Doctors “Bending” Ethical Norms to Best Serve Their Patients who can’t Bend their Joints

Rheumatic diseases, such as rheumatoid arthritis and lupus, are a common cause of disability. they affect all sectors of the population, diminish quality of life and have a significant social impact.

Yet, despite the benefits of early treatment and effective therapies, access to rheumatologic services may be difficult, involving long wait times, even difficulties finding providers.

C. Ronald MacKenzie, MD, a rheumatologist at Hospital for Special Surgery in New York City conducted a survey among rheumatologists entitled “Bending’ Ethical Norms to Serve Patients’ Interests:Tensions in Medical Professionalism,” to examine the medical, moral and ethical dilemmas doctors face when trying to do what’s best for their patients in the current health care environment.

The study was published in the October issue of the journal Arthritis and Rheumatism. “When people receive a diagnosis, the cost of effective treatment may render it unaffordable for many,” says Dr. MacKenzie. “While an optimal or fair system would mitigate these impediments to care, our survey of the American College of Rheumatology members suggests that this is often not the case. In fact, physicians report they frequently find themselves in situations of ethical conflict in an effort to best serve their patients.”

The survey consisted of 14 closed-ended and two open-ended questions and was sent to 5,500 members of the American College of Rheumatology.

Physicians reported ways in which they see themselves as ‘bending’ ethical standards and presented justifications for doing so. Examples included ‘embellishment’ of symptoms to help patients obtain prior authorization from insurance companies; stretching the truth to obtain diagnostic tests and necessary medications and or physical therapy.

“The delivery of medical care takes place in a particular social context, and when this context includes conditions that are unfair, healthcare practitioners may be forced to struggle with ethical conflicts, making trade-offs that may go unrecognized or are not adequately discussed.”

Medicine is not merely the scientifically based treatment and care of illness. It also involves ethical issues of right and wrong. In some cases, tough ethical dilemmas force doctors and other health care providers to make difficult decisions, all while upholding the Hippocratic oath to which all doctors are bound.

In today’s health care world, where the number of health care options can be great, medical ethics is of particular concern.Awareness of this problem and its consequences is only the first step in finding solutions to the challenges that physicians face.

Fixing the system in which physicians feel they have to ‘bend’ ethical norms and compromise ethical principles in order to provide the care their patients need, is clearly what’s so desperately needed.

 

 

 

 

 

 

Testing, Testing… $, $$, $$$

If doctors knew the exact price of expensive medical tests would they order fewer of them?

That’s exactly what Johns Hopkins researchers wanted to know.

The answer has just been published in the Journal of the American College of Radiology, and it’s a resounding: No!.  According to the investigators, revealing the costs of MRIs and other imaging tests up front had no impact on the number of tests doctors ordered for their hospitalized patients.

“Cost alone does not seem to be the determining factor in deciding to go ahead with an expensive radiographic test,” says the study’s senior author, Daniel J. Brotman, M.D., director of the hospitalist program at The Johns Hopkins Hospital. “There is definitely an over-ordering of tests in this country, and we can make better decisions about whether our patients truly need each test we order for them. But when it comes to big-ticket tests like MRI, it appears the doctors have already decided they need to know the information, regardless of the cost of the test.”

Some earlier studies have suggested that much of the expense of laboratory tests, medical imaging and prescription drugs is unknown or hidden from providers and patients at the time of ordering, leaving financial considerations largely out of the health care decision-making process and likely driving up costs. Other studies have shown that doctors ordered fewer laboratory tests in some cases when they were given the price up front.

But, imaging tests appear to be “a different animal.”

Although there are certain inherent disincentives, aside from cost, to ordering some major tests, such as the potential danger of radiation used, physicians also need to learn how to explain to patients why they may not need them.

For the six months of the study, Brotman and his colleagues identified the 10 imaging tests most frequently ordered for patients at The Johns Hopkins Hospital. Five of these were randomly assigned to the active cost display group and 5 to the control group. During a 6-month baseline period from November 10, 2008, to May 9, 2009, no costs were displayed. During a seasonally matched period from November 2009, to May  2010, costs were displayed only for tests in the active group. At the conclusion of the study, the radiology information system was queried to determine the number of orders executed for all tests during both periods.

