Physician Practices, E-Prescribing and Accessing Information to Improve Prescribing Decisions

Originally published by the Center for Studying Health System Change (HSC) as Research Brief No. 20, May 2011. Funded by the Agency for Healthcare Research and Quality (AHRQ).

Can E-Prescribing Features Improve Prescribing Decisions?

Federal and state policy makers have been actively promoting electronic prescribing through Medicare and Medicaid financial incentive programs, hoping to reduce medication errors and rein in health care costs. E-prescribing systems go beyond simply writing and storing prescriptions electronically. Many offer features that give physicians access to information from outside sources that could sharpen prescribing decisions, such as medications prescribed by other practices, patient formulary details, and generic alternatives.

A qualitative study by the Center for Studying Health System Change (HSC), funded by the Agency for Healthcare Research and Quality (AHRQ), examined 24 physician practices that had adopted e-prescribing. The study found that while most practices had access to patient formulary information, only slightly more than half could access patient medication histories from other providers. More importantly, many physicians did not routinely consult these data sources when making prescribing decisions.

Two main barriers stood out. First, the tools for viewing and importing external data into patient records were often cumbersome and time-consuming to use. Second, physicians did not always consider the available data useful enough to justify the extra time required to access and review it, especially during busy patient visits. Physicians who perceived a stronger need for third-party data, who practiced in settings with more complete and accurate data feeds, and who used systems with more intuitive designs were the most likely to incorporate these features into their regular prescribing workflow.

Rapid Growth in E-Prescribing Adoption

Understanding the factors that help or hinder physician use of e-prescribing features became especially pressing as adoption rates accelerated. The percentage of office-based physicians transmitting prescriptions electronically via Surescripts, the nation's largest prescription routing network, more than doubled from 12.1 percent to 26 percent between 2008 and 2009. That jump coincided with the launch of the Medicare Electronic Prescribing Incentive Program, established under the 2008 Medicare Improvements for Patients and Providers Act (MIPPA).

Physician requests to Surescripts for patient medication histories and formulary information grew even more rapidly during the same period. Further growth was anticipated under the EHR Incentive Programs established by the 2009 HITECH Act, which required e-prescribing as part of meaningful-use criteria for electronic health records.

Patient Medication Histories: Access and Challenges

Although most physicians in the study emphasized the value of having accurate and comprehensive patient medication lists, only four of the 24 practices reported that physicians routinely supplemented their own prescribing records with a review of third-party medication history at the point of care. In one-third of the practices, the e-prescribing system either lacked a medication history feature or users were unaware it existed. Three practices had deliberately chosen not to implement the feature, and the remaining nine had implemented it but saw limited physician use.

Several factors explained the low uptake. Physicians reported that medication history data were frequently incomplete, showing only medications covered by certain insurance plans rather than a patient's full medication profile. Cash purchases and medications covered by plans not participating in the Surescripts network often did not appear. Physicians also found that when data were available, they sometimes contained outdated prescriptions or lacked information about dosage changes, making it difficult to determine what a patient was actually taking at the time of a visit.

System design posed additional challenges. In some practices, reviewing medication history data required navigating through multiple screens or performing several clicks, which disrupted clinical workflow. Physicians in time-pressed visit settings often skipped the step entirely. Practices where the data were integrated more seamlessly into the prescribing workflow and where the information was perceived as relatively complete showed higher rates of physician use.

Patient Formulary Information

Practices were more likely to have access to formulary data than to medication histories. Respondents in nearly all of the 24 practices, 22 out of 24, reported that formulary information was available through their e-prescribing systems. Even so, roughly half of physicians said they and their colleagues reviewed formulary data only on an occasional basis, pointing to similar challenges around data completeness, usefulness, and system design.

As with medication histories, physicians noted that formulary information was not always available for every patient's plan. When available, the data sometimes lagged behind actual plan changes, showing outdated tier structures or coverage rules. Some physicians found the formulary displays difficult to interpret or too time-consuming to navigate during a patient encounter. Others felt confident enough in their existing knowledge of common formularies that they did not see the added step as worthwhile.

Generic Alternatives and Substitution Practices

To encourage generic prescribing, most practices configured their e-prescribing systems to default to allowing pharmacist substitutions. This meant that even when a physician selected a brand-name drug, pharmacists were permitted to dispense a generic equivalent unless the physician specifically overrode the default by marking the prescription "dispense as written."

Some practices went further, using additional e-prescribing tools to proactively identify and select generic alternatives at the point of prescribing rather than relying solely on the pharmacy to make the substitution. About two-thirds of practices had systems that displayed therapeutic alternatives, and physicians in those settings reported the feature was useful for identifying lower-cost options within the same drug class. However, the quality and presentation of these suggestions varied across systems, and some physicians found the alternative recommendations too broad or not sufficiently tailored to the clinical situation.

Realizing E-Prescribing's Full Potential

Physician access to e-prescribing systems with advanced features was expected to keep expanding as more physicians adopted e-prescribing, vendors added capabilities to their products, and practices upgraded to systems certified under the EHR Incentive Programs. However, federal requirements at the time related to formulary and medication history did not directly require physicians to review the information when making prescribing decisions. Having the feature available and actually using it to inform clinical choices turned out to be two very different things.

The study findings point to several areas where progress was needed. Improving the completeness and accuracy of medication history and formulary data would help address physicians' concerns about data quality. Vendor improvements to system design, particularly making it easier to view and act on external data within the clinical workflow, could reduce the time burden that discouraged many physicians from using these features. Better training and peer support within practices could also help, especially for physicians less comfortable with technology.

The core lesson from this research is that deploying e-prescribing technology is a necessary but insufficient step toward improving prescribing decisions. For e-prescribing to deliver on its promise of reducing medication errors and lowering costs, the data flowing through these systems must be perceived by physicians as trustworthy, the tools for accessing that data must fit smoothly into clinical routines, and the broader policy environment must create incentives for physicians to use these capabilities rather than simply have them installed.

Data Source

This study was part of a larger qualitative research project on physician practice and pharmacy experiences with e-prescribing, encompassing 114 telephone interviews conducted between February and September 2010. Respondents were drawn from 24 physician practices and 48 community pharmacies actively transmitting prescriptions electronically via Surescripts. Sampling frames were developed from Surescripts-registered physicians and pharmacies in 12 Community Tracking Study sites: Boston, Cleveland, Greenville (S.C.), Indianapolis, Lansing (Mich.), Little Rock (Ark.), Miami, northern New Jersey, Orange County (Calif.), Phoenix, Seattle, and Syracuse (N.Y.). Two physician practices and four pharmacies were interviewed per site.

Sources and Further Reading

Grossman, Joy M., et al., "Physician Practices, E-Prescribing and Accessing Information to Improve Prescribing Decisions," HSC Research Brief No. 20 (May 2011).

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

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

Bell, Douglas S., et al., "Evaluating the Technical Adequacy of Electronic Prescribing Standards," Journal of the American Medical Informatics Association (2011).