Starting in March of 2016, all prescriptions in New York State must be electronic prescriptions (also known as “e-prescriptions”) in which prescribed medications are transmitted over the internet to a specific pharmacy. This will be mandatory, and prescriptions done by paper, fax, or a phone call to the pharmacy will no longer be permitted. Currently, paper prescriptions and electronic prescriptions are both allowed.
What are the desirable aspects of this practice? One is that electronic prescriptions will be legible and thus potentially reduce prescription errors. To construct the electronic prescriptions, however, health care providers will be picking drug dosages from a drop-down menu, often with multiple choices, and may inadvertently choose the wrong one. This possibility is compounded by the fact that many electronic prescription systems do not require the provider to review a final version of the prescription before submission. Therefore, prescribing wrong dosages with electronic prescriptions may be more likely than with legible handwritten prescriptions but should be formally studied. In addition, we are aware that some less “tech savvy” health care providers have delegated the electronic prescriptions to their clerical personnel without review and approval before submission to the pharmacy. Another benefit of electronic prescriptions, in theory, is that electronic prescriptions can be transmitted to a pharmacy during the doctor visit, thereby enabling the pharmacy to have the prescription already packaged by the time the patient arrives. In reality, however, many pharmacies do not actually fill the electronic prescriptions until they are certain the patient will in fact be using their services, and thus still require an interaction with the patient before filling the prescription. A third benefit is that for some electronic prescribing programs, there are alerts about drug interactions and adverse effects, thereby potentially reducing adverse events. However, if there are too many insignificant alerts, this can lead to “alert fatigue” and actually promote prescription errors.
In addition to the potential problems mentioned above, there are many other negative aspects of mandatory electronic prescriptions that must be acknowledged and that may have “flown under the radar” in terms of the general public’s understanding. First, patients have to know before the health care provider visit the exact pharmacy where they want prescriptions to be sent. Although this may work for some ambulatory patients, many, particularly the more disenfranchised and the elderly, or those visiting urgent care centers or emergency departments, may not know a specific pharmacy or may use several pharmacies. They also may confuse one pharmacy with another. It is surprising, and unclear to us why electronic prescriptions must be sent electronically to only a particular pharmacy and not to some central pharmacy internet site (“cloud” system) from which any pharmacy the patient chooses could access the prescription. Once the prescription is completed by a particular pharmacy, a notation would then warn other pharmacies that the prescription had been filled, avoiding duplicate prescriptions.
Second, the use of only a single pharmacy makes it more difficult for patients to compare prices of drugs dispensed by different pharmacies, which can vary substantially. Third, not all pharmacies stock certain less frequently prescribed medications, and the patient cannot be expected to know at the time of the encounter with the health care practitioner whether the selected pharmacy has the drug in question. Fourth, pharmacies have different hours of operation. A patient’s chosen pharmacy may not be open when the prescriptions are transmitted, thereby causing an undesirable delay in obtaining the needed medication. Another concern with electronic prescriptions is that the pharmacy does not confirm to the health care provider that the electronic prescription was received, prompting the provider or the office staff to spend additional time confirming receipt by the pharmacy. In addition, if the pharmacist suspects an error in a prescription, he/she may be less likely to call a provider who used electronic prescribing because the “difficult to read” excuse cannot be used as the reason for questioning the accuracy of the prescription. A further concern is the possibility of internet outages; as this piece was being written, a prominent New York City hospital was in its second day without access to electronic prescribing because of problems with the computer system. Another concern is whether there will be frequent enough updates to the electronic prescription software to capture new formulations of existing drugs, as for example the introduction of a tablet preparation of a medication previously only available as a capsule. Finally, it is conceivable, if not probable, that this protected health information will eventually be hacked and fall into the wrong hands, whether the current or a “cloud” system is used, causing loss of confidentiality, great concern, and embarrassment for all involved.
From the practitioner’s perspective, other issues associated with electronic prescriptions include the cost of setting up the systems and the additional expenses of software maintenance and training.
A simple solution, perhaps too obvious and straightforward, is to make electronic prescriptions optional rather than mandatory. This would allow patients to voice an opinion regarding their prescribing preferences, and if they choose to receive a paper prescription from their health care provider, and enable them after the visit to select a pharmacy, or pharmacies of their choice, on the basis of drug costs, availability of a particular medication at the pharmacy, convenience, and other variables.
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-Gary P. Wormser, MD, Markus Erb, MD, Harold W. Horowitz, MD
This article originally appeared in the March 2016 issue of The American Journal of Medicine.