And, when they compared the ordering rates to the rates from a six-month period a year earlier, when no costs were displayed at all, they found no significant difference in ordering patterns.

Is this a good or a bad thing?

Certainly there are many instances when expensive tests are justified. When a key diagnosis is needed there are limited options for comparison shopping.  For example, when a patient appears to have had a sub-acute stroke, an MRI is needed regardless of cost.

That is not to say there aren’t times when physicians need to look more closely at whether too many imaging tests are being ordered. Do ventilated intensive care unit patients really need a daily chest X-ray to look for potential lung problems?  Especially when there is good medical evidence that outcomes aren’t compromised if X-rays are ordered only when the patient’s condition appears to be worsening.

“For too long, there has not been enough attention paid to the bottom line in health care,” Brotman says. This isn’t about rationing care to hold down costs, he says, but about choosing tests a little more wisely.

Even though price transparency didn’t influence the way physicians ordered imaging tests in this study, financial considerations may play a role in other circumstances if tied to clinical evidence.

If you show a provider that he or she is ordering four times as many CT scans as a colleague whose patients have similar outcomes, it could change the decision-making calculus for the better.

“Cost transparency must be part of the solution to solving fiscal challenges in medicine,” Brotman says. “Providers have no idea how much they’re spending. Patients don’t know either. Having everyone understand more of the economics of health care is a great place to start cutting costs in medicine.”

Seems logical to us.

The Growing Cost of Aging

With the election looming, we’ve heard a lot of rhetoric about healthcare. Rising costs, limited access, reforming Medicare…the list goes on and on.  Whatever happens on November 6, it seems the American public has already spoken. According to new research just unveiled at the American Public Health Association’s Annual Meeting, the cost of lifestyle drugs now exceeds the cost for medications used to treat chronic disease.

The research suggests that medicines used to treat conditions considered a normal part of aging, including those related to hormone replacement therapy, sexual dysfunction, menopause, aging skin, hair loss and mental alertness, are becoming so popular that they now rank third.  Only diabetes and high cholesterol have a greater cost impact among commercially insured patients.

Researchers at Express Scripts in St. Louis looked at trends in prescriptions filled for aging medications.  In 2011 alone, the cost per person for aging medications ($73.30) was 16% greater than the amount spent on both high blood pressure and heart disease medications ($62.80).  The cost for diabetes medications was $81.12 and high cholesterol medications was $78.38.

The research found that among these insured individuals use of drugs to treat the physical impact associated with normal aging was up 18.5% and costs increased nearly 46% from 2006 to 2011. Increased use of these drugs was even more pronounced for the Medicare population (age 65+), up 32% from 2007 to 2011. The largest utilization jump among Medicare beneficiaries was from 2010 to 2011, up more than 13% and outpacing increases in the use of drugs for diabetes, high cholesterol and high blood pressure combined.

“At a time when people are forgoing care due to rising health costs, this study reveals a growing trend on where the public is placing its healthcare dollars,” said Reethi Iyengar, PhD, researcher at Express Scripts.  “Continued monitoring and potential management may be warranted for this category of medications.”

While there is no doubt that pharmaceutical advances and greater awareness have improved the quality of life for many aging Americans what was not known, until now, is the significant cost associated with treating these conditions. Couple that with the proliferation of people living longer and it’s clear that managing the trend and spend from treating conditions associated with aging will become increasingly important.

The United States is in the midst of a profound demographic change, with the number of elderly people projected to reach nearly 20% of the entire population by 2030, up from less than 13% in 2009. This increase will continue to drive both use and costs of medications to treat the natural conditions of aging.

But the problem may be even bigger. The greatest growth in cost per insured was seen among the 45 to 54 age group – up almost 21% over the last five-years. And because the study only analyzed prescription medications it may have underestimated the total costs of aging treatments, which include a variety of over-the-counter medications, cosmetic treatments and surgery.

