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Few Doctors Sign Off on Online Prescribing

By Ceci Connolly
Washington Post Staff Writer
Tuesday, November 25, 2008

Samuel Benesh, an internist who practices in Owings Mills, Md., tossed his prescription pad nearly three years ago, and he hasn't missed it since.

Patients still get their medications, but now there are no more lost slips of paper or long waits in line at the pharmacy. They don't even need to phone in for refills. It all happens electronically -- or magically, as one of Benesh's patients put it.

Benesh is among a small group of physicians nationwide using technology to transmit prescription orders from a computer to the pharmacy. In an effort to nudge more physicians in that direction, the federal government will begin offering bonuses in January to Medicare physicians who write electronic prescriptions.

Patients say the system, known as "e-prescribing," is much more convenient. More important, it offers the hope of sharply reducing dangerous and costly medication errors.

Each year, more than 3.52 billion prescriptions are written in the United States, and at least 1.5 million preventable adverse drug reactions occur, according to the Institute of Medicine. Many errors are due to doctors' infamously illegible handwriting. Other mistakes involve allergies or problematic interactions with another medication.

Electronic prescribing helps minimize errors because the computer automatically checks a patient's record and alerts a doctor to potential trouble.

"This definitely improves quality and safety," said Benesh, who began e-prescribing as part of a pilot project with CareFirst BlueCross BlueShield.

E-prescribing is one small attempt to make medicine a bit more modern. Experts say technology is an underappreciated medical tool that could bring accurate, fast information to physicians and consumers.

For some doctors, such as Brian Yeaman and his colleagues at Norman Regional Health system in Oklahoma, writing prescriptions electronically has not only increased accuracy, but also was the first step toward creating a fully integrated electronic medical record-keeping system.

"Using the computer templates," said Yeaman, a family physician, "it is hard to select the wrong drug or make up a wrong dose."

But Yeaman and Benesh are the exceptions. Overall, just 2 percent of eligible prescriptions written in the United States are transmitted electronically, according to the eHealth Initiative, a nonprofit group that promotes technology in medicine. Officials at the Medical Society of the District of Columbia could not identify a single local doctor who e-prescribes.

"When we talk to clinicians across the country, the key barrier to getting to electronic prescribing is financing," said Janet Marchibroda, chief executive officer of the eHealth Initiative. Some Web-based systems, including the DrFirst portal used by Benesh, are free. But others -- especially those that combine e-prescribing with full electronic medical records -- can cost tens of thousands of dollars.

Beginning in January, doctors who use e-prescribing for roughly half of all eligible prescriptions will receive a bonus of 2 percent of their negotiated Medicare payment. The program could cost Medicare $240 million next year, according to federal actuaries. In 2010, the bonus will be reduced to 1 percent, and in 2012 doctors still wedded to handwritten prescriptions will start paying penalties.

"This is the proverbial carrot and stick," said Kerry Weems, acting administrator of the Centers for Medicare and Medicaid Services. For the average Medicare physician, the 2009 bonus could total $1,600, he said.

"A lot of prescriptions end up on the dresser," Weems said. With e-prescribing, "the physician can check on patient compliance." And the electronic system helps elderly patients and individuals with multiple illnesses monitor their drug use.

By the time Julia and Jerome Lawrence make the short drive home from Benesh's office, their prescriptions have already been logged in at their mail-order pharmacy.

"This is so much more convenient," said Julia Lawrence, who helps manage her husband's 14 drugs and can now get a single printout of all his prescriptions. "I feel much better with all the information stored in the computer."

At his office outside Baltimore, Benesh and three colleagues tote laptops into the exam rooms. When it comes time to order a medication, each uses a secure password to access a patient's record complete with address, birth date, preferred pharmacy, insurance information and list of medications.

If Benesh types in a medicine to which the patient is allergic, a bright red alert pops up on the screen. "Proceed with extreme caution," it warns.

Reminders for refill requests also arrive electronically, which can be a handy reminder if the physician hasn't seen the patient in a while.

"If there's a patient I know asking for [cholesterol-lowering drug] Lipitor but they haven't come in to have their liver functions checked, I'll say no to the refill and ask them to come in," said Tamara Sobel, another physician in Benesh's group.

One glitch is that the computerized system does not automatically update when a patient finishes a course of medicine, such as a week-long dose of an antibiotic, so the doctor has to tell the computer it ran out before it can be prescribed again.

On the other end, Owings Mills pharmacist Dan Satisky worries about security.

"I know that some doctors give their password to an assistant or nurse," he said. "They could start sending in prescriptions."

And although e-prescribing is usually speedy, clogged computer servers can slow down transmission, Satisky said.

Even with the financial incentives, it may be difficult to convince doctors to ditch their prescription pads.

As part of its e-prescribing project, CareFirst provided hand-held devices, software and training to 500 physicians. Today, 350 are still enrolled. Some of the remaining 150 doctors have graduated to more sophisticated electronic medical records, but many simply returned to pen and pad.

"Providers are creatures of habit; they have processes they are used to," said Pete Stoessel, a CareFirst administrator involved in the initiative. "They are very, very averse to change."

Initially, Sobel was nervous about switching to e-prescribing.

"I'm not a computer person," she said. "But this is so easy even I can do it."

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