6. Create EMR regulations so they fix all the problems in Health Care

When you have a totally paper system for complex issues like health care you are bound to have inefficiencies and errors. Some of these errors can be significant. Others are minor. One area that has been a source of problems is medication prescribing and distribution. Over the years problems with errors in medication dosage or type, problems with adverse effects due to mixing of different types of medications, and problems recalling patients on medications that have been discontinued due to problems have plagued the industry. The reasons for this are numerous. First, we as a people take more medications. Most of the elderly population takes multiple medications. Patients aren’t always compliant with providing physicians the correct information on what medications they are taking. When the government announced it was going to help Medicare Patients pay for medication treatment through the Part D Program they realized that this would be a tremendous burden due to the fact that it was a paper program. The administration of this program in a paper world would cost a fortune so they established a program called e prescribing and developed a series of standards so that they could move the electronic prescribing of medication to the main stream. Everyone has to be e prescribing by 2013 or they start getting money deducted from their Medicare Reimbursement (disincentive program). Let’s look at the prescribing in the paper world. I will break it up into two areas: a) prescribing and b) refilling. In the paper world it works like this.

Paper Prescribing:
1. Doctor sees a patient and gets basic information
2. Doctor diagnoses patient
3. Doctor prescribes a medication he thinks is the most appropriate
4. Doctor either writes it out or has the nurse write it out on a prescription pad
5. Doctor signs the prescription and it is given to the patient
6. Doctor bills for an office visit.
7. If the medication chosen is on the list that the insurance pays for (formulary) the pharmacy fills the prescription
8. If the medication is not on formulary, the pharmacy calls or faxes a note saying that this drug is not on the formulary. They may offer one on the formulary for the doctor to approve or ask the doctor for another one.
9. Doctor or nurse needs to update the record to indicate the drug change.

Telephone Refills
1. Patient calls or Pharmacy calls to ask for a refill a patient.
2. Nurse reviews these calls and may go through a protocol to determine that there are no problems or side effects occurring.
3. If the protocol is satisfied the nurse on behalf of the physician will call the pharmacy and approve the refill.
4. If the protocol is not satisfied then the nurse will contact the physician and appropriate changes in the medication will occur or the patient will be requested to come into the office for a visit.
5. The physician is not allowed to charge if the patient does not come to the office

When we first did a time analysis for doing refills in our office, we discovered that we did about 250 refills per day. It took about 8 steps including answering the phone, sending the call to a nurse or voice mail machine, the nurse would have the medical record pulled, review the record, call the patient, go through the protocol, call the pharmacy, update the chart in writing, send the chart back to the medical records department and they had to put it in a bin and then file it back to the records stack. This process costs about $8 and the provider can’t charge for it.

Below are the problems with the above methods in the eyes of the regulators.
1. Medications are sometime being prescribed without knowledge of other medications the patient is taking. If the doctor could be connected in real time to the pharmacy, we would know all the medications or if the physician could keep an electronic running record of all medications and which ones the patient came off of and why, there would be fewer complications. To address that, e prescribing demands connections to the pharmacy and drug-to-drug interaction being formed.

2. Some people may be allergic to certain things in medications. So it would be best if the physician had a running list of allergies that were updated regularly on the patient.

3. Sometimes the drugs or the instructions are not legible, so by making them pick these from standard tables and making sure medications are coded specifically for dosage we can prevent errors.

4. If the physician is connected to a live database that tracks all insurance plans and what they allow for their drug of choice, the doctor can pick the right medication based on what the insurance company will pay for. This is subtle action but also very profound. The reason payers have different formularies and that these formularies change on a regular basis has nothing at all to do with the quality of the medication and everything to do with the cost of the medication to the insurance company.

5. This brings us to the next problem. Medications can cost a lot of money and if we provide the doctor with how much the medications cost he might choose a lower cost medication for the patient so we need to put that in the requirements as well.


Okay so the new e prescribing steps would be:

Electronic Prescribing:
1. Doctor sees a patient and gets basic information
2. Doctor diagnoses patient
3. Doctor prescribes a medication he thinks is the most appropriate $
4. Doctor checks for drug-to-drug interaction in live feed $
5. Doctor checks for allergy medication interaction in live feed $
6. Doctor checks to see if the medication is on the insurance formulary $
7. Doctor checks to see how much the medication costs this week $
8. Doctor sends the prescription that is finally approved to the pharmacy clearinghouse to send to the individual pharmacy electronically $
9. Doctor bills for an office visit.
10. Doctor must assign a “G code” which is a new billing code to the episode so that Medicare knows that e prescribing was used.
11. Only the licensed dispenser (the doctor) can electronically transmit a prescription.

The $ signs means the doctor has to pay for to meet this requirement. In short the physician cost goes up in e prescribing and so does his workload--he needs to do more and the nurse does less.

New standards coming out in April include the pharmacy sending back a report to the doctor to tell him if the patient actually picked up the medication so that the doctor can chase down the patient if they are not complying to find out why. This requirement will undoubtedly be another post in the future.

Electronic Refill

Currently the provider does not get credit for doing over the phone e prescribing and many pharmacies do not yet have the ability to send electronic refill requests, so more than likely providers who do e prescribing will begin to force their patients to get an office visit to get a refill (that way the doctor get credit and he can actually recoup some of his money) I see standing refills being given for 6 months to the patient and then the patient will be asked to return to the office for another refill. The days of just calling in to renew your medications will probably go away.

Prior to e prescribing our customers did not pay anything to write or refill prescriptions in our system. Since e prescribing requires real time or near real time information, physicians now have to pay a monthly subscription fee which is an added expense that wasn’t there last year.

Again, I believe in drug checking and allergy checking and all the things we are striving to accomplish with e prescribing; however, we have to acknowledge that increasing the cost of treating patients, reducing the fees we pay physicians to treat patients, and setting up rules where physicians have to do more work and their supporting staff is restricted from helping the physician, is not a way to encourage EMR adoption.