Initiative. "Electronic Prescribing: Becoming Mainstream Practice." (June 2008).

Grossman, Joy M., et al. "Physicians' Experiences Using Commercial E-prescribing Systems." Health Affairs, Web exclusive (April 3, 2007).

HSC 2008 Health Tracking Physician Survey, a nationally representative mail survey of U.S. physicians providing at least 20 hours per week of direct patient care, with more than 4,700 respondents and a 62 percent response rate.