E-Rx Update and Review

A few months ago I wrote a post (ERx Me) about e-prescribing. Now that I've been using Practice Fusion for a while, I thought I'd write an update.

The program, itself, has some problems. Ads for more training in Practice Fusion pop up a lot, along with dialog boxes that take up enough of the screen that I have trouble seeing what I need to see. On my work computer, an old MacBook, I couldn't see at all until I switched to presentation view, and I had to figure that out by trial and error. There was no, "If you have difficulty viewing..." message. I suspect the visual difficulties would go away if I paid for an upgrade, which I'm not willing to do.

There was a 6 month time limit for sending in my first e-prescription. After that, I think I wouldn't have been able to use the system without reapplying for eRx privileges, which may have been delayed due to my failure to demonstrate an interest in using the system. But I did "write" an eRx within the time limit. Weirdly, after that, I started getting emails and phone calls from Practice Fusion encouraging me to contact them for training so I could get started using the system. I thought I had already started.

I tried setting up a dummy chart for patient, Joe Cool. There doesn't seem to be a direct way to create a new chart. Instead, you enter the patient's name, and click on a button to search for an existing patient. Then, when it doesn't find the patient, it asks you if you want to add this as a new patient.  Seems silly.

The notes feature is comprehensive. Too comprehensive. There are all kinds of variations, and most aren’t useful for my needs. You can customize notes, but the process of doing so is prolonged and cumbersome. You can also upload a note template, which I did. It’s there now, but I haven’t figured out how to incorporate it into a chart.

I can’t really complain about the charting features, though, because that’s not why I use it. I use it only to send eRx’s to pharmacies, since I’m going to be required to do that in the not so distant future, and I don’t want to end up rushing to set up a system last minute.

I’m still not comfortable with storing patient information in the cloud. I’m not worried about HIPAA. As I found out (What, Exactly, Is HIPAA?), HIPAA allows me to take my patients’ histories and do everything  short of publishing them in a full page ad in the Times.

But according to my last malpractice tutorial, it’s a no-no, because if it’s in the cloud,  it’s not clear who owns it. I’d like that to be straightened out before I send patient data off into the stratosphere. I also wonder what the story is with personal clouds, or Network Attached Storage, or whatever.. If I have one of those, can I use Practice Fusion’s  EHR but store the data myself?

I only need minimal data for e-prescribing on Practice Fusion. The patient’s name, date of birth, and phone number. I don’t even include a diagnosis in the chart. And I always check with patients before I e-prescribe for them.

I’ve run into some problems with the actual eRx’ing, but I don’t believe they’re specific to Practice Fusion. The first issue is that you pick the medication and strength from a drop-down list. It’s VERY easy-I’ve already done it-to pick the wrong strength or formulation, even if it’s just because your hand moved when you clicked. E-prescribing is supposed to do away with prescription errors. NOT!

Also, I guess writing one eRx puts you into “the system”, because I’ve gotten refill requests for patients for whom I’ve never e-prescribed. This is a particular problem because until I realized this, I wasn’t even checking in on Practice Fusion. I found out when I logged in one day, and there was a list of erx’s I “needed” to write. This seems to be an extension of something I find incredibly annoying. I get calls from the pharmacy, asking me to call in refills for a patient, because the prescription is about to run out. Or sometimes I get faxes. But it’s automatic. There is no accounting for the fact that the dosage may have been changed, or the patient has enough 25’s left over from when we were titrating to cover for a week or two more. I end up having to call the patient to check, and there’s almost always no need to call in a Rx. But it creates extra work for me.

Refills are another thing. I initially tried checking the box for “refill as needed”, for patients I thought were reliable enough to keep track of their meds. I thought this meant that when the patient ran out and called the pharmacy, they would just refill it. Apparently, what it means is they have to call me to authorize a refill. So now I enter a specific number of refills instead.