Seems getting old hurts not only our bodies, but our wallets and the economy too.

Is Your Doctor Burned Out?

Is life / work stressing you out?  Thinking about going to see your doctor for help?  Before making that appointment you may want to think again.

According to a national survey of physicians, released this week nearly 1 in 2 US doctors are themselves suffering from burnout.  That’s more than any other US workers.

Overtaxed doctors are not only at risk for personal problems, like relationship issues and alcohol misuse, but their job-related fatigue can also erode professionalism, compromise quality of care, increase medical errors and encourage early retirement – a potentially critical problem as an aging population demands more medical care.

Survey participants completed a 22-item Burnout Inventory questionnaire, which measured emotional exhaustion, depersonalization (treating patients as objects rather than human beings) and low sense of personal accomplishment. Of the 27,276 physicians asked to participate, 26.7% responded. They had to report only one symptom to be included among those reporting burnout.

Differences in burnout rate varied by specialty: While most people assume that the surgical or cancer specialties would be at highest risk, the researchers from the Mayo Clinic found that emergency medicine, internal medicine, neurology and family medicine reported the highest rates.

“Nearly 60% of physicians in those specialties had high levels of burnout,” says says lead author Tait Shanafelt MD. “This is concerning since many elements critical to the success of health care reform are built upon increasing the role of the primary care providers.”

On the other hand, doctors practicing pathology, dermatology, general pediatrics and preventive medicine had the lowest rates of burnout.

In other words, it’s the physicians on the front line of care who are most likely to burn out.

And that’s not all. When asked about emotional exhaustion, 37.9% of physicians reported signs, compared with 27.8% reported by other workers surveyed.

“The rates are higher than expected,”. Commented Shanafelt “We expected maybe 1 out of 3.

Being asked to see more patients and not having enough time to spend with them creates an atmosphere of being on a hamster wheel, says physician Jeff Cain, president-elect of the American Academy of Family Physicians.

While the current prevalence of burnout is alarming many predict it could get worse as health care reform takes hold and the medical profession has to take on the additional workload associated with the millions of patients who will be newly insured under the health care law.

While the Affordable Care Act will put more pressure on the front lines, this new study could be an important wake-up call. The country needs to hear to build multidisciplinary health care teams to meet the need and help unburden our poor put-upon physicians, so they in turn can help us.

What happened to the Sun(shine)?

Two years ago, the Physician Payments Sunshine Provision was introduced in response to concerns that undisclosed financial relationships between Pharma and  physicians could unduly influence medical practice and patient care.

As part of the provision, all pharmaceutical companies are required to post payments to physicians of anything more than $10 on their web sites.

This law was based on the premise that transparency in these transactions is of public importance and that disclosure acts as a deterrent against quid pro quo exchanges. It was hoped that physicians would be more reluctant to accept large payments if they were publicly disclosed.  Ultimately it was hoped that such disclosure would bring transparency into the prescribing process.

So has this little ray of federal sunshine changed things?

In an attempt to gain insight, if not a definitive answer, a group of researchers examined a large database for prescription drug claims for statins and antidepressants that were written between July 2003 to March 2009 in a half dozen states, including Maine and West Virginia, which have their own sunshine laws.

In both states, brand-name and generic prescriptions were compared with two other states that do not have sunshine laws in order to determine the extent to which prescribing may reflect disclosure requirements. The analysis examined the change in prescribing, before and after their disclosure laws, and compared those results with the change in prescribing in comparison states over the same period.

The researchers postulated that a difference in prescribing in the disclosure state relative to comparison states would potentially reflect the impact of the disclosure law.

So what did they find?

Although there were some statistically significant differences between brand-name and generic prescribing for one or both types of drugs, overall, the effects were small to negligible.

In other words, there was minimal switching from brand-names to generics among two wildly popular therapeutic categories that were heavily promoted during the time period examined.

Why? The authors speculate that disclosure requirements did not capture all promotional spending by pharmaceutical companies and, while industry payments to physicians may have been disclosed to state agencies, the data may not have been disseminated sufficiently to the public to have an impact.

