Emerging and Encouraging Trends in E-Prescribing Adoption Among Providers and Pharmacies
Published Online: September 20, 2013
Meghan H. Gabriel, PhD; Michael F. Furukawa, PhD; and Varun Vaidya, PhD
Electronic prescribing (e-prescribing) is the electronic transmittal of a prescription to a pharmacy from the provider and is a tool used to send accurate, error-free, and legible prescriptions to pharmacies.1,2 Providers can e-prescribe via electronic health records (EHRs) or standalone e-prescribing systems. EHRs have advantages such as clinical notes, laboratory results and orders, and a broad range of clinical decision support that standalone systems do not offer.3 E-prescribing through EHRs improves the availability of pharmacy benefits information and patient medication histories, making potentially life-saving information available immediately.2 Evidence of the benefits of e-prescribing is mounting. E-prescribing has been found to significantly reduce prescription errors in communitybased ambulatory practices and eliminate prescription errors due to illegibility.4,5 In 2000, the Institute of Medicine (IOM) detailed the rate of preventable medication errors associated with paper prescribing practices. 3 In addition, the IOM called for the transformation of healthcare through the use of health information technology (Health IT) such as e-prescribing in “Crossing the Quality Chasm.”6
E-prescribing has been encouraged by the Federal government for nearly 10 years. The first time was when the Medicare Modernization Act (MMA) was passed in 2003.1 Federal regulations passed in 2006 and all states enacted laws to allow the electronic exchange of most types of prescriptions,7 thereby eliminating legal barriers to the adoption of e-prescribing. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorized e-prescribing incentive payments for Medicare providers, starting in 2009.8 Most recently, The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 was passed.9
The goal of the HITECH act was to help meet the objectives of the “triple aim”: to improve care, improve population health overall, and reduce the costs of healthcare.10 To help spur health information technology (IT) adoption, “meaningful use” incentive payments were designed to help with the initial costs of EHRs for eligible providers. These payments are designed to encourage and facilitate the adoption of health IT including e-prescribing. Additionally, the State Health Information Exchange Cooperative Agreement Program (State HIE Program) in the Office of the National Coordinator for Health Information Technology (ONC) awarded grants to 56 states and eligible territories.11 This program specifically focuses on pharmacy adoption of e-prescribing, and encourages grantees to employ various strategies to advance pharmacy eprescribing. ONC has also funded 62 regional extension centers (RECs) to help more than 100,000 primary care providers from individual and small practice settings adopt and use EHRs.12 Despite the potential benefits of implementing e-prescribing, due to the technical, cost, and/or regulatory barriers, studies have indicated that the adoption of e-prescribing has been slow.13 Additionally, studies have held that technical challenges such as availability of reliable high-speed network connections to operate e-prescribing systems especially in the rural areas may affect preparedness of the pharmacies to accept e-prescribing.14 Therefore, federal, state, and local governments have devoted significant efforts to the adoption of e-prescribing.
The objective of this study is to describe the growth in provider (physician, nurse practitioner, and physician assistant) adoption of e-prescribing and the growth in pharmacies actively accepting e-prescriptions using nationally representative data.
Surescripts is a leading e-prescription network utilized by a majority of all chain, franchise, or independently owned pharmacies in the United States routing prescriptions for more than 240 million patients through their network, excluding closed systems such as Kaiser Permanente.15 For national results, data from all 50 states and the District of Columbia were included in the analysis. The data represent transactions from December 2008 to December 2012. The area resource file was used to determine county level urban and rural characteristics.16
Surescripts pharmacy data include all pharmacies registered with the National Council for Prescription Drug Programs (NCPDP). The NCPDP files include indicators of whether each pharmacy is connected to the Surescripts network and whether each pharmacy processed a prescription on the Surescripts network in the given month. In this analysis, an active pharmacy is a pharmacy that has processed at least 1 electronic prescription in the given month. To support a realistic denominator of pharmacies that have the ability to e-prescribe on the Surescripts network, this analysis included chain, franchise, and independent pharmacies. Medical device manufacturers, nuclear, intravenous infusion, and government/military pharmacies were excluded.
For providers, including physicians, nurse practitioners, and physician assistants, Surescripts data provide an e-prescribing method. For penetration rates of providers eprescribing via an EHR, a method of identifying provider denominators was developed with SK&A, a proprietary data set using a combination of the title and specialty variables.17 The database is designed to comprise a census of ambulatory healthcare sites with at least 1 provider with prescribing authority. All sites are contacted twice a year and asked to confirm information on practice location, the providers who work at the site, and other site characteristics. The counts were de-duplicated to correct for individual providers who are observed at multiple sites. Data for annual percentages of new and renewal prescriptions routed through the Surescripts network data exclude controlled substances.
The total number of prescribers, including physicians, nurse practitioners, and physician assistants e-prescribing via EHR on the Surescripts network has increased, as displayed in Figure 1. In December 2008 the total number of prescribers using an EHR on the Surescripts network was approximately 47,000, representing 7% of the provider population in the United States. As of December 2012, the total number increased to 398,000, representing 54% of providers in the United States. Among current prescribers on the Surescripts network, 86% use an EHR while 14% use standalone e-prescribing systems (data not shown).
In order for providers to successfully use their e-prescribing systems, they must have pharmacies with the ability to accept these e-prescriptions. The growth in pharmacies actively e-prescribing in the United States during this study period is displayed in Figure 2. The percent of retail pharmacies actively e-prescribing on the Surescripts network increased from 43,000 pharmacies, representing 70% of all chain, franchise, and independent pharmacies in December 2008 to over 59,000 pharmacies, representing 94%, in December 2012, therefore showing a 24% increase in the past 4 years.
These increases in pharmacies actively accepting e-prescriptions and in providers’ e-prescribing mirror the increase in the volume of e-prescriptions sent on the Surescripts network. In 2008, 4% of all new and renewal prescriptions were sent electronically in the United States. It is forecasted that 45% of new and renewal prescriptions will be sent electronically in 2012. In December 2008, 61% of pharmacies in rural counties were actively accepting e-prescriptions, compared with 75% of urban pharmacies (P <.001). This 14% gap has closed during the study period. In December 2012, 94% of urban pharmacies and 93% of rural pharmacies were actively accepting e-prescriptions. For providers, adoption has remained consistent between urban and rural providers (data shown in eAppendix; available at www.ajmc.com). Additional results regarding new and renewal prescriptions and variations in e-prescribing among pharmacies and providers in rural and urban counties are also given in the eAppendix.
The majority of pharmacies in the United States have been able to accept e-prescriptions since 2008. This suggests that e-prescribing among physicians was not hindered by the lack of pharmacies able to receive e-prescriptions. In order to implement health information technologies, providers need technologies in the marketplace, be able to implement the technology in practice, and perceive that the technologies are worthwhile.18 The HITECH act and resulting programs such as the State HIE and REC have assisted with the first 3 points. However, provider perceptions are less influenced by governmental policies and programs than by their practice experience. The large increase in e-prescribers (7%-54%) suggests accumulating positive perceptions as experience grows. Over half of providers have implemented EHRs and e-prescribe via those systems. This is consistent with current literature.19
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