The automatic thing is a real problem. I saw a refill request on my Erx list. The patient had already called me to let me know she was running out. So I just approved the refill request. Later that day, the patient called me again to let me know that the pharmacy wouldn’t fill it in the requested dosage form, and then I had to call the pharmacy anyway with the change in dosage form, even though they were the ones who requested I refill it in the other dosage form.

I feel about e-prescribing the way I feel about technology in general. When it works, it’s wonderful, and when it doesn’t work, you’re so much better off with paper and pen. Everyone gets all excited about a technological improvement, as though it’s a panacea, and doesn’t come with side effects of its own.

Erx Me

In case you thought you were done with big practice changes, s/p CPT, DSM-5, think again.

"Starting August 27, 2013, all physicians who prescribe Schedule II, III and IV controlled substances will be required to consult a new online state registry designed to track the prescription and dispensing of controlled substances."

This is from the NYSPA's comment on the new I-STOP law.

Here's a good I-STOP resource, from the Medical Society of the State of NY.

From what I can tell, starting on August 27th of this year, when we write prescriptions for controlled substances, we will have to open up our laptops or ipads or whatever, right there with the patient, and check that the patient is not up to any funny business with his meds.

I'm assuming this because of the phrase, "real time", which is supposed to be defined in regulation.

So, here you are, in your office, and you look up the patient on the registry, and you say, "Mr. Patient, it seems you've been diverting your meds, so I can't write that prescription for you. Have a nice day."

I don't know. The level of monitoring is getting out of control. It's like legislative OCD. And it carries such righteous indignation. We're going to purge the country of the evil of prescription drug abuse. Yeah, okay. It's a problem. But it doesn't have to be the Spanish Inquisition.

And it's one more way the government is insinuating itself into the room with the patient. Others include implying the psychiatrist is not doing a good job unless the patient is filling out checklists, and requiring patient reviews (see this post).

But that's not all. Starting on December 31, 2014, ALL prescriptions will need to be submitted electronically.  I was trying to figure out how to implement this, and I know, from risk management classes, that electronic medical records are a no-no, since, even if you can guarantee security (and really, you never can), if the data is stored in the cloud, you don't know who owns it. So I figured there're going to be some problems with e-rx's, and I called my carrier to find out if they have any advice about potential pitfalls, etc. They didn't have a lot of information, but referred me to the AMA's website, for  A Clinician's Guide to Electronic Prescribing, which was actually not that easy to find through the site, and I ended up googling it.

What WAS relatively easy to find was their e-prescribing learning center, where you can learn about how great e-rx is, and how it will solve the age-old problem of illegible prescriptions. You can also learn about how much it will cost you to implement and maintain your e-rx system. In fact, it'll walk you through a series of questions to help you determine which system is best for your practice. And then it will give you a list of e-rx systems that meet your needs.

I tried it, and I answered all questions on the "no frills" end, i.e., I don't want any advanced features, I don't want an EMR to go with it, etc. It came up with 3 recommended systems:

Relayhealth Escript at $600, no demo available
Care360 Physician Portal 2008.3, at $240, no demo available, and
InfoScriber, version 115, at $600, no demo available

Now, I didn't try to look this up, but I'm willing to bet that the AMA has financial connections with all these systems, and any others it spits out. It certainly didn't refer me to Practice Fusion, which is free, comes with an, also free, EMR which you don't have to use if you don't want to, and is ranked #1 for both e-rx vendors, and EHR based e-rx vendors, by the Black Book Rankings.

Bottom line: I signed up for Practice Fusion (no, they're not paying me to write this), and I'm in the process of being verified for the e-rx (apparently, you have to do that). I'll let you know how it goes.

As I was writing this, it occurred to me that once we start e-prescribing controlled substances, we'll be taking diversion of these substances out of the hands of individuals who have to hustle to get hold of a one-month supply of meds, and placing it in the hands of anyone savvy enough to hack the system. Who could do that? Oh, I don't know, maybe a large scale crime organization, or your average computer science major at MIT. Goodbye, diversion in dribs and drabs, hello big-time diversion.