“If the policymakers who passed these measures were hoping for a deterrent effect they may be disappointed,” said the study’s lead author, Genevieve Pham-Kanter, Ph.D., assistant professor in the Department of Health Systems, Management and Policy at the Colorado School of Public Health and research fellow at Harvard University and Massachusetts General Hospital.

Whether these results can or should be used by Pharma as an argument for scrapping the Sunshine Act remains to be seen.

Still, what the study demonstrates is that Congress and the Centers for Medicare and Medicaid Services (CMS) along with hundreds of pharmaceutical companies, will be paying hundreds of millions of dollars each year to implement a law that may not actually have its intended effect.

While transparency is an important goal, the administrative and financial burden have unintended knock-on consequences for Industry-funded research, education, and other scientific activities. , call into question.  America is currently facing a job crisis and has still not recovered from the economic decline.  The pharmaceutical industry provides a significant portion of new jobs and taxes that may help America out of these troubled times.

In light of this study, and the tremendous burdens the Sunshine Act imposes on the numerous stakeholders, Congress should perhaps reconsider the need for a federal sunshine law or come up with cheaper, less onerous alternatives.

Nurse Practitioners Ready to Mind the Gap

‘Obamacare’ is expected to expand health insurance to 32 million Americans over the next decade. This will inevitably lead to a spike in demand for medical services; leading many people to wonder who will provide that care. Maybe we need to wonder no more.

As you read this post, nurse practitioners (NPs) are throwing their hats in the ring and gearing up to be among the front runners.

Through advertisements, public service announcements and events, the American Academy of Nurse Practitioners (AANP) will try to raise the profile of the country’s 155,000 nurse practitioners.  Their campaign aims to explain exactly what nurse practitioners do and why patients should trust them with their medical needs.

AANP will also exploit the very real, looming doctor shortage. According to the Association of American Medical Colleges  the country will have 63,000 too few doctors by 2015.

With the serious shortage of family doctors in many parts of the country, nurse practitioners  will claim, in a series of radio public service announcements, that they can provide expert, compassionate and affordable care. The AANP will follow up on the public relations blitz with state-level lobbying efforts, looking to pass bills that will expand the range of medical procedures that their membership can perform.

“A fully enabled nurse practitioner workforce will increase access to quality health care, improve outcomes and make the health-care system more affordable for patients all across America,” ­ says Penny Kaye Jensen, president of the AANP. “It is our goal to empower health care consumers in all 50 states with clear confirmation that NPs provide professional, compassionate and cost-effective primary health care, as we have done for more than forty years.”

In 16 states, “scope of practice” laws allow nurse practitioners to practice without the supervision of a doctor. Other states, however, require a physician to sign off on a nurse practitioner’s prescriptions, and/or diagnostic tests.

As the health insurance expansion looms, expanding those rules to other states has become a crucial priority for NPs. “We’re all educated and prepared to provide a full range of services,” said Taynin Kopanos, AANP’s director of state government affairs.

The nurse practitioners’ campaign, however, is unlikely to move forward without a fight. Physician groups, such as the American Medical Association (AMA), contend that such laws could put patients at risk and oppose the efforts of other professional societies to expand their medical authorities.

Nurse practitioners argue that they do have the skills necessary to treat patients with more autonomy. Unlike other nurses, all nurse practitioners hold either a master’s or doctorate degree in medical education.

Alongside the legislative push, the group also will focus on public education. Data suggest that they have their work cut out for them.

A 2010 AANP poll found that while most Americans report having been seen by a nurse practitioner, few knew that their medical expertise goes beyond that of traditional, registered nurses.

Only 14% of the adults surveyed thought that nurse practitioners could prescribe medication, an authority they have in all states and only 18% thought NPs could order diagnostic tests such as X-rays and MRIs.

“People stop at the word nurse and don’t understand the word practitioner,” Jensen said. “Obviously we are nurses, but we also have advanced education. We think there’s a misunderstanding on the patients’ behalf.”

Lend your voice to the healthcare debate by sharing with us your thoughts on NPs, their visibility, their scope of practice and their role in the healthcare of our nation.

