Early Adopters of Electronic Prescribing Struggle to Make Meaningful Use of Formulary Checks and Medication History Documentation

Jesse C. Crosson; Anthony J. Schueth; Nicole Isaacson; Douglas S. Bell

doi:10.3122/jabfm.2012.01.100297

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Table 1.

Meaningful Use Objectives Relating to Ambulatory Electronic Prescribing

Health Outcomes Policy Priority	Stage 1 Objectives	Stage 1 Measures
Core set
Improving quality, safety, efficiency, and reducing health disparities	Implement drug-drug and drug-allergy interaction checks	The EP must attest that this function is enabled for the entire reporting period
	Generate and transmit permissible prescriptions electronically	More than 40% of all permissible prescriptions written by the EP are transmitted electronically using certified technology
	Maintain an active medication list	More than 80% of all unique patients seen by the EP have at least one entry (or an indication that the patient is not currently taking any medication) recorded as structured data
	Maintain an active medication allergy list	More than 80% of all unique patients seen by the EP have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data
Menu set
Improving quality, safety, efficiency, and reducing health disparities	Implement drug-formulary checks	The EP must attest that this function is enabled and have access to at least one drug formulary for the entire reporting period

EP, eligible professional.
Adapted from Table 2 of Ref. 13.

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Table 2.

Participating Practices

Practice Specialty	Physicians (n)	Staffing	e-Rx Program
Family medicine	3	1 OM, 3 MAs, 4 S	B
	4	1 OM, 1 LPN, 4 S	A
	2	1 OM, 2 LPNs, 3 MAs, 3 S	B
General internal medicine	2	1 OM, 1, LPN, 1 MA, 4 S	B
	1	1 OM	A
	1	1 OM, 1 MA, 1 S	A
	4	1 OM, 3 MAs, 5 S	B
Obstetrics and gynecology	1	1 RN/OM, 1 MA, 1 S	A

Caremark's iScribe system and Allscripts' TouchScript system were blinded in the study as either program A or B.
e-Rx, electronic prescribing; LPN, licensed practical nurse; MA, medical assistant; OM, office manager; RN, registered nurse; S = support staff including receptionists.

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Table 3.

Perceptions of Prescription-Related Information Before And After Implementation Of Electronic Prescribing

	Before e-Rx	With e-Rx
Formulary and benefit	“Periodically we get those [formulary lists], but I … throw them out because they change so frequently, and we have so many insurance plans… I glance through them … just to see what the flavor of the month is, and then [it] goes in the wastebasket.”	“The computer will tell me … which ones are preferred. … If a patient is going to be paying 200 bucks for a prescription when I can give them something for 20 bucks, I'd rather do that if they are bio-equivalents.”
	“We do get formularies … but … the HMOs have dozens or hundreds of plans each and different formularies for each one and by the time we get anything, it's obsolete anyway.”	“[The physicians] would pull it up on the [e-prescribing system] and it would say first tier, second tier, third tier covered … and the pharmacy would call and say ‘no, it's not'. And I don't know how many times I had doctors standing on one side of me, the pharmacist on the phone and the two of them bickering back and forth.”
	“The drug reps … come in and say, ‘oh, we have this drug and it's covered on all the plans so remember our drug'… we don't have a book in the office that says ‘this is covered by this.'”	“They're not all in [the e-prescribing system] so I'm just letting it default to [one health plan] and once it gets to the pharmacy, the pharmacies will sort it out.”
	“That part [of Epocrates] … I don't use at all … because I try not to let that cloud how I'm prescribing the medication. … [But] I will change medications if, for financial reasons, the patient can't afford.”	“It really hasn't changed my prescribing habits that much.”
	“[Currently] we just rely on the patient saying, ‘Hey, it wasn't covered.' But, do we look at the lists …? No … But, I know, those computer things will help a lot if you try to write [a prescription] and it says, ‘Hey, it's not allowed.'”
Medication history	“We don't have that in any organized way right now. So basically it's up to the doctor at each visit to review the meds and record them … We're careful if we're going to prescribe something for someone … but on the chart it's not real systematized.”	“A patient is on 10 drugs and I've given 3 drugs [with the e-prescribing system] … then all I see is those 3.”
	“A lot of patients don't actually know what medicines they're taking.”	“If a person's seeing a cardiologist [who is not using e-prescribing] … is on heart medication, blood pressure medication, those medicines are not in the system.”
	“…very up-to-date … very complete.”	“We still have to write [the medication] in the chart … that is the real drawback.”
	“…pretty much up-to date most of the time.”