Prescriptions, Physicians, Patients and Payers: Let the battle commence!

Last week the FDA announced that it wants to remove obstacles to America’s most commonly used drug treatments.  If the Agency gets its way, some drugs used to control chronic conditions, such as high cholesterol, diabetes and asthma may soon be available without prescription.  But in doing so, they have reopened a  big can of worms. One that brings into question the very nature of health reforms, preventative medicine and improved access to healthcare.

Here’s the proposal: The FDA would create a new class of “safe use” drugs. While consumers would not need a prescription, they would still need to get clearance from a pharmacist or from specially designed websites to purchase them.

Battle lines are being drawn! With physicians on one side, and patients, pharmacists, pharma and payers on the other.

Doctors are most definitely not thrilled by the idea. Removing the prescription requirement for an inhaler refill, for example, doctors fear they would be taken out of the loop on everyday care decisions.

Insurers, on the other hand are embracing the move. They recognize that they could save big bucks if physician visits weren’t required for run-of-the-mill complaints and ongoing medication monitoring. They might even save on the costs of the drugs themselves because, depending upon how they’re classified, most health plans don’t pay for over-the-counter treatments.

Pharmacists see it as validation of their expertise and pivotal role in primary healthcare and the pharmaceutical industry, who has repeatedly asked for permission to sell such drugs over-the-counter, must surely be cautiously optimistic.

Even normally conservative regulators are supporting the move. “Greater over-the-counter and behind-the-counter access will lower costs and make healthcare more accessible to consumers,” former FDA commissioner Scott Gottlieb said via Twitter. “It’s a good idea, long overdue.”

Even so, the FDA will have a fight on its hands as it moves to turn its proposal into reality. The American Medical Association lambasted the idea in USA Today, saying that patients need guidance from doctors. The doctors’ association also points out that giving patients more control could complicate coordinating care, such as, tracking all the drugs a patient uses to prevent interactions.

But, as The Washington Post points out, FDA sees the doctor’s visit as a hindrance to care; some patients don’t seek treatment if they have to see a physician first. “Obviously, it’s much easier for you to go to your drug store and pick up an item than it is to make an appointment, take a prescription, drop it off and get it filled,” says Nancy Chockley, president of the National Institute for Health Care Management.

About 20% of prescriptions written in the United States currently go unfilled. Removing obstacles that keep Americans from managing their own health care is, according to one patient, namely me, a good thing.

The FDA contends, and I agree, that some consumers may not even go as far as getting a prescription because of the “cost and time required to visit a health-care practitioner.  Earlier this month, I stood in line at my local pharmacy for thirty minutes to pick up a refill prescription for blood pressure meds. On reaching the end of the line I was told that there was no prescription. The pharmacist called my doctor and the lack of prescription was confirmed. I called my doctor and was told I would need to make an appointment to have the prescription renewed. I pointed out that I had done that one month earlier and that nothing had changed regarding my health. I was then informed that it was a new policy to issue prescriptions on a month-by-month basis rather than provide automatic refills. Even when I pointed out that I have a chronic condition that I’m doing my best to manage and part of that management is the medicine I have been taking for years, they wouldn’t sway. No doctors visit, no prescription.  And the kicker, I couldn’t get an appointment to see my doctor for a week…meaning, I had to go 7 days without blood pressure meds, all so my doctor could better manage my care!

Practicing medication adherence is very hard when your doctor won’t give you medication…and leaves me wondering if this policy change had more to do with revenue generation than improving chronic disease management.

My personal experience aside, at the heart of this discussion is a fundamental disagreement over what role doctors play in managing patient care. The FDA proposal views a trip to the physician as a hindrance to care, whereas doctors see that visit as crucial, especially as chronic conditions become increasingly prevalent.

The FDA proposal is still in formative stages, meaning there’s still a lot of space for this debate to evolve. Where the discussion heads on this particular issue could end up guiding health policy on what role doctors play in managing patient care – and, at what point, the patient takes charge.

I, for one, can’t wait to see how it plays out, assuming of course that I’m not dead from uncontrolled hypertension!

20/20 on the Vanishing American Hospital

Most Americans are born in hospitals. Hospitals also provide care during many other intimate and extraordinary circumstances in our lives – serious injuries, severe sickness and mental breakdown. Hospitals are also, by and large where we go to die.

As such, hospitals serve as a cornerstone of our communities and our very existence.

According to the American Hospital Association, there are 5,754 registered hospitals in the U.S. In 2011, almost 37 million people were admitted to a hospital in the U.S. – that’s more than 1:10 people.

Yet despite all this history, hospitals are in the midst of massive and disruptive change.

Even knowing this, SRxA’s Word on Health was shocked to read an article suggesting that by 2020 one in three hospitals will close or reorganize into an entirely different type of health care service provider.

Writing on KevinMD.com, a leading physician voice blog, authors David Houle and Jonathan Fleece suggest that that there are four significant forces and factors are driving this inevitable and historical shift.

First, America must bring down its crippling health care costs. The average American worker costs their employer $12,000 annually for health care benefits and this figure is increasing more than 10 percent every year. U.S. businesses cannot compete in a globally competitive market place at this level of spending. Federal and state budgets are getting crushed by the costs of health care entitlement programs, such as Medicare and Medicaid. Given this cost problem, hospitals are vulnerable as they are generally regarded as the most expensive part of the delivery system for health care in America.

Second, statistically speaking hospitals are just about the most dangerous places to be in the United States. Three times as many people die every year due to medical errors in hospitals as die on our highways — 100,000 deaths compared to 34,000.

The Journal of the American Medical Association reports that nearly 100,000 people die annually in hospitals from medical errors. Of this group, 80,000 die from hospital acquired infections, many of which can be prevented. Given the above number of admissions that means that 1 out of every 370 people admitted to a hospital dies due to medical errors.

In other words, hospitals are very dangerous places.  It would take about 200 747 airplanes to crash annually to equal 100,000 preventable deaths. Imagine the American outcry if one 747 crashed every day for 200 consecutive days in the U.S. The airlines would stand before the nation and the world in disgrace.

Currently in our non-transparent health care delivery system, Americans have no way of knowing which hospitals are the most dangerous. We simply take uninformed chances with our lives at stake.

Third, hospital customer care is abysmal. Recent studies reveal that the average wait time in American hospital emergency rooms is approximately 4 hours. Name one other business where Americans would tolerate this low level of value and service.

Fourth, health care reform will make connectivity, electronic medical records, and transparency commonplace in health care. This means that in several years, and certainly before 2020, any American considering a hospital stay will simply go on-line to compare hospitals relative to infection rates, degrees of surgical success, and many other metrics. Isn’t this what we do in America, comparison shop? Our health is our greatest and most important asset. Would we not want to compare performance relative to any health and medical care the way we compare roofers or carpet installers? Inevitably when we are able to do this, hospitals will be driven by quality, service, and cost — all of which will be necessary to compete.

So hospitals are about to enter the open competitive marketplace. And as we know there will be winners and losers.  According to Houle and Fleece a third of today’s hospitals will fall into the latter category.

Will your hospital be among them?  Let us know what you think.

Musing on MLK

Today, many Americans will be enjoying a day off work in observance of Martin Luther King.  Among these, some will be occupied in the annual tradition of trying to guess what the good Doctor would have said about current health issues if he was still alive today.

What Martin Luther King would have thought about President Obama’s health care reform requirement that all Americans buy health care insurance?

Sarah Palin wrote that, “He fought for liberty and equality because he knew they were God-given and he knew that no government should be empowered to thwart our freedom.”  The implication, being that King would have been against health care reform because it would be a blow to freedom.

Others have complained that the bills don’t go far enough towards King’s vision of equality.  They point out that millions will remain uninsured. Expensive health plans could hurt middle class workers, and the subsidies don’t go far enough towards helping poor families.  They are probably right to a certain extent – King would have pushed for a bill that did more to help poor and working families, and a bill that covered everyone.

So what do we think? Certainly Dr King would have wanted to see improved access to care for minority populations.

Health disparities are well documented in minority populations such as African Americans, Native Americans, Asian Americans, and Latinos. When compared to European Americans, minority groups have higher incidence of chronic diseases, higher mortality, and poorer health outcomes. Minorities also have higher rates of cardiovascular disease, HIV/AIDS, and infant mortality than whites.  Additionally:

• African Americans have higher rates of mortality than any other racial or ethnic group for 8 of the top 10 causes of death. For example, the cancer incidence rate among African Americans is 10% higher than among European Americans.
• U.S. Latinos have higher rates of death from diabetes, liver disease, and infectious diseases than do non-Latinos.
• Adult African Americans and Latinos have approximately twice the risk as European Americans of developing diabetes.
• Native Americans suffer from higher rates of diabetes, tuberculosis, pneumonia, influenza, and alcoholism than does the rest of the U.S. population.

In some cases these inequalities are a result of income and a lack of health insurance.. Almost two-thirds of Hispanic adults aged 19 to 64 were uninsured at some point during the past year, a rate more than triple that of working-age white adults. One-third of working-age black were also uninsured or experienced a gap in coverage during the year. Compared with white women, black women are twice as likely and Hispanic women are nearly three times as likely to be uninsured.

A patients’ race also influences physician prescribing. Numerous studies have found racial differences in prescribing and treatment patterns for hypertension, hypercholesterolemia, cancer, pneumonia and diabetes.

Race has played a major role in shaping systems of medical care in the United States. The divided health system persists, in spite of federal efforts to end it. We hope that those in a position to change such inequalities take today, to reflect how such change can be implemented.

e-prescribing: e-fficient, but still e-lusive?

Electronic prescribing or e-prescribing, has multiple potential benefits, including helping to reduce the risk of medication errors caused by illegible or incomplete handwritten prescriptions.  However, according to a study funded by the U.S. Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ),  neither prescribers, pharmacists or indeed patients are getting the full benefit of the technology.

The study, published online in the December issue of the Journal of the American Medical Informatics Association focused on a key aspect of e-prescribing: the electronic exchange of prescription data between physician practices and pharmacies. This practice can save time and money by streamlining the way in which new prescriptions and renewals are processed. The study showed that while physician practices and pharmacies were generally positive about electronic transmission of new prescriptions and prescription renewals, connectivity between physician offices and mail-order pharmacies continue to pose problems. Additionally problematic is manual entry of certain prescription information by pharmacists, for example, the drug name, dosage form, quantity, and patient instructions.

“Physicians and pharmacies have come a long way in their use of e-prescribing, and that’s a very positive trend for safer patient care and improved efficiency,” said AHRQ Director Carolyn M. Clancy, M.D. “This study identifies issues that need attention to improve e-prescribing for physicians, pharmacies, and patients.”

Researchers at the Center for Studying Health System Change, conducted 114 interviews with representatives of 24 physician practices, 48 community pharmacies and three mail-order pharmacies using e-prescribing. Physician practices and pharmacies used e-prescribing features for electronic renewals much less often than for new prescriptions. More than a quarter of the community pharmacies reported that they did not send electronic renewal requests to physicians. Similarly, one-third of physician practices had e-prescribing systems that were not set up to receive electronic renewals or only received them infrequently.

Physician practices reported that some pharmacies that sent renewal requests electronically also sent requests via fax or phone, even after the physician had responded electronically. At the same time, pharmacies reported that physicians often approved electronic requests by phone or fax or mistakenly denied the request and sent a new prescription.

The study noted that resolving e-prescribing challenges will become more pressing as increasing numbers of physicians adopt the technology in response to federal incentives. Physicians can qualify for Medicare and Medicaid electronic health record incentive payments by generating and transmitting more than 40% of all prescriptions electronically.

The study concludes that a broad group of public and private stakeholders, including the federal government, e-prescribing standard-setting organizations, vendors and others will need to work together to address these issues.

Do you have any experience, good or bad with e-prescribing?  Let us know.